Acute decompensated CHF is something we see on almost every shift in the ED. Presuming the patient is not hypotensive, more than likely that patient will be receiving IV Lasix. When I was a resident, I was taught that if the patient is on Lasix at home, find out their home dosage and just give that IV. At SGH, it seems that many residents will find out the home dosage, double it, and give that dosage IV. So, I went on a quest to figure out if there are actually any reasonable, evidence-based recommendations on the subject.

My first stop was EBMedicine.net, which has a large library of evidence-based medicine articles on a variety of topics; you guys have access to all of this material. Having written an article for this publication, I can verify that these articles are well-researched and heavily peer reviewed and edited. So I found an article from 2014 called “Current Guidelines for the Evaluation and Management of Heart Failure”. Here is their recommendation regarding IV Lasix usage in acute decompensated CHF: “If patients are already receiving loop diuretic therapy, the initial IV dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or as a continuous infusion. Urine output and signs and symptoms of congestion should be serially assessed, and the diuretic dose should be adjusted accordingly to relieve symptoms, reduce volume excess, and avoid hypotension.”  (ACCF/AHA, Class I, Level B).

There are a couple of interesting things here. First is that the initial IV dose of Lasix should be at least as much as the patient’s DAILY dose, meaning if they are on 40mg BID, we should give 80mg IV. The other interesting thing is that they do not really specify if we should be giving more than this or not. The editor made this comment regarding dosage: “The ESC guideline does not specify dosing, noting the lack of good evidence for the use of high-dose over low-dose loop diuretics and tradeoffs that include transiently worsened renal function.”

Ok, so there’s no firm recommendation over what dosage should be used, other than it should be at least as much as the daily home dosage. So then I went to the AHA’s website and found a great article that addressed this exact question. This is what they had to say: “In a retrospective analysis, Butler et al²² identified higher loop diuretic dosage as an independent predictor of worsening renal function in ADHF even after controlling for disease severity and the degree of diuresis…however, it may be impossible to completely adjust for other confounders of disease severity that could effect both diuretics requirements and the risk of worsening renal function. Thus, it remains unknown whether higher diuretic requirement are simply a marker for higher risk or whether higher doses of loop diuretics contribute directly to the development of the cardio-renal syndrome in patients with ADHF.”

Then they give this graph, essentially stating that the more Lasix someone is given, the higher the mortality. Of course, the confounding factor here is that sicker people are probably given more Lasix, but here it is:

So, unfortunately, I think that all we can reliably conclude is to verify the patient’s home dosage, and give the total daily home dosage, or more, IV. I think what I will do is find out their daily home dosage, give that, then reassess the patient and give more if necessary. But it’s not wrong to find out their daily dosage and double it, so you will need to develop your own practice habits and talk to other attendings about this and get their opinions. I welcome and encourage any comments!

Dr Duhe and I had a case last night, very straightforward. A kid burned the top of his foot with some hot water. He had some blistering over his MTP joints causing him pain. Dr Duhe wanted to send him home with pain control, I had always been taught that the blisters need to be debrided. I’m the attending, so I won and the blisters were debrided (Dr Duhe used the scissors in the suture kit and cut the dead skin overlying the blister), Silvadene was applied, the foot was bandaged and the kid was sent on his way.

This of course brought about a debate of whether burn blisters need to be debrided or not. I did a PubMed search and the first source I found that looked useful was a consensus statement from the American Burn Association, released in 2012. They stated: “Among the most direct and effective interventions for reduction of risks from cutaneous burns is removal of the burn eschar. Devitalized skin is a rich medium for microbial growth, and also is known to promote inflammation by release of cytokines and growth factors from injured or lysed skin cells. Consequently, practices for care of burn wounds have favored early and complete removal of the burn eschar.” So I thought, “cool, I win!”, except that I’m not sure that a blister is an eschar so I’m not really sure that they are advocated for popping the blister and removing the dead tissue. So the lit search continued.

To make a long story short, I ended up finding an EM Practice article that gave a class IIa recommendation to leave the blister intact. Hmm, I lose. Then, I went to Wikipedia, the ultimate source for all medical information. They state “it is not clear” what to do with intact blisters. So we both win. Then they recommend AGAINST using Silvadene! Now my world has been turned upside down. I will need to investigate this recommendation against Silvadene next.

So, at the end of the day, there is no clear answer as to what to do with intact burn blisters. Do whatever you want. Probably leaving them intact and applying a dressing is the quickest and easiest thing to do. But the real overriding message here is not everything that you are learning on-the-job is necessarily the right thing to do. I was taught that debriding a burn blister was, without question, the right thing to do. This was from a pediatric surgeon that used to run the burn unit at Children’s. Not that he’s wrong, but it’s important to know that a doctor’s opinion is not the same as fact, and new evidence is emerging all of the time, so you have to stay on top of your stuff. You have to be curious and research things on your own and form your own informed opinion. When I work with you guys, I try to make sure you are aware of certain things that you do that are “Sinai-Grace”-ish and not necessarily how things are done at other hospitals. More than a few of you have been on the receiving end of my rants against routinely ordering a BNP on patients with CHF. There are a lot of ways to practice medicine, and you need to form your own opinions based on a myriad of information thrown at you. Look things up, ask questions, and try to picture how you will handle certain patients and situations because in a few short years (or months), it’s all up to you!