# BVM Question



## SONOWUKNOW (Oct 18, 2007)

I'm relatively new to this ... a certified EMT-B but limited field experience. My question pertains to guidelines for using the BVM. It's clear enough and rather straight forward for the nonresponsive / arrest patient.... but not as clear with the altered mental status, loc pt.

The textbooks refer to the " assisted ventilations " scenarios.... my experience as limited as it is, has been a patient even those in significant distress isn't always willing to have anything placed over their mouth and nose no matter how reassuring we are.

Fortunately, we're usually within a 10 minute run to the local hospital and the non-rebreather has been a great " Plan B ". Some of the medics have been critical in our use of BVM.... but no one has been consistent in when to use or not use them.... any help is appreciated.


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## seanm028 (Oct 18, 2007)

In EMT school one of our teachers told us about a Pt he ran on that was having an asthma attack.  His pulse ox was down to some ridiculously low value, but he was somehow still conscious and breathing on his own (definitely ALOC though, acting "loopy") so they sat him down and ventilated him for a little while they were preparing albuterol Tx, etc.  Within a few minutes he was back up to normal LOC and they were able to transport him no problems.


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## Jolt (Oct 18, 2007)

Take this for what it's worth because I'm even newer than you are, but I've been taught, "Less than eight [resp/min], ventilate."


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## KEVD18 (Oct 18, 2007)

vent medic should be along shortly to chime in here, being his forte and all, but i'll toss my 0.02 in the pile.

you would bag any patient that isnt adequatley ventilating on their own. sometimes that meas assisting spontaneous(sp) resps that are being made, sometimes its overriding the pt's vent rate to slow them down.

sometimes the concious pt wont let you bag them. nrb and haul gluteus maximus.

anyway, thats all i can think of 3 johhnie walkers deep. take care


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## DisasterMedTech (Oct 18, 2007)

Ive never heard the less than 8 ventilate referred to in terms of respirations per minute. What I'd heard as far as "less than 8, ventilate" was and is in terms of a personals GCS or Glasgow Coma Score, which takes in respirations as only a part of the equation.

According to the pocket guide I have- GCS takes in three broad categories

One is Eye Opening and takes in things like " to speech" which would get our patient a three, etc.

Then there is Best Verbal Response and take is things like confused which would earn our patient a wopping four points.

The Final aspect of GCS is Best Most Response-  Lets say our patient withdraws from pain...another 4 on the old GCS.

This means when we call the receiving facility our patient would get

11/15 which reads as mildly AMS which could be do to a panic attack or some other more severe and downgoing condition.

And this field guide says "Less than or equal to 8, prepare to intubate." Referring to overall GCS, not respirations, which are not part of the GCS equation.

My two cents.

Hope it helps.


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## VentMedic (Oct 19, 2007)

Bag Valve Mask:

Of course you should already know what to do for the apneic lifeless appearing patient.

Assisted ventilations are just that: you will ASSIST the patient with their own respirations. They make an attempt to breathe, you are right there with them. Not against them. Not trying to over ride them.  When their inspiratory effort kicks in you squeeze to give them the breath they would like to take on their own.  You will also tell them that you are going to assist them whether they appear conscious or not. 

There are 2 types of breathing that you should assist regardless of rate. Quality counts more.

1. Agonal Breathing - looks like an abreviated sigh gone wrong - pt may be unconscious or semi-conscious.  The rate may be 6 or 16. This breathing pattern will need assistance due to poor quality.

2. Guppy Breathing (gasps going nowhere) - looks like a fish out of water, mouth opens nothing much happens. The rate may be 6 or 16.  Assistance will be required. 

*When you decide to ASSIST:*
Match their rate in the beginning regardless of how fast or how slow until their body relaxes or the fast RR starts to slow.   For the fast rate, gradually increase the tidal volume (squeeze) until the breathing slows.  For the very slow rate (less than 6), after several squeezes matching each breath, gently see what the response of the patient presents if you try to "initiate" another breath. If they fight, continue squeezing at their rate but with a more adequate tidal volume. 

For the very conscious patient, keep them comfortable.  The COPD patient who is in the "tripod" position and mentating on a NRBM; the body is in its full rescue mode. This patient will go down with a fight. Unless he fatiques and decompensates quickly, he will struggle to stay in control. If he fatiques, it'll probably be quick. Be ready.  Reminding him about pursed lip breathing may help. He probably knows the procedure and just needs a little reminding. This patient's problem may be more ventilation than oxygenation. His respiratory rate may be 8 due to air-trapping.  Keep that in mind if you have to assist his ventilations. 

If you decide to assist someone on a NRBM, be ready. You may not have many breaths before they lose oxygenation.  The same is true if you stop assisting to unload at the ER. Keep that NRBM handy to place during the unloading.  

Remember a self inflating BVM provides no free flow O2 at the mask.  If you place the mask on the patient's face, it may take up to -20 cmH2O to open the valve for a breath with a perfect seal. They may not be able to open it at all if the face mask is not sealed properly.  Don't miss a beat with their respirations when assisting so they do not have to stuggle to open the valve.  

This is important to know with the conscious and alert (or getting loopy) person such as the asthma, CHF or PNA pt with adequate but tiring breaths.  Just a squeeze enough to open the valve until they are confident in your ability. If you are able to keep their head somewhat elevated, they may resist and/or vomit less.  No pillow. Head flexed forward may give resistance or will ventilate the stomach. 

Have suction available anytime you are using a BVM. 

A lot will be a clinical judgement call. How far to the hospital? How much oxygen is he on? Rate and QUALITY of respirations?  What is the patient is saying? Or, not saying?


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## SONOWUKNOW (Oct 19, 2007)

Thanks for the help from everyone...

It's great to have a place to ask questions from the people that have the experience..... be well and stay safe.


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## DT4EMS (Oct 19, 2007)

There was a comment about a person with asthma getting bagged.......... careful, careful  Remember the big issue isn't getting air in, it's getting air out.


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## DisasterMedTech (Oct 19, 2007)

Excellent point DT4EMS.

When are you coming to the land of Lincoln to be our sensei-

Signed- 

Your EMT/Medical-Legal Friend from IL


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## BossyCow (Oct 19, 2007)

In a class called ACLS for EMT-B's, one that taught EMT's how to 'assist' with ALS interventions, we took turns bagging each other.  It is a very humbling experience but gives you an amazing perspective on the process.


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## Gbro (Oct 19, 2007)

If there is ALS available(intercepts) this needs to be initiated any time a Pt. is in the need of assistance.
This limits the amount of practice you will get on sick Pt.
i have to admit, i have never practiced on other crew members, Although not in distress, it should be better than manikin training.


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## Tincanfireman (Oct 19, 2007)

(Vent, please feel free to jump in here and correct me if I'm too far off base with this...)

Don't forget that, when dealing with patients with lung diseases, don't try to get every last cc out of the BVM when bagging. Chances are their lung tissue is already fragile and won't tolerate the same type of robust bagging that a young adult of the same size will.  If you are working a scene with less experienced helpers, they may try and inflate the person like a balloon if you don't watch them.  My mantra has always been that the first pulse you take at a life and death incident is your own. You have to be able to maintain yourself if you're gonna be any good to the guy on the floor.  Just my .02; and welcome to the tribe!


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