# Question about assisted ventilations



## Glorified (May 8, 2007)

This is a scenario for septic shock in my workbook.  

You are dispatched to a long term care facility for an older man with a history of high fever.  You arrive to find an 80-year-old man who is responsive to painful stimuli and has the following vital signs: blood pressure 80/40 mm Hg, weak radial pulse of 140 beats/min and irregular, respirations of 60 breaths/min and shallow, and pulse oximetry of 80% on 4L/min nasal cannula.

My answer:

possible septic shock.  maintain airway and assist ventilations with a BVM and supplemental oxygen at a rate of 12 ventilations per minute and place in trendelenburgs position.  

The books answer was the same except it said was give supplemental oxygen and said nothing about assisting ventilations.  Since he was suffering from severe tachypnea at a rate of 60 and shallow I thought I should assist ventilations.  

Are you not supposed to assist ventilations because he is compensating for massive vasodilaion?  Or was I correct in that a BVM should be used?


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## TKO (May 8, 2007)

I too would ventilate, but carefully.  He has an irregular heart rate so I would have to listen to those lungs before attempting to force air in.  If he's filled with fluid then bagging him only leaves so much space for the air to go and blowing his lungs apart won't make you popular.


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## Ridryder911 (May 8, 2007)

Actually, assisting him with fluids would potentially be PEEP fluid back into the alveoli. Hard question, without witnessing tidal volume. I would suggest assisting him, since he's hypoxic

R/r 911


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## MMiz (May 8, 2007)

I had to scroll up to make sure this was in the BLS section.  I too, as a BLS provider, would assist with ventilations via BVM.


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## Guardian (May 9, 2007)

Glorified said:


> This is a scenario for septic shock in my workbook.
> 
> You are dispatched to a long term care facility for an older man with a history of high fever.  You arrive to find an 80-year-old man who is responsive to painful stimuli and has the following vital signs: blood pressure 80/40 mm Hg, weak radial pulse of 140 beats/min and irregular, respirations of 60 breaths/min and shallow, and pulse oximetry of 80% on 4L/min nasal cannula.
> 
> ...





It sounds like this person is dying.  I would bag as if the pt's life depended on it.  To me, based on the limited information given, this is a no-brainer.


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## TKO (May 9, 2007)

I know there are "useful" numbers that they teach in school for assisted ventilations but they aren't always practical; the rule of thumb on bagging a pt is whether or not the pt's own effort is successful.  If a pt is puffing along at, say, 60 RR/min but is (A)VPU, somewhat "pink" and follows commands, you may want to try giving them a NRB to try on before you try forcing a BVM on their face.  However if a pt is breathing at 12 RR/min, but AVP(U), visibly cyanotic and obviously just not getting enough on their own, you will want to assist.

And bagging is an artform.  I had an instructor that loved to tell the story of a call where he had a big burly firefighter bag a little old lady while he was working.  The big guy almost immediately complained how difficult it was to put air into the ol' girl.  Turns out he caused double tension pneumos!  Oh well, he meant well.


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## bstone (May 9, 2007)

I'd assist ventilations based on the increased rate of respiration. I believe that would be good BLSing.


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## omak42 (Jun 3, 2007)

As a BLS provider your most important job is to check the ABCs.  Once you verify that his airway is clear, you then move onto breathing.  It is difficult when it comes to breathing because you cant just count and say thats not enough, or thats too much.  The important thing to remember is that you need to make sure that the breathing is adequate to support life.  As said above if the pt is breathing at 60 breaths/minute and still alert and talking to you, you would probably just put them on high flow O2 via non rebreather.  But since the breathing obviosly isnt adequate in this case the only option you have IS to assist ventilations.  I would have to say that I agree with your answer more than the books.  Good catch!!


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## Gbro (Jun 3, 2007)

I also would assist, We need to take advantage of all assist situations to perfect our skills. 
I did that recently on a ETOH w/good O2 sats, only to have the ER react to this by ordering an intercept. 
I am all for the pt's well being but BLS is airway management. I believe when the pt starts to circle the drain good old fashion BLS is in order.
We do appreciate our ALS intercepts, but ER's are getting to used to having lines in place and tubes sticking out.


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## ffemt8978 (Jun 4, 2007)

Gbro said:


> We do appreciate our ALS intercepts, but ER's are getting to used to having lines in place and tubes sticking out.



Yeah, I've noticed that also.


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## Guardian (Jun 4, 2007)

Gbro said:


> I am all for the pt's well being but BLS is airway management. I believe when the pt starts to circle the drain good old fashion BLS is in order.



ougggggggggggggggg


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## Ridryder911 (Jun 4, 2007)

Gbro said:


> I also would assist, We need to take advantage of all assist situations to perfect our skills.
> I did that recently on a ETOH w/good O2 sats, only to have the ER react to this by ordering an intercept.
> I am all for the pt's well being but BLS is airway management. I believe when the pt starts to circle the drain good old fashion BLS is in order.
> We do appreciate our ALS intercepts, but ER's are getting to used to having lines in place and tubes sticking out.




There is a reason. It is a called providing medical treatment. Compromising airways with just ventilation's when the airway needs to be secured is not just a precautionary measure, but is in the best interest of the patient. I suggest visiting an ICU with a patient that has had chemical aspiration pneumonia, then you will see why ER's expect patients to have medical care performed on patients. 

R/r 911


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## Gbro (Jun 5, 2007)

I knew i would get a responce out of that comment. 
I have seen so many great tube placments during intercepts, but there have been some ugly work done also. Granted the back of a crowded type II is a challenge at best, but the "must suceed" mindsrt that rules some of these Medic's is awfull. Lines also, to sit on the side of the road 15 min, and 4-5 sharps on the floor before we announce we are rolling.
It happens,


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## Ridryder911 (Jun 5, 2007)

That is what TQI or QI is for. Why the stop? If my medics are not able to achieve at least a 95% ratio (or at least document a reason why?) they need to go for some clinical refresher time. Either practice on an IV arm, or ER, surgery for practice, if no improvement then OTD. (Out the door) 

R/r 911


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## Guardian (Jun 5, 2007)

Gbro said:


> I knew i would get a responce out of that comment.
> I have seen so many great tube placments during intercepts, but there have been some ugly work done also. Granted the back of a crowded type II is a challenge at best, but the "must suceed" mindsrt that rules some of these Medic's is awfull. Lines also, to sit on the side of the road 15 min, and 4-5 sharps on the floor before we announce we are rolling.
> It happens,



Oh, now it makes sense.  I didn't realize your paramedics (if they're even that) and your QI system both sucked that much.  I guess if I were in your shoes, I'd feel the same way.

On the other hand, instead of giving up and promoting a low standard of care (not intubating someone who needs it is unacceptable), why not advocate change.  You are the patients advocate aren’t you?  This whole thing makes me sad.


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## Gbro (Jun 7, 2007)

Ridryder911 said:


> That is what TQI or QI is for. Why the stop?
> 
> R/r 911



TQ-1, Q1 ?? meaning please?

"Why the stop" just what are you referring to here?

As for your 95% or document why,  Well its in that area that i was referring to in my post. The "must succeed" is probably driven by the must document why + the radio report of tube unsuccessful.


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## Flight-LP (Jun 7, 2007)

Gbro said:


> TQ-1, Q1 ?? meaning please?
> 
> "Why the stop" just what are you referring to here?
> 
> As for your 95% or document why,  Well its in that area that i was referring to in my post. The "must succeed" is probably driven by the must document why + the radio report of tube unsuccessful.



Total Quality Improvement.

I think Rid was referencing the "pull over and stop comment". There is no reason to stop to gain IV access or intubate. You should have a high success rate of these interventions while staying en route to the ER.


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## Ridryder911 (Jun 7, 2007)

As FlightLP described there is really no reason to have to "pull over" to perform either skill. Most EMS have or should have a "Quality Improvement" or something similar in place to monitor the percentages of attempts, sucesses, and how to improve in patient care. 

Most medics realize that after two or three IV attempts (in total), a successful IV is not going to happen. There is no reason in attempting such endeavors, if the patient is that critical either peripheral IV should be abandoned and if warrants an I/O, or central line be placed. If one cannot perform this, then continuation to the ER is the preferred route. 

We need to remember the reason of why we are establishing an IV. For the route of medication(s) and or introduction of fluids.... that's it. 

For as documenting such, we (my EMS) has to justify on why continuation of attempts were made as well as why one was not obtained. It is expected by the medical director (which is the ER Director as well) to have a life line upon arrival. We keep the ratio about 96% efficiently within 2 venapunctures. Documenting the patient had poor peripheral venous access is acceptable, it happens. 

R/r 911


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## Jay114 (Jun 7, 2007)

It's discussions like this that have led to my checking this forum daily. It's great to read of real-life events from the field that are directly related to the material in my book and lectures 
_must suck up knowledge_^_^


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## Ravamedic (Jun 16, 2007)

Hi people - 

Without being on scene, but with the information provided I would have assisted the patient with ventilations.

The patient is breathing at 60/min - shallow - which spells out acidosis to me!


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## SMC (Jun 19, 2007)

*Dnr ?*

DNR ?   



> Without being on scene, but with the information provided I would have assisted the patient with ventilations.





This is a sentence to make my post not so short.  LOL


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## DocHoliday (Jun 22, 2007)

*Better safe*

better safe then sorry.  I agree with ravermedic you do need to be on sceane but you can bag someone if you suspect some thing


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## Ravamedic (Jun 24, 2007)

If the patient is overbreathing or under breathing you'll need to assist them.

Pt presentation will let you know exactly what is required - if the pt is breathing at >30bpm but is allert and orientated then they are perfusing well and their acid/base balance is is not effecting cognitive function so I will choose to put them on a partial or non rebreather!

If they have arn't completely altert and over or underbreathing I will use the BMV and assist them to get air in and out so that all form of respiration are getting carried out effectively

They might be getting air in but are they expelling enough Co2? 

What is the tidal volume?

What is their skin colour, temperature and condition?

By assisting with your BMV you are ensuring they are getting enough air in, the Co2 is being expelled - so start to use your BMV and then monitor the patient as you would for every drug and monitor them for the desired effect - the desired effect of BMV is to assist with external, internal and cellular respiration!

And you may notice its effectiveness where?


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## BossyCow (Jun 24, 2007)

SMC said:


> DNR ?
> 
> 
> 
> ...



Do - Not - Rescusitate term used in some places for pts with an advance directive that they do not wish to be revived.


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## Ravamedic (Jun 24, 2007)

Not wanting to change the subject but in Australia we cannot comply with A DNR unless the Doctor is with us on scene.

Bit of trivia for ya!


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## DocHoliday (Jun 25, 2007)

*Really??*



Ravamedic said:


> Not wanting to change the subject but in Australia we cannot comply with A DNR unless the Doctor is with us on scene.
> 
> Bit of trivia for ya!



Really?? How many times does a Doc role on scence?  We have to have the DNR on scene.  When taking a PT I always make sure we have it.  and when i don't know I will continue until a base hospitol tells me to stop.  Better safe then sorry.  I would rather get sued for doing something then not doing something.  One could lead to Life the other leads to death.


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## Ravamedic (Jun 25, 2007)

DocHoliday said:


> Really?? How many times does a Doc role on scence?  We have to have the DNR on scene.  When taking a PT I always make sure we have it.  and when i don't know I will continue until a base hospitol tells me to stop.  Better safe then sorry.  I would rather get sued for doing something then not doing something.  One could lead to Life the other leads to death.



I've never had the Dr arrive before we have departed - I'm not sure if they where even attending. I have not actually started a resus as each time they have been well and truly dead - or just after some pain releif and transport. But if they did arrest in my truck - I'd have to intervene.


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## IrishMedic (Jul 10, 2007)

as an EMT-B, i'd go with what you said.... i mean we are taught in class if Px is breathing more than 20 or less than 12 consider assisted ventilations, check vitals, and it sounds like the Px in the scenario needed it, theres a lot of talk of advanced care stuff in this forum, and as a trainee Paramedic, i can understand their side, but its based on a EMT-B giving treatment...nice one on picking it up..


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## Aileana (Jul 28, 2007)

from what I've heard, I'd have to go with what everyone else has been saying in this thread. The man does not have adequate respirations, thus I would help with a BVM. (guess my post is kinda useless then )


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