Oxygen

You arrive on scene for a patient with a painful broken hand. The first responder, as he is trained, has a nonrebreather on the patient. You thank him for the report, and then take the nonrebreather off and say to the patient, we’re going to see how you do without this for a minute.

Sometimes I see in the first responder’s eyes the hint of a reprimand. Am I quietly putting them down for putting on the 02 or am I a bad medic for taking it off? The scene plays out over and over every day. Sometimes I have to tell them later that I know they are just following their protocols, but I need to assess the patient off the 02, and I don’t mean against them when I take it off the patient.

But who ever came up with this idea of putting a nonrebreather on everybody, respiratory distress or not?

I got into a discussion once with one of my preceptees about their putting a nonrebreather on a patient who wasn’t in respiratory distress. Why? I asked. because it will make them better, he answered. Because that’s what we’re taught. And besides oxygen can’t hurt.

Yes, I’ve heard that before, but I’ve been hearing and reading other things as well. Here’s the latest:

UCLA imaging study reveals how pure oxygen harms the brain

Now this is just one study (one of a growing number) and I’m certainly in no position to advocate not giving someone in respiratory distress or arrest high-flow oxygen, but can’t someone authorize the first responders to ease up on it instead of telling them to continue putting high-flow oxygen on everyone.

Someone is making a lot of money selling oxygen and oxygen masks.

***

Here are some of the (conflicting?) things the American Heart Assosiation has to say about oxygen.

Oxygen by first responders:

There is insufficient evidence to recommend for or against the use of oxygen by a first aid provider (Class Indeterminate), and concern exists that oxygen administration may delay other interventions.

Oxygen by basic life support and advanced life support:

To improve oxygenation, health care providers should give 100% inspired oxygen (FiO2 + 1.0) during basic life support and advanced cardiovascular life support as soon as it becomes available

Oxygen for Asthma:

Provide oxygen to all patients with severe asthma, even those with normal oxygenation. Titrate to maintain SaO2 >92%.
Oxygen for stroke patients:

Both out-of-hospital and in-hospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation <92%) stroke patients (Class I) or those with unknown oxygen saturation. Clinicians may consider giving oxygen to patients who are not hypoxemic (Class IIb).

Oxygen for people having chest pain:

EMS providers may administer oxygen to all patients. If the patient is hypoxemic, providers should titrate therapy based on monitoring of oxyhemoglobin saturation (Class I).

And more:

Administer oxygen to all patients with overt pulmonary congestion or arterial oxygen saturation <90% (Class I). It is also reasonable to administer supplementary oxygen to all patients with ACS for the first 6 hours of therapy (Class IIa). Supplementary oxygen limited ischemic myocardial injury in animals, and oxygen therapy in patients with STEMI reduced the amount of ST-segment elevation. Although a human trial of supplementary oxygen versus room air failed to show a long-term benefit of supplementary oxygen therapy for patients with MI, short-term oxygen administration is beneficial for the patient with unrecognized hypoxemia or unstable pulmonary function. In patients with severe chronic obstructive pulmonary disease, as with any other patient, monitor for hypoventilation.

Oxygen for Pediatric Basic Life Support:

Despite animal and theoretic data suggesting possible adverse effects of 100% oxygen,82–85 there are no studies comparing various concentrations of oxygen during resuscitation beyond the newborn period. Until additional information becomes available, healthcare providers should use 100% oxygen during resuscitation (Class Indeterminate). Once the patient is stable, wean supplementary oxygen but ensure adequate oxygen delivery by appropriate monitoring.

***

I was teaching a protocol rollout class the other day talking about how we are now doing things we thought were bad (morphine for abdominal pain) and no longer doing some things we thought were good (Hi-flow fluid recusitation in trauma). Who would have thought oxygen might be harming people?

13 Comments

  • Blue Ridge Medic says:

    I read this article yesterday and found it very interesting. It goes to show you how much things can change. If this study is expanded upon and accepted in the medical community, it could change one of the fundamentals of EMS care.Regards,BRM

  • Rusty aka Emma says:

    Don’t know how it is in the USA but in England now O2 is considered a drug and has to be prescribed by the Drs.I am a chronic asthmatic but am able to sustain reasonable O2 sats during an attack, so being given O2 while be transported only slows my treatment down as my ABGs need to be done 30 mins off O2. Have had several major arguments, well head shaking and hand waving, with paramedics in the past. Always an interesting journey!!!

  • Craig D says:

    We’ve had a changing perspective on O2 in New Zealand lately.We are no longer routinely giving 02 to CVA pts (I think a study might have said that O2 may make a CVA worse)And every few months there’s a bulletin/study that talks about the general over-use of O2 by the ambulance service.I’d say you’ve got over-cautious First Responder training. If they’re warm, pink, well perfused, nil chest pain and breathing comfortably – why give 100% O2? You can’t push SpO2 past 100%!

  • Toledo, Oregon CERT says:

    One of our first responder agencies routinely gives o2 to every patient. Even the ones with isolated psych issues…My agency is only doing low flow o2 to CVA patients, unless they need it. There’s something out there about oxygen, free radicals & additional brain damage…

  • Secondshooter says:

    Just took my National Registry practicals a few weeks ago for EMT-B. On most of the stations failure to administer oxygen is an automatic fail, regardless of the scenario.It’s what they’re teaching.

  • Ambulance Driver says:

    I believe the thinking is that free oxide radicals help speed destruction of brain cells in stoke patients.The problem with indiscriminate oxygen therapy on the part of EMT-Bs can be traced back to the 1993 revision of the EMT-B National Standard Curriculum. A number of special interest groups succeeded in whining loudly enough to keep the curriculum limited to 110 hours, this forcing the deletion of a great deal of theory and A&P from the curricula. What we got was monkey-see, monkey-do EMS. Interventions with few known contraindications, like oxygen therapy, were encouraged with an all-or-nothing approach. This, many EMTs trained under the current model are encouraged to DO, without knowing WHY.

  • J-chan says:

    I hate, hate, HATE (as a newly-trained and not-yet-tested EMT-B with little field experience in ride-alongs and the like) being asked why do we do action X and only being able to answer, “Because that’s how I was trained” and that’s basically the only reason I know to give high-flow O2 to almost every patient: Because that’s what my instructors taught me when I took my class. “Never withhold oxygen from a patient; It might help and will never hurt.” The only exception we ever got to this was infants, and a short little chat about old people with COPD and the hypoxic drive, which I know nobody in my class will ever remember, because that crowd embodied the EMT stereotype of idiots who lift things, carry people, and drive the flashy band-aid box. x_X;; My take on it? Pure O2 calms people down, gives ’em a high, almost. An alternative to the popular “oxygen therapy” of whacking ’em in the head with the tank. 😉 One of my more cynical instructors thinks this may be the reason we oxygenate all patients, to attempt to shut them up…

  • PC says:

    Thanks for all the comments.It is always interesting to ss how things are handled in other countries.I do feel bad for a genneration of responders who were given “the dumbed down” curriculum.I also agree that putting 02 on someone does have a big placebo effect.As I wrote I feel bad when I tactfully take the oxygen off.A problem I see in EMS is that the medicine changes faster than the educational structure. Also, I think what you are first taught tends to stick much deeper in the brain that reteaching. An example is one of our hospital’s numbered the rooms a certain way and so I knew where all the rooms were. When they renumbered them, now no matter how often I go there, I need to look at the sign to find the rooms. My brain won’t give up what I initially learned. We have had a problem teaching some older responders new ways, and I know of some older teachers who are slow or unwillinging to teach the newer ways. Sometimes, sadly, they can’t teach the new ways because they are restricted by a mandated older curriculum.We have been debating going allowing basdics in our region to implement the selective spinal immobilization protocol, but in initail discussions, have encountered not just resistance (We don’t have an x-ray machine and won’t put ourselves at liability) to the agruement we can’t let them do it because it is nat a part of the national curriculum and the state regulations say we have to abide by the national curriculum.Thanks again for the comments,PC

  • Anonymous says:

    Overuse of high-concentration oxygen and cspine immobilization is two of my biggest annoyances in EMS. Especially when they are combined, like the patient who fell from standing height with no LOC or neuro defect coming in to the ED collared/backboarded with the non-rebreather cranked so high their hair is flying in the wind.I think it goes to support the kind of cookbook medicine that says, “We MUST to do something for the patient” even if theres no proven effect in it helping and might even be hurting the patient.As much as medicine has progressed, I sometimes sigh that we’re in someways no better than leeches, snake oils and trepanning.

  • Nathan says:

    Based on what I can see those AHA protocols only say to use high conentrations of oxygen only in hypoxemic patients and patients in cardiopulmonary arrest. Why oh why then cant the EMS protocols say that too then?

  • Chris says:

    Peter:Would you happen to have links to any further primary research on this topic?-Chris

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