What do you prefer - LR or NS?

[Hmac]

I'm a paramedic in NC. For the most part, 0.9% NS should be used for fluid replacement. Every ambulance in my county carries only NS. NS is good for rapid fluid replacement as well as maintenance fluid resuscitation.

LR on the other hand, should be used only in major trauma with significant blood loss, burns, or severe acidosis. LR is usually used for a short period of time because it is too high in sodium and too low in potassium compared to the homeostatic balance of the body. It can create an electrolyte imbalance if used for long periods of time (ie, more than 1000mL infused).

NS is good for treatment of dehydration if the Pt is unable to take in PO fluids fast enough or effectively enough.

In short, LR used for major trauma or burns. NS used for fluid resuscitation or maintenance fluid.

Source: Aehlert, Barbara, Paramedic Practice Today, Vol. 1

In a prehospital setting, the concern is volume expansion. Worrying about electrolytes is way down the list and rarely of any importance for the amount of time the patient is in the field. Just hang the NS and go on to the next problem.

[sleepdr]

Unless I'm dealing with head trauma, in which case I'll prefer NS, I often hang whatever falls into my hand first.


IMHO, the issues of electrolyte, lactate, and potassium are usually eclipsed by the overwhelming acidosis from hypovolemia in trauma. It's a useful academic exercise that doesn't always translate well into actual treatment processes. Saline alone in large enough volumes can lead to acidosis. BTW, the world also won't end if you run LR and blood together. Is it optimal, no, but I know anesthesia folks have given many thousands of gallons of blood mixed with LR.

[Iraq Ninja]

With that said, my superior here really shoves down our throats the idea of using LR. He is a South African medic.....and lets just say that I am a bit suspect of his claimed experiences with using LR over NS.

Would he happen to go by the nickname of Bear and currently working out of Camp Adder? If so, I know very well and he is good to go.

I carry NS and Hextend. We are only issued NS by our company, and the main reason is related to cost. We have to get our Hextend from the military units.

There seems to be more debate CONUS than OCONUS about stuff like this, and other techniques like wound packing and tourniquet application that we take for granted.

[Gutshot John]

I used what was at hand unless contraindicated by protocol. People get too wrapped around the axle on this I think.

While certain fluids might be preferred in certain circumstances, I agree with those that say this is much ado about nothing. With very very few exceptions, if you've got a serious traumatic injury, the fluid is the least of the patient's problems as it's unlikely to make that big of a difference in the outcome.

NS is probably more universally applicable but LR seemed to be more commonly used.

[chuckman]

In the pre-hospital environment it really doesn't make much difference. Even if you pour 10 liters into a patient, it likely won't change their outcome (if someone needs 10 liters they have bigger problems). In the ICU, however, you can see the manifestations of the acidosis of prolonged NS administration. As far as giving blood with LR vs NS, I have seen a few cases of blood gelling up in the blood tubing when given with LR (which was hung by accident). I think if you are slamming in blood it likely won't make much difference as well, like giving blood through a massive transfusion protocol.

This debate won't be settled by troglodytes like us, though.

[Chris@conditionred.us]

Gents,

Keeping warmth and permissable hypotension in mind, ATLS does not draw a hard line between LR and NS.

It does describe LR as the fluid of choice for burn resuscitation, as mentioned previously.

Additionally, Hextend, once again mentioned earlier, is the fluid of choice for hypovolemia secondary to hemmorhage. Unfortunately, $ dictates a lot of what we do. One liter of Hextend, is eqivalent to more than 7 liters of Normal Saline, as it has a greater affinity to remain intravascular. Unfortunately, at $80.00 per liter we dont see too much Hextend on the street.

http://www.hospira.com/Products/Hextend.aspx

Check out the link, as they afford us with a study pertaining to this topic.

The only item of consideration would be the use of the product in the presence of Rhabdomyolysis, "with caution" as provided by the manufacturer.

Hope this helps.
Be safe.

C-

[Decon]

Of course someone would have to bring up hetastarches

[e1harris]

In the field I use NS for all non-trauma. That saves my LR for burns and all other trauma. I hang Hextend if a Turniquet is in place.

[Hmac]

So, you civilian EMT-P's...are these fluid resuscitation choices left to you in the field, or are you working off a set of protocols that you are obliged to follow? I realize it varies from state to state, but I'm not aware of laws in the civilian world that allow roving bands of paramedics without physician supervision.

[NinjaMedic]

It depends on the medical director. Some are very very hesitent to allow you to deviate from the written protocols, others allow medics quite a bit of lattitude to use their judgement as long as they can articulate afterwards why they did what they did.