** NEW OXYGEN PROTOCOL **

[Admin]

Bit of a long read but worth it. Taken from the www.medatrain.co.uk blog:

Good afternoon all,

Below is some information on the new oxygen protocol. It's a bit of a long read but it is worth it.

"The British Thoracic Society has developed new oxygen protocols using evidence-based medicine. The new national guideline will provide clarity on emergency oxygen use in adults.

Oxygen is routinely given to seriously ill adults in a variety of emergency settings and it can save the life of patients with illnesses which have caused hypoxaemia. It is essential to correct hypoxaemia quickly for these patients and the widespread use of targeted oxygen therapy will hopefully allow health care professionals to seriously ill patients and this may save lives.

AMongst healthcare professionals there is a widepsread belief that oxygen relieves breathlessness, yet there is no evidence thast this is the case, providing that oxygen levels in the blood re normal (which is true in many serious illnesses, even if breathlessness is present). In fact, giving oxygen when blood saturation levels are normal will produce hyperoxia which may stimulate reflexes that actually reduce the blood flow to organs such as the heart and might therefore reduce the delivery of oxygen to these vital organs.

Unnescessary oxygen therapy can hinder the efforts of healthcare professionals by delaying the recognition of patiernt deterioration due to the false reassurance that can be provided by a high oxygen saturation reading. Additionally, patients with some lung dieases, such as COPD, are sensitive to oxygen and an excess can have harmful consequences.

Before the widespread adoption of oximeters, oxygen saturation could only be estimated by clinical examination, which is unreliable, or by taking blood from the arteries, which is a specialist technique (and uncomfortable for patients). This has meant that protocols have been developed to ensure that patients received sufficient oxygen. Audit in several countries has shown that the protocols were rarely followed due to the complexity of the protocols and the lack of a standardisation of oxygen use within and between the units.

The introduction of oximeters, however, allows blood oxygen saturation to be monitored, allowing more accurate initial assessment of the patient's condition as well as ongoing monitoring. This paves the way for more effective oxygen therapy, targeted at patients with a clear, clinical need*.

One Ambulance Trust is commencing on the New guidelines TODAY. They feel that by running the guideline for CFR's alongside it's road staff will "reduce the risk of embarassment or conflict if a crew came into a room and immediately reduced or increased the flow of oxygen.

A significant change in the new guidelines is confirmed for suspiscion of paraquat poisoning. The guidelines state that patients may be harmed by supplemental oxygen so avoid delivery unless SaO2 <88%. Paraquat is no longer contraindicted*2.

There is no change to the way we deliver oxygen to children. All children with significan illness or injury should recieve HIGH levels of supplementary oxygen"

If you want to know where you can get a quality finger tip pulse oximeter for the special price of just £39.95, visit the medatrain store at www.medatrain.co.uk.

* British Thoraic Society. 2008. Emergency Oxygen in Adults. Online (Available at www.brit-thoraic.org.uk/clinicalinformation/emergencyoxygen/tabid/219/default.aspx)

*2 Joint Royal Colleges Ambulance Liaison Committee. 2009. Oxygen Update. Online. (Available at www.jrcalc.org.uk/newjrcalcguidance/oxygen_guideline_combined220409.pdf)

Let us know what your opinions are

[markw]

Hi,

So what is the actual guideline measurement in normal circumstances, i.e at what point should O2 be administered. A reading of less than ? spO2

Obviously different Trusts will inform CFR's as to what their new policies are but many will need approved Pulse Oximeters as I happen to know the one I carry isn't strictly speaking approved, but as I'm useless at counting a pulse I thought it better to get one for my own purposes ;-)

Paramedics in our area (Devon) are attending the training sessions on the new policies but nothing has come to CFR's yet as far as I am aware.

[marjar]

Anyone spotted the iceberg yet?

Unless the Trusts explain to their crews and Paramedics that not all CFR's have been updated, have the necessary equipment etc. there is almost certainly going to be conflict.

Just as an observation we should also remember that a pulse is not just a number is it strong and bounding or weak and thready etc.

[bungle]

Hi, to the op, this statement needs the scource listed. I have some issues to raise here but will start with this : Each Ambulance trust has different policies regarding what kit cfr's can and cannot carry or skills that they can or cannot do. Pulse ox is one such item. ANY responder reading the above post SHOULD contact thier CFR manager before purchasing such devices, with adequate training then to be provided by the trust.

The new BTS guidelines (oct 08) have many holes, not least that they directly contradict what the the uk resus council advise, to such an extent that a statement was released by themselves. Ontop of this it advise no o2 unless hypoxic in mi and cva's with NO evidence to support thier theories, most of the guidelines are devised through consultation and lit reviews and dont appear to be researched based, however, it should also be noted that it profers some good advice too, such as titration of o2, consideration of need for o2 in certain circs. Titration to pulseox is very flawed and does require an element of skilll and knowledge, eg: they are poor in carbon monoxide poisoning, hypovoleamia, cold patients ect... you should always rely on your clinical observational skills too, again ie cyanosis, breathlessness ect...

Above all, as CFR, you must follow youre trust's policy and not soley jrcalc, as sometimes the two have differing opinions.

[medatrain999]

Bungle... you are quite right... the BTS guidelines DO contradict current UKRC. However, the UKRC are looking at their current position with a view to releasing new guidelines in 2010. The British Red Cross are continuing the current regime until the UKRC's position is updated. Also, the comment about the statement being sourced... it is referenced at the bottom of the article on the website. See the new downloads section.

CFR's SHOULD follow their respective Trusts' policies on oxygen delivery. The document on the med-a-train website DOES NOT instruct anyone to follow the BTS guidelines; it merely informs them of development. This is what we will continue to do... make CFR's aware of new developments, not to implement them. If the JRCALC issue new guidelines, Trust's will implement them.

Markw... take a look at the JRCALC guidelines at www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/clinicalpracticeupdates/oxygen_guideline_combined_final_published_version_22apr09sb.pdf. It is worth a look at them.

We all know that any equipment used for first responding must be approved for use by the Trust. You will then be required to complete training and be proficient in its use prior to operational use.

Finally, a multi-discipline team guideline development group have authored the BTS guidelines. Something as revolutionary as these guidelines MUST be evidence-based. The British Thoracic Societys’ Standards of Care Committee established a working party, in association with 21 other Societies and Colleges, to produce an evidence-based, up-to-date guideline for the UK. More information on the guidelines can be found at www.brit-thoracic.org.uk and www.jrcalc.org.uk

[bungle]

Jun 3, 2009 20:31:39 GMT medatrain999 said:

Bungle... you are quite right... the BTS guidelines DO contradict current UKRC. However, the UKRC are looking at their current position with a view to releasing new guidelines in 2010. The British Red Cross are continuing the current regime until the UKRC's position is updated. Also, the comment about the statement being sourced... it is referenced at the bottom of the article on the website. See the new downloads section.

CFR's SHOULD follow their respective Trusts' policies on oxygen delivery. The document on the med-a-train website DOES NOT instruct anyone to follow the BTS guidelines; it merely informs them of development. This is what we will continue to do... make CFR's aware of new developments, not to implement them. If the JRCALC issue new guidelines, Trust's will implement them.

Markw... take a look at the JRCALC guidelines at www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/clinicalpracticeupdates/oxygen_guideline_combined_final_published_version_22apr09sb.pdf. It is worth a look at them.

We all know that any equipment used for first responding must be approved for use by the Trust. You will then be required to complete training and be proficient in its use prior to operational use.

Finally, a multi-discipline team guideline development group have authored the BTS guidelines. Something as revolutionary as these guidelines MUST be evidence-based. The British Thoracic Societys’ Standards of Care Committee established a working party, in association with 21 other Societies and Colleges, to produce an evidence-based, up-to-date guideline for the UK. More information on the guidelines can be found at www.brit-thoracic.org.uk and www.jrcalc.org.uk

forgive me, but in the op inplies that cfr scheme's must obtain a pulse ox, which at present is not the case, my scource query was more to do with who wrote it, or was it an actual post ?

The concern shared among many, is that the BTS's guidelines make two KEY recommendations based on NO evidence by simply saying there is NO evidence to give o2. One of these is withdrawal of routine use of o2 in the mi patient. This decision is more likely to do with an article in the lancet in07/08 titled mi an historical perspective (think thats the title soz), which in it, it showed that in certain conditions o2 could possibly be harmfull, but emphasised that a full study should be carried out soonest. The bts guidance goes on to point out simular reasoning behind CVA's yet neuro parametes in hospital are set to achieve po2 >12 and co2 4-4.5, sats probes do not correlate sats to po2 very well and therefore its very dangerous imo to say in both these cases that you should only give 02 in hypoxic pts in these specific groups.

[bungle]

Further to my above post i should also add that this is not the first set of guidelines they have issued that have by thier own admission been drawn up on opinion and lit review, see thier guidelines on niv use 2002. It should never be for a charity, no matter how emminent its members, to draw up guidelines of care, this should and must be done and endorsed by NICE. NICE have previously released such guidance on o2 and copd in around april 2003 or 4.
It will be intresting to see, how many trusts both pre and hospital that adopt this guidance. Correct me if im wrong on this, however, LAS last year jumped ahead and started adopting these guidance's, but have now retracted from them, why is this (this last statement is from third hand so am more than happy to be corrected !)

[medatrain999]

The guidelines by JRCALC clearly state that "DOSAGE AND ADMINISTRATION: Measure oxygen saturation (SpO2) in all patients using pulse oximetry." I don't know about you, but the Trust I work for adheres to these guidelines. Therefore, it is clear that at some point after your Trust implements these guidelines, people administering oxygen (regardless of whether you are CFR, ECA, Tech, Para, Doc etc) will need pulse oximetres.

My HEMS unit are not adopting the BTS guidelines du to the level of illness and injury we see. However, the Trust I work for HAS adopted it as has at least two other Trusts I know of.

[bungle]

Jun 7, 2009 13:04:25 GMT medatrain999 said:

My HEMS unit are not adopting the BTS guidelines du to the level of illness and injury we see. However, the Trust I work for HAS adopted it as has at least two other Trusts I know of.

Which given what the guidelines suggest, goes against what they are saying. (although i agree with your hems stance) Out of intrest are most the doctors or the lead medic a gas man ? if yes, this stance does not suprise me in the slightest.

[Kelexorma]

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