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Nasal Cannula for Cardiac Symptoms?
I was on a call the other day, 50s male with chest pain, cardiac history, pain 8/10, etc. Pulse about 80. NYS BLS protocol states that high flow oxygen should be given via non-rebreather mask. This has been the protocol for the past 20 years at least, and is also considered routine medical care for all levels in our area.
ALS arrives on scene while I prepare the NRB. The ALS tech says "No, put him on 4 lpm with a cannula." I considered that a moment, then said "Nope, I'm giving him 15 per protocol."
Two or three minutes later, the patient reported vast relief from pain with the NRB. Having transferred care over to another crew, I watched as the ALS tech removed the NRB so as to get a room air sat level.
Apparently, there is some belief that indicates that too much oxygen can constrict the cardiac vessels and complicate the situation. However, a "belief" is overruled by protocol, in my book.
Any thoughts or data on this?
ALS arrives on scene while I prepare the NRB. The ALS tech says "No, put him on 4 lpm with a cannula." I considered that a moment, then said "Nope, I'm giving him 15 per protocol."
Two or three minutes later, the patient reported vast relief from pain with the NRB. Having transferred care over to another crew, I watched as the ALS tech removed the NRB so as to get a room air sat level.
Apparently, there is some belief that indicates that too much oxygen can constrict the cardiac vessels and complicate the situation. However, a "belief" is overruled by protocol, in my book.
Any thoughts or data on this?
Replies to This Discussion
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Permalink Reply by Paul Montpetit on
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ALS person was wrong.....it is that simple...Oxygen should NEVER be withheld from a patient esp on that could be Cardiac....Good thing I wasn't in the receiving ER....I would have "informed" Him/Her so....I am an ICU/ER nurse as well as a medic/firefighter
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Permalink Reply by Oldman on
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Mother nature requires balance. When things are out of balance, other things happen in an attempt to re-balance. Chest pain in a cardiac situation is telling the body something is out of balance in the heart ... IE O2/CO2, potassium, sodium, calcium. Supplemental O2 CAN and DOES ease cardiac pain, the same as it lessens PVCs due to hypoximia. It causes a shift more toward balance. The pulseoximeter is a tool just like the monitor. You don't treat the machine. The pulseoximeter only detects the color red. The more red it detects, the higher the reading. Simply relying on the SpO2 to establish parameters for supplimental oxygen is a dangerous habit to fall into. What is the patient telling you? What is their LOC, and skin palor? Combine these signs and symptoms with what your other diagnostic tools are telling you.
Oxygen is a drug. And ANY drug used in excess can have adverse effects. Years ago, before we had cook book medicine, we started small and went up. If the NC wasn't helping, we went to a higher delivery device, (simple face mask, partial rebreather, then non rebreather). Called titrating to effect. Somewhere along the way, we lost our ability to use our brains, and if it ain't in the book, than we can't do it. Was the ALS wrong? Maybe, maybe not. Were you wrong? No. In EMS today, the best protection we have is by following our protocols. They were at least reviewed and approved, (if not written) by sombody with more education than us. New studies come out almost daily contradicting what was found in a previous study. Do I agree with all of the protocols my department has? No. Do I follow them? Usually, but if I don't, I'll have at least a half dozen reasons why, and the one with the MD/DO after their name will usually have a dozen more why I should have.
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And what if this pt also had history of COPD....not uncommon for cardiac pts...and their "Normal" spo2 runs 86-90% on room air...which you may find is not all that uncommon.. I also have to ask you about NOT following protocols...what is the definition of gross negligence..?? If the pt. had a bad outcome.....and an investigation ensued...who would be at fault...? I believe the first question would be...."Was proper protocol followed..?" Sorry to say....If it walks like a duck and it quacks like a duck....then it is probably a duck....Of course the proper thing to do if a disagreement occurs would be to call med control and ask...wonder why no-one thought of that...? Stay safe all.....Paul
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Permalink Reply by Joe Stoltz on
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Great feedback. I'll bet that the ECC 2005 report is the one the ALS crew has been using as guidance.
However, regarding the SpO2 > 90, is it not true that someone with a fairly high CO concentration will give a false higher reading?
And regarding the reduction in pain that the patient reported, that could have been partly because of the reduction in stress - knowing that help had arrived and he was being treated.
One item of interest: after being treated at the local ER, this patient was shipped to the city cath lab where 2 stents were put in.
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Tom, I have seen both 3- and 12-lead assessments in the field in this area. I'm not sure what was done with this patient because I didn't ride the rig... it was a morning drive-time call, on my way to work, another medic was covering, etc.
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Permalink Reply by Annette on
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You can't give a cardiac patient to much oxygen....flood those little red blood cells! I have removed it when I've had patients who just couldn't stand the confining feeling of the mask, I'd rather have them on 4L than nothing at all. You were right, but the responsibility for the patient care rests with the Paramedic once they are on scene. Document, document, document.....
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Permalink Reply by Ben Waller on
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How can you be sure that we can't give a cardiac patient too much oxygen? Is there a reliable study that indicates this? We used to think that we couldn't give a closed head injury patient too much oxygen and we hyperventilated them like crazy. Then...SUPRISE...we found out that hyperventilation is actually harmful to patients with closed head injuries.
Also, what if your cardiac patient is also a COPD patient? You might not hurt their AMI with lots of O2, but you surely can impair their respiratory status with hyperoxygenation, especially if you have a long transport time.
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Permalink Reply by Jenna on
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Protocols are just guidelines...
When making a decision to use a NC v NRB in a cardiac pt you have to look at the pts SPO2, work of breathing, do they have nausea, etc... lot of factors come in to play. Treat your pt not your protocol book. Not everyone needs a NRB like they teach in EMT school. As a paramedic I have learned otherwise.
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Permalink Reply by Rusty on
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I've got to agree with Oldman on this one. Even though I'm a fairly new medic (only 8 yrs, 11 in EMS) I learned from alot of old medics when I first started, and I agree with rule out the simple stuff first. I also agree with the saying titrate to effect. It kinda goes hand in hand with treat your pt, not your instruments. All that being said, I tend to lean towards at least considering low flow O2 first. I've found that most of my patients, especially the elderly, are more comfortable with an NC vs. an NRB. If their symptoms and V/S change or don't improve, then I can always up the liter flow. I think alot of new medics tend to overthink things and end up missing out on the small things, but that's just my opinion.
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Nope, no COPD reported by the patient. In any event, the tech had not gotten ANY medical history at that point; nor had cardiac monitoring, pulse oximetry or any other procedures been started. The tech walked up, made a quick general impression, then issued the order.
It was just the automatic response regarding the switch to the NC (that I have heard so many times in the past) that had me curious. The rationale behind this was explained to my satisfaction earlier in this discussion.
Oh, and thanks for the advice regarding paramedic school, but I think I'll pass. As Clint said, "A man's got to know his limitations" and I believe I do. People have told me I would have made a good one, but we'll never find out for sure.
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Christopher,
Did you mean a CO2 of between 30-45. A CO of 30-45 is a serious carbon monoxide poisoning.
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The high-flow O2 from a non-rebreather mask stems from protocols that "have always done it that way". Those protocols were initially written when there were no reliable, field-proven SaO2 monitors. Now that we have a reliable measurement tool for SaO2, there's no reason to use a non-rebreather for every patient with chest discomfort.
As Tom states, you can't have an O2 saturation of 101%.
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