Emergency Oxygen Administration

Importance of Oxygen
Found in the air we breathe, oxygen is the most essential element the human body requires to live.

Effect of Illness or Injury
When a serious illness or injury occurs, the body’s ability to process oxygen can be compromised.

Low Oxygen Levels
Low levels of oxygen in the blood, or hypoxia, can result in a deteriorating condition known as shock.

Unless the effects of the decreased amount of oxygen can be reversed, shock can quickly progress into a life-threatening emergency.

Priority Care First
Basic priority care, such as maintaining a clear and open airway, ensuring adequate breathing, and controlling external bleeding, should always be your initial priorities of care for an ill or injured person.

Use of Emergency Oxygen
The use of emergency oxygen by a first aid provider can help meet an ill or injured person’s critical need for oxygen to further improve the person’s outcome. State or local regulations regarding the requirement for medical control and direction with the use of emergency oxygen can vary. Always be familiar with and comply with any state and local regulations.

Use of Oxygen
Many medical authorities recommend that a person be provided the highest concentration of oxygen available during many medical emergencies.

Increasing Oxygen Percentages
The air we breathe contains about 21% oxygen. In an emergency, oxygen delivery systems can potentially increase oxygen percentages to close to 100%

Indications for Emergency Oxygen Use
Conditions that could benefit from emergency oxygen include the following:
Divers with a decompression injury
Serious bleeding
Difficulty breathing
Suspected internal injury
Warning signs of serious illness
Serious mechanisms of injury

Low Risk for Use
There are few significant medical risks when providing supplemental oxygen in an emergency. When in doubt, provide emergency oxygen for someone who shows signs of respiratory difficulty, if it is available, local protocols allow, and you are trained in its use.

Part of a Bigger Picture
Although the use of oxygen during a medical emergency can be helpful, it is important to remember that it is only a part of your overall approach to care and should not interfere with more urgent care considerations.

Priorities of Care
Always follow the priorities of care prior to providing emergency oxygen.

Scene Safety
Make sure an emergency scene is safe.

Activate Emergency Medical Services, or EMS.

If a person is unresponsive, determine the absence of normal breathing.

If a person is not breathing, perform CPR beginning with chest compressions

Serious Bleeding
Control any serious bleeding with direct pressure.

Significant Injury
Manually stabilize a person’s head if you suspect a neck or spinal injury.

Position of Comfort
Allow a seriously ill person to assume a position in which he is most comfortable.

Never Delay Priority Care
Never delay priority care for a seriously ill or injured person to locate or set up emergency oxygen equipment. When possible, have a bystander or other provider retrieve emergency oxygen equipment while you stay and provide care for the person.

Smooth Integration
When you are able to, integrate emergency oxygen smoothly into your existing first aid care following local protocols.

Monitor Person
Monitor the person for any changes in condition and monitor pulse oximetry, if available. Continue care until the person can receive a more advanced level of care.

Recommendations for Use
It is recommended by medical authorities that a person be provided the highest concentration of oxygen available during a medical emergency.

Key Factors That Affect Delivery
Factors that affect the ability to provide high concentrations of oxygen include the following:
The type of oxygen delivery device or mask
The ability of the oxygen first aid provider
Oxygen flow rate
The seal of the mask around the person’s face

Emergency Oxygen Delivery Systems
An emergency oxygen delivery system is a complete unit capable of providing emergency oxygen to a person. There are many different types of oxygen delivery systems for use in an emergency. Although design variations exist, all of the systems operate in the same general manner.

Emergency Oxygen Defined
In the United States, the Food and Drug Administration, also referred to as the FDA, requires that emergency oxygen systems deliver a minimum of at least 6 liters of oxygen per minute for a minimum of fifteen minutes.

Primary Oxygen System Components
Four primary components of an emergency oxygen delivery system.
Oxygen Cylinder
Delivery Device

Oxygen Cylinder
The oxygen cylinder contains purified oxygen. A typical cylinder is highly pressurized to increase the volume of oxygen available for use.

Cylinder Valve
A cylinder valve located on the top of the cylinder controls the release of oxygen from the cylinder.

Oxygen Regulator
The oxygen regulator attaches to the cylinder at the cylinder valve. It reduces the pressure of compressed oxygen inside the oxygen cylinder to a level more appropriate for patient care.

Regulator Gaskets
A sealing gasket is used between the regulator and the oxygen cylinder to prevent leaks. Single-use plastic “crush” gaskets and reusable metal-bound rubber gaskets are available.

Flow Types
A regulator can have a fixed flow, which provides a pre-set flow volume when the cylinder valve is opened. An adjustable flow regulator allows you to use a flow rate controller to set a flow rate of your choice. Oxygen flow rates are typically measured in liters per minute.

Pressure Gauge
Most regulators include a pressure gauge to allow providers to monitor cylinder pressure.

Outlet Ports
Oxygen flows from the regulator through outlet ports designed to be used with specialized tubes or hoses.

Oxygen Tubing
Oxygen tubing delivers oxygen from the regulator to an oxygen delivery device. It has specially designed ends that allow providers to connect it directly to a regulator or delivery device.

Oxygen Delivery Devices
Oxygen delivery devices deliver oxygen directly to the person. These devices are attached or held closely to the person’s mouth or nose to create a higher percentage of oxygen.

Ready to Use
Some systems automatically begin the flow of oxygen once dislodged from their storage case. A pre-connected ventilation mask ensures that the unit is ready to use in an emergency.

Safe and Easy to Operate
Other systems are designed with a fixed-flow regulator so you simply move a lever to begin oxygen flow. Rugged cases can protect pressurized oxygen cylinders from being damaged.

Device-Specific Training
Although a wide variety of systems and delivery devices are available, your training needs to be specific to the emergency oxygen systems you would use in an emergency.

Delivery Devices for a Breathing Person
Certain delivery devices are intended for use on a person who is breathing adequately. These devices allow the person to draw the oxygen in with their own breath.

Ventilation Mask
A ventilation mask with an oxygen inlet port is a very common delivery device included with emergency oxygen delivery systems. Depending on the flow rate, ventilation masks can deliver oxygen concentrations as high as about 50%.

Multiple Uses
Ventilation masks can also be used on a non-breathing person by blowing through the port on the top of the mask. It can increase oxygen concentration from approximately 16-17% found in a rescuer’s exhaled breath to about 50%.

Appropriate Flow Rate
Use an oxygen flow rate of between 6 and 15 liters per minute with a ventilation mask. Make sure the mask seals well on a person’s face.

Simple Face Mask
A simple face mask is similar to a ventilation mask except for the lack of a ventilation port. It provides oxygen concentrations as high as 60%.

Nonrebreather Mask
A nonrebreather mask can deliver the highest oxygen concentration to a breathing person. Requiring a minimum flow rate of 10 liters per minute, nonrebreather masks can reach oxygen delivery concentrations of between 60% and 95%.

Reservoir Bag
Nonrebreather masks have a reservoir bag that stores free-flowing oxygen until it is inhaled. One-way valves help ensure that high oxygen concentrations are delivered by keeping outside air out of the mask and exhaled air out of the reservoir bag.

Nasal Cannula
A nasal cannula is not considered a high-oxygen concentration delivery device. Up to 40% oxygen concentration can be delivered with this device at a maximum flow rate of 6 liters per minute. It has limited application in an emergency and its use is not covered in this program.

Delivery Devices for a Non-breathing Person
Other delivery devices are used when a person is not breathing. These devices use a provider’s breath, compressed bag, or pressure within the oxygen tank to force oxygen into the lungs of the person.

Design Features
Masks are clear to make it easy to detect vomit or other foreign material and are equipped with a one-way valve for protection from disease transmission.

Bag-mask Device (BVM)
A bag-mask device, also known as a BVM, uses pressure created by squeezing a self-refilling bag to force air containing oxygen into a person.

BVM Application
With an attached reservoir bag connected to a 10 to 15 liter-per-minute flow of oxygen, this device can provide nearly 100% oxygen concentrations. A BVM is primarily an option for healthcare professionals and professional rescuers.

Unique Delivery Systems
Although all emergency oxygen delivery systems include the same basic features, individual systems may have other unique features to consider.

Automatic Systems
Some systems automatically begin the flow of oxygen once removed from their storage cases. A pre-connected ventilation mask ensures that the unit is ready to use in an emergency.

Lever-activated Systems
Other systems are designed with a fixed-flow regulator so you simply move a lever to begin oxygen flow. Rugged cases can protect pressurized oxygen cylinders from being damaged.

Disposable Systems
Some systems are disposable. These systems typically cost less and can be discarded after use.

Can Monitor Effectiveness of Emergency Oxygen
Pulse oximetry is increasingly being used in the management of acute and chronic respiratory disease. It is also a method that can be used to monitor the effectiveness of emergency oxygen for persons in respiratory distress.

Easy to Operate
Typical pulse oximetry equipment is inexpensive, does not break the skin, and is user-friendly.

Usually Clips Onto a Fingertip
The measuring device usually clips onto a fingertip or an earlobe, as these are fairly translucent parts of the body.

Uses Red and Infrared Light
The system uses both red and infrared light to measure the peripheral oxygen saturation, or SPO2, of hemoglobin, which is responsible for transporting oxygen in the blood. Pulse oximetry also measures heart rate and is accurate to within plus or minus 2%.

Part of a Comprehensive Assessment
Pulse oximetry can be helpful as part of a comprehensive assessment in determining when emergency oxygen may be appropriate. It should not be the only method used to determine the need for emergency oxygen.

What the Numbers Mean
An SPO2 level of 95% or higher is considered to be normal. SPO2 of 93 – 94% may indicate mild hypoxemia, or low oxygen, and a level of 92% or less, at sea level, indicates a need for emergency oxygen.

Limitations of Pulse Oximetry
Pulse oximetry does not measure carbon dioxide levels and is not a substitute for, or as accurate as, an arterial blood gas measurement, or ABG. The oximetry reading may be less accurate if the ill or injured person is wearing nail polish, artificial nails, has poor circulation, has been exposed to the cold, or is hypothermic. Victims of carbon monoxide poisoning or smokers may have inaccurate or higher readings than their actual oxygen saturation. Excessive movement, lowered blood pressure, hypoperfusion, or shock, and a poor fitting sensor can also affect the accuracy of the oximetry reading.

Individuals with COPD Need Lower Levels
Some individuals with severe, chronic lung disease such as chronic obstructive pulmonary disease, or COPD, may develop excessive carbon dioxide in the blood, known as hypercapnia, if given too high a concentration of oxygen to bring SPO2 levels above 95%. Targeted saturation levels for these persons should be approximately 88% to 92%.

Using Pulse Oximetry Equipment
Incorporate pulse oximetry into a primary assessment.

Assess Need for Emergency Oxygen
Ensure priority care is being provided. Assess and determine the need for emergency oxygen based on signs, symptoms and pulse oximetry, if available.

Follow the manufacturer’s instructions.

Equipment Use
Turn on the unit and allow for any self-tests.

Apply the probe to the appropriate area, such as a fingertip.

Take Reading
Allow the oximeter to obtain a reading and record the results. If trained, compare the pulse reading with the person’s actual pulse.

Deploy Emergency Oxygen System
Deploy the emergency oxygen delivery system based on a thorough assessment of signs, symptoms, and a pulse oximetry reading.

Emergency Oxygen Increases Concentration
When a person is adequately breathing, the use of emergency oxygen can increase the percentage of oxygen delivered to the lungs with each breath.

How it Works
Oxygen delivery devices used for breathing persons are designed to create a higher concentration of oxygen around a person’s nose or mouth. It is the draw of a person’s own breath that pulls oxygen into the lungs.

Activate EMS
If a responsive person is not seriously injured, begin care by activating EMS and allowing her to find a position in which she is comfortable.

Set Up and Prepare the Oxygen System
Place the oxygen system in a stable position near the person. Pressurize the regulator and check for leaks. If it is not already connected, connect the delivery mask to the regulator using connector tubing.

Set Flow Rate
Set the regulator’s flow rate appropriately for the delivery device you’re using.

Verify Flow of Oxygen
Listen for the flow of oxygen through the mask and inflate the reservoir bag if necessary.

Inflate Reservoir Bag
If you are using a nonrebreather mask, make sure the reservoir bag is inflated prior to placing the mask on the person’s face.

Seal Valves to Inflate
To do this, seal the valve between the mask and the bag with your fingers or thumb.

Inform Person of Treatment
Ask permission from the person to provide oxygen and inform her that oxygen may assist her in breathing.

Place Delivery Device
Place the device on the person’s face around her mouth and nose. If she’s apprehensive about the mask, allow her to first hold it in place. Instruct the person to breathe normally.

Ensure Adequate Seal
Once the person seems comfortable, adjust the mask strap to hold the mask in place. Ensure that the mask seals well around her face.

Monitor Pressure Gauge
Monitor the regulator’s pressure gauge. When the pressure falls below 200 pounds per square inch, prepare to change cylinders. If additional oxygen is unavailable, remove the delivery mask when the supply is exhausted.

Unresponsive Person
If a person is unresponsive yet breathing adequately, emergency oxygen can be used after placing the person on her side in a recovery position.

Monitor for Change
Be prepared to provide additional care if the person becomes unresponsive or stops breathing. Monitor the person, oxygen flow, cylinder gauge, and pulse oximetry, if available.

Ongoing Care
Comfort, calm, and reassure the person while completing additional assessments until EMS arrives and takes over care.

Provide Priority Care First
Care for a collapsed person who is not breathing must be initially focused on activating EMS, performing CPR, and getting an AED.

Benefit of Emergency Oxygen
The use of emergency oxygen can increase the percentage of oxygen delivered to a person from rescue ventilations.

Smooth Integration
Provide oxygen as soon as it can be conveniently incorporated into your care. Be sure to integrate the use of oxygen without interruption to other treatments.

Activate EMS / Ensure Priority Care
Before using emergency oxygen for a non-breathing person, activate EMS and ensure that basic priority care is being provided.

Assess Need for Emergency Oxygen
Assess and determine the need for emergency oxygen based on signs, symptoms, and pulse oximetry, if available.

Deploy Emergency Oxygen Delivery System
Place the oxygen unit close to the person, near the person’s head. Position it in a way that prevents accidental tipping or falling.

Prepare Delivery Mask
Open the cylinder valve to pressurize the regulator and listen for any leaks. Connect the oxygen tubing to the delivery mask and then to the outlet on the regulator.

Pre-connected Systems
Some oxygen systems may already have the mask connected to the regulator

Delivery Devices for Non-breathing Persons
Delivery devices that provide oxygen to non-breathing persons use external pressure to force oxygen through the mouth and airway and into the lungs. This can be done with your own breath or by mechanical means, such as with a bag-mask or pressurized ventilator.

Set Flow Rate – Fixed Flow Device
Set the regulator to a flow rate appropriate for the delivery device. Some regulators have pre-set flow rates that begin immediately when the unit is turned on, or when it is removed from its storage cabinet.

Set Flow Rate – Adjustable Flow Device
Set the oxygen flow rate to highest rate available up to 15 LPM.

Check for Oxygen Flow
Listen for the flow of oxygen through the mask.

Integrate Oxygen Into Care
Smoothly integrate the oxygen delivery mask into the care already being provided.

Integrate the mask with oxygen smoothly without disrupting care. Position the mask to create an effective seal on the person’s face. Establish an airway with head-tilt, chin-lift.

Ventilation Technique
As with CPR, the ventilation technique should remain the same. Ventilations should be given over one second in length and cause the chest to visibly rise, but no more. Each time you provide a ventilation, ensure a good mask seal by lifting the person’s jaw into the mask. Be careful not to over-ventilate.

Continue Care
Continue to provide oxygen in conjunction with your care until EMS arrives or someone with an equal or higher level of training comes to assist you. Monitor the person, oxygen flow, cylinder gauge, and pulse oximetry, if available.

It is important to make sure emergency oxygen equipment is ready to be deployed as rapidly as possible in an emergency. Once used, an oxygen system must be restored to an operational condition so it is ready to use again.

Disposable Items
Discard any one-time-use-only items in appropriate disposal containers. Some masks may be cleaned. Follow the manufacturer’s recommendations on cleaning.

Disassembly – Depressurize Regulator
Close the cylinder valve, open the regulator’s flow controller and wait for the sound of flowing oxygen to stop. This depressurizes the regulator so it can be removed.

Disassembly – Remove Regulator
Loosen the regulator and slide it off the neck of the oxygen cylinder. Check for corrosion or debris.

Refill After Use
An oxygen cylinder should be refilled or replaced with a full cylinder after each emergency use. To refill a non-disposable oxygen cylinder, a provider must go to a medical or compressed gas distributor.

FDA Requirements
The U.S. Food and Drug Administration, or FDA, states that oxygen equipment intended for emergency use can be distributed over the counter without a prescription if it provides at least 6 liters of oxygen per minute for at least fifteen minutes. The FDA requires medical oxygen cylinders to bear a label that states: “For emergency use only when administered by properly trained personnel for oxygen deficiency and resuscitation. For all other medical applications, Caution: Federal Law prohibits dispensing without a prescription.”

Be Aware of Requirements
Even with the FDA statement and labeling on emergency oxygen, it may still be necessary to have a prescription and/or show proof of proper training, such as certification, in order to get an oxygen cylinder refilled. It is also important to become familiar with any state or local regulations concerning the use of oxygen in an emergency.

To reassemble your emergency oxygen system:
Briefly open and close the cylinder valve.
Examine and insert the gasket.
Attach the regulator to the oxygen cylinder.
Pressurize the system and check for leaks.
Depressurize the regulator.

Return to Service
Replace any disposable delivery devices that you used during your care. Return the oxygen system to its designated storage location, where it will remain ready and available for use in an emergency.

Regular Inspections
Regular inspections can ensure the readiness of your emergency oxygen delivery system.

Ensure that Equipment is in Place
Make sure all of your system’s components are present and undamaged.

Ensure that Delivery Devices are Present
Make sure your delivery devices are in place and, if desired, are clearly connected to the regulator.

Periodically Test System
Turn on the system and confirm the flow of oxygen. Check the pressure gauge. A low volume could indicate that a leak is occurring.

Safety First
Although the use of emergency oxygen equipment is safe under normal conditions, you should be aware of some potential hazards. Be sure to follow all of the manufacturer’s recommendations regarding the maintenance, operation, and use of the oxygen equipment.

Pressurized Cylinders
When full, oxygen cylinders are highly pressurized. If damaged, they could rapidly release their contents, causing serious injury or damage.

Cylinder Safeguards
To improve the safety of oxygen providers, a number of safeguards are built into the oxygen equipment. Oxygen cylinder valves and regulators use a pin-indexing system to prevent the use of incompatible regulators with oxygen cylinders.

Color Coding/Labeling
Oxygen cylinders are color-coded to prevent accidental use of another gas. In the United States, green is the color code for oxygen. Medical cylinders are also required to be labeled specifically for the gas and its intended use.

Color Coding/Labeling
Oxygen cylinders are color-coded to prevent accidental use of another gas. In the United States, green is the color code for oxygen. Medical cylinders are also required to be labeled specifically for the gas and its intended use.

Storing Cylinders
Store oxygen cylinders in clean, dry locations away from sunlight or high temperature that could increase the pressure in the cylinder. Choose a storage location that protects cylinders from objects that could fall on them. Secure cylinders in a manner to prevent them from tipping over or rolling.

Oxygen and Fires
While oxygen is not flammable, all substances require oxygen to burn. Concentrated oxygen can rapidly accelerate the rate at which things burn. Problems associated with fire and emergency oxygen delivery equipment are rare. However, it is always best to extinguish smoking materials and any open flame around oxygen equipment.

Sealing Gaskets
The FDA has concluded that the improper use of plastic sealing gaskets could increase the risk of an oxygen regulator fire. Injuries have occurred as a result.

Single-use Gaskets
These single-use gaskets are commonly provided free of charge with refilled oxygen cylinders. Only use gaskets once, because leaks can occur that could ignite the gasket material and result in a fire or explosion.

Multi-use Sealing Gaskets
Consider the use of metal-bound rubber sealing gaskets that can safely be used multiple times.

Additional Recommendations – Reducing Oxygen-related Fires
Follow the manufacturer’s instructions for attaching regulators to cylinders.
Use a sealing gasket specified by the regulator manufacturer.
Open cylinder valves slightly before attaching regulators to expel foreign matter from the valve’s outlet port.
Visually inspect sealing gaskets for damage before use.
Be sure the valve, regulator, and gasket are free from oil or grease.
Never use wrenches or tools to tighten the regulator to the cylinder. This could damange the gasket. Hand-tighten only.
Open the cylinder valve slowly. If a leak is heard, quickly close the valve. Verify that the regulator is properly attached and that the gasket is properly placed and in good condition.

Oxygen and AEDs
Precaution should be taken to prevent oxygen-related fires when using both emergency oxygen and an Automated External Defibrillator, or AED. Direct the delivery device or mask away from the person when delivering a defibrillation shock.

Appropriate Labeling
Ensure that cylinders are appropriately labeled for oxygen use and that they are within the required hydrostatic test date.

Protect Equipment
Use plugs, caps, and plastic bags to protect equipment from dust and dirt when it is out of service.

Trained Personnel
Cleaning, repairing, or filling oxygen equipment should be performed by qualified, properly trained personnel.

Adequate Training
Ensure that everyone who may use the oxygen equipment is adequately trained in its operation and in oxygen safety. Also, oxygen providers should have knowledge of operating instructions from the equipment manufacturer.

Set Flow Controller to Off
Ensure that the constant flow controller on the regulator is set to the “Off” or zero position before securing it tightly to the cylinder.

Point Cylinder Valve and Gauge Away
When pressurizing the regulator, point the oxygen equipment so the cylinder valve and regulator pressure gauge are pointed away from the oxygen provider and any other people.

Adequate Training
Ensure that everyone who may use the oxygen equipment is adequately trained in its operation and in oxygen safety. Also, oxygen providers should have knowledge of operating instructions from the equipment manufacturer.

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