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

- Rogue Medic

Oxygen in the New AHA Guidelines

With all of the concern about deviating from the AHA (American Heart Association) Guidelines, will EMS agencies be as aggressive in changing their treatment with oxygen?

Will IRBs (Institutional Review Boards) be as aggressive in demanding that research not deviate from this standard of care?

Will the EMS agencies, that do not adopt this guideline, be sued by plaintiffs’ lawyers for harm that was clearly due to deviation from this standard of care?

Since everybody seems to interpret what the AHA includes in the guidelines as the standard of care, should this be any less of a standard of care than, Everybody dead gets epi?

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]

In case all of those words make this seem a bit too complicated –

basic EMT’s

Not just doctors, nurses, or paramedics.

If the patient is dyspneic, hypoxemic, has obvious signs of heart failure, or an oxyhemoglobin saturation <94%

Not just because the patient is being treated for an Acute Coronary Syndrome (Chest Pain or an atypical cardiac presentation), but only with actual assessment findings that there is a probable lack of oxygen.

should administer oxygen and titrate

Not just deliver as much as they can.

administer oxygen and titrate therapy to provide the lowest administered oxygen concentration that will maintain the oxyhemoglobin saturation 94% (Class I, LOE C).

Not the highest oxygen concentration possible.

Not even in the upper 90s.

Not any mention of this being for COPD (Chronic Obstructive Pulmonary Disease) patients, who may actually be better off at lower oxygen saturations.

Not a, possibly helpful, Class IIa recommendation.

Not a, We don’t have any good evidence, but we would rather make the mistake of doing something harmful, than make the mistake of not doing something beneficial, ClassIIb recommendation.

This is a Class I recommendation.

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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Comments

  1. I had this conversation with my medical director. She agrees that we use too much oxygen. It looks like what I’ve been saying for the past five years is correct and we’ll see some changes in our practice. At least I hope so.

    • Too Old To Work,

      Yes. We have been giving too much oxygen, at least when we have been managing the airway so that the oxygen ends up where it is supposed to. We have not been giving enough of opioids, sedatives, nitrates, CPAP, and maybe a few other things.

      This is changing in some places.

      Keep working on the medical director. 🙂

  2. Hello
    Sorry for my ignorance of U.S. English, I used to wonder why 15 liter minute on insufflation when the ball does not inflate and accurately.
    Secretly rescuers must make arrangements without the support guidelines?
    Oxygen should not be a business but a service to humanity.
    Ok this is oxidant but it gives life
    Why can provide resuscitation if
    Who will have the courage to express the way I do?
    No statistics … but did ..
    So 15L or 30L min min
    See more? But in the context of the emergency, the emergency does not benefit the screw max 15 min … it’s just?
    Yours

    ref:

    http://jap.physiology.org/content/74/2/793.short

    http://www.oxygenatwork.com/

    http://www.avweb.com/news/aeromed/181937-1.html?redirected=1

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2941910/

    if have lest job

    with my respect

    David

    • David,

      Sorry for my ignorance of U.S. English, I used to wonder why 15 liter minute on insufflation when the ball does not inflate and accurately.

      If the ball is the oxygen reservoir attached to the BVM or to the oxygen mask, it should inflate fully with 15 LPM (Liters Per Minute) at the ventilation rates we use (8-12 breaths per minute).

      The exceptions would be extremely acidotic patients hyperventilating to try to balance pH by eliminating CO2 (Carbon DiOxide). They probably do not need a lot of oxygen. They only need ventilation (the removal of CO2). Aspirin overdose is an example.

      If the reservoir bag is not inflating fully, then ventilation is probably much too fast and the problem is not a lack of oxygen.

      If the oxygen supply is not delivering the oxygen, then that is a different problem.

      Secretly rescuers must make arrangements without the support guidelines?

      I do not know what you are referring to.

      Oxygen should not be a business but a service to humanity.

      Adequate oxygen is free in the air – roughly 21% at sea level in a clean environment.

      If a person is sick in a way that supplemental oxygen is likely to be therapeutic, then a prescription for medical oxygen (a drug) is necessary.

      Ok this is oxidant but it gives life

      Oxidants damage the cells of our bodies and can result in death. That is what appears to be the result of the research.

      Too much oxygen for chest pain, for cardiac arrest, for COPD, . . . means decreased survival –

      In other words, oxygen kills.

      Why can provide resuscitation if
      Who will have the courage to express the way I do?

      I do not know what you are expressing.

      No statistics … but did ..
      So 15L or 30L min min
      See more? But in the context of the emergency, the emergency does not benefit the screw max 15 min … it’s just?

      15 LPM is probably harmful.

      30 LPM is probably much more harmful than 15 LPM.

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