March 15, 2024

Welcome to UH EMS Institute’s Pharmacy Phriday. This coming weekend, many across the world will be celebrating St. Patrick’s Day. With that celebration comes green clothing, green rivers, parades, corned beef and cabbage, and beer. Though St. Patrick’s Day is not the most popular drinking day in America (New Year’s Eve, Christmas, and the Fourth of July actually rank ahead of St. Patrick’s Day for alcohol consumption), green beer and other spirits will be a big part of many celebrations.

These celebrations can bring many challenges and interesting calls for EMS, Fire, Police, and emergency room agencies. In preparation of the holiday approaching, a review of the “Alcohol / Withdrawal Related Emergencies” algorithm within the protocols seems appropriate. In this article, we will review one of the treatments in that algorithm. 

In previous Pharmacy Phriday articles this year, we reviewed some medications listed within the alcohol-related protocol. Today, we review the use of Normal Saline in cases of dehydration associated with these emergencies.

Fluid therapy is critical in the management of our patients. Within the protocol for cases of alcohol intoxication or an alcohol-related emergency, Normal Saline is used to treat associated dehydration, not to lower alcohol levels or speed up time to sobriety. Fluid therapy is most often accomplished using normal saline, a mainstay of crystalloid intravenous solutions that are commonly used.   It is an isotonic fluid consisting of sodium and chloride electrolytes administered as a bolus via large-bore peripheral IV lines in cases of dehydration, hypovolemia, hemorrhage, sepsis, and other shock states. Normal Saline is also used to provide a route for the administration of lifesaving medications and is run as a “to keep open” (TKO) infusion in these cases.

Boluses of Normal Saline 0.9% are typically weight-based under UH protocols at 20 ml/kg for the adult patient. Goals of administration would include the ability to maintain a MAP greater than 65, a systolic blood pressure greater than 90, or the presence of radial pulses when BP measurement is not available. In the pediatric patient, boluses range from 10-20 ml/kg to a systolic pressure of 70 + 2X their age. 

As “normal” as Normal Saline may sound, it is a medication and is not without side effects. In the case of any fluid resuscitation, possible fluid overload is a concern, especially for patients with CHF, renal disease, or insufficiency and where peripheral edema is present. Other complications from NS fluid boluses can include metabolic alkalosis and electrolyte imbalances. In all patients, be sure to reassess vital signs and patient condition frequently, including signs of fluid overload such as dyspnea, abnormal lung sounds, jugular vein distention, ECG changes, etc.

In shock states, Normal Saline and other crystalloids are administered to expand intravascular volume quickly, but they are not blood, nor do they provide the same benefits as blood or blood products. In fact, too much of a crystalloid administered in the shock state can lead to increased problems with acidosis and coagulopathy, two of the three factors in the “trauma triad of death.” 

As providers, we must be cautious with our administration of Normal Saline in the prehospital setting, monitoring the patient, and limiting doses to meet the established parameters within our protocols. 

Finally, we wish you a happy St. Patrick’s Day. If you do encounter these types of alcohol-related calls, be sure not to assume the cause is intoxication and miss other potential causes. Be sure to protect the patient’s airway. And be sure to stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

March 17, 2023

Dear colleagues:

Welcome to this week’s UH Pharmacy Phriday offering. In last week’s installment we reviewed oxygen, the #1 medication administered by UH squads in 2022. This week on Pharmacy Phriday we look at the #2 medication administered in 2022, Normal Saline (NS 0.9%). 

Fluid therapy is critical in the management of our patients. In the prehospital setting, that fluid therapy is most often accomplished using a crystalloid solution. Normal saline is a mainstay when one talks of crystalloid intravenous solutions commonly used.  It is an isotonic fluid consisting of sodium and chloride electrolytes that is administered as a bolus via large bore peripheral IV lines in cases of dehydration, hypovolemia, hemorrhage, sepsis, and other shock states. Normal Saline is also used to provide a route for the administration of lifesaving medications and is ran as a “to keep open” (TKO) infusion in these cases. Over the past years the TKO line has been replaced with the Saline lock. This is preferred for patients who do not need immediate medications or fluids. 

Boluses of Normal Saline 0.9% are typically weight based under UH protocols at 20ml/kg for the adult patient. Goals of administration would include the ability to maintain a MAP of >65, a systolic blood pressure >90, or the presence of radial pulses when BP measurement is not available. In the pediatric patient, boluses range from 10-20 ml/kg to a systolic pressure of 70 + 2X their age. 

As “normal” as Normal Saline may sound, it is a medication and is not without its side effects and even controversy! In the case of any fluid resuscitation, possible fluid overload is a concern, especially for patients with CHF, renal disease or insufficiency, and where peripheral edema is present. Other complications from NS fluid boluses can include metabolic alkalosis and electrolyte imbalances. In all patients, be sure to reassess vital signs and patient condition frequently, including signs of fluid overload such as dyspnea, abnormal lung sounds, jugular vein distention, ECG changes, etc.

Debates and clinical studies regarding the use of Normal Saline continue to be seen in the medical sciences. In one paper reviewing the use of NS, a “pearl” from the study concluded “One of the most significant issues from these studies is that the amount of IV fluid administered is likely more important that the specific type of fluid (i.e., worse outcomes with excess IV fluid).[1] This thought has been supported in recent CE offerings presented by UH Medical Directors and doctors. In the recent Geriatric trauma lecture, it was pointed out that the infusion of more than 1.5 liters of a crystalloid fluid is associated with increased mortality. And in a trauma lecture last year it was stressed that the trauma patient often needs a trauma center and blood products. 

Normal Saline and other crystalloids are administered to expand intravascular volume quickly, but they are not blood, nor do they provide the same benefits as blood or blood products. In fact, too much of a crystalloid administered in the shock state can lead to increased problems with acidosis and coagulopathy, two of the three factors in the “trauma triad of death”. As providers, we must be sure to be cautious with our administration of NS in the prehospital setting, monitoring the patient and limiting doses to meet the established parameters within our protocols. 

Finally, we wish you a Happy St. Patrick’s Day. Whether working and responding to some of the more interesting calls that can happen during the celebrations, or off duty and celebrating yourself, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals