# Oxygen



## joe1795 (Oct 20, 2013)

I was just on a call and had a question about oxygen. The patient had just come back from dinner and was experiencing face tingling/numbness and his arms and legs were shaking. He said he had a lump his throat and had "slight" difficulty breathing. No history of asthma, no food allergies, no meds, no history. No history of anxiety attacks. Lung sounds were clear and patient wasn't short of breath and didn't seem to be in respiratory distress. BP was 128/82, HR 88, Resp 18. SpO2 99%. 
Would you have put O2 on this patient?


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## jkmerrill (Oct 20, 2013)

If I had a choice, no.

There was a review article on prehospital oxygen therapy published in _Respiratory Care_ earlier this year, and to quote the authors of that:

"The only evidence-based indication for oxygen therapy is hypoxemia confirmed by oximetry, blood gas analysis, or physical observation. However, oxygen is also often delivered on presumption of need based on disease state (head injury, stroke, myocardial infarction, etc), to alleviate breathlessness, and to prevent hypoxemia in sick patients at risk. These presumptions are not based on evidence that oxygen is useful in these situations, but rather the belief that the oxygen will provide relief of symptoms or prevent untoward effects of hypoxemia. However, oxygen delivery to patents without hypoxemia can lead to worsening outcomes in the presence of hyperoxia."

I don't have the ability to put a link in a post yet apparently, but the URL for the full-text article is: rc.rcjournal.com/content/58/1/86.full

Of course, there are a lot of backwards protocols out there that require EMS providers to strap non-rebreathing mask on every single patient who looks vaguely uncomfortable, and depending on how much leeway your system grants you may be required to do so no matter what. . . 


Jason Merrill


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## joe1795 (Oct 20, 2013)

That's how I feel. I didn't put him on oxygen. We're a QRS for a college, and I thought it would agitate him more. I got QA'd for not putting him on O2. I wrote in the chart it wasn't indicated. We were only on scene for about 5 minutes before Philly medics arrived too. He was certainly not critical and if anything his symptoms were improving.


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## Akulahawk (Oct 20, 2013)

joe1795 said:


> I was just on a call and had a question about oxygen. The patient had just come back from dinner and was experiencing face tingling/numbness and his arms and legs were shaking. He said he had a lump his throat and had "slight" difficulty breathing. No history of asthma, no food allergies, no meds, no history. No history of anxiety attacks. Lung sounds were clear and patient wasn't short of breath and didn't seem to be in respiratory distress. BP was 128/82, HR 88, Resp 18. SpO2 99%.
> Would you have put O2 on this patient?


Probably not, but I'd likely have kept some nearby and a close watch on his lungs. I'd expect him to complain of some constriction before he starts to wheeze. I think whatever he just ate, he's developing a sensitivity to.


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## 2eggs (Oct 20, 2013)

It sounds like he may have been hyperventilating,  were his hands or feet clenching at all?


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## 2eggs (Oct 20, 2013)

It wont let me edit my post for some reason, but I was going to say: It sounds like he may have been hyperventilating,  were his hands or feet clenching at all?   Did he have any itching in his mouth or throat?    Its possible hes having an allergic reaction to something (had he eaten anything new?), but id also try to calm him down a little and see if that helps his symptoms.  His Spo2 is good, no apparent difficulty breathing,  lungs are clear, more than likely he dooesnt need oxygen, hes managing to saturate his blood with o2 just fine on his own, with an spo2 of 99 (assuming this number is accurate) his blood cant hold much more o2, so he doesnt need supplemental o2.


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## EMT B (Oct 20, 2013)

i might have done nasal prong capnography, i dont think i would have turned the oxygen on though.


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## joe1795 (Oct 20, 2013)

I just found out that the patient had an adverse reaction to MSG.


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## mycrofft (Oct 20, 2013)

Ah, "Bushutsuru" (then pres George Bush Sr vomited on the Japanese prime minister after a MSG reaction post tennis match).


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## Giobobo1 (Nov 15, 2013)

joe1795 said:


> I just found out that the patient had an adverse reaction to MSG.



Case Closed.

jkmerrill has a neat little theory there too, in most cases it just acts as a placebo


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## medic6676 (Nov 21, 2013)

New standards dictate that you don't. AHA recommends anyone 94-99% be kept on room air unless other symptoms dictate the use of oxygen. This is because when you reach 100% you actually end up with more oxygen via treatment resulting in free radicals, and then ozone in the blood, this is bad as ozone at the right levels is toxic.

So in this case the patient was at 99% and other vitals were stable, so no. It sounds like the patient was having an anxiety attack of sorts.


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## Clipper1 (Nov 22, 2013)

medic6676 said:


> New standards dictate that you don't. AHA recommends anyone 94-99% be kept on room air unless other symptoms dictate the use of oxygen. This is because when you reach 100% you actually end up with more oxygen via treatment resulting in free radicals, and then ozone in the blood, this is bad as ozone at the right levels is toxic.



An SpO2 of 100% does not always mean hyperoxygenated. Some barely make an adquate PaO2 but still have a high SpO2. Some factors shift the oxyhemoglobin curve which could mean a higher SpO2 but a lower PaO2.  Be very careful with assuming especially with sick patients you are seeing for the first time.


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## medic6676 (Nov 22, 2013)

Clipper1 said:


> An SpO2 of 100% does not always mean hyperoxygenated. Some barely make an adquate PaO2 but still have a high SpO2. Some factors shift the oxyhemoglobin curve which could mean a higher SpO2 but a lower PaO2.  Be very careful with assuming especially with sick patients you are seeing for the first time.



Very rarely, if you are presented with good capture, are SPO2 monitors incorrect. Unless there is some other situation to mimic good oxygen, such as CO or a smoker, than generally they are pretty accurate. In the case of this patient, there was no reason to give him oxygen, the presentation, the vitals, and everything about the patient made him appear stable and able to maintain oxygenation without assistance.

As for the oxyhemoglobin curve, if the patient was cold to the touch, or there was some reason to the believe that the patient was acidotic, than the SPO2 should be accurate. Again in this case with the representation of the patient at the time of care, it sounds like the patient may have hyperventilated prior to arrival, resulting in an alkalotic state, which would further mean withholding oxygen therapy so that the patient builds up more CO2 to reverse the effects.


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## Carlos Danger (Nov 22, 2013)

medic6676 said:


> As for the oxyhemoglobin curve, if the patient was cold to the touch, or there was some reason to the believe that the patient was acidotic, than the SPO2 should be accurate. Again in this case with the representation of the patient at the time of care, it sounds like the patient may have hyperventilated prior to arrival, resulting in an alkalotic state, which would further mean withholding oxygen therapy so that the patient builds up more CO2 to reverse the effects.



Even in the presence of a left shift, I can't really see how additional oxygen is helpful when a good saturation is already present. I suppose one could argue that a very high serum partial pressure will always result in more diffusion of oxygen into the tissues than a lower serum partial pressure will, and that is probably true, but it seems that at normal Patm the effect would be far too small to fix any clinically significant tissue hypoxia.   

100% is 100%.....you can't get higher than that. It's like trying to pour more water into a glass that is already full.


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## medic6676 (Nov 22, 2013)

Halothane said:


> 100% is 100%.....you can't get higher than that. It's like trying to pour more water into a glass that is already full.



The problem with that statement is that the 100% is only measured on the hemoglobin itself. The rest of the blood is not measured, and if there are free radicals, which is oxygen molecules that are not attached to any blood cell, then you create ozone, which is toxic in the blood. And there is more than 100% in that instance.

In the case of a left shift, you can have a higher than correct value on your pulse oximeter. Note the image below. While the shift on this is minimal, if there is a greater change in any of those factors, the inaccurate reading would be more so. SPO2 measures PAO2 when all the factors are normal, otherwise the readings are inaccurate.


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## Clipper1 (Nov 22, 2013)

Halothane said:


> Even in the presence of a left shift, I can't really see how additional oxygen is helpful when a good saturation is already present. I suppose one could argue that a very high serum partial pressure will always result in more diffusion of oxygen into the tissues than a lower serum partial pressure will, and that is probably true, but it seems that at normal Patm the effect would be far too small to fix any clinically significant tissue hypoxia.
> 
> 100% is 100%.....you can't get higher than that. It's like trying to pour more water into a glass that is already full.



But, what about the tissue perfusion?  In the ICUs we are able to see the SaO2, PaO2, ScvO2 or SvO2.  We adjust fluids and pressors according with the O2 in place until we know we can improve delivery. 

The SpO2 can remain at 100% but the PaO2 can change.  Unfortunately all you might have as an EMT or Paramedic is a pulse oximeter.  In the ICUs we quickly learn 100% and just a pulse ox tells us very little about the patient especially if the clinical presentation looks bad.  




medic6676 said:


> The problem with that statement is that the 100% is only measured on the hemoglobin itself. The rest of the blood is not measured, and if there are free radicals, which is oxygen molecules that are not attached to any blood cell, then you create ozone, which is toxic in the blood. And there is more than 100% in that instance.
> 
> In the case of a left shift, you can have a higher than correct value on your pulse oximeter. Note the image below. While the shift on this is minimal, if there is a greater change in any of those factors, the inaccurate reading would be more so. *SPO2 measures PAO2* when all the factors are normal, otherwise the readings are inaccurate.



No. SpO2 does not measure PAO2. PAO2 is calculated.  Even if you meant to state PaO2, SpO2 still does not measure it. But, with a known PAO2 and the PaO2 we can get the A-a gradient which will give us an idea about how sick the patient. Also, the vertical axis on the oxyhemoglobin curve is SaO2 and not SpO2. If you ever get a chance to see co-oximeter reading for the actual components you would see the difference.


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## medic6676 (Nov 22, 2013)

Clipper1 said:


> No. SpO2 does not measure PAO2. PAO2 is calculated.  Even if you meant to state PaO2, SpO2 still does not measure it. But, with a known PAO2 and the PaO2 we can get the A-a gradient which will give us an idea about how sick the patient. Also, the vertical axis on the oxyhemoglobin curve is SaO2 and not SpO2. If you ever get a chance to see co-oximeter reading for the actual components you would see the difference.



My apologies on the mistake. And thank you for the clarification. I should have stuck with my original statement of 100% isn't always full in the case of SpO2,


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## Jawdavis (Nov 22, 2013)

Just a question that might stray from your original answer (but no no o2 needed with sats that high) do you happen to know what his blood sugar was?


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## Carlos Danger (Nov 22, 2013)

medic6676 said:


> *The problem with that statement is that the 100% is only measured on the hemoglobin itself. *The rest of the blood is not measured, and if there are free radicals, which is oxygen molecules that are not attached to any blood cell, then you create ozone, which is toxic in the blood. And there is more than 100% in that instance.
> 
> In the case of a left shift, you can have a higher than correct value on your pulse oximeter.



Right.....Sp02/Sao2 are measures only of the percentage of bound hemoglobin, not dissolved oxygen. My point was that since dissolved oxygen makes up only about 1% of the total arterial oxygen content, you can increase oxygen delivery very little by continuing to add supplemental oxygen when Sp02 is already adequate. 

This is true regardless of whether a right or left shift is present. A left shift represents a greater affinity of hgb for oxygen, but this is not changed by increases or decreases in Pao2 or Sa02.

A left shift will not affect your pulse oximetry readings. It simply describes how readily oxygen leaves the hemoglobin to diffuse into the tissues. 


What we really need to think about when considering supplemental oxygen is oxygen delivery:

Oxygen delivery (D02) is Cardiac output (CO) x Arterial oxygen content (Ca02): 

Ca02 is the oxygen carried on hemoglobin + the oxygen dissolved in plasma, or  [1.39 x Hb x SaO2 + (0.003 x PaO2)]
CO, of course, is HR x SV, and SV is affected by preload, contractility, and afterload.
 The complete oxygen delivery equation looks like this: DO2 = Ca02 [1.39 x Hb x SaO2 + (0.003 x PaO2)] x CO [HRxSV]

Being that there are only 2 parts to the equation, there are only 2 things that can be manipulated to improve oxygen delivery: cardiac output and oxygen content.

The primary ways to improve oxygen content are increasing hgb levels (giving PRBC's), and increasing oxygen saturation. If you calculate the equation out using different values, you'll see that increasing Pa02 has a very negligible effect on oxygen delivery, and increasing Sp02 has a small effect as long as it is already above ~95%. Increasing hemoglobin generally has a large effect, however. 

The basic first step is to always maximize the Ca02 side of the equation first, which simply means ensuring an adequate hemoglobin level and Sp02.




Clipper1 said:


> But, what about the tissue perfusion?  In the ICUs we are able to see the SaO2, PaO2, ScvO2 or SvO2.  We adjust fluids and pressors according with the O2 in place until we know we can improve delivery.



When you manipulate fluids and pressors in the ICU, you are simply manipulating the other side (the CO side) of the equation. Scv02/Svo2, CVP, SVR, SVV, lactate, etc are simply clues to help you decide whether CO needs to be manipulated, and if so, which component of CO (HR, SV, preload, or SVR) will have the biggest impact.

Changes in Pa02 have very little impact on total oxygen delivery. Assuming, of course, that abnormal forms of hemoglobin or other blood toxicities (methemoglobin or cyanide toxicity) are not present. Also, pulmonary problems that can make it difficult to properly oxygenate the blood (ARDS), or deleterious effects of certain therapies (increased Mv02 or renal or splanchnic hypoperfusion due to vasopressor therapy, etc.) obviously need to be assessed and managed.

It also does not take into account the effects of a serious right or left shift, but that is a problem separate from blood oxygenation. Shifts are avoided primarily by maintaining normal C02 and pH level, not by manipulating Fi02.


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## Jawdavis (Nov 22, 2013)

I realize that some of you are trying to play devils advocate in this situation but in the end if you do not have ABGs you would not give O2 with someone satting at 99% because of the potential of resp alkalosis. If he was having trouble breathing an anti-anxiety med could be considered giving his condition or even vocal reassurance.


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## Brandon O (Nov 22, 2013)

Very well said, Halothane.

PaO2 is the direct driver of SaO2, but SaO2 itself is the clinically relevant target as far as tissue oxygenation.


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## Clipper1 (Nov 22, 2013)

Jawdavis said:


> I realize that some of you are trying to play devils advocate in this situation but in the end if you do not have ABGs you would not give O2 with someone satting at 99% because of the potential of resp alkalosis. If he was having trouble breathing an anti-anxiety med could be considered giving his condition or even vocal reassurance.



Withhold oxygen?
Apparently that is the message some might be trying to drive home if the "SpO2" is high.
The objecive should be to decrease work of breathing.  
Are you going to with hold oxygen for someone who is suspect for a pulmonary emboli. The cassic sign might be rspiratory alkalosis but with a low PaO2. Also some one who is anxious does not always equal "hyperventilation".  Their PaCO2 might actually be climbing due to air trapping or pending failure.  Tachypnea does not always mean anxiety or "hyperventilation".


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## Clipper1 (Nov 22, 2013)

Brandon O said:


> Very well said, Halothane.
> 
> PaO2 is the direct driver of SaO2, but SaO2 itself is the clinically relevant target as far as tissue oxygenation.



Do you also believe it is appropriate to with hold oxygen on someone who is trying in increase their oxygenation by increasing overall minute ventilation?

This would have similar results as telling someone with DKA to slow their breathing.  Unfortunatelly some do fixate on an SpO2 and are quick to go with the "hyperventilation/anxiety" diagnosis and forget or not know about all the other possibilities.

I can quote from a textbook or websie also but EMS is very limited for obtaining SaO2 or PaO2 in the field. They are also limited for treatment to improve perfusion. What can an EMT do to improve cardiace output?  Do you suggest to allow a pt to continue breathing at a high rate or giving a little supplemental O2 to help maintain their PaO2?  We may also intubate someone with an SpO2 of 100% for a variety of reasons.

We seriously need to be discussing clinical assessment with potential problems and not allowing one number (SpO2) be a guide to withholding oxygen or assumig all is fine with the patient because the SpO2 is high.


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## Brandon O (Nov 22, 2013)

Clipper1 said:


> Do you also believe it is appropriate to with hold oxygen on someone who is trying in increase their oxygenation by increasing overall minute ventilation?



No. But that's a separate matter. Someone may have a sat of 100% which is due to tenuous compensation in the presence of a respiratory challenge, but noting that compensation is a clinical matter (tachypnea, etc).

Knowing that patient's PaO2 would give you a better sense for how tenuous their SpO2 truly is -- whether they have a surplus of oxygen tension or barely enough to fully saturate their hemoglobin. But again, that's not a direct factor in oxygenation status, which seemed to be the topic here. Barring a failure of the equipment or some fairly unlikely confounders, a measured SpO2 of 100% does denote normoxemia; the patient's PaO2 was one of the factors that made that happen, but that's where its contribution ends.

Actual, total oxygen DELIVERY will involve factors like hemoglobin content and cardiac output and oxygen affinity and so forth. But PaO2 doesn't really measure these either. (Well, I suppose it technically speaks to oxygen affinity when compared to the sat...)


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## Bullets (Nov 24, 2013)

Stop saying "withhold"

This implies that everyone should receive oxygen. Do medics withhold epinephrine, or duoneb? No. they administer it as needed. Oxygen is a medication like all others and should be administered as such


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## Clipper1 (Nov 24, 2013)

Brandon O said:


> No. But that's a separate matter. Someone may have a sat of 100% which is due to tenuous compensation in the presence of a respiratory challenge, but *noting that compensation *is a clinical matter (tachypnea, etc).
> 
> Knowing that patient's PaO2 would give you a better sense for how tenuous their SpO2 truly is -- whether they have a surplus of oxygen tension or barely enough to fully saturate their hemoglobin. But again, that's not a direct factor in oxygenation status, which seemed to be the topic here. Barring a failure of the equipment or some fairly *unlikely* confounders, a measured SpO2 of 100% does denote normoxemia; the patient's PaO2 was one of the factors that made that happen, but that's where its contribution ends.
> 
> Actual, total oxygen DELIVERY will involve factors like hemoglobin content and cardiac output and oxygen affinity and so forth. But PaO2 doesn't really measure these either. (Well, I suppose it technically speaks to oxygen affinity when compared to the sat...)



If all of these is true, why has EMS been called?  If the person is "sick" do they not benefit from an assessment beyond "SpO2"?   All of the factors you mentioned do play a role in assessing a patient. One should not assume "normal" just because of a number on a pulse oximeter.   

Do you take into consideration the WOB to maintain an SpO2 of 100%?  If the patient has marked increased WOB, what exactly is "normal" about that 100%?

I think it should be stressed that nothing is too normal if the patient has to struggle for that 100%.  The same if they are profoundly acidotic.   We could also get into temperature correction for those who are doing TH s/p ROSC which also has a CO factor to be considered.

Granted this is a prehospital forum so many of these factors probably are not a concern in the short term.


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## Clipper1 (Nov 24, 2013)

Bullets said:


> Stop saying "withhold"
> 
> This implies that everyone should receive oxygen. Do medics withhold epinephrine, or duoneb? No. they administer it as needed. Oxygen is a medication like all others and should be administered as such



Would your indication also be based purely off of a number like SpO2? What if the patient is moving over 20 L of MV to maintain a high SpO2? Would you give oxygen or would you wait for them to tire and the SpO2 to drop to fit the number in your protocol? 

That is the point I am trying to make since on this forum, the SpO2 is quoted and not much else about the clinical assessment.


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## Carlos Danger (Nov 24, 2013)

Clipper1 said:


> Would your indication also be based purely off of a number like SpO2? What if the patient is moving over 20 L of MV to maintain a high SpO2? Would you give oxygen or would you wait for them to tire and the SpO2 to drop to fit the number in your protocol?
> 
> That is the point I am trying to make since on this forum, the SpO2 is quoted and not much else about the clinical assessment.



Do higher minute volumes improve oxygenation?


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## Brandon O (Nov 24, 2013)

Clipper1 said:


> Do you take into consideration the WOB to maintain an SpO2 of 100%?  If the patient has marked increased WOB, what exactly is "normal" about that 100%?



Like I said, the effort and compensatory mechanisms involved in maintaining a high SpO2 are obviously critical to assess. I'm only saying that, by and large, actual oxygen delivery (in the sense of hypoxemia) is fully and accurately represented by the oxygen saturation. All these other factors are different pieces of the puzzle.

I don't think we're disagreeing about anything.


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## Clipper1 (Nov 24, 2013)

Halothane said:


> Do higher minute volumes improve oxygenation?



In certain disease processes, yes.
This can be both a good thing and a bad thing.


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## Carlos Danger (Nov 24, 2013)

Clipper1 said:


> In certain disease processes, yes.
> This can be both a good thing and a bad thing.



What types of diseases processes?


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## Clipper1 (Nov 25, 2013)

Halothane said:


> What types of diseases processes?



Asthma, PF, COPD, infant/pedi RDS, PNA to name a few. Diseases which affect acid-base also affect breathing patterns. Some patients actually do what ICU practitioners attempt with ventilators.  The body also attempts to correct the pH which can also affect the oxygenation curve.  

 There are good websites where you can read about respiratory diseases, acid-base and how the body attempts to compensate as well as how each are related. Just like SpO2, not just one factor is alone and everything is related.  Working in an ICU is where you really see how this all comes together.


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## Carlos Danger (Nov 25, 2013)

Clipper1 said:


> Working in an ICU is where you really see how this all comes together.



Well, I guess I better go spend some time in one of those ICU's, then.....


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## EMT856 (Dec 13, 2013)

If they could benefit from O2, why not? You are not going to hurt them by giving them high flow O2 en route to the hospital. If they coulda used it, but didnt get it, you are likely liable because of standards of care. My way of looking at it is, it cannot hurt at all, so why not try?


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## STXmedic (Dec 13, 2013)




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## TransportJockey (Dec 13, 2013)

EMT856 said:


> If they could benefit from O2, why not? You are not going to hurt them by giving them high flow O2 en route to the hospital. If they coulda used it, but didnt get it, you are likely liable because of standards of care. My way of looking at it is, it cannot hurt at all, so why not try?



You're wrong. Oh so very wrong. And a good example of what is wrong with ems as a whole.


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## Glucatron (Dec 13, 2013)

I would not have. If your protocols say different though, than go by that. If he looks good, mentation good, negative stroke scale and is not having SOB. SpO2 values were good too though I would treat pt not monitor. If he started to look really sick, lose mentation, then that ofcourse would change. /2 cents


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## Anjel (Dec 13, 2013)

EMT856 said:


> If they could benefit from O2, why not? You are not going to hurt them by giving them high flow O2 en route to the hospital. If they coulda used it, but didnt get it, you are likely liable because of standards of care. My way of looking at it is, it cannot hurt at all, so why not try?



Oh lord... No!

Oxygen can hurt! High flow o2 is contraindicated in stroke and Myocardial Infarction. Look it up.


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## EMT856 (Dec 13, 2013)

TransportJockey said:


> You're wrong. Oh so very wrong. And a good example of what is wrong with ems as a whole.



Explain exactly how 20-30 minutes of oxygen is exactly what is wrong with EMS as a whole?


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## Glucatron (Dec 13, 2013)

Anjel said:


> Oh lord... No!
> 
> Oxygen can hurt! High flow o2 is contraindicated in stroke and Myocardial Infarction. Look it up.



What state do you work in where it's contraindicated? If they are sick enough, high flow O2 is an absolute must! Atleast 2lpm if nothing else!


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## EMT856 (Dec 13, 2013)

Anjel said:


> Oh lord... No!
> 
> Oxygen can hurt! High flow o2 is contraindicated in stroke and Myocardial Infarction. Look it up.




Explain how an EMT-B is supposed to field diagnose an AMI? Chest pain and Neuro protocols basically order you to use O2 anyways.


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## Anjel (Dec 13, 2013)

EMT856 said:


> Explain exactly how 20-30 minutes of oxygen is exactly what is wrong with EMS as a whole?



The philosophy it's not gonna hurt so why not do it. That's being a protocol monkey. You are allowed to think, and think of why you are giving oxygen, and how it will effect the body. You might not see any negative effects while you have them for 20-30 minutes, but it is doing more harm than good.


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## Glucatron (Dec 13, 2013)

EMT856 said:


> Explain exactly how 20-30 minutes of oxygen is exactly what is wrong with EMS as a whole?



I think what they are referring to is EMS giving O2 without having a justification because "it can't hurt". In the medical field justification is supremely important. If someone gives O2 "just cuz" what impression does that give? That we will do things without a good reason.


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## EMT856 (Dec 13, 2013)

Anjel said:


> The philosophy it's not gonna hurt so why not do it. That's being a protocol monkey. You are allowed to think, and think of why you are giving oxygen, and how it will effect the body. You might not see any negative effects while you have them for 20-30 minutes, but it is doing more harm than good.



Studies have been done by those with Medical Degrees, the ones who write the protocols that we all _should_ at least consider, that have shown that prehospital high flow oxygen is not going to cause any ill effects. We do not know in the field what is going on for certain no matter how much we think we do most of the time. Yes, I can think for myself, and If I think there is potential for benefit for the patient, I am willing to try it.


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## Anjel (Dec 13, 2013)

Glucatron said:


> What state do you work in where it's contraindicated? If they are sick enough, high flow O2 is an absolute must! Atleast 2lpm if nothing else!



2-4lpm in a stroke and MI is approved. 

15lpm via NRB is contraindicated. 

http://m.jems.com/behind-the-mask


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## EMT856 (Dec 13, 2013)

Glucatron said:


> I think what they are referring to is EMS giving O2 without having a justification because "it can't hurt". In the medical field justification is supremely important. If someone gives O2 "just cuz" what impression does that give? That we will do things without a good reason.



I am not by any means saying just do it because you can, _but_ if you think that it might be of use, then use it.


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## Anjel (Dec 13, 2013)

EMT856 said:


> Studies have been done by those with Medical Degrees, the ones who write the protocols that we all _should_ at least consider, that have shown that prehospital high flow oxygen is not going to cause any ill effects. We do not know in the field what is going on for certain no matter how much we think we do most of the time. Yes, I can think for myself, and If I think there is potential for benefit for the patient, I am willing to try it.



You seriously have no idea what you are talking about, and I am not going to waste my time arguing. If you do a simple google search, you will find tons of studies by people with real medical degrees, talking about how hyperoxia is dangerous.


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## EMT856 (Dec 13, 2013)

Anjel said:


> You seriously have no idea what you are talking about, and I am not going to waste my time arguing. If you do a simple google search, you will find tons of studies by people with real medical degrees, talking about how hyperoxia is dangerous.



Yes, I know it is dangerous in a longer term exposure. I am saying if you are in doubt or unsure then putting someone on HF 02 for 10-30 minutes until a doctor or other advanced practitioner can make the assessment that they dont need it, you are not going to do any damage.


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## Anjel (Dec 13, 2013)

Ok let's say you are having a stroke. Your brain is oxygen deprived. Because there is a clot. Now when you give someone high flow o2 it causes vasoconstriction. Your body is like "oh hey we have all the o2 we need, no need to make these vessels any bigger". 

So now you are constricting blood vessels in the brain, that are already blocked. Any blood getting through before isn't any more. So you are making it worse. Now say you have a 15 minute transport time. For 15 minutes you have an even more oxygen deprived brain. That can hurt them. 

I'm obviously over simplifying this. But all national standards state to never give a stroke patient high flow o2.


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## TransportJockey (Dec 13, 2013)

Anjel said:


> Ok let's say you are having a stroke. Your brain is oxygen deprived. Because there is a clot. Now when you give someone high flow o2 it causes vasoconstriction. Your body is like "oh hey we have all the o2 we need, no need to make these vessels any bigger".
> 
> So now you are constricting blood vessels in the brain, that are already blocked. Any blood getting through before isn't any more. So you are making it worse. Now say you have a 15 minute transport time. For 15 minutes you have an even more oxygen deprived brain. That can hurt them.
> 
> I'm obviously over simplifying this. But all national standards state to never give a stroke patient high flow o2.



And the AHA and ACLS support this. I'll reply back in a bit with a better response to some of the above when I get to a computer. I need to get the links to some studies


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## EMT856 (Dec 13, 2013)

Anjel said:


> Ok let's say you are having a stroke. Your brain is oxygen deprived. Because there is a clot. Now when you give someone high flow o2 it causes vasoconstriction. Your body is like "oh hey we have all the o2 we need, no need to make these vessels any bigger".
> 
> So now you are constricting blood vessels in the brain, that are already blocked. Any blood getting through before isn't any more. So you are making it worse. Now say you have a 15 minute transport time. For 15 minutes you have an even more oxygen deprived brain. That can hurt them.
> 
> I'm obviously over simplifying this. But all national standards state to never give a stroke patient high flow o2.



Now lets say protocols say put patient on 02, and you dont. Patient dies anyways, but now you are liable because you didnt follow protocols. My AMS protocol states any pt with AMS gets oxygen.


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## EMT856 (Dec 13, 2013)

TransportJockey said:


> And the AHA and ACLS support this. I'll reply back in a bit with a better response to some of the above when I get to a computer. I need to get the links to some studies



Well, then I guess they need to revise a lot of protocols. I am sorry if y'all have different protocols but I am basing my responses on the protocols that I have worked with my entire career.


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## Anjel (Dec 13, 2013)

EMT856 said:


> Now lets say protocols say put patient on 02, and you dont. Patient dies anyways, but now you are liable because you didnt follow protocols. My AMS protocol states any pt with AMS gets oxygen.



Oxygen yes. But but not high flow! O2 isn't an all or nothing sort of thing. You can use nasal cannulas. That's why we have them.


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## EMT856 (Dec 13, 2013)

Anjel said:


> Oxygen yes. But but not high flow! O2 isn't an all or nothing sort of thing. You can use nasal cannulas. That's why we have them.



I was taught to use NRB first and NC if they cant tol. a NRB. This wasnt that long ago either.


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## TransportJockey (Dec 13, 2013)

EMT856 said:


> I was taught to use NRB first and NC if they cant tol. a NRB. This wasnt that long ago either.


I can count on one hand the amount of times I've used an NRB lately that hasn't had a neb chamber on it. If anything most of my sick patients get a nasal cannula just so I can monitor etco2. 

And as for you post about protocols, when you hit ALS everything becomes shades of gray, and with the standard of care being dictated by things like the aha and ACLS, protocols tend to turn into more like guidelines.


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## JPINFV (Dec 13, 2013)

EMT856 said:


> Explain how an EMT-B is supposed to field diagnose an AMI? Chest pain and Neuro protocols basically order you to use O2 anyways.




Acute Coronary Syndrome is a valid clinical diagnosis when additional testing is unavailable or yet to be performed (including serial cardiac enzymes). 

The 2010 AHA ECC guidelines pulled back their recommendation for oxygen use for both strokes and ACS since the problem is perfusion (train getting to the station), not an inability to load the train. Also, when the train gets overloaded (hyperoxygenation), bad things tend to happen (free radical damage).


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## JPINFV (Dec 13, 2013)

EMT856 said:


> Studies have been done by those with Medical Degrees, the ones who write the protocols that we all _should_ at least consider, that have shown that prehospital high flow oxygen is not going to cause any ill effects. We do not know in the field what is going on for certain no matter how much we think we do most of the time. Yes, I can think for myself, and If I think there is potential for benefit for the patient, I am willing to try it.


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## JPINFV (Dec 13, 2013)

EMT856 said:


> Now lets say protocols say put patient on 02, and you dont. Patient dies anyways, but now you are liable because you didnt follow protocols. My AMS protocol states any pt with AMS gets oxygen.




I bet you supplied your patient with a minimum FiO2 of 0.21 during your transport.


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## jrm818 (Dec 13, 2013)

JPINFV said:


>



Oh please...you just don't understand, there are _studies_!  I don't see any Medical Degrees after your name


anyhoo....like he said...there are studies....http://www.ncbi.nlm.nih.gov/pubmed/20959284


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## JPINFV (Dec 13, 2013)

jrm818 said:


> Oh please...you just don't understand, there are _studies_!  I don't see any Medical Degrees after your name
> 
> 
> anyhoo....like he said...there are studies....http://www.ncbi.nlm.nih.gov/pubmed/20959284




May is coming...


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## Glucatron (Dec 13, 2013)

Anjel said:


> 2-4lpm in a stroke and MI is approved.
> 
> 15lpm via NRB is contraindicated.
> 
> http://m.jems.com/behind-the-mask



Interesting article. That being said these are studies and it is not a conclusive thing. If your protocols say not to use high flow O2 then by all means don't use it. But it's not a national protocol to not use high flow O2. There are studies demonstrating back boards do more harm than good but until it's a state or national protocol we better keep on boarding.  If the pt is showing signs and symptoms of a stroke or MI, O2 will definitely be used. It depends on the severity of their s&s though.


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## NomadicMedic (Dec 13, 2013)

*Folks, let's play nice.*

I understand that many of us (myself included) no longer believe the old "Oxygen  can't hurt" mantra... but not everyone was taught that way.

Rather just being abrupt and dismissing these comments out of hand, this is a prime opportunity for education. State your points and back them with citations.

_And if you continue to be nasty to each other, I'm coming back with the infraction book. _


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