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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 Ben Waller on
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Siren,
In addition to your right-on-target social commentary, 11,000+ items of anecdotal evidence per year is still anecdotal.
In other words, it's not scientific evidence.
Ben
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Permalink Reply by anne potter on
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I feel that nobody can be wrong in this situation.. tooo much tooo little . I feel does not make a matter.. Runs to the ER is not very long.. I have seen cardiac pt's only on nasel with having a heart attack in the ED .. I feel there is a protocol system in place in our field for a reason..So follow it. We do the best care we know who to for that pt.. You cannot be wrong for that.
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Permalink Reply by scott t on
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ACLS states give patient 4lpm for patient that has chest pain from suggestive ischemia. Book ACLS for Experienced Providers.Page 9 box 3.
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Permalink Reply by Reg Mathis on
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We were always taught to use the NRB unless the pt has a "REAL" problem with the mask, then go with the nasal...
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Permalink Reply by Jim on
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I agree for the most part that NRB is the way to go, but if the sat is in the 90's and the pt is breathing 20+ times a minute you run into the problem of the pt blowing off too much co2 causeing a secondary problem to the chest pain. You now have a pt with carpil/pedal spasms in his arm or unconcious. is it from the hyperventilation or the CP. Not knowing more on this case it is difficult to say why the paramedic prefered the NC over the NRB. When in doubt 15 Lpm NRB is the way to go, but all the vitals must be taken into consideration.
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Permalink Reply by united 289..{Dave} on
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Below is right out of our protocol.
EMT-B
"Open and manage the airway and provide oxygen by nasal cannula at 4 lpm and increase as needed with respiratory distress, if not previously done by First Responders. Apply pulse oximeter and treat as indicated. Apply monitor and run strip for interpretation by medic or physician"
Tritrate to the effect needed. Imagen that.
One other thing is not told here. What does the rest of your protocol say about chest pain. There is more here than what is being told.
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Permalink Reply by Joe Stoltz on
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Here are excerpts from New York State’s on-line Statewide Basic Life Support Adult & Pediatric Protocols (EMT-B and AEMT)
Adult Cardiac Related Problem
1. Assure that the patient’s airway is open and that breathing and circulation are adequate.
2. Administer high concentration oxygen.
3. Place the patient in a position of comfort, while reassuring the patient and loosening tight or restrictive clothing.
4. Transport, keeping the patient warm.
5. Ongoing assessment. Obtain and record the patient’s vital signs, repeat enroute as often as the situation indicates.
6. If patient has not taken aspirin and has no history of aspirin allergy and no evidence of recent gastrointestinal bleeding, administer nonenteric chewable aspirin (160 to 325 mg).
7. If chest pain is present and if the patient possesses nitroglycerin prescribed by his/her physician and has a systolic blood pressure of 120mm Hg or greater, the EMT-B may assist the patient in self-administration of the patient’s prescribed sublingual nitroglycerin as indicated on the medicine container.
A. In the absence of standing orders for nitroglycerin, contact medical control for authorization to administer the nitroglycerin.
B. Confirm the systolic blood pressure is 120mm Hg or greater.
C. Question patient on last dose administration of nitroglycerin, effects, and assure understanding of route and administration.
D. Administer one (1) metered dose of nitroglycerin spray or one (1) nitroglycerin tablet under the patient’s tongue without swallowing and record the time of the administration.
E. Recheck blood pressure within two (2) minutes of administration and record any changes in the patient’s condition.
8. Record all patient care information, including the patient’s medical history and all treatment provided, on a Prehospital Care Report (PCR).
NYS Protocol for high concentration oxygen from SC-1:
2. Administer high-concentration oxygen.
a. First choice—Non-rebreather mask at 12 LPM or greater so reservoir bag does not collapse during inhalation. If reservoir bag collapses and does not refill adequately, increase to 15 LPM.
b. Second choice—Nasal cannula at 6 LPM (used only if a mask is not tolerated).
Do you see where I am coming from, now? By the way this protocol was last updated in February 2007.
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Permalink Reply by Michael D Ries on
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I say follow your protocol and note on your run report the conflict and report the incident to your capt or chief.
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Permalink Reply by John on
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I know our protocol is for NRB 2 15lpm unless they cannot tolerate a mask, then we go to the NC.
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That is why there is a protocol.. I myself vast relief of just o2 with out nitro.. could be alot of things wrong,but not a Dr... Once in the Er Odds are that the o2 is going to be given at 2 liters or 4liter.s... If sats are in good shape.... Als have different guide lines and if the Md orders may consists of lowering the o2 to sats that are with 90-100%. If Als changes the o2 you as a BLS has handed your pt to a higher level of care and no longer responsible for that pt.... We have alot to look at did they put the pt on a monitor what was the stip like. POsts like this never have the whole story so it is hard to know what to say.... We all want what is best for our pt...
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"POsts like this never have the whole story so it is hard to know what to say.... We all want what is best for our pt..."
I haven't re-read through the entire discussion but I think I have shared everything that I can regarding the incident... if there are any further questions I will be happy to answer them as best as I can.
In retrospect, my conclusions are:
The reason for the N/C has been explained in this discussion by others, and I believe I now understand it, and concur.
The patient DID in fact have a cardiac event and had two stents placed to alleviate blockages in his heart.
The BLS protocols for acute coronary symptoms vary from state to state regarding oxygen administration
New York State has some catching up to do regarding this protocol
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