There is so much we don't know in medicine that could make a difference,
and often we focus on the big things, and the little things get forgotten. To
highlight some smaller but important issues, we've put together a series of
pearls that the Red Whale found at the bottom of the ocean of knowledge!
Oxygen use in a medical emergency
The BTS produced guidance on the use of oxygen in emergency situations in 2008. However, it doesn't seem to have percolated
down to primary care. Because it challenges many assumptions we have summarised it here. Take note if you carry an oxygen
cylinder in your emergency bag!
In many situations O2 should only be given if the patient is hypoxic. (This guidance assumes you have a pulse oximeter
to assess hypoxia!)
Normal oxygen sats should be in the range 94–98%, although in elderly people, even when well, they may be lower than
this.
Life threatening situations
Most other conditions
In primary care the main scenarios are:
Resuscitation/arrest
Shock
Sepsis
Also applies to:
Major trauma
Near drowning
Pulmonary haemorrhage
Major head injury
Carbon monoxide poisoning
I've listed the commonest seen in primary care:
Acute asthma
Pneumonia
Lung cancer
Acute heart failure
MI and ACS
Stroke (O2 may be harmful if not hypoxic)
Sickle cell crisis
Pregnancy/obstetric crises
Most poisonings (but in carbon monoxide
poisoning give high flow O2)
Give high flow oxygen to all
Give O2 only if hypoxic. Moderate flow only
15l/min via face mask with reservoir
Aim for target O2 sats of 94–98%
5–10l/min via simple face mask
Aim for target sats of 94–98%
How to remember this?
I think this can be simplified to:
Life threatening situations (left hand column): arrest/shock/sepsis: high flow O2.
Everyone else: moderate flows of oxygen ONLY if hypoxic.
Why might too much oxygen be a bad thing?
Too much oxygen is associated with a number of problems:
Coronary vasoconstriction.
Reduced cardiac output.
Release of chemically reactive oxygen molecules that can actually damage tissues.
Small areas of lung collapse (absorption atelectasis).
None of these things are desirable in an acutely unwell patient!
Oxygen in COPD
We have always been cautious about oxygen use in COPD because of concerns that hyperoxia may depress ventilatory drive
and/or worsen ventilation perfusion mis-match. This was thought to be mainly with longer term use and high-dose oxygen in acute
severe disease was, at one stage, encouraged.
However, evidence is emerging that even in emergency pre-hospital settings (e.g. primary care whilst waiting for an ambulance),
high-flow oxygen may be harmful.
The study was done in Australia, using people with presumed acute exacerbations of COPD being transported to hospital by
paramedics. Here I'll discuss the results of the 200 people with confirmed COPD, not those who later turned out not to have COPD.
Patients were randomised either to titrated oxygen (to achieve oxygen sats of 88–92%) or high-flow oxygen (the control arm).
Arterial blood gases were taken on arrival at hospital (BMJ 2010;341:c5462).
Mortality was significantly lower in the group who received titrated oxygen.
Mortality rates were 9% (11 people) in those on high-flow oxygen (control group) and 2% (2 deaths) in the titrated group.
That's a 7% reduction in mortality and is statistically significant.
Those titrated according to oxygen sats were also significantly less likely to have respiratory acidosis and hypercapnia.
The BTS recommend aiming for sats of 88–92% unless seriously ill, using oxygen at 28% (4 l/min) via a Venturi mask (the
ones with coloured ends controlling flow). If sats persist below 88% on this, change to a simple mask at 5 l/min.
In reality, I suspect most GPs don't carry Venturi masks, so use 4 l/min to start and titrate flow to achieve sats of 88–
92%.
So what does this mean in practice?
You need a pulse oximeter (we tie ours to the oxygen cylinder – but make sure you don't send it back to BOC when the
cylinder is empty as they are costly to replace!).
Make sure you have both simple masks and reservoir masks.
Stop and think before giving high flow oxygen to all.
But continue to use high flow oxygen in life threatening situations.
Use oxygen judiciously in COPD: even in acute severe exacerbations high flow oxygen may be harmful.
Oxygen in emergencies
Guidance from the British Thoracic Society changes the way we think about O2.
Use high flow oxygen in life threatening emergencies.
Use low flow and titrate according to sats in those with respiratory conditions including
COPD.
In most other situations, including cardiovascular emergencies, give oxygen only if the
patient is hypoxic.
Do you have a pulse oximeter? Do all the clinical staff know how to use it and what target sats
you are aiming for in an emergency?
We make every effort to ensure the information in these pages is accurate and correct at the date of
publication, but it is of necessity of a brief and general nature, and this should not replace your own good
clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances.
In particular check drug doses, side effects and interactions with the British National Formulary. Save insofar as
any such liability cannot be excluded at law, we do not accept any liability for loss of any type caused by
reliance on the information in these pages.
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