Oxygen therapy in ED

Guest374845 · May 12, 2018

Try to 'treat the patient in front of you' and pick your delivery device based on their sat and how short of breath they appear.

A pt's O2 sat alone shouldn't always be how you decide your treatment. Their history, their chief complaint, and their work of breathing are all interwoven. A COPD/asthmatic pt with hypoxia and a silent chest needs nebs and/or bipap, but not necessarily very much O2. A pt with cirrhosis and 4L in their belly may be taking shallow breaths and satting at 70%, but they may only need 1-2L NC to tide them over. An otherwise healthy young person may OD, aspirate and require 70L NRB just to maintain a crappy sat while you get set up to intubate them.

inthecosmos, BSN, MSN, RN, APRN · May 12, 2018

It's always about what you assess, you'll get a feel for it as time passes.

akulahawkRN, ADN, RN, EMT-P · May 12, 2018

First off, congratulations for landing a job in the ED. It's going to be an interesting ride! I pretty much say that ED nurses have to be part squirrel because we're always going this way and that, changing our priorities as patient conditions change, and we get to get it all done right now. You have to learn to be a jack of all trades, master of very few, and very inventive. Sometimes you don't have quite exactly what you need so find a way to make it!

Now then, to your question: How do you know how much oxygen and what device to use to deliver it? Honestly, experience over time will be your guide. Sometimes your patients will do just fine on room air, sometimes they need a couple liters by nasal cannula, sometimes a simple mask does the trick, but remember that the FiO2 with those won't get close to 100%... a non-rebreather can get close. An oxymask can be very versatile and delivers an amazingly wide inspired FiO2 but it won't work well with nebs. CPAP and Bi-PAP can help keep someone off of a vent and can be used with nebs.

Eventually you'll just get to see that your patient just needs to be intubated and put on a vent. Eventually you'll just get a feeling about certain patients that "look" OK but are actually early into respiratory failure. The pediatric assessment triangle can also be useful for respiratory patients too...

meanmaryjean, DNP, RN · May 12, 2018

You should make very good friends with the RTs and let them know you are eager to learn.

psu_213, BSN, RN · May 12, 2018

As others have said, there is a lot more to O2 amount and delivery device than just sats. You will learn as you go. Talk to you preceptor about it as you go along. And, don't forget, in the ED there is always a doctor there if you really are unsure.

Horseshoe, BSN, RN · May 12, 2018

There are no definite parameters for all patients. Patient medical history and condition determines this to a great degree.

That Guy, BSN, RN, EMT-B · May 14, 2018

To answer your question, I would say "whatever is necessary". Time will show you and give you experiences so you can answer that question easier. Sometimes you can just look at someone and know they need bipap, others you know need to bite the tube. We have a new grad I am working with right now and she got to intubate her first pt the other day. She learned a lot from that experience from impending respiratory distress to failure ( and how hard it can be to get a good seal bagging them ).

offlabel · May 14, 2018

Give O2 for SpO2 > than about 92%. Start with NC up to about 6 lpm then NRM, then bi-pap then ET tube.

Penelope_Pitstop, BSN, RN · May 14, 2018

Give O2 for SpO2 > than about 92%. Start with NC up to about 6 lpm then NRM, then bi-pap then ET tube.

When I left acute care, we tolerated SpO2 of 90 vs. 92. And that was for patients without COPD and CHD.

Also, sometimes you can't get a decent pleth anyway, so you need to go by assessment in that case (and blood gasses).

akulahawkRN, ADN, RN, EMT-P · May 15, 2018

You should make very good friends with the RTs and let them know you are eager to learn.

There are no definite parameters for all patients. Patient medical history and condition determines this to a great degree.

Give O2 for SpO2 > than about 92%. Start with NC up to about 6 lpm then NRM, then bi-pap then ET tube.

Respiratory Therapists get a LOT more education in ventilation and perfusion than most other folks, RN's included, as they are educated to be specialists in that arena. You'll find that hospitals do NOT use the RT's to their full potential/scope... sometimes nowhere close.

Horseshoe does make a good point, but it's perhaps not complete. All patients will need a certain amount of oxygen. There is a LOT that goes into determining how much oxygen is sufficient for a given person. Some people don't mentate well at 90%, some mentate just fine at 88% or lower... and above 91% they start having oxygen problems (from too much). You just have to get to understand what's going on and why. Personally I don't worry much about oxygen in the COPD patient unless they're really, really advanced COPD. Experience is and excellent teacher, but lean on those that are specialists and really lean on them if they love to teach...

Trauma Columnist · May 15, 2018

Moved to a different forum for more answers.