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?

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Permalink Reply by Michael J Burke on August 8, 2009 at 11:04am

Big sick Big Oxygen(NRB or BVM) Little Sick Little Oxygen(NC). Or as Protocol states in your area.

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Permalink Reply by Annette WALKER on October 3, 2009 at 2:38am

Way to go Joe never wrong giving O2 for chest pain.We can give by nc 4lmp or nrb 10 t0 15lmp. per Protocol for chest pain. Per whats going on with the pt and how they tolerate your treatment.

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Permalink Reply by Bonnie on November 23, 2009 at 4:04am

I replied to this discussion a while ago but wanted to add a bit more. I had a recent incident that I wanted to share. I work as a paramedic for a private co that contracts with fire for ALS and transport. I responded to what was dispatched as a possible MI. When I arrived and began patient care, I assessed that the patient was not having an MI but was having another medical issue, coupled with anxiety. I did however want to give the patient additional O2. I requested my EMT partner place the patient on O2 via nasal cannula 4lpm. I had looked at several things- the patient's overall presentation, the EKG, O2 sats and his work of breathing. One of the responding firefighters, who had not had patient contact but was on scene, hooked up at NRB at 15lpm and in a very abrupt way told my partner to put the NRB on. I did not make an issue of it on scene because I felt it would be unprofessional and would hinder patient care to confront the firefighter. In addition to the firefighter disregarding my request, he said to my EMT partner "those f*cking paramedics just love their nasal canulas."
I was pretty upset after this. So these are my thoughts- I am the senior EMS person on the call. If anything happens to that patient, I am solely responsible. The additional education we receive in paramedic school goes further in depth in to disease processes, physiology, etc. I also have additional tools that can help me assess and decide what is going to benefit the patient the most. Protocols are a good guideline to follow but not all situations or patients will be a cut and dry case. In the county I work we have separate guidelines for BLS, ILS and ALS.
I would have to think that the paramedic on your scene had a reason for wanting a nasal canula. As did I on my call. I think arguing on scene is detrimental and damages the patient's confidence in us. Like I said before, protocols are an excellent guideline but we have to be able to rely on our education and experience to formulate the best care plan for the individual patient.

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Permalink Reply by Mike Schlags (Captain Busy) Retd on November 23, 2011 at 1:56pm

Bonnie - Now that some time has passed, was there ever an outcome to the inappropriate use of language or the lack of knowledge and respect by the firefighter? If you work with this crew a lot, it's always better to keep it low key, reporting the firefighters actions to the Captain. He should make the problem go away. If it continues, or if you are in a place where this is the norm, then document the actions and behavior, and give a copy to your company as well as the local EMSA folks and hospital. No one likes liability issues, and if you identify them in writing, name names and agencies, I'm betting the problem will stop. But then again I'm in the mood right now to stir the...
Let us know how the story ends.
-CBz

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Permalink Reply by Ben Waller on November 23, 2011 at 7:30pm

Necroposting, Mike?

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Permalink Reply by Mike Schlags (Captain Busy) Retd on November 23, 2011 at 10:42pm

Another way I suppose to say, bump...

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Permalink Reply by Aric Stewart on November 23, 2011 at 11:55pm

i don't know about anyone else but what i learned when i went thru EMT-B class i was taught that O2 is therapeutic to a chest pain pt. i also learned that if a protocol states to put them on high flow O2 then do it unless there are circumstances that don't permit then contact medical control and let them decide. Protocols are guidelines but they are also there to CYA. If you deviate from them then you need to document why and weather med control was contacted. If you have a good QA person they will help you questions as to treatment and protocol and if someone did something that you thought was wrong then they can deal with. Just some food for thought so to speak.

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Permalink Reply by John Crabbe on November 23, 2011 at 11:59pm

Eh, good bump nonetheless,

The issue of addressing disagreements on scene and even focusing on who really is in charge does hold true. If I was responding to such a call and had the same comments directed at me, I would have words immediately after the call. I have no problem with someone making suggestions and working as a team, but there is a difference when undermining someone's call on scene. It is one thing if you see something which can be detremental to pt care and can seriously harm the pt, but another to think one knows better and does what they want despite what is asked for.

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Permalink Reply by Mike Schlags (Captain Busy) Retd on November 24, 2011 at 1:05am

There are better qualified people to address this, but I believe COPD patients are the exception here Aric. High flow O2 can knock out the respiratory drive necessitating low flow O2 instead. Not everything demands high flow oxygen, and it's a big enough deal now that oxygen is considered a drug that needs doctors orders, or as you mentioned standing orders.

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Permalink Reply by Ben Waller on November 24, 2011 at 7:21am

Actually, with the advent of pulse oximetry and the move to evidence-based medicine, high flow 02 isn't indicated nearly as much as was thought even three years ago.

The reason - some medical conditions release free radicals. Free radicals plus oxygen equals ??? (You're a hazmat guy, so that's a teaser for you. Think "hazmat reaction inside the body".)