Hello! So I'm newer to the ER so I was hoping I might get some perspective on a scenario that came about the other day about a patient who came into our ER by EMS. The report given to me was the patient was found unresponsive by her parents in her bed after last seeing her the previous night reading. When EMS arrived to our hospital, the patient was only responsive to pain, vitals were w/in normal limits, pupils dialated, but reactive. However, I noticed she wasn't on any oxygen. Even though she was 98% on RA, I felt given how she was presenting that she might need some supplemental oxygen.
I questioned EMS about this and their response to me was it wasn't their protocol since her sats were fine. They looked at me like I was silly for asking. Okay, well....
Her parents arrive later. I start talking with them. They tell me they found a bottle of meds and all the pills weren't accounted for. For the life me I can't remember what meds they were only that it was a benzo. Also, they tell me that the patient had just recently caught her boyfriend cheating on her with another girl and the patient has a history of depression. this is starting to sound like a suicide attempt to me. Hours later, when the pt starts to wake up tells me she was in fact trying to kill herself.
Anyway, my question is was I wrong to ask them why they didn't put her on oxygen? Things aren't always what they seem. I've heard not to treat the monitor, but what I see. What do you think?
In the grand scheme of things you weren't wrong for asking, however ems does have their own protocols and theirs usually state that supplemental o2 isn't needed unless sat are below normal.she'd be required I believe if she were completely unresponsive but she responded to painful stimuli as you stated. So all they had to do was montero for possible intubation. The only time I've seen etco2 in Ems is post intubation
The standard of care in EMS should be the availability of ETCO2. This is measured with a special nasal cannula that can also deliver oxygen. This is the best way to measure ventilation. I personally have seen patients with SaO2 of 98% and a CO2 of 50+. EMS was mistaken to withhold oxygen because of SaO2, they should be guided by clinical presentation. An OPA or NPA should have been placed if intubation was deferred from some reason. Hyper oxygenation is not harmful in the short term, as one poster alluded. So when in doubt, in the ED, place oxygen. Studies have shown poorer outcomes when pressure of oxygen is >200, for example, especially in head injuries. But these are patients on 100% oxygen for long time periods. I agree the patient may not have needed oxygen, but you were not wrong to consider it. As for asking EMS their thought process, it is usually best to move forward and treat the patient the way you feel is appropriate. Good luck!
Generally speaking, patients that are oxygenating well (SpO2 > 92%) and are clearly moving good air (no diminished lung sounds) and aren't obstructing their airway don't need supplemental oxygen. If you were to give supplemental oxygen when it's not needed, you may not change the SpO2 value much (say 94%->98%) but you very easily could bump the PaO2 well over 100 and that's basically more oxygen than needed. The "extra" oxygen is then able to act as an oxidizer in the body (same role O2 has in combustion, just not as energetic) and that can cause damage to the body.
If you're concerned about a patient's ability to ventilate despite "good" oxygenation, put the patient on an EtCO2 cannula and track that also. I had a patient last night that reminded me that I should have at least one EtCO2 cannula nearby for those patients that are possibly retaining CO2. Of course it also helps to have a monitor module that can sense CO2...
Prehospital folks are generally of the same mindset. Increasingly they're being equipped with EtCO2 capable monitors and my suspicion is that eventually they'll get to a point where if a prehospital (not interfacility) patient has to be put on oxygen or if there's any suspicion of CO2 retention, they'll also monitor EtCO2. From what I understand, they'll only monitor EtCO2 now if there's a suspicion of retention, the patient is intubated, or on CPAP/Bi-PAP.
Do not EVER think you are wrong for asking a question. You would have been wrong had you not asked and simply assumed, even if your assumption was correct. Why? Because it was a gamble.
Specializes in Adult and Pediatric Vascular Access, Paramedic.
Ok, lets stop with the OVER USE of oxygen!! Her saturation was 98%, she did NOT need oxygen. More and more studies are finding that over oxygenating does more harm than good!
I wish I could get a dollar every time I brought in a STEMI that was sating >94 %, who we brought in on room air for that reason, but the ER put on a nasal cannula even though AHA is against it since it can cause coronary artery constriction.
Please do some research, oxygen is NOT a harmless drug!
Your patient was oxygenating well on her own and did NOT need oxygen!
Specializes in Adult and Pediatric Vascular Access, Paramedic.
The standard of care in EMS should be the availability of ETCO2. This is measured with a special nasal cannula that can also deliver oxygen. This is the best way to measure ventilation. I personally have seen patients with SaO2 of 98% and a CO2 of 50+. EMS was mistaken to withhold oxygen because of SaO2, they should be guided by clinical presentation. An OPA or NPA should have been placed if intubation was deferred from some reason. Hyper oxygenation is not harmful in the short term, as one poster alluded. So when in doubt, in the ED, place oxygen. Studies have shown poorer outcomes when pressure of oxygen is >200, for example, especially in head injuries. But these are patients on 100% oxygen for long time periods. I agree the patient may not have needed oxygen, but you were not wrong to consider it. As for asking EMS their thought process, it is usually best to move forward and treat the patient the way you feel is appropriate. Good luck!
FYI oxygen is not going to effect CO2, it may actually slow their respiratory rate which would INCREASE CO2 retention.
You would NEVER use an oral airway on a living patient, especially one that is responsive to painful stimuli since they will have a gag reflex! The same with intubation, if the service does not have RSI intubation is not going to happen, unless they have nasal. Clearly you have never tried to put either device in a non-sedated paralyzed patient, it doesn't work!
This patient DID NOT need oxygen, she was oxygenating well on her own. Please, let's stop over using oxygen, as it can be harmful!!! If you are the ER nurse and you feel better with oxygen on them, fine go for it, but don't argue with an ambulance crew about it!
FYI oxygen is not going to effect CO2, it may actually slow their respiratory rate which would INCREASE CO2 retention.
You would NEVER use an oral airway on a living patient, especially one that is responsive to painful stimuli since they will have a gag reflex! The same with intubation, if the service does not have RSI intubation is not going to happen, unless they have nasal. Clearly you have never tried to put either device in a non-sedated paralyzed patient, it doesn't work!
This patient DID NOT need oxygen, she was oxygenating well on her own. Please, let's stop over using oxygen, as it can be harmful!!! If you are the ER nurse and you feel better with oxygen on them, fine go for it, but don't argue with an ambulance crew about it!
Annie
I have to agree with most of the points nurse 2033 made.
Oxygen can affect the CO2 levels as seen with the alternative explanations to the hypoxic drive myth such as pulmonary vasoconstriction and alveolar deadspace. But, that doesn't mean they stop breathing and some don't slow their respirations especially if the clinicians understand this process and provide the appropriate interventions.
Many EMS agencies do not have RSI and yet are able to intubate successfully. It is rare to see nasal intubations and they are really not encouraged except as a last resort.
Oral airways can be tolerated by the "living" since there are many reasons for a lost of gag requiring temporary splinting of the oral cavity. We use nasal airways as suction assist devices when multiple passes are required.
In the ER and ICUs we have the ability to determine just how much oxygen is required. The SpO2 is not always indicative of good oxygenation since other substances can bind to the hemoglobin to give a false high reading. You also don't know which way the oxyhemoglobin curve has shifted until more labs are done. The SpO2 reading could be just barely enough to give a good number but the actual SaO2 and A-a gradient could have a huge gradient. This is often seen in sepsis and metabolic acidotic states. The curve is also very steep when close to the edge and you can go to the hypoxic side quickly. Brain dead patients and those who are well sedated can also maintain a high SpO2 without any ventilations for an extended period of time. We see this in brain death trials off the ventilator and during intubation all the time.
I also think as Paramedics you go all or none. It is different in the hospital situation. In the hospitals we have the advantage to titrate. We don't have to use nonrebreather masks. But then, some patients are difficult to get to the point of hyperoxygenation with a nonrebreather.
Once we have a little more data which doesn't take long, the O2 can be weaned quickly. Cardiac and stroke are examples of patients we will get off O2 quickly. But, there are always those patients which present with more than one issue which must be taken into consideration. That is all part of patient assessment and clinical correlation rather than a rigid protocol which EMS sometimes must follow.
You would NEVER use an oral airway on a living patient, especially one that is responsive to painful stimuli since they will have a gag reflex! The same with intubation, if the service does not have RSI intubation is not going to happen, unless they have nasal. Clearly you have never tried to put either device in a non-sedated paralyzed patient, it doesn't work!
Annie
Hi Annie,
We put oral/nasal airways in people with active reflexes all the time, even those only lightly sedated. If a patient is aware they will simply just spit the oral airway out, nasals can be tolerated by people wide awake.
To the OP,
If the sat is normal there is no indication to use supplemental O2. It's also highly unlikely to have respiratory failure from Benzodiazapines alone. The issue is generally when it is combined with some other form of CNS depressant. Your best bet to assess this is like what other posters mentioned in that of End Tidal C02. Hypercapnia will lead to CO2 narcosis which is the eventual downfall of many overdose patients. My guess is that she didnt take much, probably just a few more than usual, which happens all the time. People just want attention with no intent of cause harm, which makes sense since her boyfriend broke up with her. Normal sats = no intervention. Take it from a PACU nurse who stares at them all day! Normal CO2 = no intervention. Abnormal CO2 = means you'll need something to boost rate (or volume) or your patient is heading towards smoking plastic.
One thing that is important to remember, especially while you're gaining ER experience, is to learn from everyone you can. Pre-hospital is a great resource to learn from... Just like in the ED where you don't know what's coming in next, they are in the same boat, except they have to scoop the patient up, assess them, and figure out what's really needed. Sounds like the patient was at least protecting her airway enough to keep from getting tubed, and if she didn't have any signs of respiratory distress, adequate o2 sats, normal respiratory rate, I would have looked for other causes of AMS.
Sometimes when we ask EMS why they didn't do something it puts them on the defensive. If lack of intervention causes deterioration or it's someone that just didn't do something they are supposed to, that's definitely a time to speak up.
Specializes in Emergency, Case Management, Informatics.
I'm on board with the "stop over-utilizing supplemental oxygen" camp, and so is the AHA and plenty of peer-reviewed research.
We used to think that everyone needed oxygen and that oxygen was benign at worst. If your patient is oxygenating well and does not appear in distress, they don't need supplemental oxygen. OP mentions a decreased mental status as a rationale for oxygen. I agree that the patient needs to have their airway protected, but as long as the airway is patent, there's no issue with oxygenation.
As always, treat your patient and not your vitals. If your patient is satting 98% but they look like a guppy, maybe it's time to throw on a little oxygen. Otherwise, think before you act.
I'm on board with the "stop over-utilizing supplemental oxygen" camp, and so is the AHA and plenty of peer-reviewed research.
We used to think that everyone needed oxygen and that oxygen was benign at worst. If your patient is oxygenating well and does not appear in distress, they don't need supplemental oxygen. OP mentions a decreased mental status as a rationale for oxygen. I agree that the patient needs to have their airway protected, but as long as the airway is patent, there's no issue with oxygenation.
As always, treat your patient and not your vitals. If your patient is satting 98% but they look like a guppy, maybe it's time to throw on a little oxygen. Otherwise, think before you act.
Why do we waste time doing vitals?
Do you blow off a patient in your ED that "looks fine" to you without taking any vitals?
Do you ignore a tachy arrhythmia on the monitor because the patient "look fine"...now?
A patient can be breathing 34 and perfectly comfortable except their pH might be 7.19.
People have made that statement for a long time but usually it is made by people who are not aware of just how valuable that data can be to treating a patient. It is time to stop saying that and start utilizing the assessment tools you do have for the benefit of the patients. We have those tools and hopefully the knowledge for many reasons.
Do you ignore a tachy arrhythmia on the monitor because the patient "look fine"...now?
A patient can be breathing 34 and perfectly comfortable except their pH might be 7.19.
People have made that statement for a long time but usually it is made by people who are not aware of just how valuable that data can be to treating a patient. It is time to stop saying that and start utilizing the assessment tools you do have for the benefit of the patients. We have those tools and hopefully the knowledge for many reasons.
You're right, for the most part - but an overemphasis on the numbers can lead to badness too. It's a balancing act: "Is the clinical picture more good than bad or more bad than good?" as they put it in my acls courses. Treat the patient, not the monitors.
elijahvegas, ASN, RN, EMT-P
508 Posts
In the grand scheme of things you weren't wrong for asking, however ems does have their own protocols and theirs usually state that supplemental o2 isn't needed unless sat are below normal.she'd be required I believe if she were completely unresponsive but she responded to painful stimuli as you stated. So all they had to do was montero for possible intubation. The only time I've seen etco2 in Ems is post intubation