In Ottawa, pre-hospital care includes paramedics authorized to treat acute cardiogenic pulmonary edema in the setting of respiratory distress. Their treatment, sensibly, includes nitroglycerin. It also, insensibly, includes furosemide.
Decompensated heart failure, resulting in pulmonary edema and dyspnea, is indeed a sort of fluid overload. However, these patients frequently are not hypervolemic – they may be euvolemic or even hypovolemic, with other underlying etiologies for decompensation than fluid retention. This pushes the concept of a strategy for the treatment of acute cardiogenic pulmonary edema with furosemide even further down the nonsense pathway. Yet, there it is.
This study, a retrospective review of presentations with pre-hospital furosemide administration and hospital diagnoses of acute decompensated heart failure, demonstrates essentially nothing. The primary outcome was designed to detect serious adverse outcomes associated with furosemide administration, but their comparison groups – furosemide given to heart failure, furosemide given to misdiagnosed heart failure, and furosemide not given to heart failure – are clinically heterogeneous and require probably meaningless adjusted comparisons. The authors find no significant difference, but this is simply a matter of sample size and study design – a treatment given to a group with no chance of benefit obviously suffers only harms.
Most damning, however, is the utter failure of pre-hospital providers to correctly diagnose heart failure. Of the 272 cases of heart failure diagnosed on arrival to the ED, pre-hospital providers made the diagnosis in only 110 instances. Then, pre-hospital providers incorrectly diagnosed an additional 58 cases with heart failure and administered furosemide – when the patient was diagnosed with pneumonia, COPD, or another alternative.
Just say no.
“Prehospital use of furosemide for the treatment of heart failure”