Oxygen Question

[leoemt]

This is awful reasoning on the MD's part if it is indeed the reasoning. Did the MD also get rid of monitors on ALS units?

Nope, they still got the monitors. I think it came out of too many EMT's using the pulse ox to obtain a HR rather than do the skill themselves.

Most counties around here have them on the BLS units. I would prefer to have them but I have gotten pretty good at making oxygenation evaluations.

You make due with the tools your given. I can't do glucometry either, even though it is a basic skill in this state.

 

[mycrofft]

That's what they mean by "Stay hungry". Know there's more and you can go for it.

 

[AnthonyM83]

So, what do you do if you have an unconscious patient and you can't see their oxygen saturation? No everyone with a low 90s pulse ox is going to have outward signs of hypoxia.

 

[Akulahawk]

Just reading the previous few posts, including the first ones of this thread, it struck me that it was probably likely that the patient did not need the C-spine or the oxygen to be administered. Even though the patient was alert and oriented, but did not know why she fell, tells me that she may have had a seizure given the fact that she's in a drug rehab facility. A thorough examination should rule out spinal precautions as something that is necessary, and the fact that she is breathing, has no shortness of breath issues, is warm pink and dry, and so on tells me that she probably does not need supplemental oxygen. If I were to hazard a guess, she probably fell on her side, with her arms at her side, or she fell on something that resulted in fracture of her clavicle. I think that is the only injury she sustained based on these signs and symptoms she had: a deformity and point tender on her clavicle.

I can understand placing the patient C-spine precautions by protocol, because you have to, for unwitnessed mechanical fall, even if it's a ground-level fall. Given her overall presentation, I do not see any indication for oxygen at this time. Most likely, even if I had a pulse oximetry are handy, I would not have used it, unless I had to by protocol.

My treatment plans are derived from my own evaluation of the patient. I say evaluation instead of assessment, because I don't just take into consideration physical findings, I try to look at as much of the clinical picture as I can. I then come up with a treatment plan that makes sense given the presentation. I then implement what I can, based upon my limitations as a provider. If I'm working as an EMT, I only do EMT stuff, if I'm working as a paramedic, I add the paramedic level stuff as well.

That particular patient, I probably would consider not putting the patient in C-spine, I would not put the patient oxygen, I probably would however provide an ice pack of some sort to control pain. That would be if I was working as an EMT. As far as transport decision goes, no lights, no siren, no drama. If I was a paramedic working that particular call, I would probably do the same things as above, and consider opiate pain control measures if the ice was not working, depending upon specific protocol for pain control and trauma. Otherwise, I would just "BLS it in" and call it good.

The only thing else I would add would be finding out why the patient was admitted to the drug rehab facility. We can see polypharmacy issues in skilled nursing facilities, but it is not out of the realm of possibilities that polypharmacy could be a big issue with these types of facilities too.

So, after all of this rambling, taking all of the above into consideration, I would simply transport patient in a position of comfort, cold pack on the clavicle, nice quiet ride to the ED for evaluation. The other guys have certainly covered the issues of too much oxygenation. My take on oxygen is simply this: it is a drug, it is relatively benign, like all drugs it can be harmful if used improperly. That is why you only give it when it is indicated in the amounts that it is indicated for.

 

[mycrofft]

So, what do you do if you have an unconscious patient and you can't see their oxygen saturation? No everyone with a low 90s pulse ox is going to have outward signs of hypoxia.

True, but are they all in need of resuscitation? I pulse-ox around 94 quite often but don't need resuscitation. I get a little gray, however....

 

[AnthonyM83]

True, but are they all in need of resuscitation? I pulse-ox around 94 quite often but don't need resuscitation. I get a little gray, however....

It does get gray...As much as people get indignant about not giving oxygen (and I definitely don't like handing it out like candy), it's not always clear cut.

But yes, if you read the actual AHA language, it does say you look at the oxygen saturation IF they're dyspneic, hypoxemic, or obvious signs of heart failure. Low oxygen saturation alone isn't an indication for O2. But if he's unconscious and only mild hypoxia, how will we know he has dyspnea?

Wording from guidelines: "there is insufficient evidence to support its routine use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to ≥94% (Class I, LOE C)."

Keyword is ***ACS*** What about all the various other non-ACS/CVA cases? Do we have Class I evidence for or against? What about trauma with significant injury? Trauma with shock? Trauma with head injury (can get into capnography here)?

What about shortness of breath with accessory muscle use but pulse ox of 95% ?

 

[leoemt]

Just reading the previous few posts, including the first ones of this thread, it struck me that it was probably likely that the patient did not need the C-spine or the oxygen to be administered. Even though the patient was alert and oriented, but did not know why she fell, tells me that she may have had a seizure given the fact that she's in a drug rehab facility. A thorough examination should rule out spinal precautions as something that is necessary, and the fact that she is breathing, has no shortness of breath issues, is warm pink and dry, and so on tells me that she probably does not need supplemental oxygen. If I were to hazard a guess, she probably fell on her side, with her arms at her side, or she fell on something that resulted in fracture of her clavicle. I think that is the only injury she sustained based on these signs and symptoms she had: a deformity and point tender on her clavicle.

I can understand placing the patient C-spine precautions by protocol, because you have to, for unwitnessed mechanical fall, even if it's a ground-level fall. Given her overall presentation, I do not see any indication for oxygen at this time. Most likely, even if I had a pulse oximetry are handy, I would not have used it, unless I had to by protocol.

My treatment plans are derived from my own evaluation of the patient. I say evaluation instead of assessment, because I don't just take into consideration physical findings, I try to look at as much of the clinical picture as I can. I then come up with a treatment plan that makes sense given the presentation. I then implement what I can, based upon my limitations as a provider. If I'm working as an EMT, I only do EMT stuff, if I'm working as a paramedic, I add the paramedic level stuff as well.

That particular patient, I probably would consider not putting the patient in C-spine, I would not put the patient oxygen, I probably would however provide an ice pack of some sort to control pain. That would be if I was working as an EMT. As far as transport decision goes, no lights, no siren, no drama. If I was a paramedic working that particular call, I would probably do the same things as above, and consider opiate pain control measures if the ice was not working, depending upon specific protocol for pain control and trauma. Otherwise, I would just "BLS it in" and call it good.

The only thing else I would add would be finding out why the patient was admitted to the drug rehab facility. We can see polypharmacy issues in skilled nursing facilities, but it is not out of the realm of possibilities that polypharmacy could be a big issue with these types of facilities too.

So, after all of this rambling, taking all of the above into consideration, I would simply transport patient in a position of comfort, cold pack on the clavicle, nice quiet ride to the ED for evaluation. The other guys have certainly covered the issues of too much oxygenation. My take on oxygen is simply this: it is a drug, it is relatively benign, like all drugs it can be harmful if used improperly. That is why you only give it when it is indicated in the amounts that it is indicated for.

My running theory is she fell out of bed and landed on her right arm causing the clavicle injury.

Anthony, if they are unconscious then I am going to look at why they are in that state. I will give Oxygen if necessary. While I like using pulse ox when I have one, it is not a definitive tool. Cold fingers, dirty fingers, fingernail polish, etc. can all alter the readings.

While you can check accuracy of the pulse ox by palpating the radial pulse and comparing that to what the pulse ox says, there are plenty of reasons why it could be wrong. It is an assessment tool that can be beneficial but I am not going to make an oxygen decision based solely on a pulse ox reading. Treat the patient.

 

[silver]

Its not that we can't do spo2. It is a Basic skill in this state. We do it when we arrive at the ER. However, in King County, the medical director believes in treating the patient and not the numbers.

Its pretty useful for trending to clue you to re-assess situation.

 

[silver]

What he said is the short and simple version.

I would just add the free radicals damage cell membranes (particularly RBCs), this damage can initiate apoptosis cascades, attract immune cells from IgM and IgG binding(like fixed macrophages in the spleen), which recognize the damaged cell as foreign, expose compliment binding proteins, and initiate inflammatory cascades.

While this cellular damage may initially be subclinical, it can take days to manifest. Even if it doesn't manifest as acute injury, in can cause damage that will shave years off of both quality of life and total life.

If you think cellular injury is too small to care about, let me put it into perspective...

If you take a mole of oxygen, use 1/2 to deplete natural antioxidants, you will damage 1/2 a mole of tissues.

Those tissues most likely are going to be type I pneumocytes, RBCs, vascular epithelium, zone 3 liver cells, and renal medulary cells.

In infants, to that list, add the retina.

I chuckled at this. The body gives other organisms (or self) the worst compliments ever...

 

[JPINFV]

Wording from guidelines: "there is insufficient evidence to support its routine use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, providers should titrate therapy, based on monitoring of oxyhemoglobin saturation, to ≥94% (Class I, LOE C)."

Keyword is ***ACS*** What about all the various other non-ACS/CVA cases? Do we have Class I evidence for or against? What about trauma with significant injury? Trauma with shock? Trauma with head injury (can get into capnography here)?

What about shortness of breath with accessory muscle use but pulse ox of 95% ?

I personally think that LOE C should never be considered a class 1 recommendation. After all, it basically means, "It works great... because we said so."

 

[nwhitney]

It's unfortunate but sometimes you need to play by their rules while in school and for testing purposes. A major issue with ems education is that it is skills based and not education based. There is a good chance you emt instructor doesn't know any better because he is teaching what he was taught.

Was just talking with a EMT instructor about this last night. We ran the EMT students through a code using a Hi-Fi manican and afterwards discussing the usefulness of it vs. getting them ready for the state skills test and the NREMT.

Anyways, for the medics if this pt. is in rehab for an addiction to some sort of opiate drug would that change how your approach to pain managment?

 

[nwhitney]

What he said is the short and simple version.

I would just add the free radicals damage cell membranes (particularly RBCs), this damage can initiate apoptosis cascades, attract immune cells from IgM and IgG binding(like fixed macrophages in the spleen), which recognize the damaged cell as foreign, expose compliment binding proteins, and initiate inflammatory cascades.

While this cellular damage may initially be subclinical, it can take days to manifest. Even if it doesn't manifest as acute injury, in can cause damage that will shave years off of both quality of life and total life.

If you think cellular injury is too small to care about, let me put it into perspective...

If you take a mole of oxygen, use 1/2 to deplete natural antioxidants, you will damage 1/2 a mole of tissues.

Those tissues most likely are going to be type I pneumocytes, RBCs, vascular epithelium, zone 3 liver cells, and renal medulary cells.

In infants, to that list, add the retina.

How long does it take to go from initiating O2 therapy to cellular damage? I get that it can take days to manifest but when does the damamge start?

 

[NYMedic828]

How long does it take to go from initiating O2 therapy to cellular damage? I get that it can take days to manifest but when does the damamge start?

Immediately upon formation of truly free radicals. I imagine it would vary from person to person based upon factors like diet and how much of a reserve of antioxidants a person has.

As soon as you administer more oxygen than the body knows what to do with, free radicals can begin to form and cause damage starting in the lungs and making its way through the vasculature and liver.


Pain management for an opioid user or past user only has a couple of factors.

1. They may have a very high tolerance and simply need more medicine to have the desired effect.

2. They often refuse treatment with opioids for fear of relapse into their old "habits."

 

[MKwolek]

Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.

I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.

 

[Tigger]

Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.

I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.

It very well may have been caused by literally anything else, yet you are only going to choose to give 02?

I ask again, why not give some glucose then too? After all her sugar could have been low and that's why she passed out.

Why give 02 "just in case?"

 

[Tigger]

Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.

I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.

Also, smoking is not shown to have any effect on SpO2 readings.

http://www.ncbi.nlm.nih.gov/pubmed/18272090

 

[Medic Tim]

Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.

so you would base your treatment/interventions off of a chief complaint/MOI rather than a good assessment / evaluation?

If I fell out of bed, had all vs normal with no distress, had an asthma attack the night before....would you give me a neb treatment because it could have been from my asthma? I would certainly hope not.

We provide treatment or lack there of (sometimes doing nothing is doing everything) based on our assessment/evaluation findings.

 

[NYMedic828]

Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.

I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.

Doesn't matter if the syncope was secondary to hypoxia, it's gone now and we won't know. We treat presenting signs and symptoms in the pre-hospital setting we don't perform prophylactic measures.

I don't give patients versed because they may have had a seizure I give it to them because they are seizing.

One of the favorite quotes in these parts is "The delivery of good medical care is to do as much nothing as possible." - House of god.

This means we don't do something just because we can.


Smoking doesn't produce false SpO2 readings its produces lower SpO2 readings that are still equally accurate as anyone's. Smoking damages the physical architecture of the lungs similar to emphysema and decreases available alveolar surface area for gas exchange ultimately resulting in decreased perfusion.

Most people who smoke and aren't Dx with emphysema/COPD usually sat at 94-98% vs the normal 96-100%. AHA doesn't even recommend O2 administration unless there is respiratory complaint or an O2 sat of <94%.

If you follow the Bohr curve (oxygen disassociation curve) dangerous SpO2 levels don't occur until about 90-92%. At that saturation PaO2 is assumed to be decreased which lowers the affinity of oxygen for hemoglobin and any lower you fall off the shoulder of the curve and rapidly become hypoxic.

As far as a false reading in general goes, that's why we "treat the patient not the numbers." We use diagnostic tools such as a pulseoximeter to form an impression of our patient. In the end a good "clinician" if you will, uses all of the data they have collected through their assessment to form a general impression and treatment plan for the patient. Never is treatment solely based on one aspect of assessment, unless of course you are a chef following the cookbook because you don't know any better, aka an EM-Technician... (As mycrofft likes to say )

Knowledge is power. No one can question your treatment when you posses the knowledge to stand behind it.



Edit: Screw you Tim, beat me by 2 minutes!

 

[leoemt]

Ya I think I would have given O2 simply because the reason for the fall is unknown and it very well could have been due to hypoxia.

I know everyone is bringing up the O2 sat being at 100%, but chances are the pt is a smoker, seeing as how many people in rehab facilities are. And you may have gotten a false reading.

First as stated, we don't do Pulse ox in the field here in King County. She was 100% at the ER. I did a cap refill on her prior to putting her on o2 and it was less than 2 seconds. I don't believe there is a right or wrong answer as long as you can justify it.

So, with that said: you wheel this patient into the ER. A very well known and respected doctor (on the national level) looks at the patient and listens to your report. He then asks you, "why did you put this patient on oxygen?" What will you tell him? Keep in mind the patient is fully alert and can hear your reply as well.

Patients need us to make decisions that are clinically appropriate for the situation presenting at that time.

Even if her fall had been Hypoxia induced, any signs of Hypoxia were long gone.

Oxygen is a drug and we seem to forget that. Just as Aspirin may not be appropriate for every ache or pain, Oxygen is also not appropriate in every situation.

Are you going to take a aspirin because you had a headache 5 hours ago but no longer feel it?

If you can't justify your interventions medically, your not a professional - your a taxi driver. My patients expect me to be a professional and that means they expect me to be educated.

 

[mycrofft]

Chronic smoking causes lowered oxygenation due to tissue damage. Doesn't acute smoke inhalation of most sorts potentially cause false elevations of fingertip oximetry when chemicals in the smoke (carbon monoxide, amongst others) cause haemoglobin to appear "nice and red" to the photometer?