12 lead and oxygen

[Paramagic14]

Question for all of you. ..... You have a pt c/o chest pain. pt denies sob and there is no evidence of an increased work of breathing. pt speaks in full sentences. My question is: if the pt is not in any obvious respiratory distress, do you wait to put the pt on oxygen until the 12 lead is finished. Why or why not?

Thanks.

Edited November 30, 2009 by Paramagic14

[Kaisu]

Nope - O2 first. If it is ischemic chest pain, then as much O2 that we can get (both attached to hemoglobin and dissolved in the plasma) the better.

[croaker260]

I'm surprised that this is a serious controversy, I'm curious as to the back story behind it.

1- No, O2 before or simultaneous with 12 lead.

2- Thats what you have a partner for..to help you do multiple things at the same time, right?

[kevkei]

As unpopular as it may sound, I'd recommend witholding the O2 until your 12 lead is complete - clear and readable. There are examples of missed opportunities for recording ischemia, unique injury patterns (Wellens syndrome) and the like. Cardiologists love our early 12 leads, the earlier the better (before O2, ASA, Nitro).

[Jwade]

As unpopular as it may sound, I'd recommend witholding the O2 until your 12 lead is complete - clear and readable. There are examples of missed opportunities for recording ischemia, unique injury patterns (Wellens syndrome) and the like. Cardiologists love our early 12 leads, the earlier the better (before O2, ASA, Nitro).

I agree completely....In the OP original scenario, I would not blast anyone with O2 until 12 lead was done.

If you have a blocked vessel causing injury or ischemia to the heart, then blasting O2 will not do much....(And please spare me the lecture on diffusing into the plasma again). The ENTIRE GOAL of treating, pre-hospital chest pain is to decrease MVo2 demand.

It has been my experience most people who are truly having a cardiac event will get more anxious( read: claustrophobic) when sticking a NRB at 15l on them right off the bat....I will usually start with a NC at 4-6 and titrate along with other meds to relieve MVo2 demand.

Respectfully,

JW

[tniuqs]

As unpopular as it may sound, I'd recommend witholding the O2 until your 12 lead is complete - clear and readable. There are examples of missed opportunities for recording ischemia, unique injury patterns (Wellens syndrome) and the like. Cardiologists love our early 12 leads, the earlier the better (before O2, ASA, Nitro).

Unpopular, yea think ?

Well: I am standing with croaker260 on this one.

I'm surprised that this is a serious controversy, I'm curious as to the back story behind it.

I believe I know the Cardiologists Consultant group you deal with I have been asked by one to take off 02 and do an ABG to determine if the patient was hypoxemic, when pulse ox hovering around 92% ON O2 on 4 liters n/c and then do an a/A gradient, well WTF over ? That just isn't going to happen to establish a lab value at the expense of the patients care, then again maybe I missed that lecture ?

The Intensivist in that case just shook his head in utter disbelief at the suggestion by the Cardiologist.

So following the philosophy that during infarct time = muscle, especially in the ischemic Chest Pain patient, I would highly recommend that treat the patient and as my goal, not just to obtain "lab values" first.

The Cardiologists can mess around in Cath Lab's all they would like to figure things out on their coin (so to speak)

There is some suggestion in the newer literature that lower levels of 02 delivered some patient groups may have better outcomes but until that is conclusively proven any patient that complains if chest pain to me gets care FIRST, diagnostics second, heck unless the patient was in need of immediate "electrical intervention" then O2, VS, IV then monitor.

But back again to the OP, with a broad open poll without tangible information like age, patients color, resp rate, pulse rate, b/p, pmhx or meds, and btw one does not need a machine for any of these observation's, just what is the backgrounder concern to this poll?

Take it to the extreme a 21 yo male, c/o of Chest Pain upon deep inspiration and not in distress RR = 20, chest clear ... well that would be a different story, very seriously these OPEN ENDED scenarios (the what if's crowd ) are a huge fail in my books. I was trained to be the eyes, ears, and nose of the Physician and unless one has painted a clear picture of just what one is REALLY looking at its all just a crap shoot, once again.

cheers

Edited December 1, 2009 by tniuqs

[DwayneEMTP]

It's been my experience that a pt in any significant pain will rarely speak in full sentences or show no sign of change in respiration so I'm assuming this isn't a a high level of pain.

In this pt I'm likely going to get a set of vitals, skins, clear definition and location of the pain a 12 lead and then apply O2. I can't think of a single time that an ER doc was disappointed that I came to him/her with a baseline set of vitals.

It's our job, as I understand it, to attempt to build a differential, apply interventions per our discoveries and then track the success or failure of those interventions. I've seen a couple of patients now, and it's been incredibly rare that I've come across one that would have benefited from me applying interventions without first having some idea what was wrong.

What physiologic changes occurred when I applied the O2? Was the pt tachycardic? Was he freaking out because of occasional PVCs? Anxiety attack? What effect did the O2 have on those conditions? If they partially/fully resolved I will go in one direction, if they didn't I'll go in another. Only a thorough assessment will tell.

The logic path I'm going to follow will depend on the initial presentation/assessment of my patient and the changes that occur secondary to my interventions. Oxygen is a drug, right? What other drugs do you use without being able to track their positive or negative effects?

I do find it kind of funny that some speak with scorn of those that would choose to assess and THEN treat as oppopsed to doing it the other way around.

Of course this is all with the understanding that my partner will get me rock solid vitals while I apply my 12 lead and fire is standing by chomping at the bit with their NRB already running at 15Lpm...probably the entire process will take around 90 secs to 2 mins.

I have very little faith in 12leads but they can be useful and the hospitals love them. I'm not so much withholding the O's on this guy for that so much as getting the 12lead at the same time as my assessment, doing two things at once. Either way, the O's aren't going on until I've got a halfway decent baseline and at least a vague idea of what's going on, if possible.

Dwayne

[melclin]

I'm sure we're all aware of Rawles and Kenmure's (1) old RCT from which the BETS have sprung on the matter of uncomplicated MIs. I'm sure in this situation I would already have put oxygen on him because we're told we are supposed too, and there's not really enough evidence I know of to defend my not supporting the paradigm. Presumably too, the service would already be p***ed off at me for not "slapping 8 through a hudson" on everyone anyway .

I do, however, I feel like this is one of those situations in which, with a Sp02 ~ 100%, extra O2 is of no particular help. Certainly that is the position of the British Thoracic Society which recommends that their is no need for supplemental O2 in non-hypoxaemic pts (2). Although as a student I'm not sure of the wisdom of using that as a reason to not follow service guidelines. Unless there is some research that I'm not aware of, I'm not sure any of us can answer that question with any particular authority.

It would be a terrific area to get some research done but I can only imagine the small forrest you would have to cut down to provide enough paper for the ethics approval forms.

(1) Rawles JM, Kenmure ACF. Controlled trial of oxygen in uncomplicated myocardial infarction. BMJ1976;1:1121–3.

(2) http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Emergency%20Oxygen/Emergency%20oxygen%20guideline/Appendix%201%20Summary%20of%20recommendations.pdf

The full version of the BTS oxygen guidelines makes some interesting reading:

http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Emergency%20Oxygen/Emergency%20oxygen%20guideline/THX-63-Suppl_6.pdf

[Kiwiology]

If their SPO2 is good ~ 98% RA the two litres on an NC we'll give probably has FA effect.

The 60 seconds it takes to do a good, diagnostic quality 12 lead and get the earliest capture of ischemic changes the better I say!

[MSDeltaFlt]

Question for all of you. ..... You have a pt c/o chest pain. pt denies sob and there is no evidence of an increased work of breathing. pt speaks in full sentences. My question is: if the pt is not in any obvious respiratory distress, do you wait to put the pt on oxygen until the 12 lead is finished. Why or why not?

Thanks.

It depends on the amount of chest pain and the kind of chest pain the pt complains of. Some pts' complaints of chest pain just as you described will get the full workup. Then again, some pts' complaints of chest pain just as you described will get absolutely nothing at all except maybe a trip to ED. It depends on what the assessment shows.