Prehospital use of furosemide for the treatment of heart failure

Pan, Andy; Stiell, Ian G.; Dionne, Richard; Maloney, Justin

doi:10.1136/emermed-2013-202874

Cited by 6 publications

(6 citation statements)

References 26 publications

(16 reference statements)

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“…Pan et al studied 330 patients and also found that AHF was difficult to diagnose in the prehospital setting. Additionally, they found that 49% of patients with AHF were not treated with furosemide, and greater than one-third of patients given furosemide in the prehospital setting were found not to have AHF [ 11 ]. In a retrospective study from the Helsinki metropolitan area on 100 patients transported by EMS, the use of prehospital medications was low, with only one-third of patients receiving therapy before hospital arrival [ 12 ].…”

Section: Discussionmentioning

confidence: 99%

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Prehospital Diagnosis and Treatment of Patients With Acute Heart Failure

Supples¹,

Jelden²,

Pallansch³

et al. 2022

Cureus

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Introduction Early diagnosis and optimization of heart failure therapies in patients with acute heart failure (AHF), including in the prehospital setting, is crucial to improving outcomes. However, making the diagnosis of AHF in the prehospital setting is difficult. The goal of this study was to evaluate the accuracy of prehospital diagnosis (AHF versus not heart failure [HF]) in patients with acute dyspnea when compared to final hospital diagnosis. Methods We conducted a retrospective study of adult patients transported by emergency medical services (EMS) with a primary or secondary complaint of shortness of breath. Patients were identified through an EMS electronic database (ESO) and matched to their hospital encounter. ESO was reviewed for prehospital diagnosis and management. Hospital electronic medical records were reviewed to determine final hospital diagnosis, management in the emergency department and hospital, disposition, and length of stay. The primary outcome compared prehospital diagnosis to final hospital diagnosis, which served as our criterion standard. Results Of 199 included patients, 50 (25%) had a final diagnosis of AHF. Prehospital paramedic sensitivity and accuracy for AHF were 14% (7/50; confidence interval [CI] 0.06-0.26) and 77% (CI 0.70-0.82), respectively. In the 50 patients with AHF, 14 (28%) received nitroglycerin in the prehospital setting, while 27 (54.0%) patients were inappropriately treated with albuterol. Conclusion Prehospital paramedics had poor sensitivity and moderate accuracy for the diagnosis of AHF. A small percentage of patients ultimately diagnosed with AHF had HF therapy initiated in the prehospital setting. This data highlights the fact that AHF is difficult to diagnose in the prehospital setting and is commonly missed.

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Section: Discussionmentioning

confidence: 99%

“…Prior studies examining prehospital diagnosis of AHF in patients with a chief complaint of dyspnea have found it to be challenging to make a diagnosis of AHF [ 10 , 11 ]. Other data have shown administration of HF therapies in the prehospital setting to patients with AHF is low [ 11 , 12 ].…”

Section: Introductionmentioning

confidence: 99%

Prehospital Diagnosis and Treatment of Patients With Acute Heart Failure

Supples¹,

Jelden²,

Pallansch³

et al. 2022

Cureus

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“…6 A recent Canadian publication showed similar inability of paramedics to discriminate between APE and COPD: only 40% of confirmed APE patients received furosemide, while over 34% of the patients who received furosemide did not have APE. 7 As another example: the successful use of dobutamine in post-operative cardiac surgery patients in cardiogenic shock may not translate to the management of a cardiogenic shock patient in the field. The post-operative population is not representative of cardiogenic shock patients who call 911, advanced hemodynamic monitoring (arterial lines, central venous pressure) is not available in the field, paramedics may lack foundational knowledge in cardiopulmonary failure, and ambulances are not usually equipped with medication pumps.…”

Section: Ems: Translation Challengesmentioning

confidence: 99%

Applying Hospital Evidence to Paramedicine: Issues of Indirectness, Validity and Knowledge Translation

Bigham

Welsford

2015

CJEM

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The practice of emergency medicine (EM) has been intertwined with emergency medical services (EMS) for more than 40 years. In this commentary, we explore the practice of translating hospital based evidence into the prehospital setting. We will challenge both EMS and EM dogmabringing hospital care to patients in the field is not always better. In providing examples of therapies championed in hospitals that have failed to translate into the field, we will discuss the unique prehospital environment, and why evidence from the hospital setting cannot necessarily be translated to the prehospital field. Paramedicine is maturing so that the capability now exists to conduct practice-specific research that can inform best practices. Before translation from the hospital environment is implemented, evidence must be evaluated by people with expertise in three domains: critical appraisal, EM, and EMS. Scientific evidence should be assessed for: quality and bias; directness, generalizability, and validity to the EMS population; effect size and anticipated benefit from prehospital application; feasibility (including economic evaluation, human resource availability in the mobile environment); and patient and provider safety. RÉSUMÉLa pratique de la médecine d'urgence (MU) est étroitement liée aux services médicaux d'urgence (SMU) depuis plus d'une quarantaine d'années. Aussi les auteurs traitent-ils, dans le présent article, du transfert des données probantes, du milieu hospitalier au milieu préhospitalier. Sera remis en question un dogme admis tant par la MU que par les SMU; en effet, le transfert, sur le terrain, des pratiques en milieu hospitalier n'est pas toujours la meilleure solution. Il sera question, à l'aide d'exemples de traitements préconisés dans les hôpitaux qui se sont soldés par des échecs sur le terrain, du caractère propre du milieu préhospitalier et des raisons pour lesquelles l'application directe des données probantes, recueillies en milieu hospitalier ne convient pas nécessairement au milieu préhospitalier. Les secours paramédicaux sont une discipline en évolution, si bien que la capacité de recherche sur la pratique est suffisamment importante pour jeter une lumière nouvelle sur les pratiques exemplaires. Avant d'envisager l'application des connaissances recueillies en milieu hospitalier, il faut que les données probantes à l'appui soient évaluées par des experts dans trois domaines: l'évaluation critique, la MU et les SMU. Les données probantes de scientifiques devrait faire l'objet d'examen à l'égard: de la qualité et des biais; de l'application directe des données dans la population visée par les SMU ainsi que de leur généralisabilité et de leur validité; de l'ampleur de l'effet et des avantages prévisibles de l'application préhospitalière de ces pratiques; de la faisabilité (y compris l'évaluation économique et la suffisance des ressources humaines dans un environnement mobile); et finalement de la sécurité tant des patients que des fournisseurs de soins.

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“…11,12 However, the administration of pre-hospital medication seems scarce. 3,4,13,14 Moreover, earlier studies suggest that it might be difficult for EMS personnel to differentiate AHF from other underlying causes of dyspnoea [14][15][16][17] especially when the diagnosis is based only on patient's medical history and clinical signs and symptoms. 18,19 Illustrative data on the possibilities of EMS to treat and diagnose AHF in the pre-hospital setting in accordance with the guidelines are scarce.…”

Section: Introductionmentioning

confidence: 99%

“…However, the administration of pre‐hospital medication seems scarce . Moreover, earlier studies suggest that it might be difficult for EMS personnel to differentiate AHF from other underlying causes of dyspnoea especially when the diagnosis is based only on patient's medical history and clinical signs and symptoms …”

Section: Introductionmentioning

confidence: 99%

Pre‐hospital management protocols and perceived difficulty in diagnosing acute heart failure

Miró

Martín‐Sánchez

et al. 2019

ESC Heart Failure

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Aim To illustrate the pre‐hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre‐hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre‐hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point‐of‐care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST‐elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12‐lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point‐of‐care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non‐invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST‐elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre‐hospital conditions.

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Prehospital use of furosemide for the treatment of heart failure

Cited by 6 publications

References 26 publications

Prehospital Diagnosis and Treatment of Patients With Acute Heart Failure

Prehospital Diagnosis and Treatment of Patients With Acute Heart Failure

Applying Hospital Evidence to Paramedicine: Issues of Indirectness, Validity and Knowledge Translation

Pre‐hospital management protocols and perceived difficulty in diagnosing acute heart failure

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