Contraindication for 02

[emsbrian]

I'm a fan of the simple answer. I think and EMS we think to much. While knowledge is by far our most powerful resource (as I can attest, I constantly study the strangest things as I have used what I thought the most useless information to save a life before) we tend to over think. While there may be an O's contraindication the main thing to concentrate on is that fact that the chances of running into someone using it is SOOOO low its almost pointless. On top of that the average AND the advanced stokers will not know what particular addative or pesticide was used in the developement of there stash. My associate used to come to me daily to ask me questions when her students would ask questions simular to this. I feel while it is important to inform students many lack the experience to make the decisions we need to teach the decision making skills. As you said hypoxic drive is not a contra, because again its hard to know, they need more os anyways. If it does deminish there respriatory drive then we just breath for them and get them the oxygen they need.

[medic001918]

The whole point of this question being posed to a student is to keep their mind's open to the fact that there is so much to learn we're never going to know it all. It's also a chance to learn a little fact about a drug that's not "common knowledge." While it's nice to live in really simple terms and ideas of what's practical, there's no harm (and only benefit) from doing some extra research and learning things such as this. The thought process is what I get at with this question. It makes people think, gives them something to look up and reminds them how little we truely know in terms of all of medicine. It's not as much a practical application question.

Shane

NREMT-P

[emsbrian]

I agree greatly with that. As I said I feel research and knowledge is important and while I would NEVER tell a student "its not important" more likely it would lead to a discussion of decision making. I believe that teaching people to think, especially at a paramedic level, is underdone. Just as we have to teach them that the more likely cause of a problem should be treated we have to teach them that the more likely knowledge should be used. If you have a woman in a high speed MVA expect abdominal trauma not ectopic pregnancy for the abdominal pain. But wait, it is still very important to know about ectopic pregnancies. As much as people hate it I believe we in EMS have lost focus and want to play doctor to much. There is a fine balance between transport and treatment. I worked a Major League Soccer game where a woman was shot, the stadium less then a minute hot to the hospital, yet by the time the basic called me they had been with the patient over 10 minutes trying to figure out a treatment plan. The woman was completely stable, light penetration of a small caliber apx. 2.5cm inferior of the subclavian. When I arrived I questioned why they called ALS, they lacked the knowledge to correctly ID a bullet wound (fired from over a mile away so no sound in this case). Which is a problem with knowledge, but they also lacked the thought. It was Obvious there was a penetration, with something in it. Treatement took me 2 minutes, I explained to the Pt. the situation, and that in truth we could not be sure if it was a bullet or not, but there was something. (While in most cases I know a shot when I see one, I make no assumptions). I slinged her arm and immobilized it against her body to prevent the bullet from causing further damage, told the on scenes to transport and do a lock and draw in Tx to save time at the hospital. The point is both of these two were paramedics, fresh out of big city fire academy. But had neither the experience or the knowledge, many people say we cant teach experience but we can knowledge. THING IS WRONG we can teach the ability to apply knowledge. This is our greatest problem in EMS. In all length of comment, I agree with the above statments by others and would just like to stress that point.

[dzmohr]

I'm a fan of the simple answer. I think and EMS we think to much. While knowledge is by far our most powerful resource (as I can attest, I constantly study the strangest things as I have used what I thought the most useless information to save a life before) we tend to over think. While there may be an O's contraindication the main thing to concentrate on is that fact that the chances of running into someone using it is SOOOO low its almost pointless. On top of that the average AND the advanced stokers will not know what particular addative or pesticide was used in the developement of there stash. My associate used to come to me daily to ask me questions when her students would ask questions simular to this. I feel while it is important to inform students many lack the experience to make the decisions we need to teach the decision making skills. As you said hypoxic drive is not a contra, because again its hard to know, they need more os anyways. If it does deminish there respriatory drive then we just breath for them and get them the oxygen they need.

I hope I am misreading your post, I suspect I am... but I strongly feel the converse is true, most do not think ENOUGH!

I am not talking about horses and zebras I am talking about cookbook medicine and USA Today as medical research and if you have a puzzling patient or one that does not respond as you thought they "should" do you shrug your shoulders and blow it off or do you hit the books and try to understand why?

I am one of those that believe we do diagnose and practice medicine even if we don't say the words .. we make decisons without a lot of advanced backup and we better be on our game.

What I hope you mean, and what I suspect you do, is that a simple answer is often best. Give them a firm foundation and teach THEM to research and always encourage them to question, make sure they know that while you have to memorize much of the cookbook, most of their patients will not have read the script and my throw extra ingredients at you...so be ready for it and if you are not be ready for it the next time!

[emsbrian]

I'm long winded, and as the above shows perhaps confusing, so I will try to make myself clear, but I fear I may simplify my point to much.

Memorize the cook book. Know the ingredients. Then LEARN HOW TO USE THEM. This is the missing step. I'm a big fan of easy mac, never would order the restaurant stuff. (Okay am I talking about medicine or food here?) "most do not think enough" IS my argument (all be it cryptic perhaps in my rant) We do diagnose, we do perform (who practices) medicine.

"What I hope you mean, and what I suspect you do, is that a simple answer is often best. Give them a firm foundation and teach THEM to research and always encourage them to question, make sure they know that while you have to memorize much of the cookbook, most of their patients will not have read the script and my throw extra ingredients at you...so be ready for it and if you are not be ready for it the next time!"

---> NAILED IT MY FRIEND

In medicine we rule out the simple before the rare. STRIKE THAT We rule out the COMMON before the rare. (At this point I just deleted 9 lines of ranting)

TEACH THEM TO THINK. This conversation stemmed for O's and a funny comment made was if pt is on fire O's is contraindicated. (Yes i know its a joke but i can make a point with it) If the patient is on fire A: Who cares about O's, B: How would you get O's on them. My point is the cook book may say put it on them, and god knows that some cook book medic would try to put it on him because his protocols said so!

At this point the conversation has perhaps moved to EMS education but that goes back to the original question. LEARN TO LEARN< LEARN TO THINK

[FL_Medic]

A medic preceptor today told me there is one contraindication for oxygen.

It was a quite often used street drug that is no longer in fashion. It sounded something like periquot (like aliqout, but peri) though we couldnt find anything about it on the internet. I was wondering if anyone had any legitimate reasonings behind this so call-ed contraindication to high flow 02.

No, Hypoxic drive is still not a contraindication for high flow 02 in teh acute setting. This is supposedly the ONLY contradindication for high flow 02 and that is an overdose on this medication. Wondering what it is and what the mecahnism could possibly be

OveractiveBrain

This may be another topic, but you may want to consider precautions when using high flow O2..

Stroke - high flow O2 may decrease your Pt's respiratory drive.

CPAP with MI - This may worsen the MI.

how should we oxygenate our head traumas?

[emsbrian]

Stroke - high flow O2 may decrease your Pt's respiratory drive.

True, but if we have an oxygenation problem to begin with it needs to be resolved, try O2 by NC if this doesn't resolve it then Hi-flow if your worried. In most protocols around here stroke is still instant High-flow, the possible benefits FAR out weigh problems, so it is in no way a contraindication. The reason we feel this way (beyond the whole more O to the brain thing) is that on top of numerous benefits, decreased respiratory drive is easily fixed by bagging. While I in no way recommend taking away respiratory drive (watch the morphine guys) I dont mind if the oxygen needs to get there.

CPAP with MI - This may worsen the MI.

A second excellent point but again we look at the underlying problem. If we are dealing with immediate tissue death then we need to oxygenate. But you do make to very valid points in LONG TERM consideration, I feel the immediate salvage to prevent tissue necrosis is important.

[spoil:75400b39ad]The future is here. A milky white substance will soon hang in the mini-fridge (next to the sodas) on our ambulances. (forgive me my science journal is at home on the toilet so namesake will come later) Artificial bloods are improving. While they will still not replace whole blood for its ablitity to carry waste products and other biological agents it is 50 TIMES better at carrying oxygen. This new artificial blood is also so small that that one single 50x loaded molecule can squeeze 6 side by side through a single RBC capillary. Whats this mean to us? Not only does it last longer on the truck then blood, but it carries oxygen so much better, through such smaller parts that it can bypass injured sites, including Spinal, Brain and cardiac injuries. Mouse studies have shown a 90% decrease in traumatic is chemic tissue damage with its use.

How does this apply to Oxygen discussion? The whole point is getting more oxygen to the patient by giving him more to absorb, but the underlying problem is the transport system. By giving this new form of artificial blood were looking at making super blood, we both increase oxygen carrying ability and the delivery of it. In theory a near complete blockage of a coronary artery would allow MORE oxygen through with this drug in a persons system, then if it was fully open?!?! Imagine the possibilities of this new line.[/spoil:75400b39ad]

[tniuqs]

This may be another topic, but you may want to consider precautions when using high flow O2..

Stroke - high flow O2 may decrease your Pt's respiratory drive.

CPAP with MI - This may worsen the MI. how should we oxygenate our head traumas?

Nope I believe it is on topic, I think we got a tad out of focus somewhere along the line but then again we always do.

Stroke: Perhaps let Oximetry be your guide, but walk into an ER with a patient not on O2 and you may feel the wrath of those that are "old school ideals" sure saves changing out a lot of tanks on the fly to be sure.

How should we oxygenate our head traumas?:

Just my 2 cents here but until these studies are accepted and implemented across the board (or even reproduced) Please remember that they are not generally accepted as gospel just yet, that your local protolcols should be followed. Besides, we have not invented a device that can control acurately the Fi02 delivered too in a manual resusitator, the suggestion of following the SaO2 monitor sounds very plausible to this cowboy.

CPAP: this does increase WOB, but accepted in CCUs where I have worked that low levels of PEEP do improve Cardiac function.

If one searches on the net, on the use of CPAP a study by the aforementioned author and researcher)

This a study suggests that CPAP or better yet BiPAP is indicated for CHF patients by improving C.O.

Just a passing comment on:

Hemodynamic effects of supplemental oxygen administration in congestive heart failure.

Haque WA, Boehmer J, Clemson BS, Leuenberger UA, Silber DH, Sinoway LI.

Division of Cardiology, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania, USA.

This study had a total of 10 patients and after review: The decrease in C.O. and SV, increase in PWP, and SVR.. its assumed to be and I quote "detrimental" this was not fully explained to my way of thinking, anyway. I could postulate that because of improved oxygenation at the cellular level that this may indicate a decrease in work for the heart and work of breathing? perhaps?

100% O2 administration only increases the partial pressure of 3 mmHg at the Mitochondrial level, don't really know how this may tie in but even a very small increase at the cellular level may be of significance yet to be fully understood. So don't throw the baby/ O2 out with the bath water just yet. It again is a very small study group, repeating the findings on a larger scale would be far more impressive. Just recently in fact has it become fashionable with presenters / speakers at larger Conventions to relook at how we use Oxygen as a drug.

cheers

[tniuqs]

[spoil:d9509e9663]The future is here. A milky white substance will soon hang in the mini-fridge (next to the sodas) on our ambulances. (forgive me my science journal is at home on the toilet so namesake will come later) Artificial bloods are improving. While they will still not replace whole blood for its ablitity to carry waste products and other biological agents it is 50 TIMES better at carrying oxygen. This new artificial blood is also so small that that one single 50x loaded molecule can squeeze 6 side by side through a single RBC capillary. Whats this mean to us? Not only does it last longer on the truck then blood, but it carries oxygen so much better, through such smaller parts that it can bypass injured sites, including Spinal, Brain and cardiac injuries. Mouse studies have shown a 90% decrease in traumatic is chemic tissue damage with its use.

How does this apply to Oxygen discussion? The whole point is getting more oxygen to the patient by giving him more to absorb, but the underlying problem is the transport system. By giving this new form of artificial blood were looking at making super blood, we both increase oxygen carrying ability and the delivery of it. In theory a near complete blockage of a coronary artery would allow MORE oxygen through with this drug in a persons system, then if it was fully open?!?! Imagine the possibilities of this new line.[/spoil:d9509e9663]

Ok then theres the magic of the computer...how the hell did you do that...sneaky bugger. :twisted:

[EmergencyMedicalTigger]

I worked a Major League Soccer game where a woman was shot, the stadium less then a minute hot to the hospital, yet by the time the basic called me they had been with the patient over 10 minutes trying to figure out a treatment plan. The woman was completely stable, light penetration of a small caliber apx. 2.5cm inferior of the subclavian. When I arrived I questioned why they called ALS, they lacked the knowledge to correctly ID a bullet wound (fired from over a mile away so no sound in this case). Which is a problem with knowledge, but they also lacked the thought. It was Obvious there was a penetration, with something in it. Treatement took me 2 minutes..The point is both of these two were paramedics, fresh out of big city fire academy. But had neither the experience or the knowledge, many people say we cant teach experience but we can knowledge. THING IS WRONG we can teach the ability to apply knowledge. This is our greatest problem in EMS.

Seeing that we are from the same city, are you really that shocked by the level of care these medics were giving? It is common knowledge that the most of the medics (not all) in that organization just want to play with a fire hose and are forced to go through an in-house paramedic fast track program to keep their jobs. Personally, I'm glad that I live in county jurisdiction where we have our own local EMS.

But to get back towards the topic....I think it's best to keep it simple and not waste on-scene time overanalyzing. But it's also good to have as much knowledge as possible. It gives you a better understanding of what might be happening with the pt, and you might actually be able to use some of that knowledge from time to time to render a little bit better pt care.

Everyone has had great points and information. We just need to remember to treat each pt on a case-by-case basis and not get too cook book with our care.

Just my thoughts.