# Suction



## GregEMT19 (Oct 7, 2008)

Hey guys, I'm now in my second month of EMT-B cert and have been reading this forum.  Very helpful, and I figured I would throw a question out there for anyone that knows the answer.  We just got done covering suctioning in my class and I came across something that was bothering me.  We were taught to never suction higher than 200(mmHg??)  But if thats the case, how come the suction devices go well above and beyond 200?


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## Hastings (Oct 7, 2008)

GregEMT19 said:


> Hey guys, I'm now in my second month of EMT-B cert and have been reading this forum.  Very helpful, and I figured I would throw a question out there for anyone that knows the answer.  We just got done covering suctioning in my class and I came across something that was bothering me.  We were taught to never suction higher than 200(mmHg??)  But if thats the case, how come the suction devices go well above and beyond 200?



Never heard any such limits. We just crank our's all the way up. The only limit I'm concerned with is time. No longer than 15 seconds. No deeper than what you can visualize. Those are my suctioning rules. Other than that, never heard anything about the uh...power.


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## JPINFV (Oct 7, 2008)

Because suction is used in cases other than patient's that need their upper airway suctioned and there's no real benifit for the companies to make special ambulance models where the only difference is the highest level the suction goes.


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## GregEMT19 (Oct 7, 2008)

I suppose a higher suction strength could be used to clear the catheter in the event it was clogged.  Is there any benefit to suctioning at a higher rate?  Or is there any danger to the pt by going higher?


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## VentMedic (Oct 7, 2008)

GregEMT19 said:


> I suppose a higher suction strength could be used to clear the catheter in the event it was clogged. Is there any benefit to suctioning at a higher rate? Or is there any danger to the pt by going higher?


 
The suction units go to 200 mmHg and beyond because they have can have other purposes by being attached to other equipment.

ABSOLUTELY you can do serious damage to a patient with high suction!!!




> Never heard any such limits. We just crank our's all the way up. The only limit I'm concerned with is time. No longer than 15 seconds. No deeper than what you can visualize. Those are my suctioning rules. Other than that, never heard anything about the uh...power.


Hastings! After reading some of your posts, where did you get your Paramedic cert?

Hopefully you aren't "cranking all the way up" especially when you do ETI suction. I really hope your machine is not capable of 200 mm Hg of suction if that is the way you and your co-workers think.


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## VentMedic (Oct 7, 2008)

If you use 200 mm Hg to clear a line or grap a large piece of something WITH THE FULL knowledge of the potential for damage, that is one thing.

If you are operating  a piece of equipment inside a patient's mouth or lungs with little or no knowledge about the damage you can do or even how the equipment works, that is something else all together.


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## VentMedic (Oct 7, 2008)

Now, before anybody, including Hastings, thinks what I said in reference to his post is inappropriate, I want to explain why some information on the open forums can be just misleading or in some cases can not be in the best interest of the patient.

Many things, like the suction, can be easily referenced in the EMT or Paramedic texts. Too many come off with "its the new wording or way", "I've never heard of any other way" or "I'll do it my way anyway" when spouting off about some procedure or med without any evidence that their method is better or even correct. 

There are some procedures that should not be that big of a mystery and should not be done without some knowledge and training. Many of the very fundamental or basic procedures fall into that category and should be well understood since they may be the first steps in saving a life or preventing further harm to the patient.

I don't criticize anyone for asking questions on this forum. However, if you offer advice, be able to back it up with some reference. If you are of higher level of training, you should remember some of the basics of medicine and procedures. 

The EMT and Paramedic textbooks are not that large but they do have a lot of information that should be referenced even after you have completed school. You P&P manual should also be readily available. There should be no doubt about any piece of equipment or procedure that is part of your job description. 

If you can not find information, there are many on this forum that can point you to a source with the information. 

Unfortunately, some who themselves have not found these sources or do not utilize the sources available to them are those that think they have the all the correct advice and opinions.

To the OP, check your EMT book or P&P for the specific info. If you can not find it, I'll post the links later if someone else doesn't.


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## Ridryder911 (Oct 7, 2008)

After reading many posts I do wonder what school or texts they used (or if ever read). I guess many never heard of intermittent suction as well or low volume suctioning. Yet, so many proclaim to be emergency medical experts, yet fail to understand something as simple as suctioning. 

I guess as well many has never transported patients with chest tubes using pluer-evac or drainage systems, or attach suction to Naso Gastric tubes?  Again, routine transports and as well I do wonder about the education if one does NOT know about evacuating gastric contents through a NG tube? .. One would NEVER use higher than 20mm/Hg as such causing a potential tear of the gastric lining. 

As well I guess none of these so called ALS personal ever tracheal suction patients? One should never use high pressure also causing damage... 

Again, it amazes the education level or should I say lack of education that is taught within programs...

R/r 911


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## Sasha (Oct 7, 2008)

How did we get from suction questions to bashing other peoples education and certification?


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## VentMedic (Oct 7, 2008)

Sasha said:


> How did we get from suction questions to bashing other peoples education and certification?


 
There should be some very basic knowledge that should be required to get one's certification as either an EMT or Paramedic. 

The question posed is "Are schools not teaching fundamental principles or are students not reading and retaining the material"? 

Are the educators not educated enough to teach foundation material?

Are preceptors and FTO failing to train and be available?

Too many memorize vital information instead of learning it and then it is quickly forgotten once the test is taken. This is unfortunately what happens in programs that have no prerequisites and the instructors also do not need much more than a cert in the class they are teaching.

Yet, some in this profession still manage to present themselves with cockiness and arrogance to make up for what they do not know.


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## mikie (Oct 7, 2008)

so have we come to the conclusion that 200mmHg is the max for basic oral suctioning?


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## Hastings (Oct 7, 2008)

VentMedic said:


> Hopefully you aren't "cranking all the way up" especially when you do ETI suction. I really hope your machine is not capable of 200 mm Hg of suction if that is the way you and your co-workers think.



I don't know what our machine is capable of. It's either on, or it's off. There is no choice of power. So we just flip the switch and go with it, leaving the only concerns - like I said - to be time and length of insertion. 

While that's the machine of choice for oral suctioning, we do have another machine for other purposes. Have yet to use it though.


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## VentMedic (Oct 7, 2008)

mikie said:


> so have we come to the conclusion that 200mmHg is the max for basic oral suctioning?


 
200 mmHg is more than enough to rip the soft tissue in the oral caviity. Any bleeding may lead to blood aspiration. That can lead to extended ventilator time and ARDS. That can lead to death. 

If you have someone on blood thinners or who have been taking steroids for a long time, you put them at big risk. 

If you are going to need 200 mmHg to clear and airway, you will have to know the damage it can do if you are not careful. If you leave your machine on 200 mmHg, the next person that uses it may not be so careful. It doesn't take much to cause real damage to a patient that can lead to further complications. Become familiar with your machine and airway clearance techniques. 

Hastings, do you not have access to the manual or equipment rep? If you don't, your training officer should. There is little excuse to operate suction equipment or any equipment without having some idea of how it functions. You many also need to use this equipment for a child or infant.  Don't wait until it is an EMERGENCY before you find out what you equpment is capable of.


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## Hastings (Oct 7, 2008)

VentMedic said:


> 200 mmHg is more than enough to rip the soft tissue in the oral caviity. Any bleeding may lead to blood aspiration. That can lead to extended ventilator time and ARDS. That can lead to death.
> 
> If you have someone on blood thinners or who have been taking steroids for a long time, you put them at big risk.
> 
> ...



I know how the equipment works. You turn it on and suction.

As stated, there's another device for suctioning in other cases. Such as pediatrics. And under those circumstances, we have specific guidelines as to what to set the machine at, which if we forget, are listed in the big book of everything.

I guess you could consider the first machine to be the quick suction. The one you can use for the common purpose of suctioning the adult patient orally, without having to worry about setting anything. It's convenient.


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## VentMedic (Oct 7, 2008)

Hastings said:


> I guess you could consider the first machine to be the quick suction. The one you can use for the common purpose of suctioning the adult patient orally, without having to worry about setting anything. It's convenient.


 
And hopefully you will never have to use it for any other purpose or prevent member of an ICU team from using some of your equipment if you can not tell them the amount of suction. 

Just "turning on a switch" is just the makings of a knobologist which is way too common for some who then want other equipment like ETCO2 monitors, pulse oximeters and ventilators.


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## Hastings (Oct 7, 2008)

VentMedic said:


> And hopefully you will never have to use it for any other purpose or prevent member of an ICU team from using some of your equipment if you can not tell them the amount of suction.
> 
> Just "turning on a switch" is just the makings of a knobologist which is way to common in some who then want other equipment like ETCO2 monitors, pulse oximeters and ventilators.



Actually, it's a switch. Like a light switch. Click on, click off. No turning.

So actually, it'd be a switchologist.



Never had an ICU member. Have the CC flight medics/nurses, sometimes. They choose to just flip the switch and suction too. I guess we're all just switchologists. Shame on us. Shame on us all.



Oh, also, no we don't have to use it for another purpose. We have that other machine that can be manually set for other purposes, and then a backup machine/batteries in case that one fails.


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## VentMedic (Oct 7, 2008)

Hastings said:


> Actually, it's a switch. Like a light switch. Click on, click off. No turning.
> 
> So actually, it'd be a switchologist.
> 
> ...


 
A "switchologist" is someone who doesn't know the power or capability of their machine.
Fortunately the people you have transported in your ambulance probably have worked with enough equipment to know approximately how many mmHg the equipment is applying. If you read Rid's post you would know why it is of great importance for them to know these things. They may also need to know this because they often can not expect to get that information from those whose trucks they are in.


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## traumateam1 (Oct 7, 2008)

Like many people have said, and I'll just reiterate it again. Suctioning more than 200 mmHg can cause serious damage to the mouth, cause bleeding and some other problems, which will lead to more suctioning 
So when suctioning turn it to 200 mmHg (or less) and suction for a maximum of 15 seconds (peds are 5 of course), followed by high flow O2 or BVM. After the 15 seconds of O2 suction again if needed.
If there is active vomiting or bleeding than (if possible) turn the patient onto their side to allow for drainage so you aren't tied up with suctioning every 15 seconds.

Cheers! 
Oh and welcome to the tribe *GregEMT19* :beerchug:


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## traumateam1 (Oct 7, 2008)

*Woohoo!!*

*YAY!!! My 250th post.. Forum Captain now!! *


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## Sasha (Oct 7, 2008)

Im jealous. How high do you have to be to be keeper of the nrb? I wanna steal it from JP


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## JPINFV (Oct 7, 2008)

You have to be able to do magic. (alternatively User CP->edit your details->custom user title)


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## VentMedic (Oct 7, 2008)

traumateam1 said:


> So when suctioning turn it to 200 mmHg (or less) and suction for a maximum of 15 seconds (peds are 5 of course), followed by high flow O2 or BVM. After the 15 seconds of O2 suction again if needed.


 
Whoa!!  Do not go near a child with 200 mmHg!

Please review your text books and P&Ps for the proper way to do this very basic but vital skill.


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## traumateam1 (Oct 7, 2008)

*My Mistake!*

Sorry Vent! I worded that wrong.. I would never ever ever go near a ped with 200 mmHg.. I was referring to the time limit only when I made that comment!
*I apologize to everyone for the confusion!!!*


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## Ridryder911 (Oct 7, 2008)

Personally never seen an on-board suction unit ( and I have seen many EMS units) without a method of controlling the amount of suction, met some medics that did not know the parts or how to use their suction unit device


Even each one of these suction devices has an ability to adjust the amount of suction
















There is usually a knob that those that are familiar with their equipment, located at the top of the canister and should have a gauge either on the suction or in the wall. This is to ensure patient safety. The switch is alike all other suction units just to turn it off and on.  

Not knowing is not excusable, this is general basic information that should had been discussed in the Basic EMT as it *is* part of the EMT curriculum. 

R/r 911


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## GregEMT19 (Oct 7, 2008)

Sweet, thanks all who helped answer my question.  Thanks for the welcoming Trama.  Seems like there are some pretty knowledgable people on here.  I'll contribute when I can.


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## mikie (Oct 7, 2008)

I know our ambulance mounted suction has a control knob but I'm fairly sure that our portable is just a switch (at least visible to the eye).  It hasn't been used too frequently lately, but I'm going to check it out and see if there is indeed a knob.  

[lol-knobologist]


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## KEVD18 (Oct 7, 2008)

you need 500 posts for a custom forum title.


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## marineman (Oct 7, 2008)

traumateam1 said:


> So when suctioning turn it to 200 mmHg (or less) and suction for a maximum of 15 seconds (peds are 5 of course)



Maybe it's a Canadian thing but here adult is 15 max, peds are 10, and infants are 5 (use a bulb syringe anyway so what's the point?)


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## imurphy (Oct 7, 2008)

As to why the Suction unit (LSU on my bus) goes up to 520+, I've found it's GREAT for a Vac-Mattress!


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## Foxbat (Oct 7, 2008)

Ridryder911 said:


> After reading many posts I do wonder what school or texts they used (or if ever read).


The only thing my EMT-B textbook (Mosby's, revised 2d edition) says about pressure on suction unit is "if the unit has a pressure gauge, check the pump to be sure that it can generate a 300 mm Hg vacuum".
What is even more surprising is that even some hospital staff has issues with proper suctioning (judging from this article).


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## wxduff (Oct 7, 2008)

For the benefit of discussion, I just checked my EMT-Basic book.

The book doesn't say much about suctioning, at all, which surprised me.

The book did say the following...

"To be effective, suction devices must furnish an air intake of at least 30 liters per minute at the open end of a collection tube. This will occur if the system can generate a vacuum of no less than 300mmHg when the collecting tube is clamped..."

That seems high, and I believe the medic who's teaching our class said 200 in lab...


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## Jon (Oct 7, 2008)

wxduff said:


> ...That seems high, and I believe the medic who's teaching our class said 200 in lab...


Go with the book. Medics can be wrong, especially when they are speaking in a lab classroom.


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## wxduff (Oct 7, 2008)

The only problem I have with going with the book is part of this discussion has been about how 200 should be the most suction used ever, yet the book says go with 300, my instructor says 200, etc...

It's like there isn't a straight answer...:wacko:


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## marineman (Oct 7, 2008)

Ok you guys made me go and check my text again. Mosby's paramedic textbook revised third edition. Here is a direct quote from the book so I don't miss anything (begining of page 467 for anyone that wants to follow along)

Before any suctioning is begun, all equipment should be checked. Also, the suction should be set between 80 and 120 mmHg (Higher suction is needed for tracheo-bronchial suctioning.) 

Also it goes on to say that suction should be applied for no longer than 10-15 seconds in an adult and no longer than 5 seconds in a ped. For that I owe trauma team an apology. I am 100% sure the 5, 10, 15 rule is what we were taught is that a variation set by the state, local protocols or is the book a touch off base?


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## mycrofft (Oct 7, 2008)

*My speedometer says 120 at the top...of my first car, a Rambler Ambassador.*

I've seen "switch on/switch off" units before. I've seen suction units with unreliable vacuum gauges, too. Now before I break into a James Taylor medley, let's consider the suction handpiece.

(Before I go on, let me say our cohorts are right despite their sarcasm. The sarcasm should make it stick. It just makes me look for a stick. At any rate, make sure your vacuum gauge works, and remember that the mmHg climbs rapidly if the handpiece is occluded, and over a certain point you're going to stop doing good and start doing harm).

Handpieces..yes. Don't use a one cm shotgun barrel when a Yankauer will do, and a Yankauer has lots of little holes to allow liquid pickup from four directions, but also helps keep your OP suctioning from becoming a "China Syndrome" event. And that little hole on the end by your thumb or finger or thumb-finger is designed to allow you to CONTROL the suction, mostly off/on, but if you're slick and at lower suctions it can even moderate it a little.

At my work, our erstwhile equipment manager wants us to "ramp up" to stronger suction, but we're just fine now that all our VVAC's finally ate it (all the one-way valves rotted out after six years, make it like a lousy fireplace bellows).


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## VentMedic (Oct 8, 2008)

marineman said:


> Ok you guys made me go and check my text again. Mosby's paramedic textbook revised third edition. Here is a direct quote from the book so I don't miss anything (begining of page 467 for anyone that wants to follow along)
> 
> Before any suctioning is begun, all equipment should be checked. Also, the suction should be set between 80 and 120 mmHg (Higher suction is needed for tracheo-bronchial suctioning.)
> 
> Also it goes on to say that suction should be applied for no longer than 10-15 seconds in an adult and no longer than 5 seconds in a ped. For that I owe trauma team an apology. I am 100% sure the 5, 10, 15 rule is what we were taught is that a variation set by the state, local protocols or is the book a touch off base?


 
No you are not necessarily wrong. Different text books have slight variations.  Also, there is a difference between total time of the procedure and the actual suction application.

Tracheo-bronchial does not require higher suction and the recommended should be used.  Lung tissue is very delicate as are the alveoli and changing pressures.  Oral suction may exceed slightly but only with caution.  Elderly people may need the pedi settings.

*NT, Trach and ETTs as well as oral recommendations for kids and the elderly:*

Neonatal:
40 - 80 mmHg with 60 being the most common
The procedure should take no more than 10 seconds which is about 5 seconds for suctioning.

Pedi:
80 - 100 mmHg 
Depends on the age with 10 - 15 seconds for the duration of the procedure and no more than 10 seconds for suctioning being applied.

Adult:
120 mmHg
15 seconds 

For the oral cavity, you can go slightly higher.  I will rarely exceed 150 mmHg with a yankauer except if I can visually see what I am suctioning and have a good aim at it so not to damage the soft tissue.


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## traumateam1 (Oct 8, 2008)

Oh don't worry about it marinema. I know everyone has different protocols.


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## marineman (Oct 8, 2008)

Vent fantastic post, good information that's not in my textbook but I wrote it in the margin on that page. For the neonate I'm assuming there's something more high tech than the bulb syringe that we've always been taught with but I've never seen anything. What type of cath would you use just a standard flexible or is there actually a neonatal sized rigid cath?


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## VentMedic (Oct 8, 2008)

marineman said:


> What type of cath would you use just a standard flexible or is there actually a neonatal sized rigid cath?


 
Both. There are size 5, 6 and 8 Fr suction catheters for ETT suctioning and for suctioning the stomach contents after birth (usually an 8 fr).  Note French is the measurement and not the name of the catheter.

There are also various rigid devices for clearing the nares and oral cavity with extreme caution of course. 

http://neotechproducts.com/suction-c-4.html

http://www.smiths-medical.com/catal...hmark/cathmark-neonatal-suction-catheter.html

Child trach suctioning (adult is similar) Good site for other info about trachs.

http://www.tracheostomy.com/care/suction.htm


Good article on neonatal RN techniques as observed:

http://www.marshall.edu/etd/masters/craig-register-2002-msn.pdf.pdf


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## 2boss4 (Oct 10, 2008)

why is there a 15 second rule? if there's no airway, one would think youd want to get one est. asap


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## VentMedic (Oct 11, 2008)

2boss4 said:


> why is there a 15 second rule? if there's no airway, one would think youd want to get one est. asap


 
Not all patients that require suctioning need ETI. The 15 second rule can apply to NT or oral suctioning as well as ETT suctioning. 

Unfortunately suctioning is not a skill that is understood or mastered by all and since a little device known as CPAP has come to EMS, we are seeing many more patients with aspiration because the airway was not cleared before strapping the mask tightly to the patient's face.


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## mikie (Oct 11, 2008)

Wouldn't you have to adjust vacuum pressure if you're using a different size cath?  200mmHg isn't the same for a 14french vs a 16?  am I right or just not at all?


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## VentMedic (Oct 11, 2008)

mikie said:


> Wouldn't you have to adjust vacuum pressure if you're using a different size cath? 200mmHg isn't the same for a 14french vs a 16? am I right or just not at all?


 
If you are using a soft catheter, I would hope you wouldn't be using 200 mmHg.   Lung, nasal and pharyngeal tissue are very delicate and easily damaged.   

You use the correct mmHg for the size, age and medical conditions of the patient.  

There must be some common sense judgement used also in some procedures.


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