Oxygen and heart attacks

Underoath87

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The vasoconstrictive effects of oxygen are widely recognized and mentioned in current textbooks. Do a google search for hyperoxemia.
 

SeeNoMore

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That being said it's still very common to see patients managed with excessive amounts of oxygen despite a SP02 of 100 or access to ABGs. I don't think the culture/folk wisdom of many EMS providers and some EDs/ICUs has caught up with the science.
 

SandpitMedic

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I rarely put anyone on O2...

The oxygen oxygen oxygen mantra is long gone.

Our protocols state our goal for SpO2 is 94-99% for a normal human or greater than 90% for folks with chronic breathing issues.

Obviously, SpO2 is not always 100% reliable based on why my patient is a patient- for example CO poison, hypovolemic, etc.

If I think they need it or are legitimately SOB I will administer PRN.

But doing it just to do it is not something I'm about. Goes for other treatments as well.
 

SandpitMedic

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Science is finding that too much O2 is not good for your patient. "Free radicals" of oxygen actually make ischemia worse.

Evidence based medicine.

Slow learning curve.
 

SeeNoMore

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I still regularly put people on 02 or titrate 02 levels. But rather than leave it on high levels I evaluate their response based on the assessment/lab results available to me and titrate 02 down as appropriate. I use high flow 02 during intubation but don't maintain it once they are on a vent unless needed.
 

RedAirplane

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I was always taught that, yes, oxygen can have harmful effects. But in the short term, I'll do more damage trying to figure things out than just using 15L NRB for the ten minutes I'm with the patient. I asked about COPD patients and was told that if they stop breathing then I can breathe for them.

If this is a little off base, how do you determine how much oxygen is needed? Especially without pulse oximetery?
 

STXmedic

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I was always taught that, yes, oxygen can have harmful effects. But in the short term, I'll do more damage trying to figure things out than just using 15L NRB for the ten minutes I'm with the patient. I asked about COPD patients and was told that if they stop breathing then I can breathe for them.

If this is a little off base, how do you determine how much oxygen is needed? Especially without pulse oximetery?
Yes, that is off base- especially with a NRB. Do you not have pulse oximetry?

Regardless, you determine the need for oxygen by looking for signs of hypoxia and respiratory distress (in conjunction with pulse oximetry if you have it). Cyanosis, pallor, respiratory rate, work of breathing, etc. If they are not showing any signs of hypoxia or respiratory distress, they don't need oxygen. Oxygen is not a comfort measure. It's not an antiemetic. It's not an analgesic. It's a medication with indications and side-effects. Also, COPD is not a contraindication, and I would not expect you to come across somebody that has a hypoxic drive and stops breathing. It is rare, and with prolonged exposure to increased FiO2.

A NRB is typically overkill, too. It's been well over a month since I've had to use a NRB. A nasal cannula is usually more than enough. Without pulse oximetry to assist in your decision-making and ability to titrate, I could understand being a little quicker to put a borderline patient on O2, but if they're borderline and not showing obvious signs of hypoxia, a nasal cannula should work just fine.
 
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SeeNoMore

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Given a short transport time and lack of access to pulse oximetry I don't think anyone would fault you for erring on the side of high flow 02 for patients in some degree of distress. However, I have seen plenty of providers use a NRB with high flow 02 based solely on a complaint/presentation (chest pain, traumatic injury ) without any respiratory distress or signs of hypoxia. I think EMS education and clinical time focuses on "doing something" and it can be hard to restrain yourself from putting on 02 as a matter of habit. This gets ingrained early on in many EMT programs and I remember being chastised for choosing not to use 02 without a clear indication early on in my student career because I had read about the detrimental effects of excessive 02 administration. There is a huge gap between the practice of self motivated clinicians who spend plenty of time hitting the books and useful internet sites and many others who treat evidence based medicine with skepticism or open hostility. Especially when time honored EMS traditions are called into question. That being said the flip side of the coin is relying on a brief review of the literature , a single study or a casual conversation to inform a change in your practice. I think organizations should develop strong internal education programs to bridge this divide and ensure consistent and coherent delivery of care.
 

RedAirplane

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Thanks guys.

For me, pulse oximetery is considered ALS. It's interpreting a medical device, categorized along with EKG.
 

STXmedic

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Thanks guys.

For me, pulse oximetery is considered ALS. It's interpreting a medical device, categorized along with EKG.
So grandma at home with COPD is more of an ALS provider than EMTs there?... We've all *****ed about how ridiculous SoCal EMS is (assuming that's where you're from), but it still blows my mind.
 

SandpitMedic

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CNAs interpret SpO2 readings.... And you can too... Don't be a...... Nevermind.
 

irishboxer384

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I was always taught that, yes, oxygen can have harmful effects. But in the short term, I'll do more damage trying to figure things out than just using 15L NRB for the ten minutes I'm with the patient. I asked about COPD patients and was told that if they stop breathing then I can breathe for them.

If this is a little off base, how do you determine how much oxygen is needed? Especially without pulse oximetery?

It takes seconds rather than ten minutes to ascertain whether the patient requires any amount of O2 (STX has reminded you of a few of the things to look for)...it is part of your assessment to determine if and when a patient requires O2...not sure who was teaching you to not bother to try and 'figure things out' but that is what emergency medicine is...treating as you FIND the patient- not how you are told from a book...good luck
 

SeeNoMore

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It takes seconds rather than ten minutes to ascertain whether the patient requires any amount of O2 (STX has reminded you of a few of the things to look for)...it is part of your assessment to determine if and when a patient requires O2...not sure who was teaching you to not bother to try and 'figure things out' but that is what emergency medicine is...treating as you FIND the patient- not how you are told from a book...good luck

Surely there is still room for book learning.
 

irishboxer384

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Surely there is still room for book learning.

yea I didn't mean it to come across as definitively as I'd written. I was just over-emphasing the point that 'figuring out' things (based on prior knowledge) is an important part of the patient assessment.
 

Christopher

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Thanks guys.

For me, pulse oximetery is considered ALS. It's interpreting a medical device, categorized along with EKG.
Much like a speedometer is an engineering device, right?

Move away as fast as you can from whatever hole you've fallen into. They have no idea how to do EMS, or medicine, or common sense, or rational thought.
 

SeeNoMore

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To paraphrase the Dead Kennedys "This hole could be anywhere....this hole could be everywhere."
 

RedAirplane

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Much like a speedometer is an engineering device, right?

Move away as fast as you can from whatever hole you've fallen into. They have no idea how to do EMS, or medicine, or common sense, or rational thought.

The pulse ox seems to be a county-by-county thing in California. I have a full time job as a software engineer so where I live is sort of tied to that.

With Red Cross and other organizations I volunteer with, we actually have an expanded scope because we have our own medical director. Some things, however, seem to be prohibited by the state. Such as pulse ox. Our medical director was able to get us blood glucose monitors (with the caveat that California law states that the patient or family member has to do the prick, not us). We also have baby aspirin for chest pain, which I think a lot of BLS around here does not.
 
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The pulse ox seems to be a county-by-county thing in California. I have a full time job as a software engineer so where I live is sort of tied to that.

With Red Cross and other organizations I volunteer with, we actually have an expanded scope because we have our own medical director. Some things, however, seem to be prohibited by the state. Such as pulse ox. Our medical director was able to get us blood glucose monitors (with the caveat that California law states that the patient or family member has to do the prick, not us). We also have baby aspirin for chest pain, which I think a lot of BLS around here does not.
We utilize baby aspirin on a BLS level for CP in my county, and we've also been authorized to use pulse oximetry as well.
 

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