COPD Patient

[Paramagic14]

what about textbook hyperventilation syndrome. Carpo-pedal spasms,numbness in fingertips and lips,provoked by an argument. i just ask beacause i put high flow oxygen on a patient and my paramedic preceptor told me that was the wrong thing to do.

[VentMedic]

You just answered your own question hyperventilation "syndrome".

The actual determination of hyperventilation is confirmed by blood gases unless the pt just goes back to normal RR, mentation and emotion.

You can have all of those symptoms, blowing off CO2 in an effort to maintain acid/base or oxygenation.

Although rare, A leftward shift in the HbO2 dissociation curve and vasospasm related to low pCO2 may cause myocardial ischemia in patients with coronary artery disease.

Arguments strong enough to provoke those symptoms have lead to serious coronary events.

The blowing of of CO2 has a cause; emotional or physical.

They will still get a full work up in the hospital even if it reveals nothing physically.

Hyperventilation Syndrome (HVS) as in behavioral breathlessness or psychogenic dyspnea should be more accurately determined in a controlled environment because their needs are not likely going to be met in the prehospital environment.

HVS can be either acute or chronic each with different physiological/psychological patterns.

For pre-hospital;

Physical assessment, meet their immediate needs and let M.D.s and Ph.D.s do their magic on this this type of pt.

Of course, you may have to obey your preceptor now. Later, you'll get a good feel for "there could be more". Stereotyping people with those symptoms would be hard to defend in court.

If you can't sleep, try this article;

http://thorax.bmj.com/cgi/reprint/52/suppl_3/S30.pdf

[sledogg1]

Put pt on probe O2 sats, double the 02 to 6 l/m see if he increases sats probably won't increase alot in low 90's. Pt's oxyhemiglobin disassosation Curve is shot. I am interested in what the hotdog medic did.

[mdparamedic]

Ok let me just start out by saying that all of us paramedics don't think we are gods yes we have an ego to some extent some of us more then others. As a medic high flow 02 is not going to hurt the PT for a short time. there is also a condition called air trapping with copd it's not the fact they can't inhale it's more like they can't exhale and then they air trap or build up CO in the body and then resp acidosis sets in so the question is was the Pt moving air in and out when you first arrived. Rather then bumping the PT to a full 15 LPM maybe you should have increased his 02 to the max for a N/C which is 6LPM and see what happens then switch to NRB and go to 10LPM and so on. I'm not saying you did the wrong thing but maybe just being a little more conservative with the 02 and gradually raise the level would be better for the PT. Please don't categorize all medics in one we are not all full of yourselves some do remember where we started from and thats either a cfr or emt and remember BLS before ALS. I hope i have helped you and your next copd PT.

[emtnap6]

Like the last medic said, gradually raise his O2, ask the pt how he feels and go from there. Always go from what the pt tells you

[scope2776]

urgh.... i can almost see it know.... i love how the COPD pt's are always pushing like 2 lpm through about 30-50 feet of after-market nasal cannula tubing and call for "shortness of breath".

You did exactly the right thing! Oxygen is what they need most! (15 LPM NRB) If you wanted to be really cool, you could titrate LPM down to a good SpO2.

Paramedics in services with ETCO2 "Capnography" can't complain about, (or yell at the EMT's) about hypoxic drive. Just slap the ETCO2 cannula on under the NRB mask and if their carbon-dioxide goes up with continued oxygen administration, titrate the oxygen down to a compromise between SpO2 and ETCO2.

[AnthonyM83]

I still do not understand the whole hypoxic drive thing. People still spout off "do not give COPD patients oxygen" like its dogma.

Our EMt instructor told us that it used to be that people were taught before. It was drilled into their heads. So, I understand why that user's mom who was in EMS for 20 years would say that...she's probably out of it now and many people might not have that topic covered in refresher courses. But in their minds, they're truly trying to save the patient by witholding O2 b/c that's what THEY were taught.

Just shows why continued and updated education is important. What you learned when you take your class won't hold you through a 20 year career, I guess.

[Medic119]

IN reference to the COPD patient, There is absolutely no reason why anyone should withhold high flo 0/2 from a person that is in respiratory distress. You will not knock out anyone's hypoxic drive to breath in your short transport time to the ER. The individual that "chewed your head off" for placing the starved 0/2 pt on high flo 0/2 was wrong. I have been in EMS for 31 years, 23 of those years as a paramedic. If I have a patient in respiratory distress, I will use what I have in my arsenal to keep them going instead of intubating them. High Flo 0/2, Albuterol treatments, CPAP, and then if all else fails either the King airway or intubate the patient.

[canadian_ghost]

I had this case not to long ago, maybe a week ago. A COPD was short of breath, we were first on scene and my partner called for ALS backup. We put him on 10 lmp via a NRB, because from my understanding to knock out the hypoxic drive it takes 4 or 5 hours ? So we figured high flow O2 would obviously help, anyways ALS arrives and lays in on me right away for giving a COPD high flow O2, I had done just as AZCEP recommended, and asked him quietly and calmly how long it takes to knock out the drive ( this whole drama had caused the patient to become a little more stressed ) and just like AZCEP said the ALS response to my question was priceless. They backed off and didn't criticize me for anything else I did, I think I might of even got a good job :shock:

But you did a good job by giving your patient high flow O2

Take care.

[tniuqs]

You just answered your own question hyperventilation "syndrome".

The actual determination of hyperventilation is confirmed by blood gases unless the pt just goes back to normal RR, mentation and emotion.

You can have all of those symptoms, blowing off CO2 in an effort to maintain acid/base or oxygenation.

Although rare, A leftward shift in the HbO2 dissociation curve and vasospasm related to low pCO2 may cause myocardial ischemia in patients with coronary artery disease.

Arguments strong enough to provoke those symptoms have lead to serious coronary events.

The blowing of of CO2 has a cause; emotional or physical.

They will still get a full work up in the hospital even if it reveals nothing physically.

Hyperventilation Syndrome (HVS) as in behavioral breathlessness or psychogenic dyspnea should be more accurately determined in a controlled environment because their needs are not likely going to be met in the prehospital environment.

HVS can be either acute or chronic each with different physiological/psychological patterns.

For pre-hospital;

Physical assessment, meet their immediate needs and let M.D.s and Ph.D.s do their magic on this this type of pt.

Of course, you may have to obey your preceptor now. Later, you'll get a good feel for "there could be more". Stereotyping people with those symptoms would be hard to defend in court.

If you can't sleep, try this article;

http://thorax.bmj.com/cgi/reprint/52/suppl_3/S30.pdf

Firstly this is an old dragged up thread and 2 issues: please re read Ventmedics comments there quite to the point and consise, please refer to 'Oxygen rate for chest pain" thread as it is a more current "view" of 02 therapy.

1- Hypoxic Drive The Myth yes still in acualility this myth is still a huge concern for EMS today and quite self evident with the initial post and self perpetuating from old school thinking Paramedic's.

To keep it brief the % of COPDers that are truely Hypoxic Drive is more akin to 5 % of this population, yes, it can take hours to identify and MANY of this group do not follow any rule book ...... in passing, they just dont read all the studies..lol.

The only way to identify these patients as truely Hypoxic Drive, is Serial ABGs in a more controlled enviroment than the back of a delivery truck, and the underlying pathology is as as complex as pulmonary mechanics...yet another thrilling read.

My Suggested Guidelines:

The target for 02 therapy in the COPD group and more or less a concensis with respirologists these days in this group so let SaO2 be your guide: of 88% to 92% so titrate your 02 to accomplish this, but remembering that Pulse Oximetry can be + or - 2 to 4 % in error as well. ETCO2 may be of some assistance but can be frought with complications as breathing patterns change and purse lip breathing can affect clear readings.

If in any doubt use the squezzy thingy, all EMS providers can assit breathing with this handy lttle gaget.

2- That said: on the underlying thread, so please take a minute and find a book by Dale Carnagie (sp) called how to make friends and influence people...it just may help get the point across and educate others whatever there god like status and without conflict, the best EMts I have worked with know my next move before I do in a lot of cases, GOOD EMTs are not a dime a dozen...they are GOLD!

Frankly BiPAP is my prefered method to "thwart the tube" in this group of patients and the use of Broncho Dialators...ie Atrovent is stongly advised, yes, I am aware that EMT Bs are restricted but at the very least this not so stellar Paramedic should have been thinking this route...as well but no mention in the thread that I saw, did any GOOD EMT ask if this drug may be indicated....perhaps your getting my subtle hint now?

ACE really did contribute some good and current data, perhaps review and some questions to query's will be clearly answered as well.

Punisher is not the only RT in EMT city, never has and more to come I bet $$$.

Ventmedic....maybe leaches and bloodletting ?...LMFAO.

cheers