O2 in ACS

[tssemt2010]

symptomatic vs asymptomatic, like everyone else has said, treat your patient not the monitor or in this case the pulse ox, i have seen a pulse ox read 83% while it was resting on a car seat not hooked up to anything, so they can be wrong

 

[shockinainteasy75]

So O2 can clear coronary blockages and decrease MvO2? Neato...

Haha. No, but its part of the process, in conjunction with NTG, and pain relievers in the prehospital world. And until we start carrying heparin and start cathing people at home ill stick with the original miracle drug. Lol

 

[usalsfyre]

Carried heparin, it's not going to clear coronary blockages either.

Look up the CaO2 equation, you'll realize how little supraphysiologic levels of O2 add. In addition, O2 does nothing to help lower MvO2. It theoretically might help meet demand, but coronary ischemia tends to be caused by other factors that won't be affected by O2. NTG has never been shown to have a true effect on outcome in AMI and pain management is just a humane effort.

The two things you can do for these patients are aspirin and transport to a cardiac facility.

 

[Shishkabob]

Haha. No, but its part of the process, in conjunction with NTG, and pain relievers in the prehospital world. And until we start carrying heparin and start cathing people at home ill stick with the original miracle drug. Lol

Can you explain to me why we use NTG and analgesics in MIs?

 

[JPINFV]

symptomatic vs asymptomatic, like everyone else has said, treat your patient not the monitor or in this case the pulse ox, i have seen a pulse ox read 83% while it was resting on a car seat not hooked up to anything, so they can be wrong

So a patient who is asymptomatic, but with a SpO2 of 88, provided the displayed heart rate matches your measured pulse rate and a good waveform is present if applicable, shouldn't have supplemental oxygen started?


More importantly, we should ignore a device that measures a physiologic parameter by using light wavelengths because when it's left out and it senses light wavelengths that correspond to a specific reading, it displays the reading? What's next, we should ignore EKGs because of CPR artifact?

 

[JPINFV]

Haha. No, but its part of the process, in conjunction with NTG, and pain relievers in the prehospital world. And until we start carrying heparin and start cathing people at home ill stick with the original miracle drug. Lol

So oxygen, NTG, and narcotics can clear coronary blockages? Neato...

 

[Shishkabob]

symptomatic vs asymptomatic, like everyone else has said, treat your patient not the monitor or in this case the pulse ox, i have seen a pulse ox read 83% while it was resting on a car seat not hooked up to anything, so they can be wrong

Actually... as has been stated before, the monitor is a viable and important part of our assessment.

If you have no monitor or other tools, and an unconscious patient, you telling me you'll give every drug in the box hoping it works? Or would you want to utilize the monitor to make a better diagnosis?

So a patient who is asymptomatic, but with a SpO2 of 88, provided the displayed heart rate matches your measured pulse rate and a good waveform is present if applicable, shouldn't have supplemental oxygen started?

Depends... hx of COPD or other disease? 88% COULD be their baseline... Granted, I don't like 88%, but that's not the question

 

[JPINFV]

Can you explain to me why we use NTG and analgesics in MIs?

At least with analgesics...

[youtube]http://www.youtube.com/watch?v=gRdfX7ut8gw[/youtube]


Side note: looking at the Evidence Based Protocols website, there's more evidence for nitrates that I thought there was.

 

[tssemt2010]

So a patient who is asymptomatic, but with a SpO2 of 88, provided the displayed heart rate matches your measured pulse rate and a good waveform is present if applicable, shouldn't have supplemental oxygen started?


More importantly, we should ignore a device that measures a physiologic parameter by using light wavelengths because when it's left out and it senses light wavelengths that correspond to a specific reading, it displays the reading? What's next, we should ignore EKGs because of CPR artifact?

supplemental yes but i wouldnt jump straight to 15lpm

 

[Shishkabob]

At least with analgesics...

What, nothing to do with decreasing pain which leads to decreasing catecholamine release leading to decreased blood pressure, heart rate and oxygen demand on the heart? :unsure:

 

[JPINFV]

supplemental yes but i wouldnt jump straight to 15lpm

Why start supplemental oxygen at all (no one said anything about a NRB) if the patient is asymptomatic and being symptomatic was the only thing that matters? After all, what if the pulse ox was wrong!

 

[JPINFV]

What, nothing to do with decreasing pain which leads to decreasing catecholamine release leading to decreased blood pressure, heart rate and oxygen demand on the heart? :unsure:

...and trendelenburg results in autotransfusion.



http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=144#Analgesia%20%28iv%20narcotic%29

To add, AHA ranks analgesia as class I (benefit >>> harm), but with a level of evidence of C (expert opinion).

In other words, analgesia works because we said so.

 

[Shishkabob]

Meh, I'm off to a hibachi restaurant, but I'll have to hunt down the few studies I've read of it.

 

[shockinainteasy75]

supplemental O2 can help meet the demands of the myocardium, in turn, decreasing demand (lehmans: supply vs. demand). NTG, vasodialates increasing blood flow (however little it may be) past the blockage increasing coronary perfusion. Aspirin can help re-perfuse and analgesics are not humane in nature, we shoot dogs who are in pain, thats humane, the analgesics serve to lower anxiety levels and vasodialate (we use Morphine in MD). Lowered anxiety levels equate to potentially lower BP, in turn, once again decreasing myocardial O2 demands. I agree, the best treatment is a diesel bolus and bright lights and cold steel but if thats all were gonna due, just make ACS calls BLS and save the ALS units for uncontrollable epistaxis.

 

[STXmedic]

supplemental O2 can help meet the demands of the myocardium, in turn, decreasing demand (lehmans: supply vs. demand).

We're talking physiology, not economics. If their hemoglobin is already 100% saturated, how is blowing more O2 in their face going to satisfy the demand of the heart? If hemoglobin can carry "up to 4" molecules of oxygen, it's not going to magically carry six when you slap a NRB or NC on them.

 

[Handsome Robb]

You realize how much anxiety your going to add to your patient when transporting code 3 therefore increasing their BP, HR and myocardial oxygen demand? Bad call.

Analgesics are humane, we don't give them to reduce anxiety, we give them to reduce pain. Your correct in the fact that reduced pain reduces anxiety, I'll give you that.

Aspirin does not help re-perfuse, it is a platelet aggregator, preventing the clot from becoming larger, it does nothing to break the clot and return perfusion to the ischemic tissue.

Yea NTG might dilate the vessels, but that clot is just going to move through the dilated vessels only to get caught again as the vessels decrease in size. (Remember Arteries -> arterioles -> capillaries?) NTG does nothing to break the clot up.

Morphine reduces pain, therefore reducing anxiety while also reducing preload by reducing venous return thus lowering the workload on the heart and myocardial oxygen demand.

ACS is not a BLS call, can you interpret a 12 lead? STEMI alerts activated by ALS providers after reviewing a 12 lead in the field reduce door to cath-lab time and increase survivability and quality of life in ACS patients post-discharge from the hospital.

Hyper-oxygenation constricts coronary vessels, it's a proven fact. Yea there's a high PaO2, but if the vessels are constricted then the blood with the high PaO2 can't get to the tissue what good does that do? Do some more continuing education other than the bare minimum.

This is coming from a fellow Intermediate.

 

[JPINFV]

We're talking physiology, not economics. If their hemoglobin is already 100% saturated, how is blowing more O2 in their face going to satisfy the demand of the heart? If hemoglobin can carry "up to 4" molecules of oxygen, it's not going to magically carry six when you slap a NRB or NC on them.

Even if hemoglobin could magically carry 6 molecules. It doesn't matter if the hemoglobin never actually gets past the occlusion.

 

[Handsome Robb]

Even if hemoglobin could magically carry 6 molecules. It doesn't matter if the hemoglobin never actually gets past the occlusion.

My hemoglobin is badass

 

[shockinainteasy75]

You realize how much anxiety your going to add to your patient when transporting code 3 therefore increasing their BP, HR and myocardial oxygen demand? Bad call.

Analgesics are humane, we don't give them to reduce anxiety, we give them to reduce pain. Your correct in the fact that reduced pain reduces anxiety, I'll give you that.

Aspirin does not help re-perfuse, it is a platelet aggregator, preventing the clot from becoming larger, it does nothing to break the clot and return perfusion to the ischemic tissue.

Yea NTG might dilate the vessels, but that clot is just going to move through the dilated vessels only to get caught again as the vessels decrease in size. (Remember Arteries -> arterioles -> capillaries?) NTG does nothing to break the clot up.

Morphine reduces pain, therefore reducing anxiety while also reducing preload by reducing venous return thus lowering the workload on the heart and myocardial oxygen demand.

ACS is not a BLS call, can you interpret a 12 lead? STEMI alerts activated by ALS providers after reviewing a 12 lead in the field reduce door to cath-lab time and increase survivability and quality of life in ACS patients post-discharge from the hospital.

Hyper-oxygenation constricts coronary vessels, it's a proven fact. Yea there's a high PaO2, but if the vessels are constricted then the blood with the high PaO2 can't get to the tissue what good does that do? Do some more continuing education other than the bare minimum.

This is coming from a fellow Intermediate.

A. I would kill a driver who drove like an idiot with any pt. I do not advocate that kind of transport. However i am completely honest with my pts, they know somethings wrong and by telling them the truth it takes away from the anxiety of "not knowing".

B. You are correct in that aspirin does not dissolve a clot, however, aspirin is listed as a primary initial step under reperfusion therapy in both ACS and Ischemic stroke. In the future i will be more precise with my words.

C. When it comes to NTG, i said nothing about clot busting, it vasodialates, and even if the clot moves, we now have the chance of it moving to a more branched vessel, decreasing the area of injury/ischemia.

D. I agree with your morphine statement, 100%, i do not like the terming of humane, we treat people because they deserve the treatment, not because we feel pity for them as the word humane would suggest.

E. Im not saying ACS should be a BLS, it was in response to an earlier statement that aspirin and trans was the only things we can do for these pts. As far as im concerned, if dispatchers (in our area) can advise pt.s to take aspirin prior to our arrival, a BLS provider should be able to. There are far more things we can do for these pt.s to improve their chances of survival. Yes, i can interpret a 12 lead, not as well as id like to be able to, but well enough to be effective.

F. No, hyper oxyenation is not a "proven", nor "disproven" fact. Certain agencies support and others refute. That is completely up to the providers and the service area. This can go on and on involving the dispute of pulse oximeters, remembering that pulse ox's determine the % of hemoglobin saturated with something, may not always be oxygen. And even in the studies that support the ill effects of hyperoxygenation, they are quick to point out that the potential positive effects of supplemental oxygen at low concentrations out weigh the potential ill effects of this therapy.

Please do not question my education level without knowing, nor speaking with me. I dont not claim to know half of what most people in this forum do. I do however, take the extra steps, take the extra classes, read the articles and studies and do my research.

 

[Handsome Robb]

A. I would kill a driver who drove like an idiot with any pt. I do not advocate that kind of transport. However i am completely honest with my pts, they know somethings wrong and by telling them the truth it takes away from the anxiety of "not knowing".

B. You are correct in that aspirin does not dissolve a clot, however, aspirin is listed as a primary initial step under reperfusion therapy in both ACS and Ischemic stroke. In the future i will be more precise with my words.

C. When it comes to NTG, i said nothing about clot busting, it vasodialates, and even if the clot moves, we now have the chance of it moving to a more branched vessel, decreasing the area of injury/ischemia.

D. I agree with your morphine statement, 100%, i do not like the terming of humane, we treat people because they deserve the treatment, not because we feel pity for them as the word humane would suggest.

E. Im not saying ACS should be a BLS, it was in response to an earlier statement that aspirin and trans was the only things we can do for these pts. As far as im concerned, if dispatchers (in our area) can advise pt.s to take aspirin prior to our arrival, a BLS provider should be able to. There are far more things we can do for these pt.s to improve their chances of survival. Yes, i can interpret a 12 lead, not as well as id like to be able to, but well enough to be effective.

F. No, hyper oxyenation is not a "proven", nor "disproven" fact. Certain agencies support and others refute. That is completely up to the providers and the service area. This can go on and on involving the dispute of pulse oximeters, remembering that pulse ox's determine the % of hemoglobin saturated with something, may not always be oxygen. And even in the studies that support the ill effects of hyperoxygenation, they are quick to point out that the potential positive effects of supplemental oxygen at low concentrations out weigh the potential ill effects of this therapy.

Please do not question my education level without knowing, nor speaking with me. I dont not claim to know half of what most people in this forum do. I do however, take the extra steps, take the extra classes, read the articles and studies and do my research.

A. I didn't say anything about idiot drivers. I'm all for being honest with my patients, however transporting them with lights and sirens will increase their anxiety far more than simply telling them what is happening and transporting routine. Code 3 transport barely saves any time. In a rural setting it may be warranted but at that point is when I would consider Aeromedical transport (thats another can of worms all together) but not in an urban setting.

B. Fair enough, we both seem to agree on aspirins roll in reperfusion, its a step, but technically has nothing to do with reperfusion.

C. It may move to a branched artery, yet it may also be caught in the turbulent flow found at bifurcations of blood vessels. We can play the "what if" game all day.

D. I don't feel pity, however I am empathetic towards their problem. Humane isn't technically the correct word, and I'll agree with you on that, however *random point here* does the Humane Society feel pity towards animals?

Definition of pity taken from dictionary.com : sympathetic or kindly sorrow evoked by the suffering, distress, or misfortune of another, often leading one to give relief or aid or to show mercy.

Humane as defined by dictionary.com: characterized by tenderness, compassion, and sympathy for people and animals, especially for the suffering or distressed.

From these definitions I would personally define analgesics as humane, but thats just me.

E. I concede, I misread your post.

F. Agreed it is up to the medical director of the service. Yes they do point out the potential positive effects of hyperoxygenation, however they prove through scientific studies the ill effects as well. I am aware of how pulse oximeters work regarding saturation of hemoglobin.

ill stick with the original miracle drug.

This is where I started questioning your education level. Oxygen is not a miracle drug. Besides in ACS another immediate point that comes to mind is hyperoxygenation in the presence of ICP and it's effects on CPP. I apologize for jumping to conclusions. I'm glad there are providers out there striving to further their knowledge.