# Newbie Question



## IronClaud (Sep 3, 2011)

So, I just started my emt-B class a couple weeks ago.  I'm kinda confused when it comes to ventilating and applying O2.  If someone is in respiratory arrest you would ventilate with a BVM.  I noticed they have a hook up for O2.  Would you apply the O2 if you noticed the patient to be obviously cynotic by observing blue on lips, nails, etc.  Sorry about the noob  question.  Just trying to get it straight.


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## JPINFV (Sep 3, 2011)

If you are ventilating using a bag valve mask, then it should be attached to supplemental oxygen if available.


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## EMS_Monkey (Sep 3, 2011)

If your ventilating with a bvm and have the option of applying supplemental oxygen do so.


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## JrV (Sep 3, 2011)

just like the other people said. If oxygen is there apply it to the bvm. I finished my EMT-B class a few months ago so i know what your going through, stuff will be confusing at first but you will get the hang of it. But remember, never deprive a patient of oxygen my instructors always said you can never give them too much O2... there is this diccussion about COPD patients and there hypoxic drive... buuut you are just starting we wont get into that. You will learn it in the coming weeks  goodluck!


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## JPINFV (Sep 3, 2011)

JrV said:


> just like the other people said. If oxygen is there apply it to the bvm. I finished my EMT-B class a few months ago so i know what your going through, stuff will be confusing at first but you will get the hang of it. But remember, never deprive a patient of oxygen my instructors always said you can never give them too much O2... there is this diccussion about COPD patients and there hypoxic drive... buuut you are just starting we wont get into that. You will learn it in the coming weeks  goodluck!



How would you go about preventing a patient from inhaling 21-22% oxygen in the first place?

Oh, look, another thread about how oxygen is harmless and every patient should get supplemental because obviously humans aren't adapt to our environment.


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## jjesusfreak01 (Sep 3, 2011)

You give your patient as much O2 as THEY need, no more, no less. A patient hyperventilating from a panic attack doesn't supplemental O2, but you had better be sure of the cause, as a PE, MI, pulsed VTach, SVT, or an overdose might give you the same hyperventilating anxious look, but these patients may very well need a NRB mask or nasal cannula, in addition to other emergency treatment.

I think about it this way. When you approach a new patient, you start with a first impression. Are they in respiratory distress? If so, O2. If not, begin taking basic vitals which will hopefully include SPO2. These vitals may give you insight as to the patients emergent condition, they may not. 

I like to come up with a goal for my patient's O2 saturation. An elderly COPDer is good anywhere over 90% with no respiratory distress, though I would like my young and healthy patients to sat over 95%. One hundred percent O2 saturation is not your goal.

And going with the other commenters, a BVM should be used with O2 if available, as you only only use them for patients in severe respiratory distress or failure, so no matter how much oxygen you put through their airway, there body is having a problem using it and we'd give them 110% if we could. That said, no overzealous bagging, that causes gastric distension and barotrauma, which are bad...mmmkay?


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## Melclin (Sep 4, 2011)

JPINFV said:


> Oh, look, another thread about how oxygen is harmless and every patient should get supplemental because obviously humans aren't adapt to our environment.


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## emergancyjunkie (Sep 25, 2011)

A BVM with supplemental O2 can also be used if the patients respiratory rate is extremely high like maybe in upper 20s or higher. Correct me if I'm wrong here I'm just a student as well.

Sent from my Desire HD


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## 18G (Sep 26, 2011)

The general rule is yes, if the patient's condition is that severe as to warrant assisted ventilation than use supplemental oxygen. LET ME STRESS THIS DOES NOT MEAN 100% OXYGEN, 100% OF THE TIME.

I know your a student so I won't offer info to confuse you in class but just be aware that oxygen is not innocent and yes, you can administer too much oxygen. Oxygen is not harmless. Many conditions have been shown to have worse outcomes when high-flow oxygen was administered (ie MI, CVA, ROSC, COPD, Neonatal Resuscitation).


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## joeshmoe (Sep 26, 2011)

> *Emergencyjunkie*
> A BVM with supplemental O2 can also be used if the patients respiratory rate is extremely high like maybe in upper 20s or higher. Correct me if I'm wrong here I'm just a student as well.



I dont know that I would call a RR in the upper 20s extremely high, although it is higher than normal, and could simply be the result of the patient being scared or excited. Whether or not you would assist respirations with a BVM depends on other factors as well. You obviously wouldnt automatically start trying to bag every patient with a RR in the upper 20s.

Another thing to mention if you havent already learned this, is that the process of breathing isnt simply about supplying o2 to the tissues, it also rids the body of co2.

Airway and breathing are probably the most important things you will cover in your class, so its important to pay attention, read your book, and understand whats taught. Seemingly simple skills like bagging a patient are important, and difficult to do correctly. Getting a good mask seal, providing the correct depth and rate of ventilations, being aware of gastric inflation as well as knowing when to bag someone are all important. You can kill a pediatric patient through over aggressive bagging.


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## usafmedic45 (Sep 26, 2011)

> there is this diccussion about COPD patients and there hypoxic drive... buuut you are just starting we wont get into that



We also won't get into it because it's a myth based on an antiquated and misguided belief about the human respiratory drive.


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## usafmedic45 (Sep 26, 2011)

> A BVM with supplemental O2 can also be used if the patients respiratory rate is extremely high like maybe in upper 20s or higher. Correct me if I'm wrong here I'm just a student as well.



Wait until you see a DKA patient with a respiratory rate of 40+ with tidal volumes of over a liter.  It will redefined "hyperventilation" for you.


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## JPINFV (Sep 26, 2011)

usafmedic45 said:


> Wait until you see a DKA patient with a respiratory rate of 40+ with tidal volumes of over a liter.  It will redefined "hyperventilation" for you.




...and not exactly the patient you want to bring back to "normal" respiratory rate either.


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## Tommerag (Sep 26, 2011)

usafmedic45 said:


> Wait until you see a DKA patient with a respiratory rate of 40+ with tidal volumes of over a liter.  It will redefined "hyperventilation" for you.



Or the patient I had a few months ago with a RR of 66. Cardiac related cause.


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## usalsfyre (Sep 27, 2011)

usafmedic45 said:


> Wait until you see a DKA patient with a respiratory rate of 40+ with tidal volumes of over a liter.  It will redefined "hyperventilation" for you.



And yet inevitably some jack@ss out there will want to tube this patient and then practice ventilator "knobology" to get the patient to an ETCO2 of 40...


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## Nervegas (Sep 28, 2011)

usalsfyre said:


> And yet inevitably some jack@ss out there will want to tube this patient and then practice ventilator "knobology" to get the patient to an ETCO2 of 40...



Got to love the ones who put on the blinders and ABC their way to victory, or well, failure in this case. :rofl:


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## MedicJon88 (Sep 28, 2011)

generally speaking O2 is great... especially as an EMT

In rare cases it can be detrimental- I remember an episode of ER.. where Dr.Dubenko tries to lecture the new ER docs about O2 as a free radical... but thats for far beyond BLS...

Do worry about:
~Overinflating the ambubag- perf the lung, or worse cause gastric distention leading to aspiration pneumonia
~not treating the actual cause of respiratory distress- ie. airway obstruction

Later on you can learn about respiratory alkalosis- (I've only seen it once in the ICU...)


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## usafmedic45 (Sep 28, 2011)

> but thats for far beyond BLS...



Not really....it's pretty damn simple: use the lowest amount of oxygen for the shortest amount of time to get the saturation to a level sufficient to support life (>90% as a general rule) and try to correct or minimize the underlying problem as fast as possible.


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## JPINFV (Sep 28, 2011)

AchilliesOmega3 said:


> generally speaking O2 is great... especially as an EMT
> 
> In rare cases it can be detrimental- I remember an episode of ER.. where Dr.Dubenko tries to lecture the new ER docs about O2 as a free radical... but thats for far beyond BLS...



1. What makes oxygen great for EMTs in contrast to every other level?

2. Do you think the free radicals care about the level of provider?


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## MedicJon88 (Sep 28, 2011)

JPINFV said:


> 1. What makes oxygen great for EMTs in contrast to every other level?
> 
> 2. Do you think the free radicals care about the level of provider?



1. Being limited in the amount of medical intervention EMT-Basics can administer- O2 is like a wonder drug- Respiratory distress- have more O2 in the air for inhalation. Chest pain with possible ACS- Have more O2 and lower the cardiac stress- Status post seizure/postictal- have some O2, CVA- have some O2.... 
It at least makes it look like something is done- and sometimes the placebo effect does the rest.

2. Free radicals only care about themselves... thats why they are free- and radical.


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## MedicJon88 (Sep 28, 2011)

usafmedic45 said:


> Not really....it's pretty damn simple: use the lowest amount of oxygen for the shortest amount of time to get the saturation to a level sufficient to support life (>90% as a general rule) and try to correct or minimize the underlying problem as fast as possible.



I was referring to the line of thinking involving free-radicals... just like the opposite word "antioxidant"; People know these words- just not why one is bad and one is good.

And considering that they don't even trust EMTs with Pulse-Oxymetry- how would they go about titrating the o2 to >90%?


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## JPINFV (Sep 28, 2011)

AchilliesOmega3 said:


> 1. Being limited in the amount of medical intervention EMT-Basics can administer- O2 is like a wonder drug- Respiratory distress- have more O2 in the air for inhalation. Chest pain with possible ACS- Have more O2 and lower the cardiac stress- Status post seizure/postictal- have some O2, CVA- have some O2....
> It at least makes it look like something is done- and sometimes the placebo effect does the rest.



Just because all you have is a hammer doesn't make everything else a nail.


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## Bullets (Sep 28, 2011)

JPINFV said:


> Just because all you have is a hammer doesn't make everything else a nail.



unforunatley, thats how most Basic courses are taught. O2 is my hammer


And as far as the noob question, finish the EMT-B Course, then come back here and read some of the info, follow blogs, and look on PubMed (medical study database) to really educate yourself


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## usafmedic45 (Sep 28, 2011)

> And considering that they don't even trust EMTs with Pulse-Oxymetry- how would they go about titrating the o2 to >90%?



Our medical director required them as part of first responder level kits.  When the state questioned it, his response involved telling them to go do something anatomically impossible because (and I quote because I was standing there when he said it) "The moment it's your medical license on the line, you can start dictating what I let my EMS providers do.  Understood?  Good....now get out of my office."


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## JPINFV (Sep 28, 2011)

usafmedic45 said:


> "The moment it's your medical license on the line, you can start dictating what I let my EMS providers do.  Understood?  Good....now get out of my office."


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## MedicJon88 (Sep 28, 2011)

usafmedic45 said:


> Our medical director required them as part of first responder level kits.  When the state questioned it, his response involved telling them to go do something anatomically impossible because (and I quote because I was standing there when he said it) "The moment it's your medical license on the line, you can start dictating what I let my EMS providers do.  Understood?  Good....now get out of my office."



He can be my medical director any day.


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## epipusher (Sep 28, 2011)

AchilliesOmega3 said:


> He can be my medical director any day.



Curious if this was an Indiana medical director USAF is referring too?


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## usafmedic45 (Sep 29, 2011)

epipusher said:


> Curious if this was an Indiana medical director USAF is referring too?



He worked as a medical director in both Indiana and Illinois. 



> He can be my medical director any day.



Sadly, he retired several years ago.


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## Handsome Robb (Sep 29, 2011)

AchilliesOmega3 said:


> And considering that they don't even trust EMTs with Pulse-Oxymetry- how would they go about titrating the o2 to >90%?



You might not be able to put an exact number on it, but are they cyanotic? What about mentation and cap refill, although it's not a good indicator in adults.

If they aren't blue and are A&O unless there is some underlying cause reducing their mentation I'd be willing to bet that their SpO2 is sufficient. 

Also pulse-oximetry can be skewed, it's just a percentage of how saturated the blood is, it doesn't tell you what it's saturated with, but I'm sure you know that.


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## MedicJon88 (Sep 29, 2011)

NVRob said:


> You might not be able to put an exact number on it, but are they cyanotic? What about mentation and cap refill, although it's not a good indicator in adults.



Respiratory distress seems pretty evident without the need for me to utilize cap refill... accessory muscle use and tripoding will probably give that away...



NVRob said:


> If they aren't blue and are A&O unless there is some underlying cause reducing their mentation I'd be willing to bet that their SpO2 is sufficient.



huh?



NVRob said:


> Also pulse-oximetry can be skewed, it's just a percentage of how saturated the blood is, it doesn't tell you what it's saturated with, but I'm sure you know that.



yep- cyanide poisoning, carbon monoxide poisoning, temperature, perfusion.... movement... its horribly unreliable even in the hospital... but its still a great diagnostic adjunct... the saying goes "treat the patient not the pulseox"...


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## MedicJon88 (Sep 29, 2011)

usafmedic45 said:


> Sadly, he retired several years ago.



Why do the good ones always leave? the bad ones always seem like they stay till they die or can't pratice anymore... several Attendings here i'd wish would just drop dead or get their license revoked already....


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