O2, update SPW state of MA,Intubation safer

1. Rounds October 2015
Sheila Silva and Trauma Update
Update from the State
Safer Intubation
Avoiding Disaster after Intubation
Oxygen
Miscellaneous

2. Update From the State
• SPW’s
• 1. Sepsis,
• 2.BLS LMA with CCR ,
• 3.Surgical Cricothyroidotomy to replace Cric Kits,
Epi Kits,
• 4.TXA and Multiple Trauma.
• These are all special project waivers and are NOT
in the state treatment protocols, they are waivers

3. Sepsis SPW
• Basically the medics will draw blood for a
serum lactate level and if it is > 2 the protocol
calls for administering 2 liters of saline. The
waiver may prove very useful for alerting the
hospital that they have a septic patient en
route. We will rarely have the time to give 2
liters of fluid in our area.

4. BLS LMA ,Supraglottic Airway
• With cardiac arrests in Dracut ,Patriot
ambulance has applied for waiver to use
LMA’s for the airway . The emphasis will
remain on chest compressions and CCR. They
want to use a supraglottic airway to replace
the OPA feeling that it is safer and more
effective.

5. EPI Kits
• The cost of Epipens has skyrocketed and Pro
Ems has proposed a way to markedly decrease
the cost of epi and still make the likelihood of
administering IV epi very unlikely. Basically
they are purchasing a kit from Seattle at $5
per kit [ versus $700 for epi pens] . The
needles on the epi syringe are NOT
REMOVABLE and the IV tubing is needless.
There may be an increase in the risk of needle
stick exposures .

6. TXA and Trauma
• This project is one I am very interested in
pursuing. It is low cost and almost certainly will
save lives. It is currently approved for use by St
Lukes Hospital, in conjunction with the New
Bedford Fire Department.
• Tranexamic acid is a cheap generic medication
that has been in use for many years. It inactivates
plasmin which lyses clots and thus it helps to
allow the body to clot after major trauma when
patients are bleeding out.

7. TXA Continued
• There are 3 major studies. Crash 2 from Europe with
20,000 patients and a decrease in mortality of 1.5 %
with no significant adverse effects . In those patients
with a BP of 75 or less the decrease was 15 %.
• The Matters study from the US military experience in
Afghanistan with 900 combat injuries and massive
hemorrhage with a 7x increase in survival !
• There was also a study on pediatric trauma patients in
Afghanistan from a US military hospital that showed a
3x increase in survival . The drug is helpful when given
in the first hour and probably harmful when given
more than 3 hours after the trauma.

8. TXA Cont’d
• There is a study ongoing in the US in Ohio and
thus far it appears to be working.
• Researchers using the available data have
estimated that we could save 4,000 victims of
trauma per year in the US if we were using
this drug.
• The WHO [not the rock group] has recently
added this rx to the list of essential drugs that
every health care system should have.

9. Update on Toxicology

10. Reduced Nicotine Cigarettes
• In a recent NEJM article a study was discussed on
the use of low nicotine cigarettes and it seems
likely that if we move in that direction we can
markedly decrease the number of people who
smoke.
• “People smoke for the nicotine and die from the
tar”
• “Smoking kills half the people who engage in it
long term” [per the CDC] . We can expect 20
million Americans to die prematurely from
smoking if they continue .

11. Proposal on IVDA
• Governor Baker has proposed that hospitals
have the authority to hold addicts against
their will for 3 days and evaluate whether to
file a section 35 that will mandate 90 days of
rx.

12. Bath Salts
• Derivatives of cathinone . Low doses produce
euphoria , higher doses result in tachycardia ,
hallucinations, delirium, hyperthermia,
psychosis rarely death. The drugs are available
over the internet and at head shops and even
gas stations. Think of them as “legal cocaine,
amphetamines and ecstasy”. Snorting is the
most common method of use, although they
are injected and taken by mouth as well.

13. Bath Salts Cont’d
• They are derived from the khat plant from Africa
which has been chewed by the locals for
generations.
• The drugs interfere with the reuptake of
neurotransmitters serotonin , dopamine, and
norepinephrine. They result in an agitated
delirium.
• The toxic screen is usually negative and the
toxicity may last for a few days!
• The treatment is symptomatic, usually lorazepam
2 mg IM. More may be required and at times
Haldol may be needed as well.

14. Safer Intubation

15. Preoxygenation and Prevention of
Desaturation During Emergency
Airway Management
• Based on the article by Scott Weingart and
Richard Levitan , Ann. Emerg. Med. 2012:59:165-
175
• Patients requiring emergency airway
management are at great risk of hypoxemia. They
often have lung pathology, increased metabolic
demands with fever and anemia, and are at high
risk of aspiration. You can minimize the risk of
critical hypoxia while securing a tracheal tube
rapidly.

16. Concepts
Emphasis must be on maintaining good oxygenation
at all times . Both the O2 saturation and the ETCO2
must be monitored.
Pulse oximetry will lag 30-60 seconds and as the sats
are dropping this must be considered. The O2
saturation should not be permitted to drop to < 90 %.
Try to get the O2 saturation as high as possible prior
to attempting intubation, if possible.
Remember that the key is preventing hypoxia , not
getting in a tube. We are intubating to prevent
hypoxia and /or to prevent severe hypoventilation

17. Oxyhemoglobin Dissociation Curve
Hypoxic below 60% High Risk Below 89%
• Weingart SD. AnnEmergMed 2013.

18. Safer Intubation
When patients are being intubated
the key to decreasing mortality is
avoiding hypoxemia. When the O2
mask is removed the patient is at risk
for hypoxia and a respiratory arrest.
How can we minimize the chance of
this occurring ?

19. Concepts cont’d
• Safe Apnea is a term that refers to how long a
patient will take to desaturate while they are
paralyzed. Obese patients will desaturate more
quickly. Sick , anemic, volume depleted patients will
desaturate more quickly than normal patients.
• On room air a normal patient will desaturate in
45-60 seconds while paralyzed. They utilize 250 ml
of O2 per minute and there are 450 mls of oxygen
in the lungs. A non paralyzed patient will use more
O2 and will desaturate must faster.

20. Concepts
• KEY :Delaying the time until the patient will
become hypoxic , maximize the oxygen in the
blood stream and lungs.
• Positioning
• Preoxygenation and Denitrogenation
• Positive pressure Devices
• Passive Apneic Oxygenation

21. Position the patient
• Putting the head of the patient up to 20
degrees
• Why? When we are flat it is harder to take a
full breath and more of the posterior lung
becomes atelectatic. The diaphragms are
higher and the total lung volume is less. This
will increase the safe apnea time.

22. Maximize the O2
• We have approximately 5 liters of air in our lungs
, only 16 % is oxygen. By getting rid of the
nitrogen [over 80 % of the lungs is filled with
nitrogen] and filling the lungs with oxygen prior
to intubating the patient we can markedly
decrease the risk of hypoxemia.
• Preoxygenate the patient . When the Oxygen
saturation is up to 100% we need to continue
BVM for 3 more minutes to get rid of all the
nitrogen and fill the air spaces in the lungs with
oxygen , giving us close to 5 liters of oxygen.

23. Preoxygenation and Denitrogenation
• How to maximize the O2 in the lungs prior to
intubation
• 1.High Flow O2 via a nasal cannula
• 2.Non rebreather mask, crank up the oxygen
as high as possible.
• 3.With Tidal Volume breathing [normal
inspirations]

24. How to give the O2
• A nonrebreather face mask will deliver only
60-70 % O2 when it is set at 15 LPM. If you
turn the flow rate up to 30-60 LPM you can
deliver 90 % FIO2. A tight seal must be
achieved to deliver more than ambient O2,
[21 % ] .
• A standard reservoir facemask with the
flow rate set as high as possible is the best
source of O2

25. Add a Nasal Cannula
• When we remove the mask to intubate the
patient we should always place a nasal cannula
and turn the oxygen on the wall to maximum.
• The keys are that the patient has No O2 when the
mask is removed and by placing a nasal cannula
and turning up the O2, now the oxygen is under
pressure and is being forced into the lungs and
across the alveoli during your intubation. This will
prolong the time it takes to desaturate. They will
become hypoxic more slowly.

26. More Benefits of Nasal O2
• “Nasal O2 boosts the FiO2 ,flushes the
nasopharynx, and fills the upper airway with a
high concentration of oxygen available for the
next breath. Combining nasal and mask
oxygen increases the volume of oxygen
available for the patient to inspire.” This may
decrease CPAP or mask intolerance.

27. Use Of CPAP or Positive Pressure
Devices
• If patients are unable to achieve an O2 sat >
95 % then they are likely to desaturate during
your intubation. There are alveoli that are
perfused but not ventilated . Open the alveoli
with positive pressure to increase the O2 sat.

28. Apneic oxygenation
• This clearly works, article on RSI in Australia
with decreased desaturation times
• Tolerance of high flow nasal O2 seen in a
study
• Remember 3 bits of info :1. get the nitrogen
out of the lungs by maintaining 100 % Sat for
3 minutes , if possible,2. nasal O2 at high flow
before the mask removed to intubate the
patient, 3. if unable to get sats up use of PEEP
or CPAP

29. NEJM 6/14/2015
• Newest study on the use of high flow O2 via
nasal cannula
• The study was in 313 patients in ICU’s in
France and Belgium between 2011-2013.
• They studied High flow O2 [50L/min] vs mask
O2 [>10L/min] vs NIPPV [PEEP 2-10 cm].
• Over 90 days the High flow O2 delivered by
Nasal cannula was safest. The mortality was 2
-2.5 higher in the other 2 groups.
• Of interest is that they reported that most
patients had relief of their dyspnea within one
hour.

30. Another New Study on NC and O2
• JAMA June 16,2015
• They used High Flow 60 L/min O2 by nasal
cannula on postoperative respiratory failure
patients versus NIV [BIPAP] and found them to
be essentially equivalent for care. Again a
study that was longer term and not
prehospital.
• The O2 is heated and and humidified
• Get used to this concept and begin to use it.

31. SUMMARY
• Position the patient at 20 Degrees
• Tight seal with Non rebreather
• Turn Flow rate to maximal
• Try to get O2 Sat to 100%
• Keep the O2 sat at 100% for 3 Minutes
• If Unable to get sat to 100%, Use CPAP
• Prior to Intubating, Use a NC at MAX FLOW

32. Avoiding Disaster After Intubations
• Oxygenation: “ Preoxygenate with Nasal Cannulas and
a face mask”, intubate as upright as you can. Try to
avoid a high pressure face mask when the patient is in
a flat position. Get the head higher than the stomach.
• Try to mimic the minute ventilation of the patient prior
to intubation.
• In the severely ill asthma or COPD patient start with
500ml and 6 breaths /min, going slow and allowing the
maximal time for expiration. Increase the minute
ventilation slowly. “Permissive Hypercapnia” .
• Avoid overinflation, which will lead to gastric distention
and vomiting.

33. Minute Ventilation
• The amount of air a patient breathes in one
minute . It is simply the tidal volume x the
respiratory rate. Normally it is 7 L/min. With
heavy exercise it may exceed 40L/min . The
only way we can increase our oxygen is to
increase our TV and respiratory rate.
Therapeutically we can increase the oxygen
concentration or add PEEP [keep alveoli open]
.

34. Minute Ventilation
• When patients are experiencing respiratory distress it
may be that they have a problem with obstruction.
They cannot get the CO2 out fast enough to bring in
more oxygen. If we turn up the O2 that may relieve the
problem, if we try to breathe faster than they can get
the air out because of obstruction they will have
“stacking”, Autopeep. They will have hyperinflation .
They run the risk of barotrauma .They may develop a
pneumothorax. Also these patients may become
severely hypotensive [from decreased cardiac return] .
Postintubation hypotension is often due to this .

35. Oxygen ?
Is oxygen a useful treatment ? High
flow, low flow or no flow? What
evidence do we have that it is harmful?

36. It Is Time
We must use our knowledge of the potential harm
from the use of O2 and only use it where it is
indicated. O2 should not be used on patients with
chest pain or possible CVA’s unless the O2 sats are
<94 %

37. Oxygen and Cardiac Harm
• There have been multiple studies that have
examined the effects of oxygen and it seems
clear that oxygen increase coronary resistance
and decreases coronary blood flow. It
decreases cardiac output.

38. Cochrane Database
• The Cochrane database review in 2010 and in
2013 reported that there are 4 trials of AMI
and O2 that looked at 430 patients. You are
more than 3 times more likely to die if O2 is
given when you are having an acute MI if the
O2 saturation is >than 94 % [you don’t need it
] .

39. Oxygen in other settings
• There is data that high concentrations of oxygen
are harmful to neonates needing resuscitation,
and in exacerbations of COPD.
• In a study of 405 patients with an acute
exacerbation of COPD in Australia [BMJ 2010] the
mortality was more than twice as high with high
flow O2 [8-10 LPM] compared to titrated O2 [sat
kept between 88-92%].
• Again more is not better. There is no good reason
to have an O2 saturation greater than 94%. I
would suggest that oxygen should be titrated in
almost all situations to <100%.

40. Oxygen in the Post cardiac arrest
setting
• There is good data that after a resuscitation
from cardiac arrest that the O2 sat should not
be 100%. The AHA recommends that oxygen
be used at the lowest level to keep the O2 sat
at 94% [or higher ].

41. Where is the data?
• In the Impact study at 120 U.S. hospitals between
2001 and 2005 with 6,326 post cardiac arrest
patients and the group that had “hyperoxia” [Pa
O2 > than 300 mm] had almost a twofold risk of
death compared to those patients who had a
“normal oxygen sat” [Pa O2 > than 60mm and <
than 300mm]. This data is retrospective , but
until there is better data the o2 sat SHOULD NOT
BE 100%.

42. Post Cardiac Arrest and O2
•Providers should titrate oxygen during
the post-cardiac arrest phase to the
lowest level required to achieve an
oxygen saturation of >94 %.
•This helps to avoid any potential
complications associated with oxygen
toxicity.

43. More on O2
• Other studies reveal that at cath that coronary
blood flow will decrease by 30 % with 100%
FIo2 compared to RA.
• Hyperoxia will decrease cerebral blood flow,
shown in a 1988 study.
• These studies make it clear that O2 is a
vasoactive drug and that it should be given
only to patients who need it…. Per the AHA
2010 guidelines

44. Oxygen Toxicity
• There is a great deal of animal and human
data that high concentrations of oxygen are
deleterious, injuring the airways and resulting
in tracheobronchitis and diffuse alveolar
damage, similar to ARDS.

45. Why is oxygen harmful?
• High concentrations of oxygen cause damage to
airways and pulmonary parenchyma. Erythema and
edema of large airways is seen on bronchoscopy as
early as 6 hours after high flow O2. High
concentrations of oxygen also cause washout of
alveolar nitrogen which causes atelectasis of the
alveoli. Shunting of blood will result and in older
healthy adults shunting as high as 11 % after only 30
minutes of breathing 100 % FIO2 has been seen . This
absorptive atelectasis is not quickly reversed.
Decrements of up to 20 % of vital capacity can be the
result.

46. The Mechanism for Harm
• Even 1 hour after breathing 28 % FiO2 there is an
increase in reactive oxygen species. These oxygen
free radicals promote an inflammatory response
leading to secondary tissue damage. Those cells
exposed to the highest concentration of oxygen
are at the highest risk for damage –those cells
that line the tracheobronchial tree and the
alveoli. These are the cells that manifest the
injury. Thus even a short exposure to high flow
O2 may be deleterious.

47. Summary of O2 and Cardiopulmonary
Effects
• High flow oxygen is harmful to both the
cardiac and pulmonary systems.
• It is harmful to both the pulmonary
parenchyma [the alveoli and the
tracheobronchial tree] and the cardiovascular
system by a decrease in the cardiac output .

48. Oxygen and Acute MI, CVA and ACS
• The 2010 ACLS guidelines suggest that EMS
care include oxygen only if the O2 saturation is
< 94 % for all patients with acute MI, CVA and
ACS patients.
• The use of oxygen is also suggested for
patients with dyspnea, obvious heart failure,
or if the oxygen saturation is unknown.

49. Harm
• “ There is no single threshold of FiO2 defining
a safe upper limit for prevention of oxygen
toxicity .” [UPTODATE 2011] How long the
patient is exposed to a high FiO2 , and the
concentration of the oxygen determines how
likely the patient is to suffer harm.

50. Preshock Pauses
• Remember that a preshock pause of <20
seconds is associated with improved survival
in cardiac arrests. The less interruption of
compressions the better the patient will do.
All defibrillators should always be on manual
mode . The automatic mode should not be
used.

51. Intranasal Narcan
• Remember it is faster to administer [no IV
required], but it less potent . Frequently we
need 6-8 mg of narcan for complete reversal
of obtundation.

52. Intranasal fentanyl
• A recent study looked at kids and the use of
intranasal fentanyl. 5 Minutes after its use the
pain was rated as only half as severe. It works
quickly, and it should be kept in mind both for
adults and children, especially if an IV is
problematic.

53. Anaphylaxis
• Definition: remember skin plus either upper
or lower respiratory involvement with
shortness of breath , hypoxemia, wheezes , or
stridor .
• OR
• Skin or mucosa, plus decreased BP, or
respiratory symptoms, or syncope, or GI
symptoms.

54. Anaphylaxis contd
• The Rx of choice is epinephrine.It should be
given in the thigh IM. Do not give it in the
arm, do not give it sub Q.
• Benadryl is slow in onset and has no effect on
BP, upper airways and lower airways.
• If the BP does not rise with the epinephrine a
fluid bolus of 1-2 liters is indicated.