Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

More Oxygen in the New AHA Guidelines

Just kidding. We have Less Oxygen in the New AHA Guidelines.

I had a patient who had a pulse oximetry in the 80s. The people on scene were trying, unsuccessfully, to keep a non-rebreather mask on the patient. The patient has dementia, is uncooperative, and is oxygen dependent. I switched her from high-flow oxygen by mask to a cannula at 2 LPM. Everything I did would be criticized by someone who follows the old EMS rules, but these rules are not valid rules. The patient had nice pink conjunctivae, warm extremities, strong pulses, good capillary refill, and good lung sounds, although she was rather agitated. She had kept fighting to take the mask off, but she did tolerate the cannula.

Once she was no longer fighting to remove the mask, we were able to obtain a more accurate oxygen saturation. The number had been displayed on the pulse oximeter with a waveform that was consistent with partial capture, but that does not mean that the actual oxygen saturation is higher than the number displayed. That just means that the number displayed may not be accurate. It could be inaccurately low. It could coincidentally display an accurate number. It could also display an inaccurately high number. My assessment of the patient contradicted the low oxygen saturation reading, so I chose to follow my assessment, while continuing to reassess.

We moved her to the ambulance and my partner started to drive, then the patient calmed down and we were able to see the oxygen saturation rise to the upper 90s.

No sedation. No mask. Just some hand holding and a quiet ride.

If I were concerned with the rules, I would have done things very differently and the patient would probably have been much worse off. The patient was not benefiting from wrestling with medical personnel in a fight to force an oxygen mask onto her face, just to make a number look better on the documentation. I also left a copy of the good waveform with her, when I transferred care, so that others would have some evidence that she is able to produce adequate oxygen saturation with minimal oxygen. RTs are good at paying attention to what works.

Common practice has been for basic EMT’s to administer oxygen during the initial assessment of patients with suspected ACS. However, there is insufficient evidence to ‘support or refute oxygen use in uncomplicated ACS. If the patient is dyspneic, hypoxemic, has obvious signs of heart failure, or an oxyhemoglobin saturation <94%, providers should administer oxygen and titrate therapy to provide the lowest administered oxygen concentration that will maintain the oxyhemoglobin saturation 94% (Class I, LOE C).238[1]

This patient was not complaining of anything that might be considered an ACS (Acute Coronary Syndrome), but she was not complaining of anything respiratory, either.

In what way would she have been better off with too much oxygen?

TOTWTYTR writes on the same subject in More About the New AHA CPR Guidelines.

AD writes about this in Two Steps Forward, One Step Back.

Footnotes:

[1] Acute Coronary Syndromes
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 5: Adult Basic Life Support
Special Resuscitation Situations
Free Full Text Article with links to Free Full Text PDF download

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