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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 keith on
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Oxygen should never be with held from a patient.... that's one of the first things you learn as a basic... the ALS was wrong in personal thoughts.
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Permalink Reply by Jackie on
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Remember treat the patient, not the machine (lifepack). You did the right move, o2 is always good, withholding is the wrong approach to any patient.
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Permalink Reply by John Malcom on
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You said it in the beginning. BLS and they were ALS, wrong or right they supersede the BLS they are a higher medical authority. You can complain all you want they are in charge. If they get in trouble you can at least say you did what was right.
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Permalink Reply by Shareef Abdu Nur on
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Most cardiac pain is caused by ishcemia and the heart becoming hypoxic, so a NRB is a breath of fresh air that the heart has been starving for since the incident began. It is also theurpeutic for the Pt because while you are preparing the next treatments he/she can feel the rush of O2 and will subconsciously began to relax therefore lessening the workload of the heart.
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Permalink Reply by Ben Waller on
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Here's some rather startling information about giving oxygen to patients. Dr. Bryan Bledsoe's recent column in JEMS cited some research that shows that giving oxygen to patients with hypoxic tissues can actually increase reperfusion injuries, due to the presence of free radicals in the cells.
Dr. Bledsoe's column can be found here: http://www.jems.com/news_and_articles/columns/Bledsoe/the_oxygen_my...
Research is showing that oxygen may actually be harming our patients in a lot of cases where we previously thought it was helpful. This means that a lot of protocols will probably be changing as we go more to evidence-based medicine and away from the 30 years of urban legends on which many protocols are currently based.
If you're not familiar with the free radical problem, the most well-known example is that oxygen is contraindicated in Paraquat and Diquat inhalation injuries. That is due to the presence of free radicals in the lungs. When combined with oxygen, the free radicals form ions that actually cause more damage to the patient's tissues and create worse outcomes.
If Dr. Bledsoe is right, free radicals form in hypoxic tissues in the heart, brain, and other organs when they're hypoxic. Flooding those hypoxic cells with oxygen can create more harmful oxygen-free radical ions, and create the very damage we're trying to prevent.
Dr. Bledsoe states that our goal should be to ventilate the patient rather than to just flood them with high-flow oxygen. If we eliminate the free radicals over time with lower oxygen concentrations, we cause less reperfusion injury. We already know that hyperventilating head injury and stroke patients with high-flow oxygen creates worse outcomes. Dr. Bledsoe's article indicates that we may be doing the same to cardiac, neonate, and other patients as well.
It's time that we pay attention to the research instead of blindly following cookbook EMS protocols, folks.
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Permalink Reply by Jason Koontz on
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O2 is good, lots of O2 is better, especially for a cardiac patient. I don't like to push more than 4lpm through a nasal cannula, juat because then it feels like a tornado in their nose (yes, I've done it to myself just to try it). For cardiac or possible cardiac patients, we've always gone automatically to a NRB at 10-12, per protocol, and NREMT. I've never heard any contraindications, other than a long time COPD'er that has a real strong hypoxic drive for breathing. With them you have to be careful, but you can watch them and gauge whats effective. As for the Sp02, granted its a useful tool many times, but honestly, I hate that we use it so much. If the patient is breathing normally, speaking in 20 word sentences, and is pink, warm, and dry, but the pulse ox says he's at 82, why do we believe the machine and not our own training and common sense? Treat the patient not the stinking machine.
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Permalink Reply by greg on
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I have always applied O2 @ 15lt via non rebreather to any cardiac call ,simply because you must determine what is going on with your pt. and what kind of problems they are having, if they are in no destress it may be that a nasal at 6 lt is appropriate. Protocall is protocall and I sure would hate to stand before the man and try to explain why my pt. was denied a high flow when it was nec. vs. doing what someone else said to do BUT, We all know that each pt. is defferent and we must treat them by the book and how as pt. s they present. I have always aired on the side of my pt. and never have had to defend my actions.
G.K.
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I was taught to treat my pt. as to how he/she presents and to then use the equipment to monitor my interventions. Blue is bad in my book no matter what a pulse ox says. I have seen an spo2 at 95-96 and a pt. sitting bolt upright because they couldnt breath? hands on pt. care beats machines any day. Use the skills we have and the smarts and dont rely on machines is what I say...
G.K.
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It is true that reserch is out there that is contraindicating the use of o2, Yet we must follow protocol and still treat our pts. accordingly. If I was to withold o2 I can assure you that standing before the man citing reserch that may or may not be benificial to my pt. I would be in some deep ( ) It is true that we need this reserch to advance e.m.s. It is true that there are things that are going to change how we treat our pts. for the better. It is also true however that it will be a long time comming as all things in e.m.s. take time. We all can help make advances in e.m.s. by following the reserch and offering our two cents worth and becomming pro active in regards to becomming educated with the lastest advances.
Again though we must follow protocol and s.o.p.s because that is what is expected in our line of work . There are many services that value there personels input to better there services and there are systems that listen to what there medics have to say and will forward on there input. G.K.
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Giving a patient 3 or 4 LPM with a nasal cannula isn't "withholding" oxygen.
If the patient has O2 sats in the 95% or higher range, there's no reason to give high-flow oxygen with a non-rebreather.
We're supposed to be EMTs and paramedics, not robots.
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Mr. Walller,
I agree we need not be robots. I also agree that a pt. with o2 sats at 95% will not need O2 @ 15lt. G.K
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Permalink Reply by Joe Guthrie on
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Good discussion. I always start with an NRB on chest pain patients. If it is indeed a cardiac event then the high flow O2 should help. The heart muscle is in need of O2. Why not flood it with O2. What are you going to hurt? The pulse oximeter has its place mainly because it is the 5th vital sign. If it is not used then a standard of care has not been followed and that can get you in trouble. It should not be used to determine how much O2 a patient should be given. So what if the patients sat is 99%. That is just a number and how can you verify that is correct. It is just like the glucometer. They are always off as much as 7%. I was taught years ago to not get caught up in the numbers game. Treat your patient. Great discussion.
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