Monitoring Pulse Oximetry By the EMT-Basic. Objectives Understand the Kansas Regulations relative to...
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Transcript of Monitoring Pulse Oximetry By the EMT-Basic. Objectives Understand the Kansas Regulations relative to...
Monitoring Pulse Monitoring Pulse OximetryOximetry
By the EMT-BasicBy the EMT-Basic
ObjectivesObjectives
Understand the Kansas Regulations Understand the Kansas Regulations relative to monitoring pulse oximetry relative to monitoring pulse oximetry by the EMT-Bby the EMT-B
Review the signs and symptoms of Review the signs and symptoms of respiratory compromiserespiratory compromise
Understand the importance of Understand the importance of adequate tissue perfusionadequate tissue perfusion
Define hypoxia and describe the Define hypoxia and describe the clinical signs and symptomsclinical signs and symptoms
continuedcontinued
Describe the technology of the pulse Describe the technology of the pulse oximeteroximeter
Define normal parameters of oxygen Define normal parameters of oxygen saturationsaturation
Describe the relationship between oxygen Describe the relationship between oxygen saturation and partial pressure oxygensaturation and partial pressure oxygen
Describe the significance of the information Describe the significance of the information provided by pulse oximetryprovided by pulse oximetry
Describe monitoring pulse oximetry during Describe monitoring pulse oximetry during patient assessmentpatient assessment
continuedcontinued
Describe the use of pulse oximetry Describe the use of pulse oximetry with pediatricswith pediatrics
Describe patient conditions that may Describe patient conditions that may affect pulse oximetry accuracyaffect pulse oximetry accuracy
Describe patient environments that Describe patient environments that may affect pulse oximetry accuracymay affect pulse oximetry accuracy
Describe the evaluation and Describe the evaluation and documentation of pulse oximetry documentation of pulse oximetry monitoringmonitoring
Kansas RegulationsKansas Regulations
Regulation 109-6-4Regulation 109-6-4 Adopts “EMT-Basic Advanced Adopts “EMT-Basic Advanced
Initiatives”Initiatives” Allows EMTs to monitor saturation of Allows EMTs to monitor saturation of
arterial oxygen levels of blood by way of arterial oxygen levels of blood by way of pulse oximetrypulse oximetry
Appropriate physician oversightAppropriate physician oversight On line medical control or written protocolsOn line medical control or written protocols
Complete a course of instructionComplete a course of instruction
Respiratory CompromiseRespiratory Compromise
Signs and SymptomsSigns and Symptoms DyspneaDyspnea Accessory muscle useAccessory muscle use Inability to speak in full sentencesInability to speak in full sentences Adventitious breath soundsAdventitious breath sounds Increased or decreased breathing ratesIncreased or decreased breathing rates Shallow breathingShallow breathing Flared nostrils or pursed lipsFlared nostrils or pursed lips
continuedcontinued
RetractionsRetractions Upright or tripod positionUpright or tripod position Unusual anatomy changesUnusual anatomy changes
HypoxemiaHypoxemia
Decreased oxygen in arterial bloodDecreased oxygen in arterial blood Results in decreased cellular Results in decreased cellular
oxygenationoxygenation Anaerobic metabolismAnaerobic metabolism Loss of cellular energy productionLoss of cellular energy production
Hypoxemia EtiologyHypoxemia Etiology
Inadequate External RespirationInadequate External Respiration Decreased on-loading of oxygen at Decreased on-loading of oxygen at
pulmonary capillariespulmonary capillaries Inadequate Oxygen TransportInadequate Oxygen Transport
Decreased oxygen carrying capacityDecreased oxygen carrying capacity Inadequate Internal RespirationInadequate Internal Respiration
Decreased off-loading of oxygen at Decreased off-loading of oxygen at cellular capillariescellular capillaries
External RespirationExternal Respiration
Exchange of gases between the alveoli Exchange of gases between the alveoli and pulmonary capillariesand pulmonary capillaries
Oxygen diffuses from an area of higher Oxygen diffuses from an area of higher concentration to an area of lower oxygen concentration to an area of lower oxygen concentrationconcentration
Oxygen must be available and must be Oxygen must be available and must be able to diffuse across alveolar and able to diffuse across alveolar and capillary membranescapillary membranes
Oxygen must be able to saturate the Oxygen must be able to saturate the hemoglobinhemoglobin
Inadequate External Inadequate External RespirationRespiration
Decreased oxygen available in the Decreased oxygen available in the environmentenvironment Smoke inhalationSmoke inhalation Toxic gas inhalationToxic gas inhalation High altitudesHigh altitudes Enclosures without outside ventilationEnclosures without outside ventilation
Inadequate mechanical ventilationInadequate mechanical ventilation PainPain
Rib fracturesRib fractures PleurisyPleurisy
continuedcontinued Traumatic injuriesTraumatic injuries
Open pneumothoraxOpen pneumothorax Loss of ability to change intrathoracic pressuresLoss of ability to change intrathoracic pressures
Crushing injuries of the neck and chestCrushing injuries of the neck and chest Traumatic asphyxiaTraumatic asphyxia Crushing neck injuriesCrushing neck injuries
Tension pneumothoraxTension pneumothorax Increased intrathoracic pressures reducing Increased intrathoracic pressures reducing
ventilationventilation HemothoraxHemothorax
Blood in thoracic cavity reducing lung expansionBlood in thoracic cavity reducing lung expansion Flail ChestFlail Chest
Loss of ability to change intrathoracic pressuresLoss of ability to change intrathoracic pressures
continuedcontinued
Other conditionsOther conditions Upper Airway ObstructionUpper Airway Obstruction
EpiglottitisEpiglottitis CroupCroup Airway Edema-anaphylaxisAirway Edema-anaphylaxis
Lower Airway ObstructionsLower Airway Obstructions AsthmaAsthma Airway Edema from inhalation of toxic Airway Edema from inhalation of toxic
substancessubstances
continuedcontinued
HypoventilationHypoventilation Muscle ParalysisMuscle Paralysis
Spinal injuriesSpinal injuries Paralytic drug for intubationParalytic drug for intubation
Drug OverdoseDrug Overdose Respiratory depressantsRespiratory depressants
Brain Stem InjuriesBrain Stem Injuries Damage to the respiratory centerDamage to the respiratory center
continuedcontinued
Inadequate oxygen diffusionInadequate oxygen diffusion Pulmonary edemaPulmonary edema
Fluid between alveoli and capillaries inhibit Fluid between alveoli and capillaries inhibit diffusiondiffusion
PneumoniaPneumonia Consolidation reduces surface area of Consolidation reduces surface area of
respiratory membranesrespiratory membranes Reduces the ventilation-perfusion ratioReduces the ventilation-perfusion ratio
COPDCOPD Air trapping in alveoliAir trapping in alveoli Loss of surface area of respiratory membranesLoss of surface area of respiratory membranes
continuedcontinued
Pulmonary emboliPulmonary emboli Area of the lung is ventilated but Area of the lung is ventilated but
hypoperfusedhypoperfused Loss of functional respiration membranesLoss of functional respiration membranes
Oxygen TransportOxygen Transport
Most of the oxygen in arterial blood Most of the oxygen in arterial blood is saturated on hemoglobinis saturated on hemoglobin
Red blood cells must be adequate in Red blood cells must be adequate in number and have adequate number and have adequate hemoglobinhemoglobin
Sufficient circulation is necessary to Sufficient circulation is necessary to transport oxygen to the cellular leveltransport oxygen to the cellular level
Inadequate Oxygen Inadequate Oxygen TransportTransport
AnemiaAnemia Reduces red blood cells reduce oxygen carrying Reduces red blood cells reduce oxygen carrying
capacitycapacity Inadequate hemoglobin results in the loss of oxygen Inadequate hemoglobin results in the loss of oxygen
saturationsaturation PoisoningPoisoning
Carbon monoxide on-loads on the hemoglobin more Carbon monoxide on-loads on the hemoglobin more readily preventing oxygen saturation and oxygen readily preventing oxygen saturation and oxygen carrying capacitycarrying capacity
ShockShock Low blood pressures result in inadequate oxygen Low blood pressures result in inadequate oxygen
carrying capacitycarrying capacity
Internal RespirationInternal Respiration
Exchange of gases from the systemic Exchange of gases from the systemic capillaries to the tissue cellscapillaries to the tissue cells
Oxygen must be able to off-load the Oxygen must be able to off-load the hemoglobinhemoglobin
Oxygen moves from a area of higher Oxygen moves from a area of higher concentration to an area of lower concentration to an area of lower concentration of oxygenconcentration of oxygen
Inadequate Internal Inadequate Internal RespirationRespiration
ShockShock Oxygen is not available due to massive Oxygen is not available due to massive
peripheral vasoconstriction or micro-emboliperipheral vasoconstriction or micro-emboli Cellular environment is not conducive to Cellular environment is not conducive to
off-loading oxygenoff-loading oxygen Acid Base ImbalanceAcid Base Imbalance Lower than normal temperatureLower than normal temperature
PoisoningPoisoning CO will reduce the oxygen available at the CO will reduce the oxygen available at the
cellular levelcellular level
Signs and Symptoms of Signs and Symptoms of HypoxemiaHypoxemia
RestlessnessRestlessness Altered or deteriorating mental Altered or deteriorating mental
statusstatus Increased or decreased pulse ratesIncreased or decreased pulse rates Increased or decrease respiratory Increased or decrease respiratory
ratesrates Decreased oxygen oximetry readingsDecreased oxygen oximetry readings Cyanosis (late sign)Cyanosis (late sign)
PathophysiologyPathophysiology
Oxygen is exchanged by diffusion Oxygen is exchanged by diffusion from higher concentrations to lower from higher concentrations to lower concentrationsconcentrations
Most of the oxygen in the arterial Most of the oxygen in the arterial blood is carried bound to hemoglobinblood is carried bound to hemoglobin 97% of total oxygen is normally bound 97% of total oxygen is normally bound
to hemoglobinto hemoglobin 3% of total oxygen is dissolved in the 3% of total oxygen is dissolved in the
plasmaplasma
Oxygen SaturationOxygen Saturation
Percentage of hemoglobin saturated Percentage of hemoglobin saturated with oxygenwith oxygen
Normal SpO2 is 95-98%Normal SpO2 is 95-98% Suspect cellular perfusion Suspect cellular perfusion
compromise if less than 95% SpO2compromise if less than 95% SpO2 Insure adequate airwayInsure adequate airway Provide supplemental oxygenProvide supplemental oxygen Monitor carefully for further changes Monitor carefully for further changes
and intervene appropriatelyand intervene appropriately
continuedcontinued
Suspect severe cellular perfusion Suspect severe cellular perfusion compromise when SpO2 is less than compromise when SpO2 is less than 90%90% Insure airway and provide positive Insure airway and provide positive
ventilations if necessaryventilations if necessary Administer high flow oxygen Administer high flow oxygen Head injured patients should never Head injured patients should never
drop below 90% SpO2drop below 90% SpO2
SpO2 and PaO2SpO2 and PaO2
SpO2 indicates the oxygen bound to SpO2 indicates the oxygen bound to hemoglobinhemoglobin Closely corresponds to SaO2 measured Closely corresponds to SaO2 measured
in laboratory testsin laboratory tests SpO2 indicates the saturation was SpO2 indicates the saturation was
obtained with non-invasive oximetryobtained with non-invasive oximetry PaO2 indicates the oxygen dissolved PaO2 indicates the oxygen dissolved
in the plasmain the plasma Measured in ABGsMeasured in ABGs
continuedcontinued
Normal PaO2 is 80-100 mmHgNormal PaO2 is 80-100 mmHg NormallyNormally
80-100 mm Hg corresponds to 95-100% 80-100 mm Hg corresponds to 95-100% SpO2SpO2
60 mm Hg corresponds to 90% SpO260 mm Hg corresponds to 90% SpO2 40 mm Hg corresponds to 75% SpO240 mm Hg corresponds to 75% SpO2
TechnologyTechnology The pulse oximeter has Light-emitting The pulse oximeter has Light-emitting
diodes (LEDs) that produce red and diodes (LEDs) that produce red and infrared lightinfrared light
LEDs and the detector are on opposite LEDs and the detector are on opposite sides of the sensorsides of the sensor
Sensor must be place so light passes Sensor must be place so light passes through a capillary bedthrough a capillary bed Requires physiological pulsatile waves to Requires physiological pulsatile waves to
measure saturationmeasure saturation Requires a pulse or a pulse wave (Adequate Requires a pulse or a pulse wave (Adequate
CPR)CPR)
continuedcontinued
Oxygenated blood and deoxygenated Oxygenated blood and deoxygenated blood absorb different light sourcesblood absorb different light sources Oxyhemoglobin absorbs more infrared Oxyhemoglobin absorbs more infrared
lightlight Reduced hemoglobin absorbs more red Reduced hemoglobin absorbs more red
lightlight Pulse oximetry reveals arterial Pulse oximetry reveals arterial
saturation my measuring the difference.saturation my measuring the difference.
Patient AssessmentPatient Assessment
Patient assessment should include Patient assessment should include all componentsall components Scene Size-upScene Size-up Initial AssessmentInitial Assessment Rapid Trauma Assessment or Focused Rapid Trauma Assessment or Focused
Physical ExamPhysical Exam Focused HistoryFocused History Vital SignsVital Signs Detailed AssessmentDetailed Assessment Ongoing AssessmentOngoing Assessment
Pulse Oximetry Pulse Oximetry MonitoringMonitoring
Pulse oximetry monitoring is Pulse oximetry monitoring is NOTNOT intended to replace any part of the intended to replace any part of the patient assessmentpatient assessment Pulse oximetry is a useful adjunct in Pulse oximetry is a useful adjunct in
assessing the patient’s oxygenation and assessing the patient’s oxygenation and monitoring treatment interventionsmonitoring treatment interventions
Initiate pulse oximetry immediately Initiate pulse oximetry immediately prior to or concurrently with oxygen prior to or concurrently with oxygen administrationadministration
Continuous MonitoringContinuous Monitoring Monitor current oxygenation status and Monitor current oxygenation status and
response to oxygen therapyresponse to oxygen therapy Monitor response to nebulized treatmentsMonitor response to nebulized treatments Monitor patient following intubationMonitor patient following intubation Monitor patient following positioning Monitor patient following positioning
patients for stabilization and transportpatients for stabilization and transport Decreased circulating oxygen in the Decreased circulating oxygen in the
blood may occur rapidly without blood may occur rapidly without immediate clinical signs and immediate clinical signs and symptomssymptoms
PediatricsPediatrics Use appropriate sized sensorsUse appropriate sized sensors
Adult sensors may be used on arms or feetAdult sensors may be used on arms or feet Active movement may cause erroneous Active movement may cause erroneous
readingsreadings Pulse rate on the oximeter must coincide with Pulse rate on the oximeter must coincide with
palpated pulsepalpated pulse Poor perfusion will cause erroneous Poor perfusion will cause erroneous
readingsreadings Treat patient according to clinical status when Treat patient according to clinical status when
in doubtin doubt Pulse oximetry is useless in pediatric cardiac Pulse oximetry is useless in pediatric cardiac
arrestarrest
Conditions Affecting Conditions Affecting AccuracyAccuracy
Patient conditionsPatient conditions CarboxyhemoglobinCarboxyhemoglobin AnemiaAnemia Hypovolemia/HypotensionHypovolemia/Hypotension HypothermiaHypothermia
CarboxyhemoglobinCarboxyhemoglobin
Carbon monoxide has 200-250 greater Carbon monoxide has 200-250 greater affinity for the hemoglobin molecule than affinity for the hemoglobin molecule than oxygenoxygen Binds at the oxygen binding siteBinds at the oxygen binding site Prevents on-loading of oxygenPrevents on-loading of oxygen Fails of readily off-load at the tissue cellsFails of readily off-load at the tissue cells
Carboxyhemoglobin can not be Carboxyhemoglobin can not be distinguished from oxyhemoglobin by distinguished from oxyhemoglobin by pulse oximetrypulse oximetry Erroneously high reading may presentErroneously high reading may present
continuedcontinued
Suspect the presence of Suspect the presence of carboxyhemoglobin in patient with:carboxyhemoglobin in patient with: Smoke inhalationSmoke inhalation Intentional and accidental CO poisoningIntentional and accidental CO poisoning Heavy cigarette smokingHeavy cigarette smoking
Treat carboxyhemoglobin with Treat carboxyhemoglobin with high flow oxygen irregardless of high flow oxygen irregardless of
the pulse oximetry reading!the pulse oximetry reading!
AnemiaAnemia
Low quantities of erythrocytes or Low quantities of erythrocytes or hemoglobinhemoglobin Normal value of hemoglobin is 11-18 g/dlNormal value of hemoglobin is 11-18 g/dl Values as low as 5 g/dl may result in 100% Values as low as 5 g/dl may result in 100%
SpO2SpO2
Anemic patients require high levels Anemic patients require high levels of oxygen to compensate for low of oxygen to compensate for low
oxygen carrying capacities!oxygen carrying capacities!
Hypovolemia/Hypovolemia/HypotensionHypotension
Adequate oxygen saturation but reduced Adequate oxygen saturation but reduced oxygen carrying capacityoxygen carrying capacity
Vasoconstriction or reduction in cardiac Vasoconstriction or reduction in cardiac output may result in loss of detectable output may result in loss of detectable pulsatile waveform at sensor sitepulsatile waveform at sensor site
Patients in shock or receiving Patients in shock or receiving vasoconstrictors may not have adequate vasoconstrictors may not have adequate perfusion to be detected by oximetryperfusion to be detected by oximetry
Always administer oxygen to Always administer oxygen to patients with poor perfusion!patients with poor perfusion!
HypothermiaHypothermia
Severe peripheral vasoconstriction Severe peripheral vasoconstriction may prevent oximetry detectionmay prevent oximetry detection
Shivering may result in erroneous Shivering may result in erroneous oximetry motionoximetry motion Pulse rate on oximeter must coincide Pulse rate on oximeter must coincide
with palpable pulse rate to be with palpable pulse rate to be considered accurateconsidered accurate
Treat the patient according to Treat the patient according to hypothermic guidelines and hypothermic guidelines and
administer oxygen accordingly!administer oxygen accordingly!
Patient EnvironmentsPatient Environments
Ambient LightAmbient Light Excessive MotionExcessive Motion
Ambient LightingAmbient Lighting
Any external light exposure to Any external light exposure to capillary bed where sampling is capillary bed where sampling is occurring may result in an erroneous occurring may result in an erroneous readingreading
Most sensors are designed to Most sensors are designed to prevent light from passing through prevent light from passing through the shell the shell Shielding the sensor by covering the Shielding the sensor by covering the
extremity is acceptableextremity is acceptable
Excessive MotionExcessive Motion
New technology filters out most New technology filters out most motion artifactmotion artifact
Always compare the palpable pulse Always compare the palpable pulse rate with the pulse rate indicated on rate with the pulse rate indicated on the pulse oximetrythe pulse oximetry If they do not coincide, reading must be If they do not coincide, reading must be
considered inaccurateconsidered inaccurate
Other ConcernsOther Concerns
Fingernail polish and pressed on nailsFingernail polish and pressed on nails Most commonly use nails and fingernail Most commonly use nails and fingernail
polish will not affect pulse oximetry polish will not affect pulse oximetry accuracyaccuracy
Some shades of blue, black and green may Some shades of blue, black and green may affect accuracy (remove with acetone pad)affect accuracy (remove with acetone pad)
Metallic flaked polish should be removed Metallic flaked polish should be removed with acetone padwith acetone pad
The sensor may be placed on the ear if The sensor may be placed on the ear if reading is affectedreading is affected
continuedcontinued
Skin pigmentationSkin pigmentation Apply sensor to the fingertips of darkly Apply sensor to the fingertips of darkly
pigmented patients.pigmented patients.
Interpreting Pulse Interpreting Pulse OximetryOximetry
Assess and treat the PATIENT Assess and treat the PATIENT not the oximeter!not the oximeter! Use oximetry as an adjunct to patient Use oximetry as an adjunct to patient
assessment and treatment evaluationassessment and treatment evaluation
NEVER withhold oxygen if the NEVER withhold oxygen if the patient ahs signs or symptoms patient ahs signs or symptoms
of hypoxia or hypoxemia of hypoxia or hypoxemia irregardless of oximetry irregardless of oximetry
readings!readings!
continuedcontinued
Pulse oximetry measures Pulse oximetry measures oxygenation not ventilationoxygenation not ventilation Pulse oximetry does NOT indicate the Pulse oximetry does NOT indicate the
removal of carbon dioxide from the removal of carbon dioxide from the blood!blood!
DocumentationDocumentation
Pulse oximetry is usually documented as Pulse oximetry is usually documented as SpO2SpO2 Distinguishes non-invasive pulse oximetry Distinguishes non-invasive pulse oximetry
from SaO2 determined by laboratory testingfrom SaO2 determined by laboratory testing Document oximetry readings as Document oximetry readings as
frequently as other vital signsfrequently as other vital signs When oximetry reading is obtained When oximetry reading is obtained
before oxygen administration, designate before oxygen administration, designate the reading as “room air”the reading as “room air”
continuedcontinued
When oxygen administration is When oxygen administration is changed, document the evaluation of changed, document the evaluation of pulse oximetrypulse oximetry
When treatments provided could When treatments provided could potentially affect respiration or potentially affect respiration or ventilation, document pulse oximetryventilation, document pulse oximetry Spinal immobilizationSpinal immobilization Shock positionShock position Fluid administrationFluid administration
SummarySummary
As with all monitoring devices, As with all monitoring devices, the interpretation of the interpretation of
information and response to information and response to that interpretation is the that interpretation is the
responsibility of a properly responsibility of a properly trained technician!trained technician!
ReferencesReferences
Bledsoe, B. et al. (2003). Bledsoe, B. et al. (2003). Essentials of paramedic care. Essentials of paramedic care. Upper Saddle Upper Saddle River, New Jersey: Prentice Hall.River, New Jersey: Prentice Hall.
Halstead, D., Progress in pulse oximetry—a powerful tool for EMS Halstead, D., Progress in pulse oximetry—a powerful tool for EMS providers. providers. JEMS, JEMS, 2001: 55-66.2001: 55-66.
Henry, M., Stapleton, E. (1997). Henry, M., Stapleton, E. (1997). EMT prehospital care EMT prehospital care (2(2ndnd ed.). ed.). Philadelphia: W.B. Saunders.Philadelphia: W.B. Saunders.
Limmer, D., et al. (2001) Limmer, D., et al. (2001) Emergency CareEmergency Care (9 (9thth ed.). Upper Saddle River, ed.). Upper Saddle River, New Jersey: Prentice Hall.New Jersey: Prentice Hall.
Porter, R., et al: The fifth vital sign. Porter, R., et al: The fifth vital sign. Emergency, Emergency, 1991 22(3): 127-130.1991 22(3): 127-130.
Sanders, M., (2001). Sanders, M., (2001). Paramedic textbook Paramedic textbook (rev. 2(rev. 2ndnd ed.). St. Louis: Mosby. ed.). St. Louis: Mosby.
Shade, B., et al. (2002). Shade, B., et al. (2002). EMT intermediate textbookEMT intermediate textbook (2 (2ndnd ed.). St. Louis: ed.). St. Louis: Mosby.Mosby.
Cason, D., Pons, P. (1997) Cason, D., Pons, P. (1997) Paramedic field care: a complaint approach. Paramedic field care: a complaint approach. St. St. Louis: Mosby. Louis: Mosby.