# To Bag or not to Bag?



## Frozennoodle (Jan 16, 2011)

I had a PT today c/c SOB with AMS and Hypotension.  Patient vitals were 94/48 BP HR 106 RR ~26-28 85% on 4LPM Responsive to Pain on scene with severe lower respiratory congestion with clear upper airway.  Patient placed on 15 LPM NRB sating at 99% with RR of ~26-28 without cyanosis patient also filled two foley bags full of what looked like almost whole blood.  Skin was pale Cool dry and he was very edemic an transported with much of the quickness on a double basic truck to a facility about 15 minutes out.  I was told that I should have bagged m patient by one of the EMT's at the station just to see how that affected his LOC.  Opinions?


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## Shishkabob (Jan 16, 2011)

Were respirations adequate?

Without having ETCO2 or a history, and I'm not really worried that the cause of AMS is something that can be fixed by bagging.


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## MMiz (Jan 16, 2011)

I probably wouldn't have bagged the patient based on what you provided.  As long as the patient was properly oxygenated, as he appeared to be, I'm not sure how much it would have helped in the short term.

It's clear something is going on and needs to be treated, but I don't think bagging the patient is the best course of action.


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## nakenyon (Jan 16, 2011)

I don't think I would have bagged this patient based on the information provided. As others have stated, he appeared to be oxygenated well enough once placed on the non-rebreather. If he had been turning cyanotic thats another story, but based on the information you provided, I think you made an appropriate decision by not bagging.


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## usalsfyre (Jan 16, 2011)

Frozennoodle said:


> I had a PT today c/c SOB with AMS and Hypotension.  Patient vitals were 94/48 BP HR 106 RR ~26-28 85% on 4LPM Responsive to Pain on scene with severe lower respiratory congestion with clear upper airway.  Patient placed on 15 LPM NRB sating at 99% with RR of ~26-28 without cyanosis patient also filled two foley bags full of what looked like almost whole blood.  Skin was pale Cool dry and he was very edemic an transported with much of the quickness on a double basic truck to a facility about 15 minutes out.  I was told that I should have bagged m patient by one of the EMT's at the station just to see how that affected his LOC.  Opinions?



Since it sounds like sepsis and possibly rhabdo was the real issue, and your patient was properly oxygenated, I'd be interested to know your coworker's
 theory on how a BVM would have helped.


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## Frozennoodle (Jan 16, 2011)

Her theory was that by forcing the fluids out his lungs with positive pressure he would have been able to breathe easier and increased his LOC but his SOB wasn't the cause of his AMS, in my "been an emt basic on the street for a month" opinion, it was the hypotension and he was adequately profusing anyway so I'm not quite sure what that would have done for him either.

To answer the earlier question: I would describe his breathing as rapid and deep


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## Frozennoodle (Jan 16, 2011)

Also, this person never saw the patient and went off my partners description on a phone call which she then stated she disagreed with the other EMT but she is as new as I am.  We were posted closest to the call and all the ALS units were tied down so we got sent.  The next closest unit was probably another 15 minutes away from where we were.


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## Soco_and_Lime (Jan 16, 2011)

Frozennoodle said:


> To answer the earlier question: I would describe his breathing as rapid and deep



If he was sating 99%, his respirations were deep and <30 I don't see how bagging would have made a huge difference.



Frozennoodle said:


> I was told that I should have bagged m patient by one of the EMT's at the station just to see how that affected his LOC



If this person had all the information that you've given us, don't sweat it.


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## MrBrown (Jan 17, 2011)

Assiting the ventilations of a spontaneously breathing patient is overrated and overused.  If oxygenation is adequate, resist the temptation to use a bag mask on them, its uncomfortable, can cause significant gastric distention which can lead to aspiration and other problems.

If oxygenation is poor then its OK, consider calling for an RSI qualified Paramedic or Doctor in this circumstance.


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## JPINFV (Jan 17, 2011)

Provided the patient isn't breathing extremely fast or with a tiny tidal volume, why bag? My nightmare scenario regarding assisted respirations is some poor EMT bagging the patient in DKA with Kussmaul breathing thereby completely messing up respiratory compensation.


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## ZombieEMT (Jan 17, 2011)

*To be a bit more specific...*

According to US DOT objectives and Brady 11th Edition Emergency Care, artificial ventilation by pocket mask, bag valve mask, or FROPVD is the appropriate intervention when the rate of breathing or depth of breathes fall outside of normal ranges. According to the text, normal breathing rates for an adult is 12 to 20 per minute.

However, like many have stated before me, it almost never happens that way. Many times oxygen alone can bring breathing to a normal rate. The truth is using the bvm is very uncomfortable to the patient and is not always necessary. We obviously would not bag someone at 22bpm even though standards say we should, but at 32 maybe.


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## Amycus (Jan 17, 2011)

My instructors really hammered that although the normal range is 12-20, they usually would only be bagging <10 or >30. Made sense to me


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## usafmedic45 (Jan 17, 2011)

> Her theory was that by forcing the fluids out his lungs with positive pressure he would have been able to breathe easier



Except that as soon as you stop, the fluid comes right back.  This includes in between breaths.  Unless you maintain a baseline elevated pressure in the lungs (read as "PEEP" or "CPAP"), you're only going to put the patient at risk of hypocapnia, pneumothorax and all the other crap inherent with unmonitored mechanical ventilation.



> We obviously would not bag someone at 22bpm even though standards say we should, but at 32 maybe.


Ever heard the adage "Treat the patient not the numbers"?  Just because someone is severely tachypneic does not mean they are going to not be adequately holding their own.


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## Bosco578 (Jan 17, 2011)

Nope,no bagging,however I'm sure (and have worked with) some who would bag with the fury of a thousand BVM's...............


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## jjesusfreak01 (Jan 17, 2011)

What exactly are you going to do with a spontaneously breathing tachypnic patient? You can't slow down their respirations significantly with a BVM, but you do risk barotrauma or gatric distension. If you really want to do something useful, throw on an SPO2 probe and if you're really crazy maybe a NC ETCO2 detector so you can monitor the patients overall respiration a tad better. Barring COPD and CO exposure patients, 99% sat with a patent airway requires no further interventions on this front.


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## MrBrown (Jan 17, 2011)

HaleEMT said:


> According to US DOT objectives and Brady 11th Edition Emergency Care, artificial ventilation by pocket mask, bag valve mask, or FROPVD is the appropriate intervention when the rate of breathing or depth of breathes fall outside of normal ranges. According to the text, normal breathing rates for an adult is 12 to 20 per minute.



*Brown throws the book into the rotor blades and averts his noggin to avoid being splattered with the remnance.

Does the book list what exactly the purpose of assisted ventilation are? Oxygenation and ventilation are not the same thing and it is very important that the difference be understood.  A patient may be well oxygenated but ventilating poorly or poorly oxygenating and well ventilated and the two are not mutually exclusive.

Pretty please resist the temptation to assist with hand ventilation if oxygenation is OK, it is an overrated and overutilised skill.  If oxygenation is poor its probably OK, consider calling for an RSI qualified Paramedic or Doctor in this circumstance.

Hmm, Brown may or may not know where to find a gaggle of RSI qualified Intensive Care Paramedics and Doctors .... 

To the ambulance station! 

Brown away! ......


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## Bosco836 (Jan 17, 2011)

We tend to use less than 8 or greater than 28 as our protocol for bagging a patient.  However, there is some discretion, especially if the patient is in no immediate distress.  Having said that, we are generally encouraged to attempt to coach breathing before proceeding with a BVM/Pocket Mask on a conscious patient.


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## MrBrown (Jan 17, 2011)

We have only ever been formally taught to use assisted ventilations in patients with poor oxygenation who are in life threatning respiratory distress eg an asthmatic patient who is exhausted or cardiogenic pulmonary edema where the patient is not ventilating adequately to oxygenate.

Are you taught something different and if so what is the rationale behind it?


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## Frozennoodle (Jan 17, 2011)

Brown, my instructor and my book both taught that with a RR <10 or >30 you should consider bagging the patient because at those rates their either not breathing fast enough to profuse or their breathing so rapidly that the chest doesn't have adequate expansion and are not adequately profusing.


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## jjesusfreak01 (Jan 17, 2011)

Frozennoodle said:


> Brown, my instructor and my book both taught that with a RR <10 or >30 you should consider bagging the patient because at those rates their either not breathing fast enough to profuse or their breathing so rapidly that the chest doesn't have adequate expansion and are not adequately profusing.



This is why we have SPO2 probes. While this may be true for some patients, it is not true for all. The goal is always proper oxygenation, not a set rates for ventilation. If a person is tachypnic and taking shallow breaths, they may not be getting enough O2. If that's the case, you can bag to increase the depth of their respirations. Its also possible they are getting plenty of O2, in which case you don't need to do anything, despite what the book may say. 

That said, if you don't have diagnostic tools like SPO2 probes, and you have to rely on signs like color to determine perfusion, then sure, if the patient is unconscious and you have reason to believe they aren't getting enough O2, go for it.


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## ShesanEMT (Jan 17, 2011)

I agree, (w/HaleEMT) the patient is conscious and breathing on their own (albeit rapidly) and sufficiently. I think the bvm would not be easily tolerated in this case. Of course if the LOC changed and breathing rate deteriorated, appropriate interventions would follow.


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## Bosco836 (Jan 17, 2011)

MrBrown said:


> We have only ever been formally taught to use assisted ventilations in patients with poor oxygenation who are in life threatning respiratory distress eg an asthmatic patient who is exhausted or cardiogenic pulmonary edema where the patient is not ventilating adequately to oxygenate.
> 
> Are you taught something different and if so what is the rationale behind it?




Hello Brown,

Hopefully I can help to address your question.  

The logic behind our teaching (at least in Ontario, Canada) is that if someone is breathing less than 8 times a minute or more than 28 times a minute, chances are their breathing is not effective. 

One of our books provides the following example:  If the average person breathes in 500mL of air with each breath, and breaths about 15 times a minute (on average) - they will be breathing in approximately 7.5L of air each minute.   Having said that, in order to get (approx.) 500mL of air....one must inhale for a second or two and exhale for another second or two.  With that in mind, if someone is breathing at 30-40 breaths a minute, they likely are not taking in enough oxygen, despite the rapid breathing (as each breath may only have 100-200 mL of air, resulting in an inadequate oxygen supply (or so the theory goes...). 

Conversely, if a person is breathing at less than 8 times a minute (especially if unconscious and/or obvious signs of poor perfusion), they likely are not able to draw adequate oxygen levels (unless they are taking huge breaths and even then....it seems rather unlikely).  

Having said that, tools, such as the PulseOx can help us to back up our decision weather to bag or not...and, as previously stated, one must exercise some common sense, and take into account factors like, the appearance of the patient, the rhythm and quality of the respiration's (not just rate), whether or not coaching the breathing (especially if its too fast) will be beneficial (i.e. if the patient is unconscious, its highly probable that coaching isn't going to do much good). 

Hopefully the above explanation will help to answer your question with respect to the rationale about as assisting with ventilations.  

Best regards,


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## Frozennoodle (Jan 17, 2011)

@jjesus That's why I didn't bag them . It didn't even cross my mind once I saw the patient and got him up at 99%. That's why I was kinda asking here because it took me by surprise they would say that and that maybe I missed something in what I described that might have indicated a BVM.


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## Hockey (Jan 17, 2011)

You know what I just realized and is sad...?  

I've only had to bag one live person.  And she had a trach.  God that was such an awkard time.  Trying to control her breathing but it wasn't working and kept pushing the bag off.


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## JPINFV (Jan 17, 2011)

Let's try an experiment people. 

Breath in over 5 seconds, hold it for 5 seconds, breath out, hold it for 5 seconds, repeate. See how long you can go.















The catch? You're obviously going to die soon since you're only breathing 4 times a minute, therefore someone should bag you even if you are feeling fine! Perform an assessment and treat based off that assessment!


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## jjesusfreak01 (Jan 17, 2011)

Hockey said:


> You know what I just realized and is sad...?
> 
> I've only had to bag one live person.  And she had a trach.  God that was such an awkard time.  Trying to control her breathing but it wasn't working and kept pushing the bag off.



I've bagged once, it was a dead person (does v-fib count), and then the medics used this shocky thing and they were slightly less dead...so i've bagged a dead and live person, though it was the same person. Things turned out better than expected.


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## Hellsbells (Jan 21, 2011)

To the OP I wouldn't worry too much about your colleagues armchair quarterbacking on this call, its probably the sign of an inferiority complex on her part.

What did the hospital do for this pt on arrival? Did they start BVM vents?


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## Frozennoodle (Jan 21, 2011)

Hellsbells said:


> To the OP I wouldn't worry too much about your colleagues armchair quarterbacking on this call, its probably the sign of an inferiority complex on her part.
> 
> What did the hospital do for this pt on arrival? Did they start BVM vents?



The hospital put him in a trendelenburg and gave him like a 1000cc bolus and left him on my non-rebreather.  After about 20 minutes they called in respiratory  and dropped a king airway into him while he still had a gag reflex.  I treated his airway and SOB and left his hypovolemia alone mainly because I had nothing to treat it with short of elevating his legs and draining fluid into his lungs compromising his breathing further. I transported in a high fowlers.  I assume he started to desat when they treated for his blood pressure pumping all the fluids into the guy with fluid in his chest but I didn't see his vitals.


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## usalsfyre (Jan 21, 2011)

Bosco836 said:


> One of our books provides the following example:  If the average person breathes in 500mL of air with each breath, and breaths about 15 times a minute (on average) - they will be breathing in approximately 7.5L of air each minute.   Having said that, in order to get (approx.) 500mL of air....one must inhale for a second or two and exhale for another second or two.  With that in mind, if someone is breathing at 30-40 breaths a minute, they likely are not taking in enough oxygen, despite the rapid breathing (as each breath may only have 100-200 mL of air, resulting in an inadequate oxygen supply (or so the theory goes...).



Except in Kussmaul respirations the patient may have a >500ml tidal volume 30-40 times a minute. Trying to bag this respiratory pattern is going to do more harm than good. 



Bosco836 said:


> Conversely, if a person is breathing at less than 8 times a minute (especially if unconscious and/or obvious signs of poor perfusion), they likely are not able to draw adequate oxygen levels (unless they are taking huge breaths and even then....it seems rather unlikely).



See JPINFV's post above about breathing 4 times a minute. 



Bosco836 said:


> Having said that, tools, such as the PulseOx can help us to back up our decision weather to bag or not...and, as previously stated, one must exercise some common sense, and take into account factors like, the appearance of the patient, the rhythm and quality of the respiration's (not just rate), whether or not coaching the breathing (especially if its too fast) will be beneficial (i.e. if the patient is unconscious, its highly probable that coaching isn't going to do much good).
> 
> Hopefully the above explanation will help to answer your question with respect to the rationale about as assisting with ventilations.
> 
> Best regards,



Learn the rates for class and testing purposes. Then promptly forget them, along with most of what you were taught about airway and the respiratory system, as EMS classes do a crappy job of teaching it. Try to tailor your treatment to each individual patient, as is noted above. You will find that you VERY rarely bag conscious people, or even people who are breathing on their own.


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## usalsfyre (Jan 21, 2011)

Hockey said:


> You know what I just realized and is sad...?
> 
> I've only had to bag one live person.  And she had a trach.  God that was such an awkard time.  Trying to control her breathing but it wasn't working and kept pushing the bag off.



It was probably VERY uncomfortable for the patient. Asynchronous ventilation with a positive pressure source is severe badness. Either sedate, or try to take the patient's vent with them.


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## usalsfyre (Jan 21, 2011)

Frozennoodle said:


> The hospital put him in a trendelenburg and gave him like a 1000cc bolus and left him on my non-rebreather.  After about 20 minutes they called in respiratory  and dropped a king airway into him while he still had a gag reflex.  I treated his airway and SOB and left his hypovolemia alone mainly because I had nothing to treat it with short of elevating his legs and draining fluid into his lungs compromising his breathing further. I transported in a high fowlers.  I assume he started to desat when they treated for his blood pressure pumping all the fluids into the guy with fluid in his chest but I didn't see his vitals.



Sounds like you did fine. Remember the initial treatment for cardiogenic shock is still fluid. 

I'm curious why the hospital used a King airway, especially with a gag present.


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## usafmedic45 (Jan 21, 2011)

> Asynchronous ventilation with a positive pressure source is severe badness. Either sedate, or try to take the patient's vent with them.



....or if the patient is conscious and coherent, let them bag themselves.


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## Frozennoodle (Jan 21, 2011)

usalsfyre said:


> Sounds like you did fine. Remember the initial treatment for cardiogenic shock is still fluid.
> 
> I'm curious why the hospital used a King airway, especially with a gag present.



That sir, I do not know.


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## usafmedic45 (Jan 21, 2011)

usalsfyre said:


> Sounds like you did fine. Remember the initial treatment for cardiogenic shock is still fluid.
> 
> I'm curious why the hospital used a King airway, especially with a gag present.


I'm trying to figure out how the hell the would get a King into a patient like that.  Was the patient Jenna Jameson?


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## usalsfyre (Jan 21, 2011)

usafmedic45 said:


> I'm trying to figure out how the hell the would get a King into a patient like that.  Was the patient Jenna Jameson?



Yeah, my first thought was actually WTF. I've been trying tact here lately, as I've been accused of being a bit ahhh, abrupt.


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## Frozennoodle (Jan 21, 2011)

My partner told me it was a king airway.  I never saw it.  She also told me not to bring the NRB the nursing home had him on 15 LPM on one already.  I look at the patient and see he is on a simple face mask at 4 LPM.  I open the jump bag and grab the mask out and she tells me no why did you open the mask!  He already has one!  I said, "they have him on 4 on a simple face mask." I had to explain to her the difference between a NRB and a simple face mask in front a room full of lpns.  So who knows what they used.


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## usalsfyre (Jan 21, 2011)

Frozennoodle said:


> My partner told me it was a king airway.  I never saw it.  She also told me not to bring the NRB the nursing home had him on 15 LPM on one already.  I look at the patient and see he is on a simple face mask at 4 LPM.  I open the jump bag and grab the mask out and she tells me no why did you open the mask!  He already has one!  I said, "they have him on 4 on a simple face mask." I had to explain to her the difference between a NRB and a simple face mask in front a room full of lpns.  So who knows what they used.



No offense to you, and not a personal attack on your partner, but this reeks of fail. She's REALLY worried about opening a NRB (total cost less the five bucks)?

I HIGHLY doubt is was a King.


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## Amycus (Jan 21, 2011)

Just had one of the few, rare instance today where our PT was getting bagged. Got called for an OD, in and out of consciousness- arrive on scene, Fire starts bagging the guy after dropping an NPA (4 times a minute, pale skin color), I sliced off his sleeve so I could grab some vitals, and out of nowhere BAM this guy woke up...full color, breathing normal rate/rythem, etc.

It's amazing what a bit of proper oxygenation can do for someone.


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## Frozennoodle (Jan 21, 2011)

usalsfyre said:


> No offense to you, and not a personal attack on your partner, but this reeks of fail. She's REALLY worried about opening a NRB (total cost less the five bucks)?
> 
> I HIGHLY doubt is was a King.



No offense taken.  She's not the brightest crayon in the box.  I just did it and showed her the difference.


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## exodus (Jan 23, 2011)

For those who bag patients who are alive and have agonal breaths and don't want to cross into their breaths... Watch the valve just before the elbow. With a good enough seal, you will see the valve move slightly, when it does, squeeze gently.  This works best with a trach because the seal is much easier to manage, but can be done on the face.


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## VirginiaEMT (Jan 23, 2011)

usafmedic45 said:


> i'm trying to figure out how the hell the would get a king into a patient like that.  Was the patient jenna jameson?




now that's funny!!!


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