emergency oxygen administration © 2012 ems safety version a

Emergency Oxygen Administration 2012 EMS Safety Version A

INTRODUCTION 2Emergency Oxygen Administration

What We Will Learn Today Safe and effective administration of emergency oxygen Definition of emergency oxygen When & how to use it Safe assembly and storage Risks associated with oxygen delivery Follow your local EMS authority or Medical Directors guidelines Always use standard or universal precautions according to your workplace and OSHA guidelines 3Emergency Oxygen AdministrationIntroduction

Key Concepts Every cell in the body needs oxygen (O 2 ) to live In a medical emergency the body may inspire (inhale) or deliver lower levels of oxygen Hypoxia (inadequate O 2 ) leads to organ and brain damage Providing supplemental oxygen during an emergency may delay damage to vital organs Emergency Oxygen Administration4Introduction

The Air We Breathe Not made of 100% oxygen Oxygen = 0 2 Made of several different gasses 21% oxygen 78% nitrogen 1% other elements The body only uses about 5% of inhaled oxygen in atmosphere 16% oxygen in our exhaled air Enough to keep someone alive w/ rescue breaths for a short time Emergency Oxygen AdministrationIntroduction5 O 2 Molecules!

Perfusion Oxygen perfusion is when cells receive oxygen-rich blood Depending on condition or emergency, the victim may be able to breathe but cant perfuse oxygen Emergency oxygen is a higher concentration of oxygen than the air we breathe Emergency oxygen can increase oxygen concentrations in the lungs, which may allow more oxygen to be absorbed (perfused) into the bloodstream Emergency Oxygen AdministrationIntroduction6

COURSE OVERVIEW Emergency Oxygen Administration7

Outline Respiration and Lung Function What is Emergency Oxygen When to Use Emergency Oxygen Patient Assessment* Oxygen Equipment* + Delivery Devices* + Risks General Guidelines Safety Optional Topics: Airway Adjuncts, Suctioning Written and Skills Testing Emergency Oxygen AdministrationCourse Overview8 * Practice session + Required skill

Certification Requirements Participate in entire course Complete all practice sessions Pass written exam with minimum score of 80% Pass skills exam Emergency Oxygen AdministrationCourse Overview9

RESPIRATION & LUNG FUNCTION Respiration: The exchange of carbon dioxide for oxygen Emergency Oxygen Administration10

Respiration & Ventilation Respiration Exchange of carbon dioxide (CO 2 ), the waste product from breathing, with fresh air from the atmosphere Ventilation Moving air in and out of the lungs for respiration Alveoli Where the exchange of O 2 and CO 2 is accomplished Small air sacs in the lower lobes of right and left lungs Shaped like miniature broccoli stems Intertwined with capillaries Exchange of O 2 and CO 2 occurs through fenestrations (tiny holes) along the alveoli and capillary beds Emergency Oxygen AdministrationRespiration & Lung Function11

Blood Flow for Respiration Deoxygenated blood Pumped from right ventricle of heart to lungs Down into alveoli O 2 /CO 2 exchanged Newly-oxygenated blood Pumped back to left side of heart Out to the rest of the body Emergency Oxygen AdministrationRespiration and Lung Function12

Lung Anatomy Emergency Oxygen AdministrationRespiration and Lung Function13 Larynx Trachea Right Lung Left Lung Alveoli Capillary beds Diaphragm

WHAT IS EMERGENCY OXYGEN Emergency Oxygen Administration14

Emergency Oxygen is a Compressed Gas Classified as a drug Regulated by the FDA 100% pure oxygen stored in a cylinder Categorized as either Medical Oxygen or Emergency Oxygen Rescuers must be trained in use and storage of oxygen Emergency Oxygen AdministrationWhat is Emergency Oxygen15

Medical vs. Emergency Oxygen Concentrations are same for each 100% oxygen Differentiated by how each is used Oxygen delivery or flow rate is calculated by the number of liters delivered per minute (LPM) Medical oxygen Requires prescription for use Delivery rate of less than 6 LPM OR Duration of less than 15 minutes Emergency oxygen Training for rescuers required, prescription not required At least 6 LPM for 15 minutes or longer Clearly labeled as emergency oxygen Emergency Oxygen AdministrationWhat is Emergency Oxygen16

WHEN TO USE EMERGENCY OXYGEN How and when emergency oxygen is used varies between Professional and Citizen rescuers. Always follow state and local protocols regarding when and how to use emergency oxygen. Emergency Oxygen Administration17

Why Use Emergency Oxygen? Primary use: Correct mild - moderate hypoxia (inadequate oxygen to organs and tissues) Reduce the work of the heart Use to treat breathing difficulty based on Patients condition Respiratory rates Emergency Oxygen AdministrationWhen to Use Emergency Oxygen18 Professional rescuers and healthcare providers may use emergency oxygen to treat signs and symptoms of certain suspected medical conditions.

When to Use Emergency Oxygen Citizen Rescuers Respiratory rates that are too fast or too slow: Adult: 20/min. Child: 30/min. Infant: 50/min. No breathing Cyanosis Diving decompression injury Professional/Healthcare Same as citizen rescuers plus: Heart attack/ACS Stroke Severe asthma Pulmonary embolism Clot affecting blood supply to lungs Shock Drowning Pregnancy-related Exacerbated COPD Lung disease Hypothermia Emergency Oxygen AdministrationWhen to Use Emergency Oxygen19

Never Delay Critical Care! The use of emergency oxygen should not delay life-saving treatments Calling 9-1-1 Applying direct pressure on a bleeding wound Starting chest compressions Only use emergency oxygen after EMS (9-1-1) has been activated Additional trained rescuers available to use emergency oxygen without interrupting life-saving activities Emergency Oxygen AdministrationWhen to Use Emergency Oxygen20

PATIENT ASSESSMENT Emergency Oxygen Administration21

Patient Assessment Signs of Breathing Difficulty Labored breathing Using accessory muscles in neck and back Speaking in broken sentences Noisy breathing Coughing Wheezing/stridor Tripod position Cyanosis To Calculate a Patients RPM Use stopwatch, second hand or other timer Watch patients chest for 15 seconds Count number of breaths Multiply number of breaths in 15 sec x 4 E.g. 5 x 4 = 20 RPM, a normal rate for adults Emergency Oxygen AdministrationPatient Assessment22 Assess effort of breathing. Calculate respirations per minute (RPM).

Demo/Practice Session 1 Skill Demonstration: Patient Assessment Skill Practice: Patient Assessment Instructions Use Practice Sheet Demonstrate skill, answer questions Each student practices skill(s) Use skill sheet to review areas for improvement Emergency Oxygen AdministrationPatient Assessment23

OXYGEN EQUIPMENT Emergency oxygen is delivered from a cylinder, through a pressure regulator and oxygen tubing, and into a delivery device such as a mask, cannula or bag mask Emergency Oxygen Administration24

Oxygen Cylinder Also known as a tank or bottle Typically green or with green markings Labeled For emergency use only Made of metal, aluminum or composite Highly pressurized Emergency Oxygen AdministrationOxygen Equipment25

Cylinders Vary in Size Each filled up to about 2015 psi Cylinder sizes: D: 425 liters Jumbo D:640 liters E: 680 liters M: 3,000 liters G: 5,300 liters H: 6,900 liters D, Jumbo D & E cylinders Small and portable Secure to gurney, stretcher or cot w/ patient Emergency Oxygen AdministrationOxygen Equipment26

Pressure Regulator Connects cylinder valve to O 2 tubing Controls rate of flow (measured in LPM) Two types Dual flow: high or low Full Control: 2 to 25 LPM Gauge displays amount of pressure per sq. inch 2000 psi = full 1000 psi = full 500 psi = time to refill Emergency Oxygen AdministrationOxygen Equipment27 Oxygen Wrench: Opens cylinder valve to begin O 2 flow into regulator Full Control Pressure Regulator

O-Ring & Oxygen Tubing O-ring Gasket creates tight seal between cylinder valve and regulator Over time may require replacement Without it air escapes between cylinder and pressure regulator Replacement o-ring usually with newly-filled cylinder Oxygen Tubing Connects regulator to O 2 delivery device Comes in different lengths Is pre-connected to delivery devices Emergency Oxygen AdministrationOxygen Equipment28 O-Ring

Delivery Device Used by the patient to breathe in emergency oxygen Usually a mask that fits over the mouth and nose Connected to the cylinder w/ oxygen tubing Emergency Oxygen AdministrationOxygen Equipment29

Demand Valve Used by specially-trained professional rescuers Triggered by patient inhaling or by push of button/lever Delivers 100% oxygen at 40 LPM Due to force adults only! Green tube attaches to special outlet on regulator Emergency Oxygen AdministrationOxygen Equipment30 Demand Button

Oxygen Humidifier Not typically used in emergency settings Supplemental O 2 can dry out mucous membranes of the nose Dryness causes irritation and possible nosebleed Humidifier passes O 2 through sterile water O 2 picks up tiny water molecules, reduces dryness & irritation Emergency Oxygen AdministrationOxygen Equipment31

Pulse Oximeter Small, portable electronic device Estimates and monitors blood-oxygen saturation level (how much O 2 in blood) Uses an infrared probe Normal level between 95% and 100% Additional training required for use Emergency Oxygen AdministrationOxygen Equipment32

Using a Pulse Oximeter How To Use: Turn on, connect probe to finger, earlobe or foot/toe Register oxygen saturation level (SpO 2 ) and pulse rate Verify pulse rate on monitor w/ patient's actual pulse Monitor and record SpO 2 Follow protocols to titrate based on target O 2 levels Typically 94% to 99% Less effective when: No breathing/heart beat Poor perfusion: shock, low blood pressure Fingernail polish present Excessive patient motion Hypothermia Carbon monoxide poisoning/some smokers Hx. of sickle cell disease or anemia Swelling of monitored extremity Emergency Oxygen AdministrationOxygen Equipment33

Connecting the Pressure Regulator Inspect valve, ensure dry & clean Slowly open & close valve to expel debris Inspect regulator and o-ring; replace if worn Line up pins on regulator w/ holes on cylinder valve Twist thumbscrew hand tight Turn gauge away from you, open valve Read gauge to determine content Listen for airtight seal Emergency Oxygen AdministrationOxygen Equipment34

Demo/Practice Session 2 Skill Demonstration: Connect Pressure Regulator Skill Practice: Connect Pressure Regulator Instructions Use Practice Sheet Demonstrate skill, answer questions Each student practices skill(s) Use skill sheet to review areas for improvement Emergency Oxygen AdministrationOxygen Equipment35

DELIVERY DEVICES The delivery device is connected to oxygen tubing, then attached to the nipple of the pressure regulator. Emergency Oxygen Administration36

Key Concepts There are four basic types Non-rebreather mask Nasal cannula Bag mask CPR face mask w/ oxygen inlet The non-rebreather and nasal cannula are for victims who are breathing on their own Different sizes of delivery devices are available for adult, child and infant patients Emergency Oxygen AdministrationDelivery Devices37

Non-Rebreather Mask High-flow device Consists of mask, O 2 reservoir and tubing Delivers oxygen concentrations between 90%-100% with each breath Use 15 LPM Emergency Oxygen AdministrationDelivery Devices38

Using a Non-Rebreather Mask Connect tubing to regulator Adjust flow rate to 15 LPM Listen for flow of O 2 Briefly cover one-way valve inside mask to speed up filling reservoir Place over the patient's mouth and nose Emergency Oxygen AdministrationDelivery Devices39

Tolerating a Non-Rebreather Mask The mask will completely cover the mouth & nose, which can make it intolerable for some Patient may complain that flow of O 2 is restricted, even though they are getting more than 90% O 2 Ensure flow rate is at least 15 LPM, oxygen is flowing and the reservoir is inflated Rescuers may have to coach a patient Help get used to mask Reassure they are getting more oxygen than normal Emergency Oxygen AdministrationDelivery Devices40

Nasal Cannula A low-flow device Provides between 2 - 6 LPM Max concentration delivered: 44% O 2 Consists of loop of oxygen tubing, two prongs for the nostrils and an adjusting band Emergency Oxygen AdministrationDelivery Devices41

Using a Nasal Cannula Emergency Oxygen AdministrationDelivery Devices42 Connect tubing to regulator Adjust flow rate: 6 LPM Listen for flow of O 2 Open cannula loop Holding loop w/ thumb and forefinger, insert prongs into nose Wrap each side around patients ears Slide adjusting band up Instruct the patient to breathe in through nose

Bag Mask Emergency Oxygen AdministrationDelivery Devices43 Also known as Bag Valve Mask or BVM Used for rescue breathing/CPR Delivers nearly 100% oxygen May reduce exposure to pathogens Requires additional training to be used effectively

Using a Bag Mask May be used with or without oxygen Science does not support or refute the use of oxygen during resuscitation Risks related to over-exposure to oxygen are low; it is reasonable to use oxygen during resuscitation Never delay resuscitation efforts in order to use emergency oxygen The use of emergency oxygen does not change how rescue breaths are delivered with a bag mask Emergency Oxygen AdministrationDelivery Devices44

Emergency Oxygen AdministrationDelivery Devices45 Bag masks use positive pressure to push air into the lungs w/ each squeeze of the bag A bag mask consists of Rigid face mask Self-inflating bag Oxygen reservoir Oxygen tubing Components of a Bag Mask

Using a Bag Mask w/ O 2 Follow guidelines for CPR/AED & activating EMS Assemble mask, bag and tubing Connect tubing to oxygen source O 2 flow of 15 LPM Use bag mask to give rescue breaths Reservoir does not need to inflate Emergency Oxygen AdministrationDelivery Devices46 Ensure a good seal between face and mask

CPR Mask with 0 2 Inlet Emergency Oxygen AdministrationDelivery Devices47 Used for rescue breathing Increases oxygen delivery w/ mouth-to- mask rescue breaths Can deliver up to 55% oxygen Available in adult, child, infant sizes Seal tightly to the face to give breaths Oxygen Inlet

Using a CPR Face Mask w/ Oxygen Follow guidelines for CPR/AED & activating EMS Assemble mask Insert tubing into oxygen inlet on mask Connect tubing to oxygen source O 2 flow of 15 LPM Press mask firmly to the face and open airway Breathe into mask and watch for chest rise Emergency Oxygen AdministrationDelivery Devices48

Bag Mask & CPR Face Mask Can be used for resuscitation, or to provide emergency oxygen to a victim who is conscious or semi-conscious but breathing abnormally Bag Mask Maintain flow rate of 15 LPM Have victim hold to his/her face if able Assist abnormal rates as needed: Less than 10 RPM: Squeeze bag between each breath Greater than 30 RPM: Squeeze bag every second breath CPR Face Mask Use 6-15 LPM Have patient hold mask to his/her face Emergency Oxygen AdministrationDelivery Devices49

Selecting a Delivery Device Regulator Type Impacts Delivery Device Full control regulator (2-25 LPM) Any type mask acceptable Dial in proper LPM according to device Dual flow: high or low Low-flow setting Nasal cannula CPR face mask (for patient is who is breathing) High-flow setting Non-rebreather mask Bag mask CPR face mask (for breathing or non-breathing patient) Emergency Oxygen AdministrationDelivery Devices50

Blow By Oxygen Delivery For infants and small children who cant tolerate a mask or cannula Use an oxygen mask and a high flow rate (at least 15 LPM) Keep mask about 2 inches from patient's face Wave mask slowly from side-to-side Allows oxygen to pass over patient's mouth and nose to be inhaled Emergency Oxygen AdministrationDelivery Devices51

Demo/Practice Session 3 Skill Demonstration: Delivery Devices Skill Practice: Delivery Devices Instructions Use Practice Sheet Demonstrate skill, answer questions Each student practices skill(s) Use skill sheet to review areas for improvement Emergency Oxygen AdministrationDelivery Devices52

RISKS ASSOCIATED W/ OXYGEN DELIVERY Emergency Oxygen Administration53

Risks of Oxygen Delivery Potential risks related to oxygen delivery Oxygen Toxicity Retinopathy of Prematurity Denitrogenation COPD and the Hypoxic Drive Emergency Oxygen AdministrationOxygen Risks54

Oxygen Toxicity Occurs when there is too much oxygen in the blood Caused by prolonged exposure to high concentrations of oxygen Usually after 24 hours or more Emergency oxygen is usually not administered long enough to cause oxygen toxicity, and is generally not a concern in the field Signs/symptoms: visual changes, ringing in ears, twitching, irritability, dizziness, seizure Emergency Oxygen AdministrationOxygen Risks55

Retinopathy of Prematurity Retinopathy of prematurity only occurs in premature infants The retinas are immature before 34 weeks gestation, and can be damaged by high concentrations of oxygen It is not a problem associated with the normal use of emergency oxygen Emergency Oxygen AdministrationOxygen Risks56

Denitrogenation Also known as Absorption Atelectasis Occurs when naturally-occurring nitrogen in the lungs is replaced with oxygen from over-saturation Oxygen shares alveolar space with nitrogen If the nitrogen is washed out by too much O 2, the alveoli collapse Can severely impair lung function (process known as atelectasis) Not usually associated with emergency oxygen delivery because exposure to high concentrations of oxygen is limited to a relatively short period Emergency Oxygen AdministrationOxygen Risks57

COPD and Hypoxic Drive Hypoxic drive is condition associated w/ COPD Normally, body stimulated to breathe when too much carbon dioxide is detected COPD patients stimulated to breathe by lower O 2 levels and to NOT breathe with higher O 2 levels Concern that emergency oxygen can eliminate the hypoxic drive of a COPD patient, causing person to stop breathing General rule: Always give emergency O 2 if indicated (even if history of COPD) Difficulty breathing may be related to a condition other than COPD Hypoxic drive is rare; do not withhold emergency O 2 Emergency Oxygen AdministrationOxygen Risks58

GENERAL GUIDELINES FOR EMERGENCY OXYGEN DELIVERY Emergency Oxygen Administration59

General Guidelines Guidelines for the delivery of emergency O 2 include the following: Monitor delivery Understand the use of oxygen in resuscitation Train emergency responders Follow federal, state and local regulations Emergency Oxygen AdministrationGuidelines for Oxygen Delivery60

Monitor Oxygen Delivery Emergency oxygen delivery should be based on target saturation levels, not fixed flow rates Using oxygen to treat breathlessness rather than low oxygen saturation has not been shown to help feeling of breathlessness Pulse oximetry is recommended to monitor blood-oxygen levels When a pulse oximeter is available, titrate oxygen delivery to the lowest effective level. Emergency Oxygen AdministrationGuidelines for Oxygen Delivery61

Emergency Oxygen & Resuscitation Science is inconclusive about the use of emergency oxygen during resuscitation Studies show emergency oxygen during resuscitation: Increases amount of oxygen in the blood Has little risk of complications Ensure resuscitation efforts are NEVER DELAYED in order to use emergency oxygen After a return of spontaneous circulation (ROSC) Titrate delivery to the lowest level possible Maintain an SpO 2 of 94%-99% Emergency Oxygen AdministrationGuidelines for Oxygen Delivery62

Training for Emergency O 2 Use The Organizations medical authority should review and approve use and training methods before equipping staff Train at least one staff member in use of emergency oxygen at all times during business hours Training should be certification level from a nationally-recognized organization Training should incorporate any local guidelines that may differ from this training Emergency Oxygen AdministrationGuidelines for Oxygen Delivery63

OXYGEN SAFETY Emergency Oxygen Administration64

Key Concepts Oxygen is very reactive and can create a dangerous situation by making items more flammable When the oxygen level is increased, it is easier to start a fire and very difficult to put it out Take precautions when Using emergency oxygen w/ defibrillator Storing and handling cylinders Emergency Oxygen AdministrationOxygen Safety65

Using Oxygen w/ a Defibrillator 100% oxygen is combustible Good chest-to-pad contact Eliminates oxygen pockets between pad and skin Reduces risk for AED use w/ oxygen Move mask at least 3 feet from victim before shocking Loudly state Oxygen clear Only shock when rescuers & oxygen are clear Emergency Oxygen AdministrationOxygen Safety66

Cylinder Storage Store cylinders Upright Secured to prevent falling Avoid storing different types of compressed gasses in the same area Store in a well-ventilated area Do not subject cylinders to temperatures greater than 125 o F, prolonged exposure to direct sunlight, or exposure to other heat sources (e.g. radiator, space heater) Emergency Oxygen AdministrationOxygen Safety67

Cylinder Maintenance Regularly inspect equipment and document inspections according to national and local guidelines and manufacturer specifications Ensure labels and signs are in compliance w/ federal OSHA, state and local regulations Do not use a cylinder that appears damaged Keep oxygen equipment clean. Dirt and debris can be a fire hazard Use a pressure gauge to check contents; do not rely solely on a tagging system (Full, In-Use, Empty) Emergency Oxygen AdministrationOxygen Safety68

Cylinder Handling Do not slide, drag or roll cylinders Do not use oil or grease on oxygen equipment When on scene, lay the oxygen cylinder on the floor so it does not get knocked over accidentally If transporting the cylinder with the patient, secure it to the cot, stretcher or gurney so that it does not slip or get knocked off Emergency Oxygen AdministrationOxygen Safety69

Storage Emergency Oxygen AdministrationOxygen Safety70 What is wrong with this picture?

Oxygen is Combustible 100% oxygen is highly reactive, and can cause other materials to catch on fire Keep away from heat sources and flammable items Avoid alcohol, aerosol sprays, solvents, perfumes and petroleum products Never combine oxygen with an ignition source (e.g. cigarette) Emergency Oxygen AdministrationOxygen Safety71

OPTIONAL TOPICS Suction Devices and Airway Adjuncts Emergency Oxygen Administration72

Suctioning & Airway Adjuncts Objectives Identify equipment associated w/ the use of emergency oxygen and airway management Key Concepts Its important to be familiar w/ the equipment that may be used by all levels of rescuers Oxygen delivery may also be associated with Advanced airway adjuncts Suction devices Emergency Oxygen AdministrationSuction Devices & Airway Adjuncts73

Suction Devices Remove blood, secretions or vomit from the airway Manual, battery operated (portable) and bedside Tip (catheter) may be rigid or flexible Emergency Oxygen AdministrationSuction Devices & Airway Adjuncts74 Portable Suction Device

Using a Suction Device 1. Measure distance from corner of mouth to ear lobe (max. distance for suction tip to be inserted) 2. Remove CPR barrier or bag while suctioning Emergency Oxygen AdministrationSuction Devices & Airway Adjuncts75 Rigid Suction Tip Flexible Suction Tip

Airway Adjuncts Used for patient in severe distress Unresponsive or semiconscious Rescue breathing Cardiac arrest Airway adjuncts establish and maintain an open airway Simple airways can be used w/ no change to CPR sequence Oral airway Nasal airway Advanced airways require change in delivery of compressions & ventilations Emergency Oxygen AdministrationSuction Devices & Airway Adjuncts76

Oral Airway Most commonly used Keeps tongue off back of airway For unresponsive victim w/o gag reflex Choose correct size Measure from front teeth to angle of jaw (or earlobe) Too large can block airway Place along roof of mouth and rotate into position The end rests on the lips Pro-Rescuer CPR/AEDSuction Devices & Airway Adjuncts77

Nasal Airway For semiconscious victim w/ gag reflex Tolerated more easily than oral airway Does not control airway as well as oral airway Measure distance from base of nose to base of ear Do not use if: Severe facial trauma Suspected basilar skull fracture Pro-Rescuer CPR/AEDSuction Devices & Airway Adjuncts78

Advanced Airways Inserted by ALS -trained personnel Blocks the esophagus Keeps vomit out of airway and airway open Do not perform cycles of compressions and ventilations 100 compressions per minute w/o pausing 1 breath every 6-8 seconds Independent of each other Pro-Rescuer CPR/AEDSuction Devices & Airway Adjuncts79

Conclusion Never delay critical care to provide emergency oxygen Follow federal, state and local protocols Only provide oxygen when indicated by patient assessment At the earliest opportunity, titrate oxygen LPM and delivery device to the lowest level possible to maintain SpO 2 94-99% Emergency Oxygen AdministrationConclusion80

emergency oxygen administration © 2012 ems safety version a

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