Normal Saline

saline

I rank Normal Saline 6 out of the 33 drugs we carry.

When I started as a paramedic the goal for every major trauma patient was to have two large bore IVs running wide open. The mark of a stud paramedic was getting your shooting victim to the trauma room in world record time while also getting bilateral 14s on the way and showing up with the bags at least half empty. 2 14s meant nothing if you only ran in 100 cc in each. Of course, we eventually learned that while trying to stay ahead of the blood pressure curve, we were actually accelerating it by pushing oxygen carrying blood out of the leaky circulatory system with replacement water and harming the body’s ability to clot the holes.

I remember one shooting I responded to while backing up another medic. While he tried to intubate, I slammed a 14 into the AC and I never saw the fluid run like it did. It ran through the drip chamber like Niagra Falls. It seemed like in only a minute the bag was empty. It was then we noticed a spreading wet pinkish damp on the man’s tee-shirt near the arm pit. In addition to multiple torso wounds, he had also been shot in the upper humerous and the bullet had evidently severed the vein the fluid was running through as it gushed out of his shoulder as fast as it gushed into his AC. Another street fatality in that hot gang-fed summer.

Now, while all of my major trauma patients get two large bore IVs (if I have spare time and always enroute), instead of hanging IV bags, even at KVO, I just pop in locks. Locks have the added benefit of not getting snagged when we transfer the patient over to the trauma bed, causing the IVs to be torn out (How I hated that!).

So why is Saline on my Essential Eight list? It can still be a life-saving drug to support blood pressure and hydration, in addition to being a great comfort drug. Hypotensive septic patients get the large bore wide-open treatment. Patients in DKA get a liter over an hour, and more if they are also hypotensive. Syncopes with resulting hypotension get boluses until their pressure stabilizes. And all those dehydrated vomiting old ladies get nice fluid boluses.

Now I am not saying it is me, let’s say it is a paramedic friend I know. We’ll call him Ernie. Anytime Ernie gets the flu, he either gives himself or gets one of his partners to give him a bag of Saline IV over an hour. He is pretty adept at sticking himself – the hard part is holding pressure on the vein while he pulls the needle out and attaches the IV drip set to the remaining catheter. Ernie uses his chin. So sometimes he spills a little blood in the exchange, but not too much. Ernie feels so much better after awards. He is truly a new man, so Ernie likes to bolus his sick patients and when they say they are feeling better after the fluid, he knows what they mean. A little Zofran and some fluid, along with a gentle ride and some caring words and we are at the heart of what paramedicine is all about.

We also carry Lactaed Ringers, although as of the last year we are no longer required to carry it. There are subtle differences between Saline and Ringers (and those differences are subject to debate and MD preference), but perhaps not important enough for our transport times. I usually reach for the Saline.

We also use Saline (sometimes with Morgan Lenses) to flush chemicals out of eyes.

And while not a direct use of the drug, the outer packaging of Saline bags when wrapped around a flashlight makes an excellent lantern in dark rooms without working light bulbs.

***

Normal Saline (0.9% NaCl)

Class: Isotonic electrolyte

Action: Fluid and sodium replacement

Indications: IV access in emergency situations
Fluid replacement in hypovolemic states
Used as a diluent for IVPB medications

Contraindications: None for field use

Precaution: Fluid overload

Side Effect: Rare

Dose: Dependent upon patient condition and situation, TKO, fluid bolus, “wide open”

Route: IV infusion

Pediatric Dose: TKO or 20ml/kg bolus

5 Comments

  • Matt says:

    I don’t think that it matters a whole lot, but the rumor is that LR is better for flushing out eyes than saline.

    Also, I have a friend that tamponades his vein with is big toe. He used to start the line in his foot because then he could use both hands, but the veins are too small and squirrely. He always feels much better, too.

  • ICU Nurse says:

    In my part of the UK, we seem to be favouring Hartmann’s solution (similar to Lactated Ringer’s) for crystalloid fluid resuscitation. Saline is definitely very much out of vogue. I think this is due to the risk of precipitating a hyperchloraemic acidosis with large volumes, and also screwing up sodium concentration in the bloodstream.

  • medicscribe says:

    ICU Nurse-

    Interesting. Maybe Ringers will make a comeback here.

    -Peter

  • CBEMT says:

    We’re still required to carry it. The old school guys use it as their second line in trauma, and we all use it for major burn patients. It is also the fluid of choice in the morgan lens protocol.

    I also know that our OB/GYN hospital uses it pretty much exclusively.

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Peter Canning

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