SOUTH PIERCE FIRE AND RESCUE PRESENTS -NITROUS OXIDE AND YOU- NITRONOX, IT’S NO LAUGHING MATTER…OR IS IT? SOUTH PIERCE FIRE AND RESCUE PRESENTS -NITROUS OXIDE AND YOU-

Nitronox Field Unit OBJECTIVES Review pharmacology of Nitrous Oxide/Oxygen mixture Discuss and treatment for pain management List indications and contraindications for use of Nitronox in the EMS setting Identify potential side effects Discuss proper dosing and administration Demonstrate proficiency with the Nitronox Field Unit

When is analgesia required? Which agent/technique should I use? DILEMMA OF ANALGESIA When is analgesia required? Which agent/technique should I use? What is the risk-benefit ratio? How much should I administer? **Narcotic Naive?

Effective and rapid acting Easy to administer, store, and carry THE IDEAL ANALGESIC Safe with few side effects Effective and rapid acting Easy to administer, store, and carry Has a short duration and easily reversible Not easily abused

Blended mixture of 50% nitrous oxide and 50% oxygen NITRONOX-PROPERTIES Blended mixture of 50% nitrous oxide and 50% oxygen Produces sedation and analgesia Colorless, odorless, heavier than air Non-explosive, nonflammable Provides a sedative effect which decreases the patients perception of pain and lowers anxiety. May partially act on opiate receptors to cause mild analgesia Readily diffuses through membranes *Rapid onset *Short duration (after inhalation has been stopped)

INDICATIONS Acute myocardial infarction, angina. Musculoskeletal pain due to poss. fractures. Burns. Severe pain with physician approval.

3. Bowel obstruction, abdominal pain. CONTRAINDICATIONS 1.Severe head injury with evidence of increased intracranial pressure, decreased LOC. 2. COPD, pneumothorax. 3. Bowel obstruction, abdominal pain.

SIDE EFFECTS Dizziness/headache/confusion Apnea* Cyanosis* Nausea/vomiting* Hypotension* May worsen conditions involving abnormal collections of air as in: Pneumothorax Bowel Obstruction *Rarely seen

USE WITH CAUTION May see transient decrease in pulse upon discontinuing use. (Wash-out effect). **Always monitor patient with pulse oximeter and provide appropriate supplemental oxygen as needed. **Always administer in well ventilated environment.

NITRONOX ADMINISTRATION • ALWAYS SELF– ADMINISTERED BY PATIENT WHO IS AWAKE, ALERT, AND COOPERATIVE! • Instruct patient to inhale deeply through the patient- held demand valve. • Patient determines number of inhalations and duration of therapy required for adequate pain relief.

If oxygen tank runs out- audible alarm and no gas delivery. Fail-Safe If oxygen tank runs out- audible alarm and no gas delivery. If nitrous oxide tank runs out- audible alarm with 100% oxygen delivery to the patient. If the oxygen line pressure drops or becomes disconnected, the nitrous oxide flow and the supply valve flow stop automatically. If the nitrous oxide supply runs out or is shut off, the supply valve continues to provide 100% oxygen at a reduced peak flow of about 70 lpm. If the patient takes abnormal shallow breaths (100 to 200mL tidal volume), oxygen concentration automatically increases

Capacities TID-BITS The Nitronox system is capable of delivering peak flows of up to 140 liters per minute at normal breathing rates and volumes. Mixture concentration is factory set at 50% nitrous oxide and 50% oxygen (± 5 percentage points oxygen), however, designated high-altitude models are set at 65% nitrous oxide and 35% oxygen (± 5 percentage points oxygen). ALS procedure in Pierce County at this time. However, application could be made at scene and pt. transferred to BLS crew. Example: Pt in pain with movement but fine once on bed.

FIELD UNITS • Carrying case containing 1 Nitrous cylinder. (Each cylinder last approximately 30 minutes). Mixer with valve to ensures premixed 50:50 delivery of gas. Oxygen supply hose. Demand valve to prevents free flow of gas when not in use by patient. *Negative pressure required to open demand valve. (Good seal and patient effort).

UPreparation for Use PREPERATION FOR USE Replace the nitrous oxide cylinder after each use. One cylinder contains approximately a 30 minute supply which is long enough for most single missions Remove the mixer assembly from the carrying case

Preparation for Use Remove the tear-off cap from the outlet of a fresh cylinder of nitrous oxide. Inspect the female connector on the mixer to assure that the o-ring is in place

Preparation for Use Attach the nitrous oxide cylinder to the mixer assembly by turning the hand wheel clockwise until it is "hand tight"

Always turn on cylinder valves slowly and fully. Preparation for Use Check the connection by opening the cylinder valve slightly and listening for leakage. CAUTION Always turn on cylinder valves slowly and fully. If a "hissing" noise is heard, close the valve and remove the cylinder. Check to ensure that the O-ring is present and in good condition. Re-assemble and check the connection again to be sure that there is no leakage or "hissing" noise. If the connection is not leaking, close the valve.

Preparation for Use Install the cylinder/mixer assembly in its case. Make sure that the mixture pressure gauge is visible. **When cylinder is open, normal is 30-35 psi (green band). Pressure will decrease slightly during each inspiration by the patient. The apparatus is now ready for use

Patient must self-administer at all times. Op Patient Use Attach the face mask, or the mouth piece to the supply valve. 2. Instruct the patient to hold the face mask lightly on the face, covering the nose and mouth or seal lips over the mouth piece. 3. Instruct the patient to breathe normally. WARNING Patient must self-administer at all times. NOTE: If the mixture pressure drops below 30 psi and whistle alarm sounds during inhalation, the nitrous oxide cylinder valve is closed or the cylinder is empty.

Operation After use, turn off all cylinder valves and disconnect the oxygen supply. Clean the valve and dispose of the mouthpiece. Prepare the apparatus for the next use

Nitrous Oxide Cylinder Replacement Make sure the nitrous oxide cylinder is replaced after each use. One cylinder contains approximately a 30-minute supply-which is long enough for most single missions. To replace the nitrous oxide cylinder: 1. Make sure the nitrous oxide cylinder valve is in a fully closed position by turning the valve knob clockwise until it stops. Ensure that the oxygen supply to the unit is off and disconnected.

Nitrous Oxide Cylinder Replacement 2. Remove the mixer assembly from the carrying case as 3. Hold the assembly in the upright position. 4. Slowly unscrew the large hand wheel by turning it counterclockwise. WARNING If a hissing sound is heard, stop and recheck that the cylinder valve is closed and that the oxygen supply is off.

Nitrous Oxide Cylinder Replacement 5. Continue by removing the cylinder and valve assembly. 6. Tag the cylinder to show it is no longer full and return the cylinder to a secure storage area. 7. Remove the tear-off cap from the outlet of a fresh cylinder of nitrous oxide and inspect the female connector on the mixer to assure that the O-ring is in place. 8. Attach the cylinder to the mixer assembly by turning the hand wheel clockwise until "hand-tight".

Nitrous Oxide Cylinder Replacement 9. Check the connection by opening the valve slightly and listening for leakage. If hissing is heard, close the valve and remove the cylinder. Recheck to ensure that the O-ring is present and in good condition. 10. Reassemble and check the connection once more to make sure there is no leak If the connection is not leaking, close the valve.

Nitrous Oxide Cylinder Replacement 10. Reassemble and check the connection once more to make sure there is no leak If the connection is not leaking, close the valve. 11. Reinstall the mixer/cylinder assembly in its case as shown. Make sure the mixture pressure gauge is visible. Always store the Nitronox® unit in a secure area and use the double zipper feature to seal and lock the case. The apparatus is now ready for use.

SUMMARY • Nitronox is a safe, easy to use gas mixture containing 50% nitrous oxide and 50% oxygen. Indicated for patients that are alert, cooperative, and complaining of severe pain. Effective, rapidly acting with easily reversed affects. Used as an analgesic for several medical and traumatic indications including chest pain after full initiation of ACLS protocol. Few contraindications or side affects NEVER administered by EMS personnel- only self-administered by patient- limiting chances of overdose. Should be used in well ventilated areas.

CONCLUSION The Nitronox Field Unit is a non-invasive, simple to use, mechanism for delivery of Nitrous Oxide. Nitrous oxide has very few side effects or contraindications. With rapid onset of pain management and minimal risk of overdosing your patient, Nitrous Oxide is the ideal analgesic agent for use in emergency medicine. Overall, nitrous oxide has a comprehensive record spanning many decades and millions of patients.

Mixture Pressure Adjustment If you have further questions please contact A/C Yount or F/F Etherton