# Oxygen in advanced care



## usalsfyre (Sep 25, 2010)

I am fortunate to work in a system that only specifies O2 administration in cases of hypoxia which can be reversed by O2 administration (chiefly, hypoxic hypoxia). The result of this is that I only put around 10% (maybe less) of my patients on supplemental O2. 

I still however, see my colleagues placing nearly everyone on at least a minimum of 2L by NC, and often a NRB when there is no complaint of SOB and no clinical signs of reversible hypoxia. The reasoning behind this is "we've always done it this way". 

So I submit to the forum. How many of you routinely use oxygen on your patients outside of the setting of hypoxic hypoxia?


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## MrBrown (Sep 25, 2010)

The good old ambo trick of more is better does not apply here oxygen is a drug and hyperoxia can lead to free radical/reperfusion injury, cereberal and arteriole hypoxaemia due to vasoconstriction and other funky things

Not everybody needs fifteen litres of oxygen crammed down thier gob and Brown praises Jeebus that somebody on your side of the Pacific seems to get that!


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## JPINFV (Sep 25, 2010)

If I think hypoxia might play a role or help, I'll start the patient on a nasal cannula, however rarely a non-rebreather (basically, unless there's some sort of respiratory distress or worse).


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## Akulahawk (Sep 25, 2010)

I'm in the same camp as JPINFV. If there's a condition that supplemental O2 can help... I'll provide that drug. Most of my patients never got additional O2.


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## lightsandsirens5 (Sep 25, 2010)

MrBrown said:


> Not everybody needs fifteen litres of oxygen crammed down thier gob and Brown praises Jeebus that somebody on your side of the Pacific seems to get that!



I get it!!!! But no one in my county will listen to me! I am getting tired of trying to change peoples minds.

Here is an idea I have been batting around with myself. If you try to keep people at a mid 90s sat, you aren't really hyper-oxygenating them, are you? Correct me if I'm wrong. 

I unfortunately had to vote that most of my patients get it even if they don't look like they need it. I only do that because that is what my protocols say, that is what my SEI demands and the hospital will yell at us if we don't bring most everyone in on high con O2. (Ok, some of the staff will. A few agree with me.)


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## Aidey (Sep 26, 2010)

I try to be judicious in my use of O2, and I tend not to use a lot of it.

I can probably count on both hands how many times I've used a NRB in the last year. That excludes using a mask to hold a neb. Unless there are signs of severe hypoxia I stick to a cannula if I'm giving oxygen. I really like the ETCO2 cannulas, and use them on a lot of pts with a respiratory complaint. There are also times I will use the CO2 cannula without hooking it up to O2, like in some hyperventilating pts.


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## LucidResq (Sep 26, 2010)

Of course,  hypoxic patients. 

Anxious patients who _think_ they are hypoxic and benefit from the placebo effect too.


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## CAOX3 (Sep 26, 2010)

We don't even carry oxygen anymore.

My partner just blows in the tubing.

Why is this in the ALS section?

When it benefits the patient, maybe once a shift.


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## MasterIntubator (Sep 26, 2010)

Oxygen is over-rated.


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## usalsfyre (Sep 26, 2010)

MasterIntubator said:


> Oxygen is over-rated.



Exactly the point I've reached. 

The reason this is in the advanced forum is I would prefer to get opinons from folks who should be able to corectly interpret if a pt needs O2. This is not something I'm convinced the current EMT-B curriculm is preparing folks for.


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## CAOX3 (Sep 26, 2010)

I don't have any idea what they teach in EMT classes nowadays but when I took my class, the entirety of the program was assessment based, treat the patient not the complaint.  Today I believe providers just need to feel and look busy, they assume when a patient dials 911 they must need some form of intervention.  If all they need is a ride that's s what they get, if after assessment I feel they need oxygen then they will receive it.  I treat oxygen like any other medication you get it when its warranted.


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## lightsandsirens5 (Sep 26, 2010)

CAOX3 said:


> I don't have any idea what they teach in EMT classes nowadays but when I took my class, the entirety of the program was assessment based, treat the patient not the complaint.  Today I believe providers just need to feel and look busy, they assume when a patient dials 911 they must need some form of intervention.  If all they need is a ride that's s what they get, if after assessment I feel they need oxygen then they will receive it.  I treat oxygen like any other medication you get it when its warranted.



What they are teaching around here is that stinking everyone gets O2. I was taught in my basic class that I could give everyone 15 liters by NRB. No questions asked. I totally disagree with that, and I don't give every pt a mask, but I am "forced" to give 90% of my pts O2. 

And in reference to your assessment bases pt care comment, that is what is so funny. Over and over and over again during my basic class and in all the ones I have helped teach the underlying theme is "treat the patient, not the machine. Treat the pt, not the scene. Treat the pt......etc." Yet in my basic class, we were taught that since we are with the pts for a short time (no more than 90-120 minutes) that hi flow O2 won't hurt. Again, I disagree, but like I said earlier, it is like beating my head against a wall to get people to even entertain the thought that I could be right. And I dunno why.


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## Shishkabob (Sep 26, 2010)

Only patients who might benefit from a little extra oxygen, such as decreased SpO2 or active MIs.


Vast majority of my patients don't get oxygen from me, and of those that do, 99% get a NC.  I hardly ever use a mask.


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## medicRob (Sep 26, 2010)

Oxygen is a drug, I don't enable junkies. Plus, im too busy texting pictures of the patient to my friends and shooting up narcs from the drug box to be worried about all that perfusion mumbo jumbo. 


J/k Actually, I administer oxygen on a case by case basis. If I feel the patient needs it (example: Chest pain with shortness of breath), I'll throw it on. Sometimes I will throw them on a cannula if I don't feel oxygen is truly warranted but still want to give them supplemental 02.


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## LonghornMedic (Sep 26, 2010)

What the hell is wrong with you guys. Once I get the patient in the back, I duct tape around the doors and open up all the flow meter valves to 25lpm. Call it a mobile oxygen tent. While we're en route to the ER, my partner chain smokes up front while driving. That shouldn't be a problem, should it?


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## Shishkabob (Sep 26, 2010)

As long as you don't attempt to defibrillate, you should be fine.


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## MrBrown (Sep 26, 2010)

Heck a few ambo's around here chain smoke anyway ....


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## emt_irl (Sep 26, 2010)

cant remember the last time i used o2 on a patient,was a few months ago id say.(just because your taking a trip in my ambulance doesnt mean your gettin o2.... come on it doesnt grow on tree's??? hahaha ) ive seen alot of crews though stick on 15lpm to the smallest of things like a sore toe or finger.

my clinical practice guidlines state spo2 below 97%(92% in copd patients) resp distress or resp arrest and an ami

it says in a few other guidlines in the book consider o2, its at our discresion if or when needed


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## Smash (Sep 26, 2010)

Linuss said:


> Only patients who might benefit from a little extra oxygen, such as... active MIs.



http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007160/frame.html


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## Veneficus (Sep 26, 2010)

Linuss said:


> Only patients who might benefit from a little extra oxygen, such as decreased SpO2 or active MIs.




Intending absolutely no offense or smartass comment. 

Logically, if the blood goes through the pulmonary circuit to the left ventrical, said ventrical contracts sending blood into the aorta, which during diastole back fills into the coronary arteries, how does the oxygenated blood get from the proximal end of the aertery through the thrombus/embolis, and to the distal part of the artery and capilay beds?

Unless there is some other disorder, there should be no problem with heme saturation until methylation or coboxy haemaglobin from pump failure, or an increase in PH. 

Correcting even the pH will not push oxygen past a clot.


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## MasterIntubator (Sep 26, 2010)

Whoa.... didn't see that one coming....  interesting ( The MI study... )


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## MrBrown (Sep 26, 2010)

You know, I wonder if Veneficus has been on that strange Japanese game show called Ninja Warrior .....


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## JPINFV (Sep 26, 2010)

Veneficus said:


> Intending absolutely no offense or smartass comment.
> 
> Logically, if the blood goes through the pulmonary circuit to the left ventrical, said ventrical contracts sending blood into the aorta, which during diastole back fills into the coronary arteries, how does the oxygenated blood get from the proximal end of the aertery through the thrombus/embolis, and to the distal part of the artery and capilay beds?
> 
> ...



In the words of the RN who taught the only EMT refresher I will ever attend said, "That science is too advanced for EMS."


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## Veneficus (Sep 26, 2010)

JPINFV said:


> In the words of the RN who taught the only EMT refresher I will ever attend said, "That science is too advanced for EMS."



Shhhh! I am trying to help...

Actually MrBrown, I have a paper that says I am a ninja. 

Dr.Tetsuya Higuchi signed it for me.


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## MrBrown (Sep 26, 2010)

Veneficus said:


> Logically, if the blood goes through the pulmonary circuit to the left ventrical, said ventrical contracts sending blood into the aorta, which during diastole back fills into the coronary arteries, how does the oxygenated blood get from the proximal end of the aertery through the thrombus/embolis, and to the distal part of the artery and capilay beds?
> 
> Unless there is some other disorder, there should be no problem with heme saturation until methylation or coboxy haemaglobin from pump failure, or an increase in PH.
> 
> Correcting even the pH will not push oxygen past a clot.



Brown is gobsmacked!

That makes absolutely 100% certified natural, organic, pesticide, carconogen, additive, synthetic bovine growth hormone and artifical colour, sweetner and preservitive free sense!

Although most of those things were probably in the food you ate that caused your heart attack in the first place but sssssh Monsanto doesn't want you to know that


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## Veneficus (Sep 26, 2010)

MrBrown said:


> Brown is gobsmacked!
> 
> That makes absolutely 100% certified natural, organic, pesticide, carconogen, additive, synthetic bovine growth hormone and artifical colour, sweetner and preservitive free sense!
> 
> Although most of those things were probably in the food you ate that caused your heart attack in the first place but sssssh Monsanto doesn't want you to know that



Shhhhh!

I just stayed at a holiday inn express last night.


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## MrBrown (Sep 26, 2010)

Veneficus said:


> Shhhhh!
> 
> I just stayed at a holiday inn express last night.



So it was you who kept me up all night with your goings-on! 

Check out this PowerPoint by Dr Bledsoe on the subject of oxygen toxicity


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## Aidey (Sep 26, 2010)

Just to play devil's advocate here, what if the pt doesn't have a complete blockage and a small amount of blood is getting through? Would it not be possibly beneficial to have that small amount of blood be hyperoxygenated? Not talking about 15 lpm via mask, but a cannula with a couple lpm. 

I understand how more O2 does nada if it can't get past an embolism, and that too much oxygen can be bad, I'm just doing the "what if" thing.


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## MrBrown (Sep 26, 2010)

Aidey said:


> Just to play devil's advocate here, what if the pt doesn't have a complete blockage and a small amount of blood is getting through? Would it not be possibly beneficial to have that small amount of blood be hyperoxygenated? Not talking about 15 lpm via mask, but a cannula with a couple lpm.
> 
> I understand how more O2 does nada if it can't get past an embolism, and that too much oxygen can be bad, I'm just doing the "what if" thing.



The problem is the amount of blood getting past the embolus to the myocardium, not the amount of oxygen in the haemoglobin of said blood.

Shoving more oxygen down this guy's gob doesn't mean it's going to bind to the haemoglobin and sneak past the clot the way Brown snuck back into bed after him and that Ninja fellow went out partying without waking Mrs Brown .... remember the oxyhaemoglobin dissassociation curve, once the Hb is fully oxygenated more oxygen is not going to do any good.


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## Cawolf86 (Sep 27, 2010)

It is sort of a shame in my county - the schools teach to only apply oxygen for patients who are hypoxic or have increased oxygen demands, and mostly by NC. But the protocols for the area all state that general ALS should apply oxygen and the preferred method is by NRB. So most patients going to the hospital here will be on 15 by mask - regardless of whether it was indicated.


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## usalsfyre (Sep 27, 2010)

Aidey said:


> Just to play devil's advocate here, what if the pt doesn't have a complete blockage and a small amount of blood is getting through? Would it not be possibly beneficial to have that small amount of blood be hyperoxygenated? Not talking about 15 lpm via mask, but a cannula with a couple lpm.
> 
> I understand how more O2 does nada if it can't get past an embolism, and that too much oxygen can be bad, I'm just doing the "what if" thing.



Diffusion of oxygen from the blood into cell is caused by two things, plasma oxygen concentration (driving pressure) and time in contact with the cell.  Oxygen is diffused into the cell out of blood plasma, not directly off the hemoglobin. So even with fully saturated hemoglobin you could theoretically increase driving pressure by hyperoxygenating a pt (ever heard of an AGB with a pO2 of >500mmHG? I did that to a patient early in my paramedic career).  In reality, it does not move O2 into the cells any more effectively than O2 with a normal pO2 does. 

These folk need a wire run over the lesion and a balloon inflated in the cath lab and/or CABG surgery. Anything you do before that is simply trying to support perfusion elsewhere and keep the infarct from extending. So it makes sense to focus on interventions that are proven to work, which right now includes only ASA and beta blockers in tachycardic and hypertensive patients.


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## lampnyter (Sep 27, 2010)

im only an EMT and im sure you all know this but they teach and emphasize "All patients get oxygen, they have a stubbed toe, put them on oxygen" I think oxygen is helpful in patients who are clearly having trouble breathing but i also think it relaxes many patients cause they think they are breathing better even if they arent having any trouble breathing.


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## Veneficus (Sep 27, 2010)

lampnyter said:


> im only an EMT and im sure you all know this but they teach and emphasize "All patients get oxygen, they have a stubbed toe, put them on oxygen" I think oxygen is helpful in patients who are clearly having trouble breathing but i also think it relaxes many patients cause they think they are breathing better even if they arent having any trouble breathing.



So does alcohol, but we don't hand that out like candy.


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## Shishkabob (Sep 27, 2010)

I hand morphine out like candy....


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## Akulahawk (Sep 27, 2010)

I hand out candy like candy... when I have candy... come to think about it, where is mine?


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## the_negro_puppy (Sep 27, 2010)

I think teaching oxygen is for everything is archaic, wasteful and possibly even harmful.


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## medicRob (Sep 27, 2010)

Linuss said:


> I hand morphine out like candy....



Trade you some fentanyl for a little bit of morphine..


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## JPINFV (Sep 27, 2010)

Akulahawk said:


> I hand out candy like candy... when I have candy... come to think about it, where is mine?



Is this your van?


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## usalsfyre (Sep 27, 2010)

Linuss said:


> I hand morphine out like candy....



What's funny is that on an average day more of my patients get Fentanyl than oxygen...


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## Shishkabob (Sep 27, 2010)

I honestly do give more morphine than oxygen to my patients. 

I've probably put 3 people on oxygen in the past 2 months...all sob.


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## Aussieaid (Sep 27, 2010)

Hmmm, interesting thread.   I agree that sometimes you can have too much of a good thing but in other circumstances a patient may look like they are fine but really at a cellular level they aren't.  I think it requires a solid knowledge base and thinking skills to know when and how much oxygen to use.  Unfortunately it seems like most protocols subscribe to the all or nothing theories to account for the lowest common denominators.

There is growing evidence that O2 can be harmful in simple MIs as well as newborns (especially premature) and some cardiac defects.  In MIs hyperoxia is known to increase coronary artery tone which can lead to decreased coronary artery blood flow.  It also causes a decreased cardiac output and stroke volume.  Not to mention the damage from free radical production. Of course if the pt has cardiogenic shock, CHF or other complicating factors they are going to need that extra oxygen.

On the other hand there are 4 types of hypoxia not just hypoxic hypoxia:  _Hypoxic hypoxia_ where there is decreased oxygen in the air or an inability for it to diffuse across the lungs (most common type).  Eg: lung disease, altitude.
_Hypemic hypoxia_ where there is a reduction in the oxygen carrying capacity of the blood.  Eg: anemia, bleeding, CO poisoning
_Stagnant hypoxia_ (or distributive) where there is reduced cardiac output. Eg. CHF, hypovolemia, arterial stenosis.
_Histotoxic hypoxia_ is where the O2 is available but the cells can't "take"  or use the O2 from the blood. Eg: cyanide poisoning.

What this is leading to is that even though a pt's pulse oximeter reading is giving you a "good" number that may not equate to adequate oxygenation of the patient.  Someone with CO poisoning may have a great SpO2 number and still be extremely hypoxic as the oximeter is actually reading the carboxyhemoglobin as oxyhemoglobin.  You also have to lose a significant amount of blood sometimes before it is reflected in your pulse oximeter reading.  One of the first signs of hypoxia is often agitation before you start seeing significantly decreased numbers.  In some pts they need the extra oxygen for increased metabolic oxygen demands such as in sepsis or fevers.

So, yes you can do harm with oxygen but you can also do significant harm by withholding it when it is warranted even without significant signs of hypoxia.  In other words you need to use sound clinical judgment before just withholding it on the majority of pts or giving it to everyone. 

Sorry I got a little carried away and rambled a bit. :blush:


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## JPINFV (Sep 27, 2010)

However, outside of hypoxic hypoxia, most of those (there's an argument for CO poisoning and higher FiO2 being able to bump the CO off) are not going to be helped by increased FiO2. For example, what good is O2 in the capillary if the cell can't utilize it because of cyanide?


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## usalsfyre (Sep 27, 2010)

JPINFV beat me to it. None of the other forms of hypoxia (with the possible exception of CO poisoning) respond particularly well to supplemental O2 alone. Stagnant hypoxias generally need inotropes and/or pressors, hypemic hypoxias blood and histotoxic hypoxias antidotes. None of which supplemental O2 provides. 

What is important is to be able to distinguish the differing types of hypoxia, and initiate the appropriate treatment.


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## Amycus (Sep 27, 2010)

usalsfyre said:


> Exactly the point I've reached.
> 
> The reason this is in the advanced forum is I would prefer to get opinons from folks who should be able to corectly interpret if a pt needs O2. This is not something I'm convinced the current EMT-B curriculm is preparing folks for.



On my first day, we had a patient with shortness of breath. Immediately I went for the NRB, and my training officer laughed so hard. From there I found out that 2-4LPM by a cannula is common practice and even then, rarely necessary


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## DrParasite (Sep 28, 2010)

As a simple bandaid provider, I think this thread shows quite a few things:

1) the majority of the providers on here don't see that many sick patients
2) the majority of the ALS providers on here don't see that many sick patients.
3) the majority of the people on here don't like using a NRB, and even more don't like giving oxygen at all, despite some educators teaching that sick patients should get high flow oxygen (despite if its needed or not).

Most patients don't need oxygen via a NRB at 15lpm (despite what some protocols push for, high flow oxygen on any sick or injured patient).

However, the fact that many medics on here say they put oxygen on only 3 patients in the past month?  I mean, do you not give oxygen to cardiac arrest patients?  I know my area is probably the asthma (and TB also) capital of the US, but do you not give oxygen to asthma patients?  What about major traumas (penetrating or multi-system trauma patients), do you not give oxygen to them?  what about cardiac patients?

Now, either you don't give oxygen to those patients (which I doubt), or you don't get those types of calls that frequently (which scares me, since if a medic doesn't see sick patients, their skills deteriorate).  So if you are only a BLS provider, I can see you dealing with non-sick patients.  But if you are an ALS, and you don't deal with sick people, well, I guess it's sad to say that my BLS coworkers deal with more sick patients than you do.


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## Aidey (Sep 28, 2010)

*raises hand*

In the last 30 days I have not had 3 asthma, major trauma and cardiac arrest patients combined. 

But only becuase I haven't had an asthma patient, oddly enough. I had a way major trauma (who did get a mask) and a unwitnessed, unknown down time ROSC (who was intubated).


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## usalsfyre (Sep 28, 2010)

Just because work has been call free for 24hrs, I'll bite. 



DrParasite said:


> However, the fact that many medics on here say they put oxygen on only 3 patients in the past month?  I mean, do you not give oxygen to cardiac arrest patients?  I know my area is probably the asthma (and TB also) capital of the US, but do you not give oxygen to asthma patients?  What about major traumas (penetrating or multi-system trauma patients), do you not give oxygen to them?  what about cardiac patients?



Let's discuss each call type. I have seen all 4 in the last 30 days.

1. My cardiac arrest patients get O2, pretty much because I don't have a choice. However, with the exception of hypoxic arrest (mostly pediatric arrest) what help does O2 provide? The primar reason pt's arrest out of the hospital is AMI, see our previous discussion regarding getting O2 to the distal end of a blocked artery. Pedi codes are different, but I bet most providers on here can count on their fingers the number of those they've run. 

2. My asthma pts get O2 as a delivery device mainly. Oxygen is required to run the nebulizer. Oxygen by itself can not break bronchospasm. Bronchodilators and steroids do that. If their hypoxic then sure, give them O2. Most of your asthma patiets that are hypoxic are going to require a lot more than a 2L out of a NC though. Generally by the time their hypoxic, their CO2 is through the roof, CPAP and/or intubation is a better choice. If it's just a run of the mill asthma attack, no O2 once the neb is done. 

3. My major traumas get no O2 or 2l via NC unless hypoxia or other respiratory comprimise is noted. 

4. See the above discussion about oxygen in AMI. CHF pt's get O2, but their usually slightly hypoxic. I usually give them either 2L or CPAP.



> Now, either you don't give oxygen to those patients (which I doubt), or you don't get those types of calls that frequently (which scares me, since if a medic doesn't see sick patients, their skills deteriorate).  So if you are only a BLS provider, I can see you dealing with non-sick patients.  But if you are an ALS, and you don't deal with sick people, well, I guess it's sad to say that my BLS coworkers deal with more sick patients than you do.




Like I just said, I see these people regularly. Many of them I don't put on O2. I'm not breaking protocol either.

Let's discuss who I do put on O2. 

1. Hypoxic people

2. People who I suspect might get hypoxic, including boderline pt's I administer sedating medications to; people who I'm about to RSI; pt's with severe respiratory comprimise who just haven't swung over to hypoxia yet; ect. 

That's it, notice there is nothing about mechanisim of injury or specific disease process. Q: What's the only drug you can administer to levels FAR above it's theraputic range and it be considered "good patient care"? A: Oxygen! Any other drug it's an overdose.


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## Aidey (Sep 28, 2010)

usalsfyre said:


> 2. My asthma pts get O2 as a delivery device mainly. Oxygen is required to run the nebulizer. Oxygen by itself can not break bronchospasm. Bronchodilators and steroids do that. If their hypoxic then sure, give them O2. Most of your asthma patiets that are hypoxic are going to require a lot more than a 2L out of a NC though. Generally by the time their hypoxic, their CO2 is through the roof, CPAP and/or intubation is a better choice. If it's just a run of the mill asthma attack, no O2 once the neb is done.



Good point. How many asthmatics do home nebulizers using an air compressor. Its the drugs not the oxygen that do the most.


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## Smash (Sep 28, 2010)

In the past 6 shifts I've intubated 7 patients using pharmacology for things ranging from status epilepticus to multi-system trauma to respiratory failure to burns and including a 10 month old with sepsis secondary to pneumonia. I've also treated COPD patients, asthmatics, a couple of STEMIs and a conscious VT. I think I'm doing ok for seeing sick people...

But I don't give everyone O2 and even in those patients I do give O2 to, I give consideration to what is wrong with them, what O2 may do to help or hinder and therefore what FiO2 I am going to give.


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## MasterIntubator (Sep 28, 2010)

No shortage of calls here... 15 to 20 calls a shift...  plenty to hand out...


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