O2 admin in cases of ETOH and AMS

[medicdan]

I have a clinical question I have been pondering for some time, have spoken to my supervisors about, but would still like to hear more opinions about. I'm presenting the thoughts and ideas in no apparent order, just the order of my decision-making, and it's likely I answer my own questions, but I'd like feedback on the decision-making tree.

The point of view I am taking is that of an EMT-B, functioning as a first responder under a conservative Med. Director on a college campus.

We call nearby ALS for transport, but this scenario discusses our decision making and treatments in the intervening minutes before ALS arrives.

Hypothetical Case:
Called to a 22 yom, ca&oX2, who consumed somewhere between 5 and 15 shots of assorted liquors within the last 2.5 hours, last drank just before we arrived, s/p regular dinner 5 hours PTOA. Able to speak, but poor historian, and walked quite a distance from where he first drank. Vomited 2x PTOA, and 2x on scene. Pt unable to sit up straight, unable to stand straight or ambulate much.
We are going to send this patient ALS.

I understand that O2 is indicated-- AMS of unknown or unconfirmed etiology. Not doubting that. My question lies more in delivery device and effectiveness in short period of time. I argue that a n/c is indicated, due to the continuing vomiting, and necessity to get more information out of the patient. Admittedly, a n/c is "bull:censored::censored::censored::censored:" oxygen, and provides little clinical benefit... but its better then nothing...? Should this patient receive an NRB (already going ALS) just because the textbook says that is best-- and because we can?

What true benefit will this patient receive (no matter the underlying cause) from just a few minutes of O2 therapy (with either delivery method, knowing the medics will rip it off anyway)? We know, based on the ammt consumed, and the last consumption, that this patient will deteriorate in mental status, and eventually pass out (unconscious). In that case, is the O2 indicated?

I disagree with cookbook medicine-- or in saying "textbook"-- AMS=O2. As a BLS provider, especially on this campus, I dont have the tools to rule anything else out... Should this become a policy (ETOH intox requiring the ER should always get O2)? That takes away the judgment of the provider...? Clearly, partially because of the fact this patient is a poor historian, and partially because of the long walk (with no present bystanders), we know nothing about a fall or TBI...but in cases where we know the parameters, is it appropriate not to provide O2...?

Is it worth the trouble of setting up the delivery method, getting it to stay on, making it stay with the patient as we move them? Vomiting pts with a NRB can cause an airway issue, so we must be ever vigilant that the mask doesn't become, ahem, clogged.

Please forgive this rant. Ultimately, I think, it boils down to a judgment call, and "gut" instinct. I often make "textbook" treatments, partially to CYA, partially because my Med. Dir. wants to see it...

What do you all think?

 

[CAOX3]

Sometime nothing is better.

If the guy isnt having any difficulty breathing why would you apply oxygen? Its possible he aspirated but again you would have to assess him, what are his lungs sounds.

We dont do things to look busy we do things to benefit the pt if O2 isnt beneficial why use it? If your going to transport him BLS place him on his side in case he vomits again monitor his airway and mental status, check his BS to rule out any diabetic issues if possible and bring him to the hospital.

 

[Shishkabob]

Do you have access to a pulseox?

If they aren't SoB, satting ok, and no other signs of possible hypoxia / hypoxemia aside from AMS which an be caused by a multitude of things, I'd tend to agree that a NC is appropriate. I've had drunks on NRBs vomit in to the mask, and it seems rather counter-intuitive to have something that prohibits easy escape of the vomit.

22-44% oxygen via NC never hurt the average person that I know of.



On the same token, it'd be ok to not give oxygen as well, if your assessment determines it's unnecessary.


Use your judgment, and be able to back it up if asked why or why not.

 

[VentMedic]

Alcohol can affect cerebral blood flow in the acute heavy intoxication as well as the chronic. This can also impair cerebral oxygen utilization. The vomiting rids the body of excess undigested alcohol but can also trigger other physiological events. If the patient is a chronic alcoholic, their electrolyes and total body chemistry will be affected setting them up for a critical medical incident. Usually you can get these patients to the hospital before they crash if they are still conscious when you pick them up.

If severe enough we will monitor SjvO2, calculate cerebral perfusion pressure (CPP) and titrate O2 and pressors accordingly in the hospital. The SpO2 will not tell much about this level.

Alcoholics or the street "drunks" may have several cerebral events occur before they ever get a CT Scan or MRI even with many ED admissions. There are also many other chronic changes that occur through the years that precipitate a major event later. Younger heavy binge drinkers also can experience these changes which are not always noticeable until later. It is like what was described in the articles about the repeated head trauma from football or boxing.

I would not suggest a mask but O2 by NC would be appropriate to raise the PaO2.

 

[reaper]

I have a clinical question I have been pondering for some time, have spoken to my supervisors about, but would still like to hear more opinions about. I'm presenting the thoughts and ideas in no apparent order, just the order of my decision-making, and it's likely I answer my own questions, but I'd like feedback on the decision-making tree.

The point of view I am taking is that of an EMT-B, functioning as a first responder under a conservative Med. Director on a college campus.

We call nearby ALS for transport, but this scenario discusses our decision making and treatments in the intervening minutes before ALS arrives.

Hypothetical Case:
Called to a 22 yom, ca&oX2, who consumed somewhere between 5 and 15 shots of assorted liquors within the last 2.5 hours, last drank just before we arrived, s/p regular dinner 5 hours PTOA. Able to speak, but poor historian, and walked quite a distance from where he first drank. Vomited 2x PTOA, and 2x on scene. Pt unable to sit up straight, unable to stand straight or ambulate much.
We are going to send this patient ALS.

I understand that O2 is indicated-- AMS of unknown or unconfirmed etiology. Not doubting that. My question lies more in delivery device and effectiveness in short period of time. I argue that a n/c is indicated, due to the continuing vomiting, and necessity to get more information out of the patient. Admittedly, a n/c is "bull:censored::censored::censored::censored:" oxygen, and provides little clinical benefit... but its better then nothing...? Should this patient receive an NRB (already going ALS) just because the textbook says that is best-- and because we can?

What true benefit will this patient receive (no matter the underlying cause) from just a few minutes of O2 therapy (with either delivery method, knowing the medics will rip it off anyway)? We know, based on the ammt consumed, and the last consumption, that this patient will deteriorate in mental status, and eventually pass out (unconscious). In that case, is the O2 indicated?

I disagree with cookbook medicine-- or in saying "textbook"-- AMS=O2. As a BLS provider, especially on this campus, I dont have the tools to rule anything else out... Should this become a policy (ETOH intox requiring the ER should always get O2)? That takes away the judgment of the provider...? Clearly, partially because of the fact this patient is a poor historian, and partially because of the long walk (with no present bystanders), we know nothing about a fall or TBI...but in cases where we know the parameters, is it appropriate not to provide O2...?

Is it worth the trouble of setting up the delivery method, getting it to stay on, making it stay with the patient as we move them? Vomiting pts with a NRB can cause an airway issue, so we must be ever vigilant that the mask doesn't become, ahem, clogged.

Please forgive this rant. Ultimately, I think, it boils down to a judgment call, and "gut" instinct. I often make "textbook" treatments, partially to CYA, partially because my Med. Dir. wants to see it...

What do you all think?

Just wondering which instructor put that into your head?

 

[VentMedic]

Admittedly, a n/c is "bull:censored::censored::censored::censored:" oxygen, and provides little clinical benefit... but its better then nothing...?

Just wondering which instructor put that into your head?

I would say that is an instructor who needs a little Respiratory 101 or should have at least taken a college level A&P course.

 

[MrBrown]

Admittedly, a n/c ... provides little clinical benefit... but its better then nothing...?

Unless hypoxemic, oxygen generally provides little clinical benefit!

There is nothing magic about oxygen and slapping your patient on fifteen litres by non-rebreather doesn't cure what ailes them!

See the new UK guidelines (which includes reference to the BTS study) herehttp://www2.warwick.ac.uk/fac/med/r...ombined_final_published_version_22apr09sb.pdf

Note that for severe trauma the JRCALC/BTS guideline is fifteen litres while we use a much lower dose at 6-10.

 

[VentMedic]

Unless hypoxemic, oxygen generally provides little clinical benefit!

There is nothing magic about oxygen and slapping your patient on fifteen litres by non-rebreather doesn't cure what ailes them!

See the new UK guidelines (which includes reference to the BTS study) here

Note that for severe trauma the JRCALC/BTS guideline is fifteen litres while we use a much lower dose at 6-10.

It is good to see the U.K. has raised the lower SpO2 level ot 94% where as some still use 92% for hypoxemia. Other than that, 10 -15 liters seem to be the recommendation for many conditions.

One also has to remember there are different types of hypoxia.

1. Hypoxic Hypoxia

2. Anemic (Hypemic) Hypoxia

3. Stagnant Hypoxia

4. Histoxic (histologic) Hypoxia (Alcohol consumption falls into this categoy.)

Good Slide Presentation:
www.rcsw.org/Download/Other_Power_Point/Hypoxia.ppt

Note that a NRB mask is not a "high flow" device by true definition.

Another presentation on Hypoxic Drive:

www.idasrc.org/Hypoxic_Drive.ppt

 

[Melclin]

Bloke needs to quit the drink I reckon. Doesn't suit him.

Assuming this is your standard 22M out for a Friday night with his mates and he's a drink too many, I don't see that he realistically needs any O2. But as a campus basic (or any ambo for that matter) I suppose you can't really make those kinds of judgements, what with a lack of equipment, time with the pt, training, scope and especially a lack of an accurate hx of the pts condition/consumption.

A nasal cannula would be just dandy. Now somebody tell our state service that will you.

 

[medicdan]

The comment about use of a n/c being useless came from one of my supervisors. At least in this area, the medics rip any O2 we admin off... so the question is of effect in the first few minutes.

From my point of view, on a college campus, there are 4 MAIN causes of AMS 1) ETOH/Drugs, 2) Head injury/TBI, 3) DM and other metabolic conditions, and 4) hypoxia or hypoperfussion of different forms.

In my first few mintes on scene, I like ruling out conditions my patient doen't have. Right now, I dont have a glucometer, but use my physical exam/skin assessment. I know that ETOH/Drugs are involved, I can't rule out TBI, can determine the lack of hypo/hyperglycemia based on PE, and can look for s/s of hypoperfusion.
Lets say we have pulseox, and it is normal, 99%.

 

[VentMedic]

Lets say we have pulseox, and it is normal, 99%.

Cerebral oxyimetry would tell you more.

If you ever go on to some type of critical care medicine (if the U.S. Paramedic even advances that far or in another profession), you will notice that we utilize the pulse ox as only one guide and in sick patients, it must be correlated with other lab work including an ABG. If a very ill patient has an SpO2 of 99% while on a NRB mask but is still short of breath, that SpO2 means little as the gas exchange may be impaired to where the level in the blood never reached what it should with a higher FiO2. The PaO2 may be very low and gas exchange must be improved or the patient can decompensate very quickly without the oxygen.

Likewise, if we have a septic patient with a lactate level of > 4 mmol/L we will keep that patient on oxygen until the level starts declining. If they are sick enough to require a ventilator, they will remain on 100% and we will monitor ScvO2. If the ScvO2 number drops out of range, we will add fluids or pressor to increase it. We may also have to make adjustments to the ventilator to either back up on the airway MAP (Mean Airway Pressure) or even consider adding Nitric Oxide. The same for some neuro patients as we may be monitoring SjvO2, ICP and CPP as a guide for oxygen delivery.

For head trauma, each patient will have a different guideline for O2 depending on injury sight, extent of injury, pneumocephalus, pre-existing conditions and pulmonary complications.

If the hemoglobin is fully saturated, other treatments will have to be relied upon to improve oxygenation at the tissue level.

What I am trying to say is there is no easy recipe especially with all the possibilities. You are on the right track for recognizing a lot of different things that could be happening. At 22 y/o, he could have been binge drinking 2- 3x per week for 4 years of college...not good. He could also have been assaulted while drinking and now has a subdural hematoma. It is also difficult in the field to know many of these things even with a thorough examine but if you at least look for these things you may not be caught off guard at the hospital. You'd be surprised what we find in the ED with young weekend warriors or college students who drink too much as well as the street alcoholics that someone failed to do a thorough assessment and just took the obvious diagnosis.

But, prehospital you will have to just rely on your M.D.'s protocols based on what you can assess.

In the hospital, the "over educated" (see the locked thread) RNs and RRTs will be titrating meds and technology based on an ongoing bedside assessment for their entire shift.

 

[medicdan]

Thank you, Vent, this is very helpful. I didnt include the field pulse ox in the original description, because I dont consider it significant in my assessment or treatment.
I am interested in other assessments or critical thinking skills I can utilize for "under-educated" EMTs in the field, while waiting for the "trained professional" paramedics to arrive.
I'd like to say I administer oxygen (or any other medication/treatment) for more significant reasons then "protocol says", or "because my Med. Director says", so am looking for deeper meaning.

Thanks again.

 

[VentMedic]

for "under-educated" EMTs in the field, while waiting for the "trained professional" paramedics to arrive.

Unfortunately in the U.S., oxygenation and ventilation are barely covered in the Paramedic curriculum.

Too often someone will read a JEMS article and take it to heart as being a statement on how to treat all patients. This may be why you have seen some Paramedics ripping off the O2 from your patients. They don't pull up the articles discussed in the references to see exactly what patient population was studied or even how many were studied. This is essentially how the "COPD and hypoxic drive" issue has stayed in the mainstream. What some fail to realize is that COPD is a very broad term and only about 5% will actually be CO2 retainers.

One could pull up literally thousands of articles about alcohol and oxygenation that have been studied over the past century.

Also, whatever treatment you see in the ED for the patient may differ greatly from what will be done in the ICU. Quite often as soon as it is determined the patient needs an ICU, the ED doctor steps aside and an intensivist takes over or their protocols are initiated. That is of course provided the RNs have some ICU education and training.

 

[Jon]

Dan,

We sometimes get called BLS to the local University Public Safety for similar patients. I assume your role is First Responder?

Often I'll BLS them. We have a ~5 minute, 1.5 mile transport, non-emergent. If I had a longer transport, I'd also be thinking more along the lines of ALS. ALSO, if I'm on a ALS ambulance, I'd likely ride the patient in. (Note - I ride with a service that is BLS only, even though I'm a medic).

Why?
I question what an ALS provider will do for the patient during the short transport, and what they really could do for the patient?


Now, if they are unconscious/unresponsive and/or unable to control their airway, They get ALS and whatever I need to do BLS until they get there.

 

[VentMedic]

Dan,

We sometimes get called BLS to the local University Public Safety for similar patients. I assume your role is First Responder?

Often I'll BLS them. We have a ~5 minute, 1.5 mile transport, non-emergent. If I had a longer transport, I'd also be thinking more along the lines of ALS. ALSO, if I'm on a ALS ambulance, I'd likely ride the patient in. (Note - I ride with a service that is BLS only, even though I'm a medic).

Why?
I question what an ALS provider will do for the patient during the short transport, and what they really could do for the patient?


Now, if they are unconscious/unresponsive and/or unable to control their airway, They get ALS and whatever I need to do BLS until they get there.

This is what is so wrong about the American EMS system.

If you are a Paramedic, you should be thinking and assessing as an advanced provider regardless of whether you are on an ALS or BLS truck. If you fail to recognize important signs and symptoms because you are only on a "BLS" truck then you may not be anticipating some very important situations. You may also fail to recognize that a different hospital might be needed rather than just the local little general and dump.

As an ALS provider, you most definitiely can do than just airway even for the short term. If you have done your assessment properly, you may find HR and BP situations that may need intervention. One should NEVER assume a patient is just a drunk by first appearance without some type of assessment and hopefully more than just one that is just "BLS" if you are capable of doing a more advanced assessment.

Never do patient care or at least not the assessment just by "the truck you are on". Even if you have limited equipment, that patient is still entitled to the full abilities of your patch and training regardless of whether you want to call your ride in "BLS" or "ALS". Someday in the very distant future, U.S. EMS will be about patient care and not the "truck".

 

[medichopeful]

I'm interested in this subject too, as our situations (work environments) are the same (college campuses).

 

[FLEMTP]

Short or long transports I ALS ETOH patients. I figure they can use the IV fluids and the sooner I start giving them fluids and get them closer to discharge, the quicker the ER can get them out the door. I also will go the extra step and contact someone who is sober to meet the patient at the ER. The ER staff love this and it helps them get things moving, especially on a friday or saturday night when ER beds are at a premuim!

 

[MrBrown]

Short or long transports I ALS ETOH patients.

Meaning what exactly, a bag of fluid? Yes that is truly advanced prehospital care, perhaps performing rapid sequence intubation or thrombolysing them based upon one's 12 lead findings I might call providing "advanced" care.

Now that is mildly unfair because that's not aimed at you specifically and I know Lee County EMS is a good setup.

That aside this "ALS" vs "BLS" thing just drives me absolutely up the wall and across the roof, down the other wall and back up again.

I suppose the biggest factor is that "BLS" in your system includes oh yes, oxygen and everything else is "advanced" so the education and mental conditioning covers just enough to enable you to do this, take some vitals and strap somebody to a board. Let's not get cute and say you can "assist" with GTN because that's not really something you can do medically, you can call and ask to help give somebody a tablet. Not the same thing.

 

[Melclin]

Often I'll BLS them. We have a ~5 minute, 1.5 mile transport, non-emergent. If I had a longer transport, I'd also be thinking more along the lines of ALS.
.

I'm so confused. It's like you blokes over there think BLS and ALS are actual procedures

But seriously, I am actually confused by this. When you say, "I'll BLS them" or "I'll ALS them", is this just a billing issue? Surely they just need the treatment, that they need. If its a ten minute transport and they need to be "ALSed", what does that involve that BLS doesn't?

 

[46Young]

I'm so confused. It's like you blokes over there think BLS and ALS are actual procedures

But seriously, I am actually confused by this. When you say, "I'll BLS them" or "I'll ALS them", is this just a billing issue? Surely they just need the treatment, that they need. If its a ten minute transport and they need to be "ALSed", what does that involve that BLS doesn't?

It's just the culture here, I suppose. Where I come from, NYC, to "BLS" them means to only treat within BLS protocols. To "ALS" someone means to perform one or more ALS only interventions. When we would give notifications to the hospital, the driver would give a radio report to the dispatcher such as: Male, 38, A&O3, R/O MI, 178/112, 108 regular, 24, ALS established, ETA 10 mins to the ED. ALS established typically means (in general) whatever interventions would be normally assosciated with the pt's condition, whatever matches that protocol.

Here's NYC's BLS and ALS protocols if you care to glance:

http://www.nycremsco.org/

To deviate from protocol, you need to call OLMC and get clearance to deviate. I believe this is due to the many different agencies providing 911 MS in NYC. Too many different agencies to place trust in any one crew without MD consult.