Oxygen Question

[leoemt]

EMS is an ever evolving field and I am always trying to learn. My legal background has made it so I want to be able to justify my actions if ever questioned.

I believe she did fracture her Clavicle. There was an obvious deformity upon palp, she screamed in pain upon palp and wanted to deck me when I palpated it. Additionally, movement of the arm caused pain to increase.

Second question, is there anything that can be done in field for an injured clavicle? Would a sling and swathe have been appropriate? I didn't even consider that at the time, but in hindsight I am wondering if that would have been appropriate.

 

[JPINFV]

NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm. Vital signs could have easily changed, you basically prevented from things getting worse. Your FTO was right.

Lots of things "don't hurt." That doesn't mean it's the right treatment choice or helpful.

 

[Medic Tim]

NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm. Vital signs could have easily changed, you basically prevented from things getting worse. Your FTO was right.

 

[Tigger]

Second question, is there anything that can be done in field for an injured clavicle? Would a sling and swathe have been appropriate? I didn't even consider that at the time, but in hindsight I am wondering if that would have been appropriate.

The sling and swath can provide comfort for many shoulder and clavicle injuries. It is not uncommon to find patients with these injuries to present with their injured arm being held across their chest. If that's the case, a sling can help ease the load.

If nothing else it's worth a shot. If the patient finds a slung position helpful, use it. If not, oh well it was only a cravat and a minute of your time. There are some times when the body' position of least discomfort is better than a splint or other adjunct.

 

[NYMedic828]

EMS is an ever evolving field and I am always trying to learn. My legal background has made it so I want to be able to justify my actions if ever questioned.

I believe she did fracture her Clavicle. There was an obvious deformity upon palp, she screamed in pain upon palp and wanted to deck me when I palpated it. Additionally, movement of the arm caused pain to increase.

Second question, is there anything that can be done in field for an injured clavicle? Would a sling and swathe have been appropriate? I didn't even consider that at the time, but in hindsight I am wondering if that would have been appropriate.

Sounds broke lol.

As tigger said, sling and swath if they can bend their arm to the position.

Ice if you want.

ALS, pain management.

 

[leoemt]

NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm. Vital signs could have easily changed, you basically prevented from things getting worse. Your FTO was right.

Explain this clincally to me?

Based on what I know Oxygen is used in a process called perfussion. When someone is perfusing normally, why should I give them extra Oxygen? What benefit am I providing to the patient for giving them extra oxygen when they are already at 100%? While I couldn't do a pulse ox, I did do a cap refill test on her. While that is not exactly accurate in adults, she was under 2 seconds.

Our doctors teach us to treat a patient, not numbers. Which is why our protocols put so much emphasis and signs and symptoms.

I give Oxygen because it is warranted based on clinical presentation, not because the book says so.

If your going to advocate giving Oxygen that is fine, but back it up with a clinical explanation to support your reasoning.

 

[NYMedic828]

The short 101 version.

Ventilation - the mechanical process of expansion/relaxation of the lungs to move air in and out of the body.

Respiration comes in two forms.

External: exchange of CO2/o2 within the lungs between the alveoli and outside environment.

Internal: exchange of Co2/o2 by body cells and blood.

Oxygenation is the oxygenating of body cells/tissues. Essentially the same as internal respiration but a more frequently used term.

SpO2 - measurement of bound hemoglobin in blood. One molecule of hemoglobin can hold 4 molecules of O2 and one red blood cell can have 280million molecules of heme.

PaO2/PO2 - measurement of the partial pressure of oxygen in the bloodstream.

We can measure SpO2 with pulse oximetry under optimal conditions and an SpO2 of 100% is roughly equal to a PaO2 of 100mmHg. So with a 100% sat we can assume a PaO2 of atleast 100.

We can't force hemoglobin to hold more than it is capable, there for SpO2 can never exceed 100%. BUT, PaO2 can be increased and a higher PaO2 alters the weight of the concentration gradiant of oxygen which tries to force more oxygen onto hemoglobin even though it can't take it. This causes heme to more rapidly bind O2 and increases its ability to get into tissues. This is how hyperbaric therapies work, increasing the pressure of oxygen so it forces substances like carbon monoxide out.

You won't increase PaO2 with a nasal cannula or non-rebreather. To increase PaO2 requires increases in atomospheric pressure. A BVM/vent mask can potentially increase PaO2 if it isolates outside pressures. The body is constantly trying to reach equilibrium with himself and the outside environment it exchanges with.

In short, if the patient is satting at 100% and you believe that number to be accurate the NC @ 2 LPM serves no purpose outside of a placebo. But we don't give placebos...

 

[the_negro_puppy]

NO matter what I have always learned it never hurts to give oxygen via NC @ 2 lpm. Vital signs could have easily changed, you basically prevented from things getting worse. Your FTO was right.

 

[PotatoMedic]

Well I'm going to place myself on the side of the administer o2 due to the dizziness a the pt being lethargic. 2lpm. My thinking is that even though vs looks good perfusion may be decreased. If symptoms resolved after o2 i would continue to hospital. If nothing got better i would remove. Even if i left it on the length of the transport would not cause any adverse effects and probably would not even dry out their nose. My bet is that she could live without it for duration. But if i can enter that er and state pt complaining of xyz and abc did not relieve symptoms then the nurses and dr can have a better idea what's going on.

 

[mgr22]

As I understand it, cells can be damaged by exposure to more O2 than those cells are able to use. I think the mechanism is free radicals interfering with cellular metabolism. Vene, can you confirm? New ACLS guidelines for ACS and CVA recommend supplementary O2 only when the SpO2 falls below 94%. This definitely conflicts with decades-old primary training that O2 can't hurt.

 

[medichopeful]

I think an F35 lightning is more appropriate. A helicopter is too slow.

Yeah I gotta admit, for this patient I'd definitely consider calling an F35 in, mostly because I'd love to see the damn thing!

 

[NYMedic828]

Well I'm going to place myself on the side of the administer o2 due to the dizziness a the pt being lethargic. 2lpm. My thinking is that even though vs looks good perfusion may be decreased. If symptoms resolved after o2 i would continue to hospital. If nothing got better i would remove. Even if i left it on the length of the transport would not cause any adverse effects and probably would not even dry out their nose. My bet is that she could live without it for duration. But if i can enter that er and state pt complaining of xyz and abc did not relieve symptoms then the nurses and dr can have a better idea what's going on.

We
Do
Not
Administer
Treatments
That
Are
Not
Warranted


Dizziness without any underlying presumed pathology affecting oxygen delivery is NOT a reason to give O2. Half the patients I pick up complain they are dizzy and 1/4 of them if even do I put on O2. Patient has no respiratory complaint, lung sounds reveal no insult to the lungs with great air flow, where is the issue with oxygen delivery?

Administering O2 for chest pain in theory, useless. Stroke? Useless. The issue is not oxygen intake of the body it is oxygen delivery which can't be fixed in an ambulance.

The three parts of oxygen delivery are vessels, Heme/RBCs, heart. If the blood/heme cannot reach the site, no amount of oxygen in the world is going to increase perfusion.

It is not a warranted treatment 9/10 when EMS providers administer it.

If a patient states they are in fact short of breath, administer o2 titrated to effect don't just slap a NRB at 15lpm on them. They may only need 2 liters. Sometimes doing nothing at all does the most good.

As I understand it, cells can be damaged by exposure to more O2 than those cells are able to use. I think the mechanism is free radicals interfering with cellular metabolism. Vene, can you confirm? New ACLS guidelines for ACS and CVA recommend supplementary O2 only when the SpO2 falls below 94%. This definitely conflicts with decades-old primary training that O2 can't hurt.

Yes. As I understand it, after talking with Vene a few times about it, the short version is the body is set up to intake 20.9% oxygen from the environment. Free radicals naturally occur as chemistry in the body utilizes oxygen and the body contains "antioxidants" to combat these free radicals that would otherwise harm tissues through the process of "oxidation." The unpaired electron of the superoxide O2- ion (free radical ion of oxygen) essentially steals an electron from what it comes in contact with, which is hopefully an antioxident such as glutathione that would prevent it from binding to tissues and interrupting important biological processes.

When we increase the FiO2 and the body has nowhere to put it, many more free radicals form than naturally would which can deplete the antioxidizing reserves of the body and actually worsen disease processes, lead to new disease or form localized scar tissue.



Oxidation: (yes I linked wikipedia)
http://en.wikipedia.org/wiki/Oxidation

 

[Aidey]

Preach it!

And if that doesn't work, start beating people with NRBs.

 

[Aidey]

Out of curiosity, can anyone name any causes of dizziness that can be improved with oxygen? Besides hypoxia.

 

[NYMedic828]

Out of curiosity, can anyone name any causes of dizziness that can be improved with oxygen? Besides hypoxia.

Honestly... I got nothing. I'm sure one of these fancy RN/MD types will spew something out for it but as far as I can think of they all relate back to hypoxia/hypoxemia as the root cause if they truly need oxygen for it?


Hypoxia is technically the only treatable condition which warrants oxygen regardless of what is causing it...

 

[PotatoMedic]

We
Do
Not
Administer
Treatments
That
Are
Not
Warranted

And in my opinion one or more of the symptoms could be an oxigenation issue. You can disagree, which you will, but thats life. No o2 is not warrented for 90% of the time we are told to put it on and i think in my two years as an emt i have used it less than 10 times. But without seeing the pt and doing an assessment myself i will always lean to the conservative side.

 

[NYMedic828]

Opinion and fact are vastly different.

Please list for me the symptoms presenting that could in any way shape or form constitute an issue with oxygenation when you know for a fact the patient is adequately perfusing.

Mind you I imply use of proper assessment techniques and pulse oximetry.

 

[mycrofft]

Out of curiosity, can anyone name any causes of dizziness that can be improved with oxygen? Besides hypoxia.

(Is there anything which can be profitably treated with an AED, besides a shockable rhythm?).

That's the way to take it down to the irreducible minimum, then own it.

Heck, can most new techs even describe the s/s of hypoxia/air hunger without resorting to something with AA batteries in it?

 

[PotatoMedic]

Dizziness and her being lethargic are the two things that i know that could be an oxygenation issue and do we know for a fact that she was prefusing normally? We have no spo2 and he never mentioned what the skin signs looked like. Her head might be warm to the touch but are her hands cold? The body may vaso constrict to keep the core warm and oxygenated. Lack of o2 reduces the amount of atp generated reducing amount of energy causing lethargia.

Yes you are correct there are many other things that could be the cause of the pt's symptoms. But with what little information we all have i can see someones logic in applying up to 2leiters of o2 and seeing if it resolves the issue. Am i more then happy to not apply o2 if i see a reason not to like good skin signs and good prefusion with the symptoms above? Yes. But again I dont know all the details i want to know to make a definitive answer.

Now since I like to learn can you take me through your thought process on what is going on with this pt and why?

 

[NYMedic828]

Dizziness and her being lethargic are the two things that i know that could be an oxygenation issue and do we know for a fact that she was prefusing normally? We have no spo2 and he never mentioned what the skin signs looked like. Her head might be warm to the touch but are her hands cold? The body may vaso constrict to keep the core warm and oxygenated. Lack of o2 reduces the amount of atp generated reducing amount of energy causing lethargia.

Yes you are correct there are many other things that could be the cause of the pt's symptoms. But with what little information we all have i can see someones logic in applying up to 2leiters of o2 and seeing if it resolves the issue. Am i more then happy to not apply o2 if i see a reason not to like good skin signs and good prefusion with the symptoms above? Yes. But again I dont know all the details i want to know to make a definitive answer.

Now since I like to learn can you take me through your thought process on what is going on with this pt and why?

Rehab center, extremely painful clavicular/arm injury, syncope for unknown reason without more info and landed on her arm.