Oxygen for an unconc stroke patient? yes/no?

[DrParasite]

Question for all:

So I was on a BLS truck two nights ago, and we were dispatched for an unconscious stroke person. we get there about 20 seconds before the ALS unit, and find an unresponsive man in his 70s, tounge sticking out the right side of his mouth, with hx of diabetes and TIA and extensive heart problems. he is on oxygen via n/c at 2 LPM at home.

I ask the paramedic if he wants a NRB applied at 15LPM. so far he has done a basic 4 lead monitor assessment, and that's it. He asks me if I think he is in resp distress. it's an unconc poss CVA person, i don't know if he is in resp distress, he hasn't checked his pulse ox levels, so I put the NRB on the patient.

after the call he says "i tried to impart some knowledge on you. and you totally missed it. were his lungs clear, was his resp rate normal, and was he changing color? if these were all normal, he probably didn't need the NRB."

Would anyone else have done this? not applied a NRB to an unconc older person based on resp rate, lung sounds, and color change? has anyone else heard of this?

 

[JPINFV]

Now that I know what I know now. Nope. Unless I find something indicitive of resp distress/depression/failure, at most I might have upped the NC flow rate a few liters. What are you basing the need for a NRB on?

 

[Sassafras]

It was drilled into us that barring cyanosis, assess first, oxygen later. Had you taken an assessment you would have known the answers. Even without a pulse ox a quick cap refil check can give insight on perfusion. Did you listen to lung sounds or count resps at that point or did you run right to the nrb? Could you see if he at least looked like he was breathing normally? If so perhaps your medic was right? But concious or not, you still need the assessment. 100% pulse ox on a NRB doesn't tell if he's improving or not without a baseline.

I'm thinking I probably would have provided supplemental O2 in some form but I'd figure out what his assessment told me before I rushed to high flow O2.

 

[ZVNEMT]

i avoid the nrb unless the pt looks cyanotic or is obviously in resp distress ( even them i ask if they want it, sometimes they get claustophobic and tear it off). A pt with an hx of copd or chf will probably only require a few lpm. and if a pt has low spo2 levels i'd still start them off low. a little O2 can go further than you'd expected.

 

[Shishkabob]

If it was just the suspected stroke, and nothing pulmonic in nature, I might have upped his NC, but probably not done a full NRB, let alone 15lpm.

 

[usalsfyre]

Unless I was getting ready to control the patient's airway, no.

 

[akflightmedic]

Agree with the others and also encourage you to look into studies of excess oxygen in a hemorrhagic CVA. Consider the damage of free radicals in the brain....

 

[Melclin]

While I've read the studies, so have the stroke experts and the ones around these parts apparently still advocate all strokes receive 6-8litres via simple face mask early on. I can read all the papers I want, but I can hardly go against the considered opinion of the neurologists can I.

And doesn't that literature usually refer to minor and moderate stokes? This guys sounds like a pretty serious stroke.

 

[18G]

Agree with everyone else. Oxygen is not a benign drug. Unless the patient is showing signs of hypoxia (skin changes, tachypnea, tachycardia, < SpO2, > EtCO2, c/o dyspnea, adventitious lung sounds, etc) they do not need to have a NRB at 15lpm. This is a major nerve jerker for me!

The majority of stroke cases are thrombotic in nature... meaning a vessel supplying blood to the brain is blocked. If the patient is already well perfused and has a normal SpO2, administering high concentration of O2 is not gonna help. The patient already has a level of oxygen in the blood that is more than sufficient to meet the demands of the body.

The problem is a blocked vessel and oxygen has no thrombolytic properties. The American Heart association only recommends O2 by N/C unless SpO2 <92%.

I believe strongly that many providers don't know what to do or they want to do something so they administer high-flow O2. WRONG.

 

[jjesusfreak01]

Free radicals in the brain are bad, but in the case of a burst aneurysm isn't your (the medical communities) primary focus on keeping the pressure down in the cerebral cavity? I think that is the point of hyper-oxygenation for hemorrhagic CVA; the brain will not strive so much to increase the pressure if the brain is being perfused adequately, despite the hemorrhage.

 

[Epi-do]

I would have to agree with the others, that I would not immediately go to a NRB until I had completed an assessment, including doing a dex. Just because it looks like a stroke/TIA, doesn't mean that it is one, since the pt is a known diabetic.

I know that it is taught that "a little is good, alot is better" and "it can't hurt" when it comes to giving oxygen, that isn't always the case. If the pt is perfusing well and able to control his/her airway, there is no reason to use a NRB.

 

[Foxbat]

While I've read the studies, so have the stroke experts and the ones around these parts apparently still advocate all strokes receive 6-8litres via simple face mask early on. I can read all the papers I want, but I can hardly go against the considered opinion of the neurologists can I.

^^ This.
Unless ordered otherwise, I'll do what our protocols require, and they require high-flow O2 on suspected CVA pts. with ALOC.
Which ("regardless of what you read here, always follow your local protocols regarding O2") is also what Bledsoe suggests in his presentation about potential detrimental effects of O2.

 

[boingo]

Free radicals in the brain are bad, but in the case of a burst aneurysm isn't your (the medical communities) primary focus on keeping the pressure down in the cerebral cavity? I think that is the point of hyper-oxygenation for hemorrhagic CVA; the brain will not strive so much to increase the pressure if the brain is being perfused adequately, despite the hemorrhage.

I think you are confusing the hyperventilation in head injury where the goal is to decrease pCO2, not increase pO2, although hyperventilating the patient w/FiO2 of 1 will accomplish both.