The Social Network & Community JUST for Firefighters
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
-
Permalink Reply by anne potter on
-
It is to for tell what is going on by a post. The guy had a cardiac event ...I just got that from your post back to me.... I would not had known it from the beginning.... But I do believe that no matter what state needs the catching up or unless you are a total idiot..When we get in the back of our rig.. It is the pt we are looking out for... OK Joe.......
-
Permalink Reply by Shareef Abdu Nur on
-
I have also seen people give a NC at 4-6 LPM for Chest pain. I always give the NRB and alot of the guys have caught on. Even when they would put on NC, I would take it off and put on a NRB. If we believe in something and have the proof to back it, we have to stick with it for the betterment of the patient.
-
Permalink Reply by David on
-
oxygen constricting the cardiac vessels making an infarction worse- that's a new one on me.
Regardless, if your protocol states 15lpm, then you can't be wrong to give it the way the protocol states.
My protocols give some leeway, and we can titrate the oxygen based on how symptomatic the patient is. I can tell you that the vast majority of our CP patients get O2 by cannula. Patients who appear quite sick naturally will get a non rebreather. Uncomplicated angina patients usually get a cannula.
I remember one training session where a cardiologist stated that if there is a coronary blockage- no matter how much oxygen you give will do nothing for those myocardial cells past the blockage. Still won't keep me from giving oxygen, but if you think about it, that kind of serves to reason.
-
Permalink Reply by SWATrauma on
-
Ok....just a side question here......why in the heck are you all still using Pulse Ox? they are very unreliable and dont tell you the whole story. Thats almost as bad as just looking at lead 2 on an EKG and thinking you can accurately determine ANY cardiac rhythm...... its just not a good tool to rely on for much of anything
I am not going into the whole protocol debate here........just suggesting that perhaps ETCO2 and a little capnography would be a better means of measuring the effectiveness of your oxygen therapy..??...whatever that therapy may be.
Just food for thought
-
Permalink Reply by walt on
-
WOW maybe u need to sit down with this person and have a talk. If that does not work go to the medical director and let them handle it.
-
Permalink Reply by Ben Waller on
-
Most capnography is colorimetric technology, and that is notoriusly unreliable compared to electronic SaO2 monitoring. Pulse oximeters are very reliable in most situations. If the patient isn't a hazmat (cynanide, nitrate/nitrite, or CO) inhalation patient and you have fingernail polish remover, you can tell a lot about the patient by using pulse ox as a tool to supplement patient assessment. Most patients are not hazmat inhalation patients. If you have a cardiac patient and you can maintain their Sao2 in the high 90's, then whatever oxygen delivery device you're using is probably the right one.
There are a lot of EMS systems that don't have any capnography available other than colorimetric adapters for ET tubes. If the patient isn't intubated, ETCO2 monitoring isn't an option for those folks.
Most importantly, ETCO2 doesn't tell you anything about how well you're oxygenating the patient. It just tells you how much CO2 they're blowing off.
Ben
-
Permalink Reply by Joe Stoltz on
-
Ben, we don't generally use a pulse ox, being a BLS agency. On a number of occasions I have heard that nail polish remover should be carried to remove polish from the patient's nail, in order to get a good measurement.
In reality, is nail polish remover really used in the field? It seems to me that carrying the remover fluid and disposing of the pads/kleenex/cloths with solvent on them would be a hassle in a prehospital setting. Also, the use of a solvent in close proximity to oxygen would be a concern.
How is this done?
-
Permalink Reply by Russell Stine on
-
Turn the probe sideways on their finger. Polish remover is available in an alcohol prep type setup.
SPO2 is an ALS skill by you? That is crazy.
-
-
I think of protocols as more of "guidelines" than actual rules. You have to have some flexibility in your treatment modality. If the medic didn't think that high flow oxygen was warranted, then that's his perogitive. I very seldom give high flows of oxygen except in the most dire of situations simply because there is no need for most patients. I spend time educating BLS companies that just because a patient is "complaining" of shortness of breath, if they aren't having to work for air or there is no sign of hypoxia, then a low flow in preferred. Most of the NRB's that come off my ambulance go to BLS companies that used them, only for them to see me replace the NRB with an NC...
Russell
-
-
Joe,
Pulse Ox is a non-invasive BLS skill. We issue nail polish remover wipes (similar to alcohol pads) to every ambulance. The quantity of nail polish is so small that it doesn't present a flammability problem. We've used them on a daily basis for years without a single problem.
You can also use the patient's fingernail polish remover with a cotton ball or Kleenex if you're at the patient's home or if she has those items in her purse.
Ben
-
Permalink Reply by Jim on
-
I would like to read te literature showing how un reliable the pulse ox is. you always treat the Pt and to the machine, but I have not read anything in JEM or the EMS Journal saying that the pulse ox is so unreliable that we should no longer use it. Since most services out in this neck of the woods don't have capnography available on the rigs and we don't tube every Pt with chest pain, those are not options. So basic vitals and pulse ox is what we have.
If there is information out there I would be interested in reading it.
-
-
I found some interesting research that adds a 3rd dimension to this discussion. Apparently, hemeglobin is very effective at carrying oxygen, but it's not very efficient at releasing it into the tissues...unless the nitric oxide trigger senses that more oxygen is needed and triggers additional oxygen release.
Here's some Duke University research that explains what happens.
http://www.dukehealth.org/HealthLibrary/News/701
Each hemeglobing molecule can carry 4 oxygen molecules. However, 3 of those 4 oxygen molecules are typically still attached to the hemeglobin molecule when it returns to the heart. That tends to indicate that high-flow oxygen may have some benefit, but it won't affect cellular perfusion in the way that we've always been taught.
In other words, the Duke research has implications that mean max oxygen flow with a non-rebreather is likely an outmoded concept. It actually states that giving patients inhaled nitric oxide may help the patient more than giving them high-flow oxygen, at least in some cases. http://www.dcri.org/news/Archives/2005/2005-10-04.jsp
Ben
© 2024 Created by Firefighter Nation WebChief.
Powered by
