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The most effective dose of prehospital furosemide in acute decompensated heart failure (ADHF) has not yet been identified and concerns of worsening renal function have limited its use.
To assess if administering high-dose furosemide is associated with worsening renal function.
The authors conducted a 2-center chart review for patients who presented via a single Emergency Medical Service (EMS) from June 5, 2009 through May 17, 2013. Inclusion criteria were shortness of breath, primarily coded as ADHF, and the administration of furosemide prior to emergency department (ED) arrival. A total of 331 charts were identified. The primary endpoint was an increase in creatinine (Cr) of more than 0.3 mg/dL from admission to any time during hospital stay. Exploratory endpoints included survival, length-of-stay (LOS), disposition, urine output in the ED, change in BUN/Cr from admission to discharge, and change in Cr from admission to 72 hours and discharge.
When treated as a binary variable, there was no association observed between an increase in Cr of more than 0.3 mg/dL and prehospital furosemide dose. Baseline characteristics found to be associated with dose were included in the logistic regression model. Lowering the dose of prehospital furosemide was associated with higher odds of attaining a 0.3 mg/dL increase in Cr (adjusted OR = 1.49 for a 20 mg decrease; P = .019). There was no association found with any of the exploratory endpoints.
Patients who received higher doses of furosemide prehospitally were less likely to have an increase of greater than 0.3 mg/dL in Cr during the hospital course.
NievesLC, MehrtensGM, PoresN, PickrellC, TanisJ, SattyT, ChuangM, YoungTC, MerlinMA. The Effect of Furosemide Dose Administered in the Out-of-hospital Setting on Renal Function Among Patients with Suspected Acute Decompensated Heart Failure. Prehosp Disaster Med. 2015;30(1):1-8.
The global burden of cardiovascular mortality is increasing, as is the number of large-scale humanitarian emergencies. The interaction between these phenomena is not well understood. This review aims to clarify the relationship between humanitarian emergencies and cardiovascular morbidity and mortality.
With assistance from a research librarian, electronic databases (PubMed, Scopus, CINAHL, and Global Health) were searched in January 2014. Findings were supplemented by reviewing citations of included trials. Observational studies reporting the effect of natural disasters and conflict events on cardiovascular morbidity and mortality in adults since 1997 were included. Studies without a comparison group were not included. Double-data extraction was utilized to abstract information on acute coronary syndrome (ACS), acute decompensated heart failure (ADHF), and sudden cardiac death (SCD). Review Manager 5.0 (Version 5.2, The Nordic Cochrane Centre; Copenhagen Denmark,) was used to create figures for qualitative synthesis.
The search retrieved 1,697 unique records; 24 studies were included (17 studies of natural disasters and seven studies of conflict). These studies involved 14,583 cardiac events. All studies utilized retrospective designs: four were population-based, 15 were single-center, and five were multicenter studies. Twenty-three studies utilized historical controls in the primary analysis, and one utilized primarily geographical controls.
Conflicts are associated with an increase in long-term morbidity from ACS; the short-term effects of conflict vary by study. Natural disasters exhibit heterogeneous effects, including increased occurrence of ACS, ADHF, and SCD.
In certain settings, humanitarian emergencies are associated with increased cardiac morbidity and mortality that may persist for years following the event. Humanitarian aid organizations should consider morbidity from noncommunicable disease when planning relief and recuperation projects.
HaymanKG, SharmaD, WardlowRDII, SinghS. Burden of Cardiovascular Morbidity and Mortality Following Humanitarian Emergencies: A Systematic Literature Review. Prehosp Disaster Med. 2015;30(1):1-9.
This chapter discusses the diagnosis, evaluation and management of acute decompensated heart failure (ADHF). Left-sided heart failure classically presents with dyspnea, usually related to pulmonary vascular congestion. Patients with severe ADHF present with respiratory distress and impending respiratory failure. The associated symptoms may include frothy oral secretions, diaphoresis, and hypoxia. Patients may also have other symptoms related to poor cardiac output and poor perfusion such as chest pain and altered mental status. Patients may be hypertensive or hypotensive depending on the etiology of symptoms and hypotension can be indicative of cardiogenic shock and is particularly concerning. Important elements of history include past history of cardiac dysfunction and potential causes of new cardiac dysfunction. When approaching a patient with ADHF, one must be sure to address any underlying cause while simultaneously managing the physiological derangements. Patients who become hypoxic, lethargic, or more confused despite noninvasive positive-pressure ventilation (NPPV) should be intubated.
High-dose intravenous nitroglycerin is a common in-hospital treatment for respiratory distress due to congestive heart failure (CHF) with hypertension. Intravenous (IV) nitroglycerin administration is impractical in the prehospital setting. In 2011, a new regional Emergency Medical Services (EMS) protocol was introduced allowing advanced providers to treat CHF with high-dose oral nitroglycerin. The protocol calls for patients to be treated with two sublingual tabs (0.8 mg) when systolic blood pressure (SBP) was >160 mm Hg, or three sublingual tabs (1.2 mg) when SBP was >200 mm Hg, every five minutes as needed.
To assess the protocol's safety, the incidence of hypotension following prehospital administration of multiple simultaneous nitroglycerin (MSN) tabs by EMS providers was studied.
This study was a retrospective cohort study of patients from a single commercial EMS agency over a 6-month period. Records from patients with at least one administration of MSN were reviewed. For each administration, the first documented vital signs pre- and post-administration were compared. Administrations were excluded if pre- or post-administration vital signs were missing.
One hundred case-patients had at least one MSN administration by an advanced provider during the study period. Twenty-five case-patients were excluded due to incomplete vital signs. Seventy-five case-patients with 95 individual MSN administrations were included for analysis. There were 65 administrations of two tabs, 29 administrations of three tabs, and one administration of four tabs. The mean change in SBP following MSN was -14.7 mm Hg (SD = 30.7; range, +59 to -132). Three administrations had documented systolic hypotension in the post-administration vital signs (97/71, 78/50 and 66/47). All three patients were over 65 years old, were administered two tabs, had documented improved respiratory status, and had repeat SBP of at least 100. The incidence of hypotension following MSN administration was 3.2%.
High-dose oral nitroglycerin administration is a practical alternative to IV nitroglycerin in the prehospital setting when administered by advanced providers. The prehospital protocol for high dose oral nitroglycerin was demonstrated to be safe in the cohort of patients studied. Limitations of the study include the relatively small sample size and the inability to identify hypotension that may have occurred following the cessation of data collection in the field.
Hypotension was rare and self-limited in prehospital patients receiving MSN.