# Help with abc's?



## lalaneedstopass (Sep 26, 2008)

So I just got some books that are definitely helping me with studying and my test scores are improving greatly and I found my flaws where I'm getting messed up. However, where my biggest flaw has been is with oxygen. I finally recognized the difference between oxygenation and ventilation. Someone with adequate breathing and unresponsive gets NRB 100% suplemental oxygen. Someone with inadequate breathing unresponsive/responsive gets ventilations. But when do you determine the use between a nasal cannula and a NRB? I've looked all over my books and even asked a family member that uses a nasal cannula. I found that the NC gives about 24% oxygen and that pts. with COPD, hypoxic drives, anyone being overwhelmed with oxygen should not receive NRB. But how do you determine when to give them the NRB. When I was on my ride along I only got about 4 pts. One pt was given an NC and had CHF but it was in house and no transport per pt. request. But another pt. was given NRB in the ambulance with the transport. My grandpa who is on a NC says it's more for convenience, which I don't believe is entirely true. But maybe it is? Considering the pt. we put on a NC was in home and that's why she was given it and the other pts. that were transported were given NRB? I've looked through all my text books and they basically just say how to apply, how much oxygen. I just want to figure out how to determine who gets the NRB and who gets the NC?

Also, I think I already know this and probably won't get an answer but I had many questions that referred to chest pain and whether to give oxygen, ventilations, NGC, albuterol. No matter what it should always be oxygen or ventilations first (determining on the quality, rate, depth of breathing of course) and NGC/albuterol determines on medical control and after assessment if it's really what they need. But breathing is always before medications. I think writing it out I basically answered my question but just want to make sure :unsure:


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## traumateam1 (Sep 26, 2008)

It's up to you to make the decision between NC and NRB. Like KEVD18 (I think) said in another thread, they would never be able to make a book large enough to cover all protocols. If you have a chest pains p/t who has good colour, easy and effective resps, and is generally good expect chest pains than start off with NC. If you get a SOB p/t who isn't looking the best give them NRB. If you have a moderate shock p/t give NRB, if you have a COPD p/t with severe chest pains or severe SOB *DO NOT WITHOLD HIGH FLOW O2!!!* You will learn thru school and precepting how and what to look for. 
What would you give to a 23 y/o M who is complaining of moderate dizziness. NC or NRB?
What would you give a 68 y/o F who called because of pain in her chest that is "killing her". NC or NRB?
I cannot tell you every situation and what to use.. but you will get to know when to use either. Remember also once you give one, there is no stopping you from upgrading to a NRB or downgrading to a NC. Some p/ts who are having severe SOB wont tolerate a NRB over their face.. so try NC. I know others will give a much more better explanation and better examples but that's what I gotta say! 

And yes O2 or vents before NGC (for me any who).


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## lalaneedstopass (Sep 26, 2008)

traumateam1 said:


> It's up to you to make the decision between NC and NRB. Like KEVD18 (I think) said in another thread, they would never be able to make a book larger enough to cover all protocols. If you have a chest pains p/t who has good colour, easy and effective resps, and is generally good expect chest pains than start off with NC. If you get a SOB p/t who isn't looking the best give them NRB. If you have a moderate shock p/t give NRB, if you have a COPD p/t with severe chest pains or severe SOB *DO NOT WITHOLD HIGH FLOW O2!!!* You will learn thru school and precepting how and what to look for.
> What would you give to a 23 y/o M who is complaining of moderate dizziness. NC or NRB?
> What would you give a 68 y/o F who called because of pain in her chest that is "killing her". NC or NRB?
> I cannot tell you every situation and what to use.. but you will get to know when to use either. Remember also once you give one, there is no stopping you from upgrading to a NRB or downgrading to a NC. Some p/ts who are having severe SOB wont tolerate a NRB over their face.. so try NC. I know others will give a much more better explanation and better examples but that's what I gotta say!
> ...



The 23 y/o I'd probably give a NC, the 68 y/o I'd give NRB. I know it's basically like pt preference and what you think it's best. But what is the NREMT preference lol. But now I guess I'm confused with inadequate breathing. If they are SOB I thought that would make it inadequate breathing therefore give ventilations? Or does inadequate breathing need to have abnormal rate, quality, and depth to all occur?


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## traumateam1 (Sep 26, 2008)

Sorry I'm Canadian so the whole NREMT preference I can't help you with lol.


> If they are SOB I thought that would make it inadequate breathing therefore give ventilations? Or does inadequate breathing need to have abnormal rate, quality, and depth to all occur?


Well not everyone that has inadequate breathing needs assisted vents. My book says if a p/t is at all cyanotic assist ventilations. HA! Not gonna happen.. give 10 Lpm NRB and the cyanosis goes away.. no need for vents. Does inadequate consist of 8 or less and 30 or above? If so, then by (my) protocol you are suppose to assist. If they are alert and responsive than you can coach them to slow their breathing down.. slapping a BVM over their face doesn't go to well when someone is already having a hard time breathing.

Patient 1: Resps: 8, normal rate, good quality and depth. I wouldn't try and assist, I'd give O2 and monitor closely.
Patient 2: Resps: 8, abnormal rate, poor quality and shallow. I would coach first and if not I would assist vents.


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## lalaneedstopass (Sep 26, 2008)

Okay well thanks for the help!


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## traumateam1 (Sep 26, 2008)

Don't know how much of a help I actaully was lol. But you are most welcome. I'm sure there will be many other people on here that can help you WAY better than me.
Take care!!


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## lalaneedstopass (Sep 26, 2008)

So basically after searching through other forums and wikipedia. IDK if I'm correct but the NREMT response would be always use a NRB in the emergency medical environment, because you can never be too cautious. And in the real world basically always use an NRB unless the pt becomes claustrophopic because you can always downgrade? But more for NREMT when I have the choices narrowed down to NC or NRB I should always choose NRB? And oxygen always comes before medication?


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## JPINFV (Sep 26, 2008)

You are correct that according to NHTSA standards (NREMT is based off of NHTSA), the indication for a nasal cannula is a patient who won't tolerate a NRB. In real life, though, it's generally more of a judgement call based on the patient's presentation. For example, the protocol for the state that I'm about ready to take the certification test in (where I used to work did not really have a set of written treatment protocols for basics) reads along the lines of "Administer oxygen as clinically indicated." for each disease covered. As well, remember, supplemental oxygen *is* a drug.


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## Jon (Sep 26, 2008)

In EMT school... if a patient needs O2... they need high-flow O2 (unless they won't tolerate the mask).

In real life... if a patient needs O2... they get a nasal cannula. Unless they look like crap, are a multi-system trauma, or we are breathing for them.

You will learn some stuff in school. Most if it is learned over time on the street.


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## traumateam1 (Sep 26, 2008)

Jon said:
			
		

> In EMT school... if a patient needs O2... they need high-flow O2 (unless they won't tolerate the mask).
> 
> In real life... if a patient needs O2... they get a nasal cannula. Unless they look like crap, are a multi-system trauma, or we are breathing for them.
> 
> You will learn some stuff in school. Most if it is learned over time on the street.



I agree.. School and the real world are a lot different. Take for instance a p/t with SOB.. you are told to lay them supine. You think someone who can't breath is going to want to lay on their back with their lungs stretched out? No they will want to be semi reclined on in a ball. A patient with slighty dizziness does not need a NRB, unless like Jon said they look like utter crap.


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## BossyCow (Sep 26, 2008)

You have to look at each individual pt. and assess it based on their needs. Not every pt who has a hx of CHF is going into the hospital for symptoms related to their CHF. An example is a frequent flier in our district who has COPD. I have probably transported the man personally 20 times over several years watching his condition deteriorate. When he calls us for respiratory distress, its generally a serious call, with ALS needed with meds. I've run code with him more than a time or two. 

His hx doesn't change from call to call, but his symptoms do. One call a few months ago he was able to walk to the ambulance unaided, and he was still able to communicate in full sentences after the walk. His diagnosis ended up being an infection causing pain on inspiration and a fever of 104°. While his COPD hx was a factor, it was not the main event on this call. He was breathing well, moving air and for him, well oxygenated. 

A lot of what we do is a judgement call, so keep your liability insurance payments up and the house in your spouses name!


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## JPINFV (Sep 26, 2008)

traumateam1 said:


> Take for instance a p/t with SOB.. you are told to lay them supine.



You might want to check that again. Hypotensive patients are supposed to go supine (trendelenburg if you still believe in fairy tales), but resp. distress is supposed to be put into fowler's position.


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## BossyCow (Sep 26, 2008)

Oh yeah.. you are going to try to get a resp. distress pt to lie down?  Not on my bus!


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## JPINFV (Sep 26, 2008)

BossyCow said:


> Not on my bus!



Hail to the bus driver, bus driver. Hail to the bus...


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## traumateam1 (Sep 26, 2008)

That's what MY book said, which is NOT with the NREMT standards. Yeah, I know that it's very dumb and I would NEVER try that. Why they have it in there.. I have no idea! lol


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## lalaneedstopass (Sep 27, 2008)

But you're all basically answering what I should do in real life. Not that I've worked in the real life yet but I know how to determine it now lol. But what is the NREMT preference? 

Like, p/t has equal chest expansion and equal lung sounds, not using accessory muscles to help with breathing, chest in pain. R24, quality is good, good depth. So they are breathing adequately but their respiratory is a bit higher than usual and could be because maybe they are anxious or somewhat because of the chest pain. Or for instance, someone who's just had an episode and is somewhat hyperventilating. Although, with the hyperventilating p/t you usually only calm them down. But somebody with chest pain and breathing adequately but abnormal R and/or P. In the NREMT world are you going to give them NC or NRB?


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## KEVD18 (Sep 27, 2008)

the default answer to just about every nremt answer is high flow o2 and rapid transport. at least that was true when i took my nremt.


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## lalaneedstopass (Sep 27, 2008)

KEVD18 said:


> the default answer to just about every nremt answer is high flow o2 and rapid transport. at least that was true when i took my nremt.



If you're right... then thank you ^_^


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## mikie (Sep 27, 2008)

I'm a TA (teacher assistant; college class) for a class right now, and teaching to the BOOK is, "high flow O2, NRB 15lpm unless they cannot tolerate the mask" (not verbatim).  So that's what your test will mostly look for as answerer.  

I went to Borders (bookstore) and when to their healthcare section and found EMT-B test books.  Mostly just multiple choice questions, with justification behind their answer.  Helped me!


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## lalaneedstopass (Sep 27, 2008)

mikie333 said:


> I'm a TA (teacher assistant; college class) for a class right now, and teaching to the BOOK is, "high flow O2, NRB 15lpm unless they cannot tolerate the mask" (not verbatim).  So that's what your test will mostly look for as answerer.
> 
> I went to Borders (bookstore) and when to their healthcare section and found EMT-B test books.  Mostly just multiple choice questions, with justification behind their answer.  Helped me!



Yeah I got some books off amazon a week ago, Stephen Rahm's EMT-B Exam review and Brady's EMT-B Exam Review. And they've helped me tremendously with multiple choice and justification on each one. But like everybody has said, there really are no books with questions that are going to exactly be like the questions on the NREMT and that was basically my last trouble. So I guess when I take my NREMT again basically if they need NRB or NC I will always choose NRB unless in the question it states they have already taken on the NRB and cannot tolerate it then I will choose NC.


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## mikie (Sep 27, 2008)

lalaneedstopass said:


> But like everybody has said, there really are no books with questions that are going to exactly be like the questions on the NREMT and that was basically my last trouble. So I guess when I take my NREMT again basically if they need NRB or NC I will always choose NRB unless in the question it states they have already taken on the NRB and cannot tolerate it then I will choose NC.



That's interesting.  I think the books helped me tremendously for the NR exam.  There was some difference in questions, but I understood more than the 'medicine' but what the questions are really asking.


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## lalaneedstopass (Sep 27, 2008)

mikie333 said:


> That's interesting.  I think the books helped me tremendously for the NR exam.  There was some difference in questions, but I understood more than the 'medicine' but what the questions are really asking.




Yeah the books have definitely helped me. But I think what people were pointing out is that the questions from the NREMT and the questions from the study books are just very different. Most of the books I've seen are basically 2 answers are right but what's the best answer as opposed to the NREMT all 4 answers are generally right, what's the best answer.


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## EMT-P633 (Sep 27, 2008)

I am assuming you are a basic student?

A good friend of mine who has been a medic for 20+ years taught me its not any certain condition or SaO2 % to use NC or NRB, base your oxygen delivery device upon your patients oxygen needs.

If the PT is calm, talking in full sentences, with no apparent distress, no cyanosis then yes, use the NC.

IF the PT is aggitated, anxious, cyanotic, lethargic, using accessory muscles, showing retractions, ETC then use the NRB.

But when I was in school. we were taught for NR if you are going to apply oxygen to the patient use high flow.

EMS contains alot of grey matter (not the kind you can cook with eggs) the kind that is between black and white. Depending on what book or refference you read you will find different answers to different statistics. Alot is due on what author wrote the material.  

I would ask your instuctor exactly what NR in your area is looking for.  Yes NR is supposed to be "national" criteria but your practical examiners are all from your region.  Thus your region may differ slightly from another region.


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## Ridryder911 (Sep 27, 2008)

lalaneedstopass said:


> . Most of the books I've seen are basically 2 answers are right but what's the best answer as opposed to the NREMT all *4 answers are generally right*, what's the best answer.



Who told you this? They intentionally misinformed you! 

The NREMT uses a 4 multiple choice answer system. One is ridiculously stupid, one is odd and the hard part is choosing between the two left, which is the most  correct answer. You will* NEVER *find exact treatment modalities on the NREMT exam. There will always be a odd part of an answer. They do NOT test protocols, so they cannot be held liable for treatment to patients. 

R/r 911


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