# To O2 or not to O2



## Kdellicker (Sep 19, 2013)

One of the guys I run with, we went to class together and got our certification together, is very adamant about putting O2 on everyone! Last night we had a run "Victim of a fall". After asking some questions I had concluded that it was possible rib fx & or bruising of the liver. Either way, something I could not see. When we checked the pt's O2 and Pulse, Pulse WNL (Within Normal Limits) O2 was 97% and BP was WNL. Lungs were clear and normal RE. RR 22. I suggested maybe holding off on Oxygen as it would be unnecessary given O2 Saturation was 97%. If someone is uncomfortable why shove a NC up their nose and why strap a NRB to their beak. If there is a downward trend in pt's O2 sat then yes you should put on Oxy but I just don't see putting O2 on every single person that enters the ambulance. And He is convinced that O2 has pain relieving property's.... I'm not sure.... Maybe he knows something I don't. Any input would be appreciated guys! And thanks for letting me Join ya'lls forum.


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## VFlutter (Sep 19, 2013)

Oxygen administration is a topic that usually gets me fired up. This has been discussed over and over again on this forum so I will keep it simple.

Oxygen is a medication. Every medication has an indication. Oxygen's indication is hypoxemia (Sp02<90ish%). Giving a patient who is not hypoxemic is a medication error and improper use. 

You would not give atropine to a patient in normal sinus rhythm nor would you give nitro to a patient without chest pain. Oxygen is no different. 

Oxygen does not have magical qualities. It does not relieve pain, reduce nausea, or decrease anxiety. 

Oxygen is not benign. Hyperoxemia can cause harm in certain patient populations.

NRBs should only be used on patients in severe respiratory distress after failure to maintain oxygen saturation with lower Fi02.

To put it bluntly your partner does not sound like the sharpest tool in the shed and should pick up an A&P book


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## Wayfaring Man (Sep 19, 2013)

In my training with MFRI, it was stressed that every single patient gets O2.  All of them.  Every patient.  From the sick person to the boo-boo finger, we're putting them on O2.  For our internship rides, if the lead provider declines O2 we need to document that we "considered" it.  The want us to oxygenate everyone, likely because of the risk-reward ratio.  If we give someone O2 who doesn't need it, nothing will happen but maybe a headache.  If we don't give it to someone who needs it, welp.

By protocol, everyone should get O2.  But realistically, it's not everyone.  There are cases where it's definitely a yes, and some where it's pretty much a no.  Low O2 sat?  Absolutely, even if they're fine, just to CMA.  Trouble breathing?  Of course, but the Medic usually takes those calls for us.  Diminished lung sounds?  Yeap.  Chest pain?  Probably, but again, medics take those over.  Heavy bleeding?  Yeah probably.  Pain?  Depends, but likely, just as a placebo if nothing else.  Garden variety sick person?  Maybe!  It's a judgment call.

I agree with Chase that it's a medication with indications and should be treated as such.  But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person.  There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us.  I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.

Incidentally, our training is also to go straight to high-flow O2  at 15LPM via NRB unless the patient cannot tolerate it.  Protocol gives us more flexibility but I was taught to go straight to the mask.


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## Rialaigh (Sep 19, 2013)

Chase said:


> Oxygen administration is a topic that usually gets me fired up. This has been discussed over and over again on this forum so I will keep it simple.
> 
> Oxygen is a medication. Every medication has an indication. Oxygen's indication is hypoxemia (Sp02<90ish%). Giving a patient who is not hypoxemic is a medication error and improper use.
> 
> ...




I echo this but would like to emphasize a point that is difficult to distinguish in the field but should be a huge teaching point. 




Chase said:


> Oxygen is a medication. Every medication has an indication. Oxygen's indication is hypoxemia (Sp02<90ish%). Giving a patient who is not hypoxemic is a medication error and improper use.



In the world we practice in COPD is a very VERY common occurrence as are CO2 Retainers. The optimal 02 level for these patients varies greatly patient to patient. Because there has to be something taught I think generally in the hospital setting and in the field protocol is taught to titrate O2 to keep the patients SPo2 level above 92%. 

However

For these CO2 retainers many of them live at home at SPo2 levels far below 92% and function on a daily basis with these diminished O2 levels. When I am dealing with a COPD patient, especially an elderly patient, I base whether I give oxygen on 2 things mainly, the first being work of breathing, and the second being level of alertness. If the patient is alert and oriented and has no increased work of breathing and no lethargy, then even if their O2 sat is 85% I will try and get by with 2L nasal cannula (or even nothing). 

 I am starting to see more medical journal articles out there on the use of prehospital oxygen in C02 retainers and the negative effects associated with it including increased Cpap use and increased ventilator use associated with a higher rate of respiratory failure outcomes resulting in death or disability. It does not take much, 45 minutes on a non rebreather needlessly for a CO2 retainer is more then enough time to start causing a dramatic increase in CO2 and a lethargic state requiring either very careful titration of O2 at the hospital or more commonly Cpap. 



If you think that you don't run into that many COPD/CO2 retainer patients then think again. I would say on any decently busy EMS unit you will likely see several a week. Keep this in mind when titrating your O2 on the truck. Place more emphisis on mental status and alertness, and work of breathing, do not focus on SPo2 for these patients. 


To close with a little story, I interned at a Pulmonology office my senor year of high school. Spent a couple days a week there with a Dr. for about 4 months seeing patients and looking at labs and imaging with him. He would frequently see COPD patients who would come from home on 2L-4L of oxygen via nasal cannula. These patients lived fairly quality lives at home, no running or athletics for them and they got out of breath easily but with some medication and proper O2 management they were able to avoid hospitalizations and enjoy life at home. These patients would frequently come in with O2 sats below 85%. It is not because they were hypoxic, it is because that is where they live all the time. If you put a non rebreather on one of these patients for several hours you would find them unconscious and needing to be intubated and placed in the CCU on a vent. 




That is my long post for the month, if anyone needs to correct me please do, I certainly don't know everything and rarely know much at all. If you want to read an article or two on prehospital O2 use in CO2 retainers I have several bookmarked away that are good.


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## Rialaigh (Sep 19, 2013)

Wayfaring Man said:


> In my training with MFRI, it was stressed that every single patient gets O2.  All of them.  Every patient.  From the sick person to the boo-boo finger, we're putting them on O2.  For our internship rides, if the lead provider declines O2 we need to document that we "considered" it.  *The want us to oxygenate everyone, likely because of the risk-reward ratio.  If we give someone O2 who doesn't need it, nothing will happen but maybe a headache.  If we don't give it to someone who needs it, welp.
> *
> By protocol, everyone should get O2.  But realistically, it's not everyone.  There are cases where it's definitely a yes, and some where it's pretty much a no.  Low O2 sat?  Absolutely, even if they're fine, just to CMA.  Trouble breathing?  Of course, but the Medic usually takes those calls for us.  Diminished lung sounds?  Yeap.  Chest pain?  Probably, but again, medics take those over.  Heavy bleeding?  Yeah probably.  Pain?  Depends, but likely, just as a placebo if nothing else.  Garden variety sick person?  Maybe!  It's a judgment call.
> 
> ...



Read my above post, there is a LOT of risk involved with giving a LARGE patient population increased (or any) amounts of O2. This is a big learning curve for EMS to learn to titrate oxygen to work of breathing and level of alertness and not to a number.


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## fma08 (Sep 19, 2013)

Does the patient need oxygen?

If yes, give them oxygen.

If no, don't give them oxygen.

:deadhorse:


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## Aidey (Sep 19, 2013)

Wayfaring Man said:


> In my training with MFRI, it was stressed that every single patient gets O2.  All of them.  Every patient.  From the sick person to the boo-boo finger, we're putting them on O2.  For our internship rides, if the lead provider declines O2 we need to document that we "considered" it.  The want us to oxygenate everyone, likely because of the risk-reward ratio.  If we give someone O2 who doesn't need it, nothing will happen but maybe a headache.  If we don't give it to someone who needs it, welp.



Here is how you document that*. 





> Pt maintained SpO2 of 97% on 21% oxygen via inhalation.











* Please note you shouldn't actually do this unless you are looking to deliberately piss someone off.


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## Mariemt (Sep 19, 2013)

The nremt now recognizes o2 titration. The text books have not all caught up but any instructor worth their salt should be following aha guidelines for o2 titration for chest pain at the very least.

Guess what boys and girls? The nremt has questions about o2 and contraindications. 

We even monitor levels per protocol with codes, head injuries and everything else.


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## Christopher (Sep 19, 2013)

Wayfaring Man said:


> In my training with MFRI, it was stressed that every single patient gets O2.  All of them.  Every patient.  From the sick person to the boo-boo finger, we're putting them on O2.  For our internship rides, if the lead provider declines O2 we need to document that we "considered" it.  The want us to oxygenate everyone, likely because of the risk-reward ratio.  If we give someone O2 who doesn't need it, nothing will happen but maybe a headache.  If we don't give it to someone who needs it, welp.



Nails on a chalkboard...ouch.

You should question everything taught at MFRI, because it has been a solid decade since O2 for everybody was acceptable. Actually, I've never heard of that in particular being acceptable medical practice (O2 via NRB for all "sick" people has only recently died off).



Wayfaring Man said:


> By protocol, everyone should get O2.  But realistically, it's not everyone.  There are cases where it's definitely a yes, and some where it's pretty much a no.  Low O2 sat?  Absolutely, even if they're fine, just to CMA.  Trouble breathing?  Of course, but the Medic usually takes those calls for us.  Diminished lung sounds?  Yeap.  Chest pain?  Probably, but again, medics take those over.  Heavy bleeding?  Yeah probably.  Pain?  Depends, but likely, just as a placebo if nothing else.  Garden variety sick person?  Maybe!  It's a judgment call.



I doubted that MD's protocol really was "give O2 to everybody", and as far as I can tell from my read of the 2012 and 2013 protocols this is not the case. I would challenge anyone to show you where the protocols require you to do this.



Wayfaring Man said:


> I agree with Chase that it's a medication with indications and should be treated as such.  But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person.  There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us.  I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.



We QA 100% of our calls, and a big thing we look for is _inappropriate_ use of treatments, which includes O2. You get in as much trouble for not documenting a need as you would for not applying it when appropriate.



Wayfaring Man said:


> Incidentally, our training is also to go straight to high-flow O2  at 15LPM via NRB unless the patient cannot tolerate it.  Protocol gives us more flexibility but I was taught to go straight to the mask.



Man it makes me cringe, but I guess if they're handing this out to you and expecting you to meet this standard...how can we blame the providers?

From a training side, we've had lots of problems with EMT's from MD who move to our area that have a really poor handle on being a clinician and spend a lot of time slaving over our protocols ("BGL is an ALS procedure" and other nonsense).

If MFRI is really spreading, "O2 for everybody," then I may have to change my tactics to acknowledge this fundamental deficiency in their whole EMS education. Scary, scary, scary.


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## Tigger (Sep 19, 2013)

Wayfaring Man said:


> I agree with Chase that it's a medication with indications and should be treated as such.  But the training a lot of guys are receiving right now, including myself, is to give O2 to every single person.  There is also a strong implication that if we don't have O2 in the documentation, then when we get a chart review it's going to not end up well for us.  I'm not a seasoned veteran or an experienced EMT, and I don't have a great depth of clinical judgment to lean on, so while I have not given O2 more than I've given it, I still consider it for a lot of calls.



When all you have is a hammer, everything looks like a nail. 

There is pretty much no reason to consider oxygen on a patient that does not present with any respiratory difficulties. 

It is acceptable as an EMS provider to provide no interventions on the way to the hospital. If something isn't indicated, don't go looking for ways to make it indicated.


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## TheLocalMedic (Sep 19, 2013)

Tigger said:


> When all you have is a hammer, everything looks like a nail.
> 
> There is pretty much no reason to consider oxygen on a patient that does not present with any respiratory difficulties.
> 
> It is acceptable as an EMS provider to provide no interventions on the way to the hospital. If something isn't indicated, don't go looking for ways to make it indicated.



^This


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## jwk (Sep 19, 2013)

Wayfaring Man said:


> In my training with MFRI, it was stressed that every single patient gets O2.  All of them.  Every patient.  From the sick person to the boo-boo finger, we're putting them on O2.  For our internship rides, if the lead provider declines O2 we need to document that we "considered" it.  The want us to oxygenate everyone, likely because of the risk-reward ratio.  If we give someone O2 who doesn't need it, nothing will happen but maybe a headache.  If we don't give it to someone who needs it, welp.
> 
> By protocol, everyone should get O2.  But realistically, it's not everyone.  There are cases where it's definitely a yes, and some where it's pretty much a no.  Low O2 sat?  Absolutely, even if they're fine, just to CMA.  Trouble breathing?  Of course, but the Medic usually takes those calls for us.  Diminished lung sounds?  Yeap.  Chest pain?  Probably, but again, medics take those over.  Heavy bleeding?  Yeah probably.  Pain?  Depends, but likely, just as a placebo if nothing else.  Garden variety sick person?  Maybe!  It's a judgment call.
> 
> ...



I don't even know who or what MFRI is but clearly they're clearly they're a menace.  What you're being taught is way more than stupid - it's dangerous.


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## VFlutter (Sep 19, 2013)

jwk said:


> I don't even know who or what MFRI is but clearly they're clearly they're a menace.  What you're being taught is way more than stupid - it's dangerous.



I am assuming Medical First Responder something. Probably less education than a Boy Scout.

I wish these people could see the ABGs of the patients they bring in on NRBs. On the other hand most of them probably do not even know what an ABG is let alone have ability to comprehend even the basic concepts of them.


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## chaz90 (Sep 20, 2013)

Chase said:


> I am assuming Medical First Responder something. Probably less education than a Boy Scout.



I'm afraid I found it, and it's worse than what you feared.

http://www.mfri.org

Yet another organization that makes it abundantly clear where they place their priorities and still manages to hold great sway over EMS stagnation. Sadly, this sort of attitude seems far too common based on some of the backwards EMS I've seen from our southern neighbors...


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## Wayfaring Man (Sep 20, 2013)

For what it's worth, we also had the instructor doing the "in the field, you probably should not give oxygen to everyone" shtick.  So there is an understanding.  The entire state of Maryland is not doing it that way, nor would I advocate for doing it that way.  I haven't given O2 more than I've given it because there's no reason to O2 someone in most cases.  I was just providing a possible rationale for where the OP's partner might have developed the "O2 everyone" idea.



			
				Christopher said:
			
		

> I doubted that MD's protocol really was "give O2 to everybody", and as far as I can tell from my read of the 2012 and 2013 protocols this is not the case. I would challenge anyone to show you where the protocols require you to do this.





			
				MD Protocols 2013 said:
			
		

> Indications:
> All medical and trauma patients.
> 
> Precautions:
> ...



Also page 27, General Patient Care:



			
				MD Protocols 2013 said:
			
		

> c) Administer oxygen as appropriate:
> 1) Administer oxygen at 12-15 lpm via NRB mask to all priority 1 patients (including COPD).
> 2) Administer oxygen at 12-15 lpm via NRB to all priority 2 patients (including COPD) experiencing cardiovascular, respiratory, or neurological compromise.
> 3) Administer oxygen at 2-6 lpm by nasal cannula or 6-15 lpm mask delivery device to ALL other priority 2 and priority 3 patients with no history of COPD.
> 4) Priority 3 patients, with a history of COPD or patients with chronic conditions, should receive their prescribed home dosage of oxygen.  If patients are not on home oxygen, they should receive oxygen at 2-6 lpm nasal cannula or 6 lpm mask delivery device, if indicated.


Emphasis original.



Again, like I said, I don't personally advocate this practice.  It's very much a "everything looks like a nail" situation and furthermore even if it weren't dangerous, it would be wasteful and inconvenient to the patient.  But they're my protocols, so I need to be aware of them and able to justify myself with them.


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## Christopher (Sep 20, 2013)

Wayfaring Man said:


> MD Protocols 2013 said:
> 
> 
> 
> ...



I guess I can see how that could be read that way, it looks more like what to use when you find you need O2. There was another table listing SpO2 and other findings with what O2 was appropriate.

Scary to think this stuff is still in protocols this way, because like I said we get a decent number of MD providers rolling thru our department and have a rough time getting them on board with EMS.


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## Wayfaring Man (Sep 20, 2013)

Christopher said:


> I guess I can see how that could be read that way, it looks more like what to use when you find you need O2. There was another table listing SpO2 and other findings with what O2 was appropriate.
> 
> Scary to think this stuff is still in protocols this way, because like I said we get a decent number of MD providers rolling thru our department and have a rough time getting them on board with EMS.



Yeah, this is the way it's written and while I take it to mean "this is how you oxygenate a patient who needs it" that "ALL priority 3 patients. . . " thing with a NC is blatant.  I don't agree with it but I'm not the ME.  At the end of the day, I don't give a treatment that I don't think is necessary and I don't withhold a treatment that I think is necessary and I feel I can back that up, but I can understand how some people might struggle with that based on "protocol says. . . "

Can you elaborate on what you mean about having a rough time getting them on board with EMS?

One of the issues we have in MD is that all our career firefighters are EMTs, which is usually a good thing except that sometimes you get firefighters staffing ambulances who want nothing to do with EMS.  But that's neither here nor there.


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## Bullets (Sep 20, 2013)

aidey said:


> here is how you document that*.
> 
> 
> 
> ...



oh im using this!


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## Christopher (Sep 20, 2013)

Wayfaring Man said:


> Can you elaborate on what you mean about having a rough time getting them on board with EMS?



The vast majority slave over the protocols with little to know understanding of how anything actually works. Lots of "aspirin is a blood thinner" cookbook medicine, which doesn't really fly. Most seem lost when they realize the expectation is you're not just a first aider who drives a taxi.

A number have benefited from retaking an EMT course in NC. We take it as fact that with an EMT you're already proficient in acquiring BGL's (and don't say ridiculous crap like "it is an ALS skill"), BIAD's, 12-Lead acquisition, numerous medications (excepting naloxone, which is "relatively" new), and protocols which exist as a _floor_ and not the ceiling. 

A few of them did not care for our Con Ed which wasn't just rereading a textbook..._"but NREMT doesn't say that!"_



Wayfaring Man said:


> One of the issues we have in MD is that all our career firefighters are EMTs, which is usually a good thing except that sometimes you get firefighters staffing ambulances who want nothing to do with EMS.  But that's neither here nor there.



I work in an area where all career firefighters possess an EMT or higher, and my department requires Paramedic (note: we have 16 non-administration employees). The folks who _tend_ make the worst EMT's are those who were made to take it to continue employment. For the most part they're all pretty good. Early on in their transition we made part of their continued competency evaluation include ride time with the EMS services.

That being said, a number of our better paramedics came from the fire side and got "bit by the bug" during their clinical time with us.


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## unleashedfury (Sep 20, 2013)

The idea of giving Hi Flow 02 to every patient is as old as johnny & roy. yet we still beat people over the head with 02 is for everyone LOTS of it too. what the hell why don't we just bag mask everyone cause that's high flow 02 and we can ensure the quality/quantity of respirations. 

oxygenation is a BLS skill its one of the few medications you may administer as a EMT-Basic and we can't get that right half the time. we want to advance the field for better practicioners, better patient outcomes and become more proficient as clinicians yet we continue to follow old outdated protocols. and standards. so we look like a bunch of friggin monkeys with needles and we wonder why

In my years I've learned that not everyone needs 02, and its acceptable to just toss someone in the back of the buggy and drive take a set of vitals or 2. and call it a day. Not everyone fits the bill for prehospital interventions. If you got a patient experiencing leg pain. and cannot ambulate requesting EMS do they need oxygen? or anything we can do prehospital most likely not. a simple ride over to the ED is all they need. or an urgent care center if your protocol allows. 

Don't withhold 02 from those who need it, but its not for everyone. follow the SP02 saturations guide. but if the patient is acutally experiencing distress treat your patient. I've seen patients with low 02 sats mid 80's but that's where they live should I dump them on 15LPM 02 via NRB mask? nope.


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## NomadicMedic (Sep 20, 2013)

unleashedfury said:


> The idea of giving Hi Flow 02 to every patient is as old as johnny & roy. yet we still beat people over the head with 02 is for everyone LOTS of it too.



As a point of note, Johnny and Roy routinely placed most of their patients on O2 via nasal cannula. Patients with respiratory distress were often given a demand head to "self administer" oxygen. Unconscious trauma patients were given an NRB. 

(Yeah, I'm an Emergency™ geek.)


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## FirstResponderCAD (Oct 3, 2013)

The negative effects of short-term oxygen administration in the vast majority of patient populations is virtually non-existent. If there is any noticeable problem with level of consciousness, airway, breathing, or circulatory function, or there is a trauma that can potentially affect ABCs, then the patient is getting oxygen (usually NRB 10-15 L/m). Low Sp02 number is also an indication we use. 

NOT EVERY SINGLE PATIENT NEEDS OXYGEN!


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## Carlos Danger (Oct 3, 2013)

Tigger said:


> *It is acceptable as an EMS provider to provide no interventions on the way to the hospital.* If something isn't indicated, don't go looking for ways to make it indicated.



Excellent quote. One of those things that seems ridiculously obvious, but which many fail to recognize.



Joshtice4All said:


> The negative effects of short-term oxygen administration in the vast majority of patient populations is virtually non-existent. If there is any noticeable problem with level of consciousness, airway, breathing, or circulatory function, or there is a trauma that can potentially affect ABCs, then the patient is getting oxygen (usually NRB 10-15 L/m). Low Sp02 number is also an indication we use.



I think this is a reasonable approach. I think it is fair to say "when it doubt, give oxygen".

I'm not saying "lets keep with the EVERYONE GETS AN NRB paradigm", I'm just saying that I'd rather see people get it who don't need it than the other way around. Obviously, many have a tough time decided who does and doesn't really need it, so I think it is safest to err on the side of giving it too frequently. 

IMO, the hazards of unnecessary oxygen administration have been drastically overstated on this forum. I'm all for better education on when / when not to use oxygen, but let's not pretend that it's an issue of patient safety, because it really isn't at all. I'm aware of the potential dangers of very high P02's, but in reality, the vast majority of our patients are probably much more likely to be hurt in an ambulance accident on the way to the hospital than by unneeded oxygen.


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## Christopher (Oct 3, 2013)

Halothane said:


> IMO, the hazards of unnecessary oxygen administration have been drastically overstated on this forum. I'm all for better education on when / when not to use oxygen, but let's not pretend that it's an issue of patient safety, because it really isn't at all. I'm aware of the potential dangers of very high P02's, but in reality, the vast majority of our patients are probably much more likely to be hurt in an ambulance accident on the way to the hospital than by unneeded oxygen.



I see more of the actual hazards for specific patient populations (premies, MI/strokes, intraarrest/post-ROSC, etc) instead interpreted as applying to all patients. An interesting precursor to this are the older overstatements of the hazards of 1.0 FiO2 for COPD'ers.

The obvious solution is to ask that O2 be treated like an actual medication and that doses be appropriate for the patient at hand.


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## Tigger (Oct 3, 2013)

I agree that the dangers of prehospital O2 use are likely over stressed. My issue with it being done inappropriately is more related to EMS becoming something more than a vocation. For that to happen we need to provide treatment for the right reasons and stop committing and accepting obvious medication errors. Even if it is not necessarily detrimental to the patient we still look like a collective bunch of morons when some applies oxygen to say relieve pain and then justifies it with "it's protocol."


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## unleashedfury (Oct 3, 2013)

DEmedic said:


> As a point of note, Johnny and Roy routinely placed most of their patients on O2 via nasal cannula. Patients with respiratory distress were often given a demand head to "self administer" oxygen. Unconscious trauma patients were given an NRB.
> 
> (Yeah, I'm an Emergency™ geek.)



lol I can see that. I remember watching some of the shows growing up. I recently added the series to my Netflix que. I actually got my stepdaughter shes 8 watching it and she likes it.


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## EEEMMMTTT (Oct 4, 2013)

Emergency! is a great show...  yes it has a ! 

as an EMT, I like to use oxygen as per protocol. I find that many EMTs strive to learn more and that is fine, but at the end, EMT is just a person that is doing what the doctor orders. 

The protocols are in place so we don't have to phone in to Rampart every time we come to a patient for instructions. 

because we are technicians, not practitioners, if we think we should do something not in protocol, we are going to have to call Rampart for authorization. And as much they always say to give the patient D5W, we cant automatically do that without permission...

God I love that show...


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## hobozach (Oct 8, 2013)

Well in this case, a "fall Victim" O2 would defiantly be indicated if fall was significant (greater than PTs height). The reason for this is because of a high impact trauma. If I were handling this I would put PT on 15L NRB.


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## Medic Tim (Oct 8, 2013)

hobozach said:


> Well in this case, a "fall Victim" O2 would defiantly be indicated if fall was significant (greater than PTs height). The reason for this is because of a high impact trauma. If I were handling this I would put PT on 15L NRB.



Is this your protocol or what you would do anyway. 
I hope you take the time to do some more research on this topic.


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## fma08 (Oct 8, 2013)

hobozach said:


> Well in this case, a "fall Victim" O2 would defiantly be indicated if fall was significant (greater than PTs height). The reason for this is because of a high impact trauma. If I were handling this I would put PT on 15L NRB.



Why does a fall "defiantly" indicate oxygen?


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## EEEMMMTTT (Oct 8, 2013)

I think it is in the protocols.


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## hobozach (Oct 8, 2013)

fma08 said:


> Why does a fall "defiantly" indicate oxygen?



Well, depending on fall height and if there are any other injuries. Possible internal bleeding for one, would defiantly be an indication for O2. That's not my protocols that's just how I would handle the situation.


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## STXmedic (Oct 8, 2013)

hobozach said:


> Well, depending on fall height and if there are any other injuries. Possible internal bleeding for one, would defiantly be an indication for O2. That's not my protocols that's just how I would handle the situation.



So why does a fall make your body less capable of utilizing oxygen, requiring a higher concentration of inspired oxygen?


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## hobozach (Oct 8, 2013)

Well by now I know I am wrong because you are the 3rd paramedic to question why I would put O2 on a fall victim. I was taught that high trauma with possible fractures or internal bleeding should be given O2. I assumed the rational behind this was the lower the volume of blood you have, the less efficient your body is at profusion, and should be put on high flow O2. If I am wrong here please explain why.


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## VFlutter (Oct 8, 2013)

hobozach said:


> Well by now I know I am wrong because you are the 3rd paramedic to question why I would put O2 on a fall victim. I was taught that high trauma with possible fractures or internal bleeding should be given O2. I assumed the rational behind this was the lower the volume of blood you have, the less efficient your body is at profusion, and should be put on high flow O2. If I am wrong here please explain why.



If they are hypoxic due to anemia then supplemental oxygen will only help to a certain extent. You are somewhat correct in the fact that you want the available hemoglobin to be saturated as much as possible but there is a limit. And oxygen dose not automatically = 15L NRB @ 100% Fi02


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## ThadeusJ (Oct 9, 2013)

Hobozach,

Hemoglobin carries 97% of the oxygen. Only 3% is dissolved.  Therefore, if you ain't got the RBC's to carry the oxygen, the oxygen ain't gonna get carried.  Even if the RBC's are 100% saturated, if you only have one little cell running around (to be extreme in this example), you still have very low oxygen delivery. You have to use hyperbarics to dissolve enough oxygen in the plasma to keep a system alive.

For those who need an analogy, I always compared oxygen delivery to trucking: the lungs are the loading docks, the RBC's are the trucks, the arteries are the roads and cells are the customers.  Normally the trucks are packed at 92-96% capacity. You can pack them higher if you want, but 100% is 100%.  If you have less trucks, they are still packed to 100%, but you will still have less arriving to deliver the goods.  That's why if yo infuse litre upon litre of fluids into a bleeding patient, you may still have good SpO2 levels, but lousy carrying capacity.  

COPD issues deal with problems on the loading dock...you get the idea.


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## FiremanMike (Oct 22, 2013)

Hyperoxia is shown to have an INCREASED mortality rate in patient populations including post cardiac arrest, myocardial infarction, stroke, and others.  From the oxygen-hemoglobin dissociation curve, we know that SpO2 of 90-99% is pretty close to actual blood oxygen levels.  Once SpO2 reaches 100%, we frankly have no earthly idea what blood oxygen levels are.  They could be 100mmHg, they could be 650mmHg, we just don't know. 


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218982/


99% is the new 100%..


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## Aprz (Oct 22, 2013)

FiremanMike said:


> 99% is the new 100%..


Ooo... I like that. *steal*


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## NomadicMedic (Oct 22, 2013)

Actually, anything >95% is the new 100%.


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## VFlutter (Oct 22, 2013)

FiremanMike said:


> Once SpO2 reaches 100%, we frankly have no earthly idea what blood oxygen levels are.  They could be 100mmHg, they could be 650mmHg, we just don't know.
> .



Arterial Pa02....



DEmedic said:


> Actually, anything >95% is the new 100%.



+1, I would even say anything >93% is the new 100%


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## FiremanMike (Oct 23, 2013)

Chase said:


> Arterial Pa02....



"We" was referring to pre/out of hospital providers.  We don't have access to real time PaO2 values.


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