# D/C o2 in SOB pt?



## EXPERTrookie209 (Jul 11, 2011)

My partner and I are en route to an ER discharge (I work for an IFT company) and we come upon a wreck where a woman was cut off and swerved to avoid the other vehicle and ends up running up the curb and over a streetlight. According to the lady that lived at the house that had the car in the front yard, the pt had self extricated, walked to the passenger side of the car, opened the door and sat down. The witness told us she was complaining of SOB and she had elevated HR and RR. I walk up to the pt and she's tripoding, holding her chest, and speaking in 5-6 word sentences. I begin to assess her mental status and do a rapid assessment. She's had no complaints of pain anywhere, just SOB. My partner places her on 15lpm o2 via NRB. By this time fire and AMR is on scene, I didnt have time to get my own BP, but I got a HR of 120 and RR of 28. The AMR EMT walks up and talks to the pt (who is still holding her chest and saying she can't catch her breath) and removes the NRB from her and escorts her to their rig. I was kind of puzzled as to why she would do that when the pt was telling her she's SOB? Can someone enlighten me and tell me why she d/c o2 on an SOB pt when she hadn't done her own assessment yet? 

Thanks for the answers in advance.


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## Aidey (Jul 11, 2011)

Because unless the patient is blue there is no need for 15lpm via NRB.









That statement is slightly oversimplified, but generally accurate.


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## EXPERTrookie209 (Jul 11, 2011)

So what would have been a more appropriate treatment? 6lpm via NC? Sorry as you can tell I don't have much scene experience, and all the school and textbooks ever do is drill 15lpm via NRB for every pt into your head.


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## DesertMedic66 (Jul 11, 2011)

Since it's just the SOB and no other problems, if I'm on a BLS rig I would have probably done 4-6 via NC. If I was on an ALS rig then I would have gotten a O2 stat reading. If the patient has a normal saturation level then I would have done no O2. And just keep reassessing during transport making sure her vitals stay the same. If she passes out during transportation well then ill grab a BVM to slow down her rate and make sure she is having good volume. When I do my call in to the hospital if they want me to throw her on O2 then I'll do it.

I've seen alot of SOB/Dif breathers come in by ambulance without O2.


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## d_miracle36 (Jul 11, 2011)

I would try to figure out what was causing her sob first of all. If she was perfusing ok NRB would not be needed. Chances are it was probably anxiety and she just needed a little coaching. Believe it or not O2 for everyone is not good, thats why it was taken out of the new aha acs protocols for chest pain.


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## abckidsmom (Jul 11, 2011)

EXPERTrookie209 said:


> So what would have been a more appropriate treatment? 6lpm via NC? Sorry as you can tell I don't have much scene experience, and all the school and textbooks ever do is drill 15lpm via NRB for every pt into your head.



Unless the patient is truly hypoxic (blue, low sats, diaphoresis, etc), they just don't need 15 lpm NRB.

A better treatment plan is to fully assess the patient, consider what might be causing their troubles, treat that as needed.

Most of the time, I usually always try to talk them down from whatever effect anxiety is having on them.  Even if there's an actual medical problem, the transition from "well" to "sick" brings with it anxiety, and it's an important part of our job to help people deal with it.  I find that a NRB adds to anxiety, 9 times out of 10.


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## EXPERTrookie209 (Jul 11, 2011)

abckidsmom said:


> Most of the time, I usually always try to talk them down from whatever effect anxiety is having on them.  Even if there's an actual medical problem, the transition from "well" to "sick" brings with it anxiety, and it's an important part of our job to help people deal with it.  I find that a NRB adds to anxiety, 9 times out of 10.



Honestly that was my first thought, but I didn't want to mention a c/c of SOB to AMR and have them freak out on me for not applying high flow o2...


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## DesertMedic66 (Jul 11, 2011)

EXPERTrookie209 said:


> Honestly that was my first thought, but I didn't want to mention a c/c of SOB to AMR and have them freak out on me for not applying high flow o2...



Everyone has their own judgement on what should be done for their patient. Once AMR takes control of patient care then it's their choice of what they want/need to do for the patient.


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## EXPERTrookie209 (Jul 11, 2011)

Thanks for the replies everyone, you've all been a big help. I guess the whole theory "start simple" rings true here.


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## medicdan (Jul 11, 2011)

You should try to figure out the etiology of her DB/SOB. My Tuesday morning QB sense is that it was an anxiety attack- or stress reaction to a possibly traumatic event, and this is consistent with the RR and HR. The fact she walked around, then sat down indicates she likely has no critical injuries and was caring for her own anxiety. I presume the AMR unit was BLS? Did you ask your patient about pain? Perform any physical exam?


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## usafmedic45 (Jul 12, 2011)

> So what would have been a more appropriate treatment? 6lpm via NC?



More like 2 L/min, if any oxygen at all.  Shortness of breath and hypoxia are not the same thing.  You don't treat shortness of breath with oxygen.  You treat the underlying cause.  You treat hypoxia with oxygen.

BTW, put a cannula on yourself, turn it to six liters and let it sit for about 10 minutes and see if you notice anything.  You'll see why high flow cannulae are a bad idea in most situations in the field.


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## EXPERTrookie209 (Jul 12, 2011)

emt.dan said:


> You should try to figure out the etiology of her DB/SOB. My Tuesday morning QB sense is that it was an anxiety attack- or stress reaction to a possibly traumatic event, and this is consistent with the RR and HR. The fact she walked around, then sat down indicates she likely has no critical injuries and was caring for her own anxiety. I presume the AMR unit was BLS? Did you ask your patient about pain? Perform any physical exam?




Pt denied any pain, whether it be in any extremities, abd, back, neck, etc... She was totally alert and oriented. I did a visual physical exam if you will, she was wearing a tank top and didn't notice any seat belt or steering wheel marks on her chest. I didn't get to do much of anything, fire and AMR were literally a minute behind us.

The AMR unit was ALS, they do all 911 out here, their BLS units are strictly BLS IFT units, they can go code 2 to the ER though if their pt deteriorates on them and they're closer than an ALS intercept.

So the lesson to take from this is unless my pt is showing signs of hypoxia, it would be best to try to coach their breathing? Slow them down and have them take deeper breaths? Being in CA, EMT's cant use a spo2 monitor, so I have no idea of knowing what their sat's are.


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## DrParasite (Jul 12, 2011)

question:  had a call yesterday, patient was an unconscious/unresponsive overdose, maybe 30 years old.  she believed to have overdosed on her anti-depressant medication.  right before the paramedic got there, she vomited, and we turned her on her side and began to suction her airway.

anyways, when the paramedic got there, he immediately wanted the patient on a NRB to "preserve her brain function".  

so my question becomes, is a NRB warranted?  there is no doubt she was a sick patient, and she ended up getting RSIed in the ambulance because was wasn't able to protect her own airway (she kept vomiting while unconscious).

but is a NRB at 10-15 LPM warranted, at least in the opinion of others?  she was also hemodynamicaly normal.


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## MrBrown (Jul 12, 2011)

DrParasite said:


> but is a NRB at 10-15 LPM warranted, at least in the opinion of others?  she was also hemodynamicaly normal.



Um ... if the patient was acutely hypoxic (poorly oxygenated) then yes oxygen is warranted if not then no.


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## medicdan (Jul 12, 2011)

DrParasite said:


> question:  had a call yesterday, patient was an unconscious/unresponsive overdose, maybe 30 years old.  she believed to have overdosed on her anti-depressant medication.  right before the paramedic got there, she vomited, and we turned her on her side and began to suction her airway.
> 
> anyways, when the paramedic got there, he immediately wanted the patient on a NRB to "preserve her brain function".
> 
> ...



I generally stay away from NRBs on patients who are actively vomiting-- it's an immediate airway hazard if you're not watching them every second. Otherwise, it really depends on their clinical presentation-- re: skin, RR, WOB, etc.


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## mycrofft (Jul 12, 2011)

*On the original post..breath sounds, chest sounds? Mucosal color?*

What does the "rapid assessment" include?

USAF, O2 via nasal cannula should be right up there with "riding on a long board in an ambulance" as things to experience before you are certified.


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## usafmedic45 (Jul 12, 2011)

> USAF, O2 via nasal cannula should be right up there with "riding on a long board in an ambulance" as things to experience before you are certified.



Pretty much.  Anything above 2L without humidification is almost akin to torture in my book.


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