# Question: Did Patient Need NRB?



## Genesis (Jul 15, 2012)

OK, I had this patient last night and I'm only asking this because the ER nurses were looking at me kinda strange. 

Code 3 to Nursing Home for severe abdominal pain. We get there and the pt is sitting in her chair obviously in pain and states that she's having trouble breathing. Her o2 sat is 98%, bp is 180/74, pulse 77, resp 18. Her pain is in the LRQ 10/10 with no rebound pain. 

Since her O2 sat is 98% BUT she's stating that she's having trouble breathing, would you still give her O2?...if so, by what method? I put her on 15 lpm NRB because of her pain and perceived trouble breathing and she went up to 100%


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## NomadicMedic (Jul 15, 2012)

As much as the forum seems to dislike JEMS, this article gives a good explanation of the difference between oxygenation and ventilation. Read it, it may help.

Your patient may have had “great” O2 sats, (The high 90s are fine) but may not have been adequately exchanging gasses. And really, at the basic level there no good way to quantifiably measure ventilation without ETCO2.

As a paramedic, if I adminsitered oxygen at all, I certainly would not have given her 15 LPM by mask. _Maybe_ 2 lpm via the micro stream ETCO2 measuring nasal cannula.

I'd hazard a guess that her perceived respiratory distress was due to the abdominal pain, not an actual "respiratory" issue.


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## MonkeySquasher (Jul 15, 2012)

What do your locol BLS protocols state?  If it says "Difficulty breathing = 15LPM NRB", then that's what you should do, unless you can have a good solid reason, with evidence, as to why the patient doesn't require that oxygen.

Or, do your protocols state something like "Difficulty breathing = Initiate oxygen therapy" ?  If so, that gives you some wiggle room...  She's at 98%, start her on 2LPM NC.  It's an oxygen therapy, it takes her to 100% and shows improvement.

MY protocols states "SPO2 <94% = Give oxygen", with no directed method.  So I probably wouldn't do anything, oxygen-wise.

From there, look at the patient as a whole.  Is she pale, cool, clammy?  Or is she warm, greasy, and just looks ill?  Any recent illness or GI distress, bowel/urinary habits?  Does she actually appear to be working to breathe, or having difficulty?  A patient's complaint is only a clue and a directional arrow, it shouldn't replace your sound clinical judgement.


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## Anjel (Jul 15, 2012)

As a basic. Which I am. I would of placed her on 4lpm of o2 via NC. Per protocol. 

Without the ETCO2 reading like the n7lxi said, you can't be entirely sure what is happening.

But her spo2 was good. Respirations were WNL. So I don't see anything that warrents high flow. 

I have never personally put someone on a NRB. I usually go with a cannula first. Then if needed I would bump it up. But I have never needed to.


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## Aprz (Jul 15, 2012)

You only told us her vital signs and some of her symptoms. From the lack of information you're telling us, I suspect you tunneled vision on shortness of breath, and didn't consider other things before giving oxygen like breath sounds, accessory muscle use, skin signs, past medical history, description of respiration (you mentioned rate, but not rhythm, effort, sometimes people give a qualitative description of tidal volume e.g. "good tidal depth", and if there were any auditory sound without the use of a stethoscope), and her position in the chair, which is information I would expect from an EMT. Although I don't expect this from an EMT even though it can be assessed by an EMT too, you could have also mentioned the i/e ratio. I have no doubt that you asked or tried to obtain her past medical history and her skin signs, and that you did a physical assessment on the patient to look for things like accessory muscle use, but the fact that you didn't mention those pertinent positives and negatives makes me believe you didn't consider them when administering oxygen to the patient. You also didn't mention if there was any change in the patient condition when you administered oxygen. Did they feel less short of breath after you administered it? Did their respiratory and/or heart rate changed? How come you didn't titrate oxygen (well, probably because the patient was already satting at 98%, but how much would it have taken to achieve the desire effect of no shortness of breath and/or SpO2 100%)? Did you suspect that the pulse oximeter was inaccurate? Protocols?

Oxygen administration used to be a huge issue on this forum. You should search the forum for past discussions with relevant research/statistical links on oxygen administration.


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## Aidey (Jul 15, 2012)

Genesis said:


> OK, I had this patient last night and I'm only asking this because the ER nurses were looking at me kinda strange.
> 
> Code 3 to Nursing Home for severe abdominal pain. We get there and the pt is sitting in her chair obviously in pain and states that she's having trouble breathing. Her o2 sat is 98%, bp is 180/74, pulse 77, resp 18. Her pain is in the LRQ 10/10 with no rebound pain.
> 
> Since her O2 sat is 98% BUT she's stating that she's having trouble breathing, would you still give her O2?...if so, by what method? I put her on 15 lpm NRB because of her pain and perceived trouble breathing and she went up to 100%




No, I would not have given her oxygen. $100 says that if you had asked her why she was having trouble breathing, the response would have been "because it hurts more when I take a deep breath". Oxygen isn't going to do anything for that.


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## 18G (Jul 15, 2012)

I would not have given this patient any oxygen based on the information you provided. Pain can produce the sensation of dyspnea. If the patient had a normal resp exam (rate, depth, lungs, SpO2) I don't see a need to give oxygen. 

Sure, you can try a N/C at 2lpm if for nothing more than the placebo effect but honestly, why? And 15lpm is certainly overkill. Inducing hypoeroxia is generally a bad thing.


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## DrParasite (Jul 15, 2012)

Genesis said:


> We get there and the pt is sitting in her chair obviously in pain and states that she's having trouble breathing.


does she have difficulty breathing, or does it hurt when she breathes? 

one might require oxygen administration, the other needs her to relax, assume a position of comfort, and transport her to the hospital for further evaluation (since you can only do so much as a basic).

Which category do you think this patient would fall into?


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## EMT91 (Jul 15, 2012)

Nremt and textbook aside, I would say 2 lpm via nasal cannula. She States she is short of breath but was she physically working to breathe ie nasal flaring etc?


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## mycrofft (Jul 15, 2012)

Abdominal pain CAN cause dyspnea, not just the sensation. If moving the diaphragm hurts that much, you too would hypo ventilate.

Me, I'd start low flow, listen to chest, listen to patient's complaint and history, palpate and auscultate her abdomen on the way to hospital and get her in there because there's not much here an EMT is going to be helping by standing around with a mask in one hand, a cannula in another, and nothing in an imaginary other-other.


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## Shishkabob (Jul 15, 2012)

NEED it?  Most likely not.  I personally would have done an NC, if at all, and gone from there.


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## Genesis (Jul 16, 2012)

Thanks all! She didn't seem to have any trouble breathing from what I could see so it was most likely that her chest wall expansion made the pain worse. Our protocol says "provide O2 therapy as needed" so 2 lpm via NC would have probably sufficed to ease her fears. I think I definitely went overkill on that one. She did feel better about her breathing though after we discontinued once we got to the ER. I will know better for next time! That was actually our first code 3 call as a completely basic unit.


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## Tigger (Jul 16, 2012)

Anjel1030 said:


> I have never personally put someone on a NRB. I usually go with a cannula first. Then if needed I would bump it up. But I have never needed to.



Glad I'm not the only one. People always look at me funny at work when I say that, I look at them funny for putting an NRB on someone in no respiratory distress.<_<


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## BLS Systems Limited (Jul 16, 2012)

Another reason for shortness of breath with normal SpO2 levels is metabolic acidosis from numerous causes (which isn't an indication for oxygen of course, but just sayin').  One thing that hasn't been mentioned is a low hemoglobin count, which could be a cause for hypoxemia with high SpO2 levels.  While a NRB may or may not solve the issue in the immediate term, it could assist in symptom relief.


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## Veneficus (Jul 16, 2012)

BLS Systems Limited said:


> One thing that hasn't been mentioned is a low hemoglobin count, which could be a cause for hypoxemia with high SpO2 levels.  While a NRB may or may not solve the issue in the immediate term, it could assist in symptom relief.



I would still take my chances without the NRB.


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## BLS Systems Limited (Jul 16, 2012)

I would have to agree.  The low Hb count is an outlier that shouldn't lead a good healthcare provider away from their SOP's in absence of solid evidence (or medical direction).


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## ECHO3ONE (Jul 19, 2012)

I would go with a NC.


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## EpiEMS (Jul 19, 2012)

Is it inappropriate to administer oxygen? Nah. Is it necessary? No. Is it going to be helpful? I doubt it.

Take a base-line SpO2, auscultate, etc.
Then *consider* 2-4 lpm on NC. If there is no relief with the NC, move up to the NRB, sure. But if I'm dealing with this call as a EMT/EMT crew, I'm probably contacting ALS. Dyspnea and abdominal pain gets ALS.


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## exodus (Jul 20, 2012)

Genesis said:


> Thanks all! She didn't seem to have any trouble breathing from what I could see so it was most likely that her chest wall expansion made the pain worse. Our protocol says "provide O2 therapy as needed" so 2 lpm via NC would have probably sufficed to ease her fears. I think I definitely went overkill on that one. She did feel better about her breathing though after we discontinued once we got to the ER. I will know better for next time! That was actually our first code 3 call as a completely basic unit.



I would have called for an ALS unit though.  Get pain management on board, relieve SOB, eat cake.


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## truetiger (Jul 20, 2012)

Respiratory hx?


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## Akulahawk (Jul 21, 2012)

Anjel1030 said:


> As a basic. Which I am. I would of placed her on 4lpm of o2 via NC. Per protocol.
> 
> Without the ETCO2 reading like the n7lxi said, you can't be entirely sure what is happening.
> 
> ...


As a Basic, I _have_ had to put someone on a NRB. Actually, more than a few times. However, I evaluate each patient for how much O2 is needed, with whatever tools I have on hand to help me decide that. In the OP's case, we have a patient with an SpO2 of 98% on room air. Great. Oxygenating well... but is the patient _ventilating_ well? As a basic, I'll see if it appears that there's good chest rise/fall with each breath. If you're in pain and it hurts to breathe, you're going to breathe less often _or_ you're going to breathe only as deeply as you can tolerate the pain. Shallow breathing doesn't lend itself well to good ventilation. 

Would I have put the patient on an NRB? I doubt it. Nasal cannula? Possibly. Neither of those address ventilation. Would I have coached the patient to breathe as effectively as possible within the pain tolerance? Yep. Would I have attempted to use visualization/guided imagery to help increase pain tolerance? Probably. Certainly when we're in pain and we don't know why, we tend to get anxious and that can lead to the sensation of breathlessness/SOB. Anxiety can also lead to an increased perception of pain... which causes the cycle to worsen.

Each patient and situation is different. For this particular patient, I don't know exactly what I'd do... just that I'd do my best to reduce anxiety, and reduce the sensation of SOB, provide a nice, smooth ride...


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