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Permalink Reply by Paul Montpetit on July 11, 2008 at 8:01am

I have a dumb question.....why, if your patient has a condition that severely limits their lung capacity would you want to with hold oxygen...??? I guess I am from the old school that tells us to never withhold oxygen from a patient for a respiratory condition. The VERY old philosophy that you give oxygen sparingly to chronic lungers (COPD) has sort of gone by the way side....but that's about the only reason I can think of....Good luck.................Paul

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Permalink Reply by Oldman on July 11, 2008 at 9:03am

In an emergency setting regardless of type of trauma or illness, there is no definitive contraindication for O2. There are some instances in long term care where it might not be appropriate. The only situations I would even consider would be if there was an ingestion of a petroleum based substance, or the patient was saturated with it. Even then if it was a saturation issue, the patient would need to be decontaminated and O2 could probably be administered safely. Or maybe in an explosive atmosphere, it would be more appropriate to remove them from that area before administration.

I posed a question to a class a few years ago concerning the treatment of a sucking chest wound. The most common dressing used for this injury is petroleum impregnated gauze. Knowing the potential of O2 and petrochemicals, would you administer O2 to a patient after treating such a wound. My research could not find any instance of a problem in doing so. The only time this would be an issue would be with hyperbaric administration where the patient is in an oxygen enriched atmosphere.

I would be interested to know his answer and reasoning.

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Permalink Reply by Ben Waller on July 11, 2008 at 10:16am

There are two clear contraindications for witholding oxygen from patients.
Both are hazmat situations. These situations are Paraquat and Diquat poisonings, particularly in respiratory exposures or massive ingestion exposure with respiratory distress.

Paraquat and Diquat inhalation creates free radicals in the lungs.
Adding oxygen to free radicals will increase the chemical reaction, and thus create additional damage to the lungs.

Here are some references:

http://www.inchem.org/documents/pims/chemical/pim399.htm#SubSection...

http://books.google.com/books?id=qEWH3To_EXUC&pg=PA646&lpg=...

http://npic.orst.edu/RMPP/rmpp_ch2.pdf
See the "Airway Protection" page of this reference.

http://www.apamt.org/papers/Therapeutic%20approach%20to%20paraquat%...

http://npic.orst.edu/RMPP/rmpp_ch12.pdf

http://pmep.cce.cornell.edu/profiles/herb-growthreg/naa-rimsulfuron...
See Item 5 under Physician Notes

Here's my department's EMS Protocol for Paraquat and Diquat Poisoning:

Protocol 5.6 HAZMAT (Paraquat and/or Diquat Poisoning)


• Perform Scene Survey and don personal protective equipment

• Activate Engine Company (Level I) or HAZMAT / COBRA team (Level II) response early

• Patient Assessment and Treatment
o Instruct in self decontamination when possible.
o Decontaminate the patient if possible without contaminating HHIFR personnel
o Remove and isolate all contaminated clothing.
o Treat immediate life threats
o Immobilize when indicated
o Control active bleeding

• Patient Symptoms may include:
Ingestion – Burning pain and ulceration to mouth, throat, chest, and upper abdomen, followed by diarrhea, which may be bloody
Dermal – Contact dermatitis, blistering, and/or ulceration
Respiratory – Respiratory distress (common) and/or nosebleed (rare)
Eyes– Severe conjunctivitis
Neurological – Irritability, nervousness, combativeness, disorientation, may progress to seizures, coma, and death

• DO NOT Administer Oxygen to Paraquat/Diquat Poisoning patients!
o Protect airway and be prepared to intubate at first sign of respiratory distress
o Ventilate patient with AMBIENT AIR
o Oxygen administration is CONTRAINDICATED in Paraquat/Diquat Poisonings due to free radical oxidation in the lungs

• Implement Cardiac Monitoring

• Establish Intravenous Access (non-contaminated site)

• Treat for Shock

• Prepare the ambulance to receive and transport patient

• NEVER ENTER HOSPITAL WITHOUT PERMISSION FROM:
(Online Medical Control)

The EPA publishes an excellent text on the treatment of agricultural emergencies that includes Paraquat and Diquat poisonings.

A hazmat rule of thumb is to avoid adding a chemical that makes a hazmat problem worse. Adding oxygen to a patient who has oxygen free radicals in the lungs can cause additional injury. That violates the primary rule of medicine PRIMUM NON NOCERE..."First, do no harm."

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Permalink Reply by Oldman on July 11, 2008 at 10:28am

Ya see, you can teach a new dog old tricks... or something like that. Thanks Ben

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Permalink Reply by Ben Waller on July 11, 2008 at 11:46am

My head hurt the first time I saw this one, too.
Something about a hazmat tech that wasn't an EMT or paramedic teaching an old paramedic a new trick...

After my head hurt for a couple of days, I figured out that there's 21% oxygen in room air, and that it doesn't hurt to ventilate a patient with it. After that, my head didn't hurt quite as much.

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Permalink Reply by Paul Montpetit on July 11, 2008 at 11:56am

Hey Oldtimer...er, I mean Oldman....(Sorry couldn't resist)..Here is a little experiment for you....Take some Vaseline jelly and put Oxygen to it......did it explode..? Did it burst into flames...?? The "petroleum" in the gauze is the same crap as in vaseline....perfectly safe for its intended use.....Man....Now I'm getting a headache.......must be the subject matter.....LOL...Take care and stay safe.........Paul

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Permalink Reply by Ben Waller on July 11, 2008 at 12:08pm

Regarding sealing sucking chest wounds and using oxygen to ventilate the patient...

A lot fo people don't actually open the vaseline guaze pack for this - the intact aluminum foil wrapper makes an effective seal for SCWs, and it's way easier to tape in place - with the 4-sided tape job, of course.

A better solution for small-to-medium SCWs is the Asherman Chest Seal. It is essentially a round Op Site or Tegaderm approximately 3.5 to 4 inches in diameter with a flutter valve installed in the center. We use them as a BLS device for sealing SCWs and as an ALS flutter valve after doing chest decompressions.

There are some photos here:
http://www.firstrespondersupplies.com/acs.htm
http://www.remotemedical.com/Asherman-Chest-Seal
http://www.armstrongmedical.com/index.cfm/go/product.detail/sec/3/s...
http://icvts.ctsnetjournals.org/content/vol6/issue6/images/small/69...

They are a little tricky to apply until you get used to the technique. I recommend removing the gauze that occludes the sticky (patient) side of the flutter valve if you're using the Asherman Chest Seal to cover a pre-installed 14 ga. IV cath in the chest wall. The nice thing about the Asherman is that you don't have to poke an IV cath through a non-sterile exam glove finger or attach a seperate flutter valve, you just decompress the chest, cover the IV cath hub with the chest seal, and back the chest seal up with tape if the wound is very bloody or otherwise wet or dirty.

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Permalink Reply by Ben Waller on July 11, 2008 at 12:39pm

Siren, are you going all English teacher on us today? :-)
The pocket guide is a good idea.

Your medical director/medical control physician may or may not need to approve the device, based on state laws and regulations. In SC, the device does not have to be approved by local medical control IF it is not invasive, is taught by commonly accepted programs/references, and has FDA approval.

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Permalink Reply by Ben Waller on July 11, 2008 at 12:46pm

I'm not a fogie, and I'm not 50.

I'm 21, with 29 years of experience!

LOL, Ben

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Permalink Reply by Oldman on July 11, 2008 at 2:34pm

I agree Paul, that was the point I was trying to make with the class. It wasn't going to hurt anything. BTW, I keep a 500 ct bottle of Ibuprofen in my desk. I'll save some for you. Works better than Willow bark that us oldtimers used back in my day.

Later

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Permalink Reply by Paul Montpetit on July 11, 2008 at 4:26pm

Thanks for the Ibuprofen....can I cheat and take it with a cold beer...? LOL... To be honest...I still carry a roll of saran wrap in my aid bag....works great for SCW's and doesn't cost much at all...I try and stress to students to use their heads....medicine is a practice NOT a science....we learn by doing and not every case is going to be the same even if it is the same type....ie cardiac calls...Hang in there Bro....and yes I have a spare one if you would like to stop by and chat sometime....Stay safe.........Paul

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Permalink Reply by Paul Montpetit on July 11, 2008 at 4:29pm

OMG....Now poor Ben is holding his own...!!!!! Oh the inhumanity........What is the world coming to...?? Yes I am a Fogie as well.....LOL Stay safe.......Paul

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