# Adult Bag Valve Mask use on child?



## Legacy_Camaro (Jun 7, 2010)

I lifeguard at a local pool here in Salt Lake, and our pool manager has been teaching the lifeguard newbies that they can use the adult bag valve mask on a child/infant if they are really really careful.

I'm also EMT-I and I'm almost positive that a lifeguard newbie who has never done CPR before in their life could use an adult BVM on a child/infant without it ending in total disaster. 

I'm pretty sure that protocol in most places says that if your going to use a BVM, you have to use the appropriate size for the patient. 

I can't find anything on the internet for or against it however, I could use some help.


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## firecoins (Jun 7, 2010)

you can use an adult but you should not defalte the whole bag.  You need alot less air than the air an adult BVM provides.  Honestly, amateurs should have the right size.


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## MMiz (Jun 7, 2010)

First, welcome to EMTLife!

You should not be using an adult BVM on a child/infant.  Just because it's possible doesn't make it right or legal.  I sure wouldn't want to be the provider on the end of a lawsuit for using an adult BVM on a child or infant.

Again, one can use adult AED pads on a child, and once I read in a medical journal about some doctor in a remote location using a car battery as a defibrillator.  Spend the extra $20 and get separate adult/child/infant BVMs.  I can't think of a single argument against separate BVMs.

I hope that helps!


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## Aidey (Jun 7, 2010)

Legacy_Camaro said:


> I lifeguard at a local pool here in Salt Lake, and our pool manager has been teaching the lifeguard newbies that they can use the *adult bag valve mask* on a child/infant if they are really really careful.
> 
> I'm also EMT-I and I'm almost positive that a lifeguard newbie who has never done CPR before in their life could use an *adult BVM* on a child/infant without it ending in total disaster.



Are we talking the mask or the bag? Because no, you really can't use the mask on a smaller person because it won't seal. You can use the bag on a smaller person. Remember, you are looking for chest rise. How big the bag is doesn't matter as long as you are only inflating to chest rise.


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## akflightmedic (Jun 7, 2010)

Agree with spend the extra $20 to have appropriate size BVM on hand.

Should that not occur anytime soon and you find yourself trying to use an adult BVM on a child, remember only inflate until you see chest rise and do not squeeze forcefully.

Also, you will not get a good seal or any seal most likely, so turn the mask upside down. It fits better and will work better and that little last resort tip is only if the numbskull does not buy the right equipment.

Otherwise, me personally, I would carry my own pocket mask and use that as opposed to using wrong equipment. Certainly would stand up better when you are explaining yourself to the lawyers in court.


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## Veneficus (Jun 7, 2010)

MMiz said:


> and once I read in a medical journal about some doctor in a remote location using a car battery as a defibrillator.




3 or 4 years ago one of my classmates actually took the time to convert 200joules to amps and volts. I admit I don't remember the exact numbers but I remember it being somewhere around 100 amps and 50,000 volts.


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## truetiger (Jun 8, 2010)

There's absolutely nothing wrong with using an adult bvm with a child mask *if you have to*, that doesn't make any excuse for not having one. Just ventilate to get adequate chest rise and be careful not to fully depress the bag, easy enough.


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## LucidResq (Jun 8, 2010)

akflightmedic said:


> Otherwise, me personally, I would carry my own pocket mask and use that as opposed to using wrong equipment. Certainly would stand up better when you are explaining yourself to the lawyers in court.



+1 

I would imagine easier to limit the volume of air you're pushing than with an adult BVM as well...


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## EMSLaw (Jun 8, 2010)

akflightmedic said:


> Otherwise, me personally, I would carry my own pocket mask and use that as opposed to using wrong equipment. Certainly would stand up better when you are explaining yourself to the lawyers in court.



Remember that in the unlikely event that a case against you made it to trial (something like only 1% of civil cases do.  The vast majority are disposed of by settlement, or pre-trial motion, or some other means), you aren't explaining yourself to the lawyers.  You're explaining yourself to the jury.  

So, if the adult BVM is the only thing you have available, and you're faced with an apneic child, the explanation would be that you did the best with what you had, presumably.  

Also, as I recall, the trick of turning the adult mask upside-down to use it on a child is mentioned in the standard EMT-B books, so it could be argued quite successfully that, while not ideal, it is a part of the standard of practice and a skill well within the scope of an EMT.  It's certainly preferable to letting someone die of suffocation.  

Incidentally, since the risk of litigation seems to come up a lot...  Consider the following.  The National Practitioner Data Bank's 2006 Annual Report reveals that from 1990-2006, 158 malpractice reports were made against 157 EMTs (or "Emergency Medical Practitioners").  The number of malpractice claims against EMTs of all levels, from basic to paramedic are vanishingly small.  While the NPDB isn't a definitive source, consider the always-risk-averse insurance industry - malpractice insurance for an EMT or Paramedic costs somewhere around $150.00 a year.  Malpractice insurance for an MD might exceed a thousand times that number, in some high-risk specialties.  

This isn't a suggestion that you go out and do what you want, and please don't take it that way.  But also don't allow the fear of litigation to rule your practice, either.  

Sorry, I'll step off my soap box now.


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## mycrofft (Jun 8, 2010)

*EMS law, that's awesome.*

Dang, facts, how can we operate with those?

Anyway...if it's life or death and likely to work, try it. You can seal the whole face ito the mask if it will allow proper inflation, but you have to look at the pt, something we do less and less of nowadays in between looking at monitors, writing paperwork, and texting our friends.


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## EMSLaw (Jun 8, 2010)

Some further information...  

According to the latest nationwide study, which is admittedly 16 years old, the incidence of litigation against EMS practioners is small:  



> Total of 76 cases over 5 years:
> • Just over 40% of the cases were
> dismissed
> • Five cases with plaintiffs' awards or
> ...



This from a very good slideshow on EMS liability by Ryan Stark, Esq. of Page, Wolfberg & Wirth in Pennsylvania.*  It's available here, and I would recommend it to anyone interested in the liability issues in EMS.  The case studies are interesting, but illustrate the sort of egregious conduct that leads to malpractice lawsuits against EMTs and Medics.

I'd be happy to discuss these issues with anyone who is interested.  Otherwise, I'm moving the soap box back into storage.  

*-Hrm... I wonder if they're hiring.  Do you think they have a physical agility test as part of the process?


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## 8jimi8 (Jun 8, 2010)

akflightmedic said:


> Agree with spend the extra $20 to have appropriate size BVM on hand.
> 
> Should that not occur anytime soon and you find yourself trying to use an adult BVM on a child, remember only inflate until you see chest rise and do not squeeze forcefully.
> 
> ...




Seriously, get a pocket mask with an oxygen inlet port.  Maybe you could go above your manager's head and ask the owner.  You can use your textbook to show him that there are different and correct sizes that need to be used.  

I'm sure there is some type of regulations that would actually require a pool to carry rescue equipment of appropriate sizes for the clients that they serve.  Honestly.  I don't understand how this could continue to be an issue after your bring the subject up.

Even if your pool can't BUY this equipment, i'm sure you could go doorbell ringing to your different EMS / FIRE services and beg some of their stuff off of them.  Or go to your local red cross / cpr instruction sites and ask for a donation.  Go to a church and explain your need.  There are plenty of ways to get the resources that you need.


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## LucidResq (Jun 8, 2010)

Not that a BVM would've saved this kid's life, or that a properly-sized BVM wasn't used, or that he even needed a peds BVM.... 

but nonetheless, a close-ish-to-home reminder that yes! Lifeguards do need to resuscitate children occasionally!


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## clibb (Jun 8, 2010)

MMiz said:


> First, welcome to EMTLife!
> 
> You should not be using an adult BVM on a child/infant.  Just because it's possible doesn't make it right or legal.  I sure wouldn't want to be the provider on the end of a lawsuit for using an adult BVM on a child or infant.
> 
> ...



It's legal here and we were taught that we could use it. NOT that we were supposed to, but if we had no other option.
Correct me if I'm wrong...
An adult's lungs are 800cc. An infants is 150 cc. As the child grows, the bigger the lungs get. So you aren't really sure how much air you're supposed to give the child as a newbie. They could be hyperventilating or damaging the lungs with the amount of pressure they are applying to the BVM. Also, using an adult BVM on a Pediatric patient sucks. It's extremely hard to get the right fit for the child without covering the whole entire face and you're not supposed to cover the eyes. 
Like suggested above, you should spend a little extra money and get a Pediatric BVM.


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## Aidey (Jun 8, 2010)

clibb said:


> I So you aren't really sure how much air you're supposed to give the child as a newbie.



Until the chest rises seems like a pretty straight forward benchmark to me. It's the same for lay people all the way up those doing ACLS. 

Maybe I'm biased because I used to work in remote situations where our gear options were limited. We carried an adult size bag, with the different mask sizes. It saved us from carrying the 2 extra sizes of bags.


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## MRE (Jun 8, 2010)

Veneficus said:


> 3 or 4 years ago one of my classmates actually took the time to convert 200joules to amps and volts. I admit I don't remember the exact numbers but I remember it being somewhere around 100 amps and 50,000 volts.



Thats going to be a little bit on the high side.  100 amps at 50,000 volts is 5 million watts, or 50,000 100 watt light bulbs.  Even for a small amount of time, this is a huge amount of power.

A joule is a measurement of total energy delivered, so you need to know how long the delivery time is to determine the voltage and current required.  

Using some numbers from Zoll's website, one of their AEDs develops an average current of a little over 15 amps through an impedance of 100 ohms.  From this you can calculate the average voltage to be 1500 volts and a delivery time of about 9mS for a 200 joule shock.  These are averages, so peak values will be somewhat higher, but probably only 20-25 amps and 2000-2500V or so.

I did calculate how long it would take to deliver 200 joules at 50,000 volts and 100 amps (which requires an impedance of 500 ohms and is much higher than what you should see) and came up with 0.00004  seconds or 40 micro seconds.  However Zoll has numbers indicating shocks are usually around 10mS which is in line with my first figure above.


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## MRE (Jun 8, 2010)

After that long and off topic post above, I figured I would hit on the real purpose of the thread.

There may be times that a pedi BVM and mask are not available, especially in rural areas where an ambulance is delayed and responders go right to the scene in personal vehicles.  In these situations, they may have an adult BVM, and in my opinion should use it.  Watch for chest rise and adjust the larger mask to fit the patient's face.  That is what is taught in CPR for the professional rescuer and for the healthcare provider.

If you are on an ambulance you should have pedi supplies and should use them.


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## foxfire (Jun 8, 2010)

As a lifeguard, I would not be in favor of carrying a pedi mask and adult mask in my fanny pack along with all the other junk I have to carry. 
I carry a adult mask and if ever need to use it for a child, will just turn it around and use it that way till other guard arrives with proper size, or EMS arrives. I am not going to wait around for the proper size to start RBs.
If I did need to bag them, I would just watch for proper chest rise.
Do the newbie guards learn how to start a o2 tank? Or do you even have that?
Personally, I would have a hard time mentally using a BVM without o2 supply.


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## MRE (Jun 8, 2010)

foxfire said:


> Personally, I would have a hard time mentally using a BVM without o2 supply.



You probably realize this, but just in case; the advantages of using a BVM without oxygen over a pocket mask are that you are delivering fresh air to the patient and not air you have exhaled already (less oxygen).

Plus you don't have to have your face down in theirs which allows you to better see what is going on, and you are further away if they vomit.


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## redcrossemt (Jun 8, 2010)

MMiz said:


> once I read in a medical journal about some doctor in a remote location using a car battery as a defibrillator.



Touch both sides of a car battery, I promise it won't defib you...


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## clibb (Jun 8, 2010)

MMiz said:


> Again, one can use adult AED pads on a child, and once I read in a medical journal about some doctor in a remote location using a car battery as a defibrillator.
> 
> I hope that helps!



Watch A-Team much?


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## LucidResq (Jun 8, 2010)

W1IM said:


> You probably realize this, but just in case; the advantages of using a BVM without oxygen over a pocket mask are that you are delivering fresh air to the patient and not air you have exhaled already (less oxygen).
> .



One of my lifeguard buddies carries a pocket mask with an inlet for 02. Actually think such a mask was required for whatever class she took for certification. 

From a study that compared mouth-to-mouth, mouth-to-mask, BVM, and PFV (portable field ventilator), with paramedics as the operators: 



> Our results suggest that mouth-to-mask ventilation with supplemental oxygen enrichment is the most efficient technique for non-invasive airway management.


Johannigman, J. A., Branson, R. D., Davis, K., and Hurst, J. M. 1991. Techniques of emergency ventilation: a model to evaluate tidal volume, airway pressure, and gastric insufflation. The Journal of Trauma 31:93-98.


Another one that found mouth-to-mask ventilation produced more acceptable tidal volumes than BVM... 



> If clinical findings confirm these experimental results, mouth-to-mask ventilation should replace the bag-valve-mask system in the initial management of respiratory arrest.


Harrison, R. R., Maull, K. I., Keenan, R. L., and Paul Boyan, C. 1982. Mouth-to-mask ventilation: A superior method of rescue breathing. Annals of Emergency Medicine 11:74-76.


Not saying we should toss BVMs, but don't completely knock mouth-to-mask, especially with 02.


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## Legacy_Camaro (Jun 8, 2010)

foxfire said:


> As a lifeguard, I would not be in favor of carrying a pedi mask and adult mask in my fanny pack along with all the other junk I have to carry
> I carry a adult mask and if ever need to use it for a child, will just turn it around and use it that way till other guard arrives with proper size, or EMS arrives. I am not going to wait around for the proper size to start RBs.
> If I did need to bag them, I would just watch for proper chest rise.
> Do the newbie guards learn how to start a o2 tank? Or do you even have that?
> Personally, I would have a hard time mentally using a BVM without o2 supply.




No, the lifeguards are not trained in o2. You are right though, i wouldn't carry around a ped mask in my fanny in addition to my adult one. Though, it's not like the fanny's we carry have anything in them anyway. So far we carry
1 CPR mask which is good, 3 Band-Aids  Which confuses me why she has us carry those while on stand because we should be paying attention, and if someone needs a band aid they can go to the very close by first aid station to get a liquid bandage, because it's just going to fall off in the watery anyway. and some of them have 1 packet of burn cream, which makes no sense at all because its an indoor pool and i little packet of sunburn lotion isn't going to be needed at all while on stand. 

I stock my own fanny however, haha. 

for the most part, if a child/infant needed resuscitation, I would just use mouth to mask. I will more than likely not use the adult BVM, though i'm sure its possible in an extreme situation, not that its something i think should be attempted when mouth to mask is available. 
    She was saying to the other guards to give small puffs. I think better tidal volume could be achieve via mouth to mask than with puffs from an adult BVM, but I'm still unsure.


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## LucidResq (Jun 8, 2010)

Legacy_Camaro said:


> She was saying to the other guards to give small puffs. I think better tidal volume could be achieve via mouth to mask than with puffs from an adult BVM, but I'm still unsure.



See above studies. You may very well be right. Some studies have shown BVMs, especially when operated by a single rescuer, do NOT provide adequate tidal volume (ie meeting AHA standards).... and this is when the BVM fits.... adult BVM on adult patient. I imagine that with a poor seal due to a too-large mask... you're going to get even worse results. 

My only question is.... are you going to get a good seal with a CPR mask designed for adults anymore than with a BVM?....


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## 8jimi8 (Jun 8, 2010)

LucidResq said:


> See above studies. You may very well be right. Some studies have shown BVMs, especially when operated by a single rescuer, do NOT provide adequate tidal volume (ie meeting AHA standards).... and this is when the BVM fits.... adult BVM on adult patient. I imagine that with a poor seal due to a too-large mask... you're going to get even worse results.
> 
> My only question is.... are you going to get a good seal with a CPR mask designed for adults anymore than with a BVM?....



at least you can use both hands to mold an adult mask down on a tiny face, no?


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## redcrossemt (Jun 8, 2010)

Legacy_Camaro said:


> No, the lifeguards are not trained in o2. You are right though, i wouldn't carry around a ped mask in my fanny in addition to my adult one.



Your guards are not trained in emergency oxygen administration? That's pretty unusual, around here at least.

If I were lifeguarding, I'd only carry the adult size pocket mask. 

I'd also advocate for the jump kit or whatever backup resource we have to contain BVMs of all sizes. Stocking only the adult size is setting yourself up for a loss in court. Hopefully you can resuscitate your patient without any neurological defects, otherwise they'll be blaming you and looking for reasons.

*Lawyer:* So, sir, you do see infant and child patrons and visitors all day long? But you thought it was okay to only stock medical equipment to treat adults? Mhm, and why? Oh, to save $15? I rest my case.

Also of note, if you are going to deliver rescue breathing using a mask without an oxygen inlet, you as the rescuer can wear a nasal cannula to promote higher levels of oxygen in the delivered breaths.


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## redcrossemt (Jun 8, 2010)

LucidResq said:


> My only question is.... are you going to get a good seal with a CPR mask designed for adults anymore than with a BVM?....



Yes! The thing is two hands available to hold the seal. With a bag, one hand is on the bag and not on the mask where it needs to be. The next time you do CPR have an extra set of hands helping with mask seal and you'll notice a huge difference even in just an adult.

That being said, I think the right mask size would always be preferred.


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## 8jimi8 (Jun 8, 2010)

redcrossemt said:


> Your guards are not trained in emergency oxygen administration? That's pretty unusual, around here at least.
> 
> If I were lifeguarding, I'd only carry the adult size pocket mask.
> 
> ...



awesome, never thought of that


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## LucidResq (Jun 8, 2010)

8jimi8 said:


> at least you can use both hands to mold an adult mask down on a tiny face, no?



Good point. Not saying you couldn't do it but I haven't played with these masks at all before so I don't know what they're like. 

This pocket mask, which is what I was referring to my friend carrying, states "can be used on adult, child and infant," but they also sell a pediatric size....


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## LucidResq (Jun 8, 2010)

Hell, why don't we all chip in a dollar or so and buy Legacy one of those pediatric masks - they're only $13. You said you have room in your fanny pack so no excuses! Then we can all feel really good about ourselves when he resuscitates some little tyke back to life. Or we can go for broke and buy them a BVM for $14!!


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## lightsandsirens5 (Jun 8, 2010)

redcrossemt said:


> Yes! The thing is two hands available to hold the seal. With a bag, one hand is on the bag and not on the mask where it needs to be. The next time you do CPR have an extra set of hands helping with mask seal and you'll notice a huge difference even in just an adult.
> 
> That being said, I think the right mask size would always be preferred.


 
If the big deal here is that sealing an adult BVM mask to a kiddo with one hand is impossible, but with two hands is, then I would say it could be solved by the application of another person. At the pool in my area, there are always at least 5 lifeguards, two on the pool and one one the wading pool and two on break not to mention office staff. Chances are that by the time the gaurd gets the kid out of the water, there will be way more than enough people to help. Even if the gaurd is an idiot and doesn't alert the rest of the staff before going in, in a matter of what, 15 seconds, everyone else can be there.

So maybe for a two person ambulance crew with no fire or first response coverage it is a big deal. You don't want the caregiver doing ped resc with an adult mask by himself. But in a setting like a pool with pleanty of trained people around.......? 

That being said, if the only reason your staff will not supply them is because they cost $15, that is a whole different issue.


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