Would you look at that! A study talking about harmful affects of hyperoxia.

[Veneficus]

Oxygen Therapy in Critical Illness

Precise Control of Arterial Oxygenation and Permissive Hypoxemia

Daniel Stuart Martin, BSc, MBChB, PhD, FRCA, FFICM, Michael Patrick William Grocott, MBBS, MD, FRCA, FRCP, FFICM
Disclosures
Crit Care Med. 2013;41(2):423-432.


"Supranormal arterial oxygenation is also associated with a number of cardiovascular responses such as reduced stroke volume and cardiac output,[43,44] increased peripheral vascular resistance,[43] coronary artery vasoconstriction, and reduced coronary blood flow,[45,46] which may be undesirable in critically ill patients.

A growing body of clinical evidence points to the potential harm of using high concentrations of inspired oxygen in clinical situations where classical teaching and physiological intuition might suggest a beneficial response."

 

[mycrofft]

You mean we might either have to reconsider the field treatment, or recognize there's nothing we can do?:unsure:

 

[Veneficus]

Well you know, there is no shortage of people here claiming high flow oxygen doesn't produce appreciable short term harm.

 

[ExpatMedic0]

"However, at present there is no direct evidence to support the immediate implementation of permissive hypoxemia and a comprehensive evaluation of its value in critically ill patients should be a high research priority."

http://www.ncbi.nlm.nih.gov/pubmed/23263574

 

[Veneficus]

"However, at present there is no direct evidence to support the immediate implementation of permissive hypoxemia and a comprehensive evaluation of its value in critically ill patients should be a high research priority."

http://www.ncbi.nlm.nih.gov/pubmed/23263574

Read the full article.

 

[ExpatMedic0]

I did, and I have been hearing this for a while now. I have to admit I agree it is probably an issue, but at present time I am not sure if someone with a GED and 120 hours of vocational training is competent enough to decide when its ok to withhold oxygen from someone who may actually need it.

If you where a medical director writing protocols for your worker bee's to adhere to, would you rather error on the side of caution and just say give o2? Sure it may harm some people, but how many more would be harmed from depriving o2? Which do you think would result in more negtive patient outcomes? hypoxemia or hyperoxemia?

When and Why would this change anytime soon when we still backboard every single person for everything in many areas.

 

[Veneficus]

I did, and I have been hearing this for a while now. I have to admit I agree it is probably an issue, but at present time I am not sure if someone with a GED and 120 hours of vocational training is competent enough to decide when its ok to withhold oxygen from someone who may actually need it.

I am sure it is a problem easily solved with mandated technology

If you where a medical director writing protocols for your worker bee's to adhere to, would you rather error on the side of caution and just say give o2? Sure it may harm some people, but how many more would be harmed from depriving o2? Which do you think would result in more negtive patient outcomes? hypoxemia or hyperoxemia?

That is an unfair question, if I had that authority the minimum demands I could make on my worker bees would permit me to write such a protocol.

But if I were to answer your loaded question, I would simply make a list of times when 15L of NRB was acceptable, which would be a very short list.

When and Why would this change anytime soon when we still backboard every single person for everything in many areas.

For EMS? Probably never. But most of the folks here are above average

 

[ExpatMedic0]

I think its a very interesting concept and I am glad its finally being discussed. I am not sure how EMT-B's are trained today but I remember 10 years ago where I was, everyone got high flow O2 on skill station scenarios to pass. BSI, scence safe, ABC's SPO2 %100 15LPM NRB, pass. "you cant hurt anyone with o2" lol
I love it.
PS: At my last agency we where using some kind of UK protocols, for the EMT's the goal was to titrate spo2 to not above %94 in almost all cases

 

[abckidsmom]

3 days ago, I got into an ambulance with one of my co-workers and he said, "I give everyone 4 L NC. It makes them feel like I'm actually doing something for them."

Is there a facepalm smiley? If I want to do something, anything for people, just for the sole purpose of making them feel warm and fuzzy about me, I sit and chat with them, and act interested in their stories.

 

[wanderingmedic]

3 days ago, I got into an ambulance with one of my co-workers and he said, "I give everyone 4 L NC. It makes them feel like I'm actually doing something for them."

I like NRB's cuz it means gross people cant cough or spit on you without having to take off the mask first.

 

[Tigger]

I like NRB's cuz it means gross people cant cough or spit on you without having to take off the mask first.

Do these patients need the high flow oxygen that you are giving them? Have you ever worn an NRB? It's not very comfortable.

There's also something called a spit sock that is not so barbaric.

 

[STXmedic]

I like NRB's cuz it means gross people cant cough or spit on you without having to take off the mask first.

If you're frequently having people spit at you, you're doing something wrong.

 

[abckidsmom]

And right when I was looking for the facepalm smiley.

I use a regular paper isolation mask when people want to spit on me. I've done it twice, ever. I usually use my words and behavior to make people choose not to spit on me.

 

[NomadicMedic]

I used to do a fair number of "intoxicated person" transports. The spit sock was a lifesaver.

For them. There's something about getting spit on that makes my blood boil.

 

[mycrofft]

3 days ago, I got into an ambulance with one of my co-workers and he said, "I give everyone 4 L NC. It makes them feel like I'm actually doing something for them."

Is there a facepalm smiley? If I want to do something, anything for people, just for the sole purpose of making them feel warm and fuzzy about me, I sit and chat with them, and act interested in their stories.

Bake cookies.

Does it mean you're giving too much O2 when, if you draw blood, it fizzes?
:wacko:

 

[EpiEMS]

"A growing body of clinical evidence points to the potential harm of using high concentrations of inspired oxygen in clinical situations where classical teaching and physiological intuition might suggest a beneficial response."

Wait...so I can't give 15 lpm NRB to everyone? Burn the witch!

Just read through this (on Medscape, not sure if it's the full version: http://www.medscape.com/viewarticle/778505_3), I guess I'm trying to think what the clinical implications for EMS are beyond reducing use of O2 including not just mechanistically titrating to ≥94% SpO2

 

[Veneficus]

Wait...so I can't give 15 lpm NRB to everyone? Burn the witch!

Just read through this (on Medscape, not sure if it's the full version: http://www.medscape.com/viewarticle/778505_3), I guess I'm trying to think what the clinical implications for EMS are beyond reducing use of O2 including not just mechanistically titrating to ≥94% SpO2

I would go with that and theraputic hypercapnia

 

[Clipper1]

I like NRB's cuz it means gross people cant cough or spit on you without having to take off the mask first.

No but they can aerosolize whatever nasties (viruses, bacteria fungi) they have in their lungs, mouth and throat for you to breath in.

A NRB mask is also not considered to be a high flow device.

The whole article explains what the authors intentions were. It is not whether EMS should limit oxygen during the first 15 minutes.

http://www.medscape.com/viewarticle/778505

The other consideration is how do you define hyperoxemia? SpO2 is not an accurate method for the purposes of the article.

Other factors include what is EMS capable of for achieving adequate tissue perfusion? What pressors can an EMT-B or even a Paramedic give? How does a Paramedic or EMT monitor cerebral perfusion and SvO2 in the field? How long do you want to stay in the field to see what happens with long term oxygen use? Have you ever read the full ARDSnet protocol which can go on for 12 pages? How many will initiate a THAM drip since hypercarbia (increased) PaCO2 may also be part of the process? ARDSnet also address permissive hypoxemia. But, is this really appropriate for the initial states where cardiac compromise with a poor EF during the first 15 minutes with limited interventions available or diagnostics to determine precise numbers?

 

[Clipper1]

I would go with that and theraputic hypercapnia

How are you determining that? Are you initiating THAM or NaHCO3 during the first few minutes in the field as an EMT or a Paramedic?

 

[Carlos Danger]

I did, and I have been hearing this for a while now. I have to admit I agree it is probably an issue, but at present time I am not sure if someone with a GED and 120 hours of vocational training is competent enough to decide when its ok to withhold oxygen from someone who may actually need it.

Or people with a GED and 1,000 hours of vocational training, for that matter.

I don't know....titrate to Sp02?

"When the red blinky number is more than 92, you don't need to do anything"

"If the red blinky number is between 88-92, use the plastic nose prong things"

"If the red blinky number is below 88, use the facemask and enough oxygen to keep the bag attached to it inflated".

Doesn't seem so hard.

I bet even a nurse could do it.


You aren't witholding oxygen; you simply aren't administering it unless it's indicated.

If you transport a person who isn't in pain and don't give them narcotics, are you witholding analgesia?

Are you withholding defibrillation when you don't shock someone with a strong pulse and a a nice NSR?