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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 pablo lister on
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well the statements say that, if you attend a patient that has chest pain you have to administrate at least 4 to 5 liters of o2 by nassal canuale. plus administer nitroglycerine 0.4mg sublingual, every 3 to 5 minutes up to 3 doses plus a dose of aspirine 325 mg CHEWABLE AND THEN SWALLOWED, plus morphine 4 mg endovenus. take an ECG IF AVAILIBLE IN THE HOUSE OR AMBULANCE AND TRANSPORT THE PATIENT TO A HOSPITAL. OBLIGATORY!!!
this terapeutics are for patients that suspect for an acute coronary syndrome. during the transport you have to check the o2 saturation of the patient and should be more than SpO295%. if you dont get it then you use the nonrebreathing mask with reservoir and the 02 flow should be between 10 and 15 liters of 02 per minute.
please check en this website: www.americanheart.org/cpr: acute coronary syndromes
Pablo Lister Blondet MD
ACLS provider
PALS provider
BLS instructor
Lima - Peru - Attachments:
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8 sica.pdf, 967 KB
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Permalink Reply by Nicholi69 on
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well im in paramedic school now and im learning but the instructor said the very first day never ever withold oxygen from a pt. It will never hurt them in the short time we shall have them. Even copd pts give them a nonrebreather because in the short duration it will be better for them and as soon as you get in the er some nurse will put them on a nasal canula. But were here to save lives and be advocates for our pts so do what you need to do for your pt
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Permalink Reply by Jason McDonald on
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As a Paramedic I feel that 4 lpm is too low. 15 LPM is better for the patiens and I am sure that will not constrict the blood vessels in the short time frame from the scene to the hospital. You can always lower the flow to check the patient but then raise back to 15 lpm.
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Permalink Reply by Ben Waller on
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This may change your perspective...
http://www.jems.com/news_and_articles/columns/Bledsoe/the_oxygen_my...
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Permalink Reply by Brian OcQue on
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Oxygen is one of those wonder drugs (after all, we're all taught that it is a drug lol), because of its vast therapeutic window and the ability to not only ease physical pain, but mental pain as well. Patient who are having anxiety attacks can be rid of their symptoms, just from touching a NRB, only because their brain senses being helped. In addition to its multi-fascited function, you can never can you give too much, now if they're hyperventilating, that;s a different story. If they look like they need it, give it to them. If they want it, give it to them. It can't hurt them. In terms of this ALS tech and his need for a room-air sat, what difference does it make. First of all, we should learn to treat the patient, not just the numbers. If he really wants to get down to number-crunching then maybe some capnography is in order, otherwise who cares? To me it almost sounds as if this tech was one of those paragods that just needed to pick on a basic for a bit, to demonstrate his prowess lmao.
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Permalink Reply by Eric on
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You gave him 15 via NRB, You then transferred the patient to ALS (higher medical authority) I'm not an EMT yet but it seems you did your Job by the book. Now, i was told that 15lpm was the protocol for patients with Respiratory problems, and other patients could have 13lpm or if they did not tolerate the mask you could put them on a NC at 6lpm. Anyone care to elaborate?
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Permalink Reply by William Roberts on
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Just FYI, for you to impact a patient's respiratory drive in a patient with COPD, I takes days not hours. 100% Spo2 will not hurt them, and they wont code in front of you. Next time you see a pulmonary doc, ask him about that. Another thing to consider is that SpO2 may read normal, however P02 maybe low. for this reason never withhold oxygen for whom its indicated. We treat patients not numbers.
Also in regards to CO2 causing false SpO2 highs I do not think so as alot of times SpO2 maybe decreased due to high CO2 levels. CO2 really doesnt bond with hemoglobin readily so I tend to lead towards no. If you can find data that may suggest otherwise please share. I do know that carbon monoxide binds readily with hemoglobin thus causing abnormal SpO2 readings.
Best advise is stick to the ABC's. You will not harm the patient by giving too much Os
As For Room Air SpO2, If you can get a baseline SpO2 great, but be leary as SpO2 tends to be not as accurate vs ABG's.
With patient's with closed head injuries yes hyperventilation is a bad idea, but a NRB or NC will not hurt the patient.
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are you talking PaCO2? Normal ETCO2 is between 35-45.
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My question was trying to clarify an earlier comment by a poster that stated that a normal "CO" was between 35 to 45. If a patient has that much carbon monoxide on board, it's a serious inhaled poisoning.
My question was intended to clarify if the poster was actually discussing normal exhaled carbon dioxide, and if the "CO" was a typo.
Or to put it another way, a normal CO level in either arterial blood gases or exhaled breath is zero.
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William, I think you're confusing carbon monoxide with carbon dioxide. A high CO level will show false oxygen saturation levels, unlike high CO2 levels, which won't fool the sat monitor.
And...there's a lot of emerging evidence - including a study linked elsewhere in this thread - that shows that too much oxygen in cardiac patients causes rebound coronary vasoconstriction and can increase myocardial ischemia.
As for respiratory impairment of high-flow oxygen taking "days, not hours", that's not 100% accurate. I've worked places that routinely had wilderness evacuations followed by 1 to 2 hour transports. Some of the COPD patients in those settings had their respiratory drive shut down after a couple of hours of high-flow oxygen and required emergent intubation, since we didn't have CPAP at the time. No pulmonologist was present.
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Thats not completely accurate. Carbon Monoxide will show 100% on SpO2. To further my explaination of why CO2 does not necessarily cause false highs on SpO2 , take for instance a patient with a pulmonary embolism. The patient's SpO2 can be in the 60's and ETCO2 be in the 80s. The patient isn't able to blow off the CO2, thus is very acidotic. This does not make the patients SpO2 go up or read high at any rate.
Heres some helpful reading
http://jficmexam.medbrains.net/files/2009/01/pulse-oximetry.pdf
http://books.google.com/books?id=aLt8xOezKIoC&pg=PA591&lpg=...
As for your COPD patient's, if they were only being relocated during an evacuation, why where they on high flow O2 if their condition was stable in the first place? or was it? Most COPD patient's can tolerate high flow O's for extended period of times. I think there may have been other factors involved.
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William, my post was completely accurate. Go back and re-read it.
I stated that carbon monoxide will cause false high oxygen sat readings.
Nowhere did I state the same for carbon dioxide, yet you go on as if I had said that.
I know carbon dioxide won't cause false high oxygen sat readings (fool the monitor) as I stated. And you wonder why I think you're confusing these two very different chemicals???
You made another false assumption about my COPD patients. I did not say that they were stable - in fact, they were trauma patients and were far from stable. They were found in remote locations where the only means of initial rescue was by four-wheel drive vehicle or on foot, and they remained critical during a long (by 911 standards) transport. Not all patients are found 10 minutes from a major teaching hospital or trauma center, and COPD patients can and do experience major trauma. COPD patients that experience trauma are still COPD patients.
In medicine, when you make blanket, absolutist statements, you need to be prepared for examples that disagree.
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