Forgot oxygen

[HMartinho]

You stated

"I really can't see why O2 is important in this patient..."

I thought you were portraying that sarcastically in the direction of they should have had oxygen based on symptoms.

My apologies.

No problem.

I think the problem is also my bad English. Anyway, I believe I can still improve, and read this forum has helped me a lot.

 

[Bullets]

Sorry! I wasn't too clear on forgetting the oxygen. In a non-respiratory emergency, I tend to judge how much o2 is needed based on pulse ox reading. There was no immediate indication for o2 on this one
I now know that I should rely more on overall patient condition. I learned a lot from this call

Ok, you need to drop the pulse ox. You can palpate a radial pulse, and you have eyes to see a patient. If they are hypoxic then you will be able to see it. Look at how the patient is presenting. No tool is a substitute for a quality assessment.

Also

 

[jjesusfreak01]

You'll find out that's a load of bull. A nasal cannula is not comfortable and it doesn't make a lick of difference half the time.

Not disagreeing with you. Hospice patient the other day on 4L NC, no COPD history, satting 92%, reports SOB. Patient was mouthbreathing. Moving the NC to their mouth bumped SPO2 to 98%, pt no longer reported SOB.

 

[Sasha]

Not disagreeing with you. Hospice patient the other day on 4L NC, no COPD history, satting 92%, reports SOB. Patient was mouthbreathing. Moving the NC to their mouth bumped SPO2 to 98%, pt no longer reported SOB.

I wish we carried simple face masks for stuff like this.

 

[Shishkabob]

I wish we carried simple face masks for stuff like this.

Pop the tabs out of the sides of an NRB and you're basically there.

Look at how the patient is presenting. No tool is a substitute for a quality assessment.

EKG?
EtCO2?
EEG?
MRI?
CT?


Tools are to augment your assessment for a reason. Just because it says 90% doesn't mean you treat, just because it says 100% doesn't mean you don't treat, but to ignore its benefits are ignoring its true purpose.

 

[the_negro_puppy]

Treat the patient AND the monitor/SP02/ECG/EtCo2

 

[NYMedic828]

Not disagreeing with you. Hospice patient the other day on 4L NC, no COPD history, satting 92%, reports SOB. Patient was mouthbreathing. Moving the NC to their mouth bumped SPO2 to 98%, pt no longer reported SOB.

...moving the NC to their...mouth?

Linuss I believe Sasha was being sarcastic suggesting what in the world you would put a NC in someone's mouth for over switching to a NRB.

There's a few issues, to me, with the patient he has presented us besides the oral NC.

Regardless of the delivery device used, a hospice patient in my eyes is not really fair to include with the general population of patients. This is a person with chronic end stage multi-system dysfunction. There body doesn't work nearly the same as a regular patient depending on what their illnesses are.

If she is blatently mouth breathing she probably is not pulling much pure o2 in from the nose/NC. A NC at 4 LpM I believe has an FiO2 of 15%+21% room air. The problem is, FiO2 is INSPIRED oxygen. The nasal canula is spraying out 100% oxygen, but without the tidal volume of room air it is nearly useless.

So she has an extra 15% o2 available to be inspired via the nose, but of course it is doing next to nothing if there is no tidal volume to take it to the alveoli.

 

[usalsfyre]

NyMedic,

I've done the NC in the mouth thing, it seems to work. Look up passive insuflation and the partial pressure concept to see why you can oxygenate even when the patient is apenic.

 

[NYMedic828]

NyMedic,

I've done the NC in the mouth thing, it seems to work. Look up passive insuflation and the partial pressure concept to see why you can oxygenate even when the patient is apenic.

I am not saying it won't work. I'm asking why would you.

If a medical director saw/heard I gave someone O2 by an oral NC, I would have a lot of explaining to do.

Oxygen is a gas, it will fill the space it is put into regardless of ventilation if nothing blocks it's path. But why would I not use a NRB for that scenario...

 

[Christopher]

I am not saying it won't work. I'm asking why would you.

Because a mask wasn't appropriate?

 

[NYMedic828]

Because a mask wasn't appropriate?

On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?

 

[usalsfyre]

I am not saying it won't work. I'm asking why would you.

Because the patient wouldn't tolerate a mask.

If a medical director saw/heard I gave someone O2 by an oral NC, I would have a lot of explaining to do.

Simple. "The patient exhibited signs of air hunger and hypoxia but wouldn't tolerate a mask. So we put the NC in his mouth, he showed less exertion and his sats went up".

Oxygen is a gas, it will fill the space it is put into regardless of ventilation if nothing blocks it's path. But why would I not use a NRB for that scenario.

Like I said above, a mask isn't always appropriate or tolerated.

 

[usalsfyre]

On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?

You haven't hauled a whole lot of hospice patients have you?

 

[NYMedic828]

On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?

You haven't hauled a whole lot of hospice patients have you?

No, I have not. A few at most. I havent done an IFT in 3 years.

I am not asking in a manor to say you are wrong, I am asking to hear your reasons why, so that I may learn.

 

[Christopher]

On a living breathing patient, other than 1/10000 scenarios how could you justify a NC in the mouth being more appropriate than a mask?

If they're mouth breathing an NC in the mouth works great. They've provided the airway adjunct and I'm providing the blow-by.

Same with an NC over a Stoma, you can cut off one of the two prongs and it usually works way better than holding a mask over it.

 

[usalsfyre]

No, I have not. A few at most. I havent done an IFT in 3 years.

I am not asking in a manor to say you are wrong, I am asking to hear your reasons why, so that I may learn.

Very often they're at a baseline diminished LOC, when they get hypoxic the claustrophobia sets in and the won't tolerate a mask. An NC in the mouth works great.

 

[AnthonyM83]

Coming full circle: no respiratory complaint or distress? No need for O2.

Really Chris? So, signs/symptoms of shock and altered (but no respiratory distress) gets no oxygen?

It certainly doesn't at less than 2 L/min

22% FiO2 at 2 L/min...20.8% in the air they're breathin', hmmm.

That would be 29%....approximately 4% increase for every L/Min increase

According to my instructor, even if a patient does not necessarily need the O2, the placebo effect may make them "feel better" and help calm the situation. I'm not in the field yet but I've never really understood how that could be true. I would think that some patients would get more worked up and wonder why they need O2.:censored:

I won't use oxygen for comfort, but I have definitely used it for placebo effect for pain control. Placebo effect can be a very strong and if I'm in pain, my healthcare provider is welcomed to palcebo the hell out of me.

Though, as more and more literature comes out about the dangers of O2 administration, I do this very rarely nowadays.

 

[AnthonyM83]

Ok, you need to drop the pulse ox. You can palpate a radial pulse, and you have eyes to see a patient. If they are hypoxic then you will be able to see it. Look at how the patient is presenting. No tool is a substitute for a quality assessment. [/IMG]

Except, now they're giving us two standards. The signs of hypoxia which is what we looked for all along. But now we're increasing the standard to include pulse ox as well. So, patient could look fine, but could still use oxygen...so they tell us.

I am not saying it won't work. I'm asking why would you.

If a medical director saw/heard I gave someone O2 by an oral NC, I would have a lot of explaining to do.

Patient is breathing through his mouth due to a stuffy nose. Chest pain. No respiratory distress, but sat is 93%. Air gets drawn in with the inhale.

Could use a mask, too...but honestly, I don't know how much I'm giving with an NRB at its lower settings (below the recommended range).



RANDOM STORY ABOUT BENEFIT OF OXYGEN:
I've had a near syncope at work before. I was sick, dehydrated, and think I vagaled myself. I dragged myself hands and knees from the bathroom to our oxygen tank with extreme weak/dizziness, sweaty, and skin felt hot/cold. Put an NRB mask on. INSTANT relief. That was the best feeling in the world right there. It was like being released from a choke hold.

 

[Christopher]

Really Chris? So, signs/symptoms of shock and altered (but no respiratory distress) gets no oxygen?

Anxiety or restlessness is a subtle sign of air hunger, indicating a potential mismatch in perfusion. At this point you can add oxygen to maybe improve their status...keeping in mind that hyperoxemia is not healthy either.

In patients with true shock they almost always have a derangement in their respiratory rate and quality as part of their compensatory drive. Both of these I would interpret as signs of "distress".

That would be 29%....approximately 4% increase for every L/Min increase

I guess this depends on the text, but I'll accept 29% at 2L/min. I just ask that at least 3 L/min be used if you have an indication for supplemental O2 therapy on a patient who is not normally on supplemental O2. At that rate you're guaranteed a higher concentration of oxygen being delivered than in room air.

I won't use oxygen for comfort, but I have definitely used it for placebo effect for pain control. Placebo effect can be a very strong and if I'm in pain, my healthcare provider is welcomed to palcebo the hell out of me.

I give pain medication for pain control, but I'm also ALS so it isn't necessarily a fair comparison for BLS providers. My only point is that supplemental oxygen should be given due to an indication, not just because someone is an EMT or Paramedic and feel like they should be doing something.

 

[NYMedic828]

RANDOM STORY ABOUT BENEFIT OF OXYGEN:
I've had a near syncope at work before. I was sick, dehydrated, and think I vagaled myself. I dragged myself hands and knees from the bathroom to our oxygen tank with extreme weak/dizziness, sweaty, and skin felt hot/cold. Put an NRB mask on. INSTANT relief. That was the best feeling in the world right there. It was like being released from a choke hold.

Not so sure that reflects any TRUE benefits of oxygen. I think you may have placeboed yourself in a time of distress that probably had you a bit out of it to begin with.

Chris, would you happen to have any articles handy on hyperoxia/hyperoxemia/oxygen toxicity? (need material for a presentation)