Bad Practice in the ED

[Brandon O]

FiO2 is a function of what the provider dials in. But I don't think that's what you meant?

Sorry, should have said that in the presence of shunt, hypoxemia (low PaO2) has no response to increases in FiO2.

 

[VFlutter]

A NRB doesn't deliver 100% oxygen, but it delivers a high enough concentration that adding more probably isn't all that helpful. I guess the way I see it is that If someone is breathing 80% oxygen, for instance, and their Sp02 is still on the low side, then they likely have a V:Q mismatch that is best addressed with something other than a higher Fi02.



I've said many times that the patients who need this to work the most are the very ones that it's least likely to have any effect on.

Do anesthesia masks deliverer higher fi02 than a NRB? I would assume so since they are likely non vented. In a pinch I think the best would be an anesthesia style mask with the straps and a BVM with a PEEP valve. Allow them to passively breath near 100% fio2 with added PEEP.

 

[Carlos Danger]

Do anesthesia masks deliverer higher fi02 than a NRB? I would assume so since they are likely non vented. In a pinch I think the best would be an anesthesia style mask with the straps and a BVM with a PEEP valve. Allow them to passively breath near 100% fio2 with added PEEP.

There's nothing special about the masks themselves. Because modern anesthesia circuits allow re-breathing of expired oxygen, they make it easy to meet virtually any flow demand in order to provide 100% oxygen, even at relatively low flows and with a relatively small reservoir. All you need is a good seal.

An ambu bag with a large reservoir and a valve that allows spontaneous breathing (some won't allow spont. breaths) will do the same thing, as long as you have your flow turned up above minute volume. And of course a good seal.

 

[MonkeyArrow]

The largest obstacle I realistically see to doing this DSI is maintaining a good mask seal for however many minutes you going to do it. If anyone saw the accompanying video by Dr.Kovacs (sp?) on Weingart's podcast post with the chest wall cut away so you could see the lung, PEEP seemed to do a great job at keeping the lung inflated and preventing repeated alveolar cycling, but then again, as soon as that mask is manipulated and seal is lost, the lung deflates.

 

[DPM]

A NRB doesn't deliver 100% oxygen, but it delivers a high enough concentration that adding more probably isn't all that helpful....

To an extent, but I've seen it work very well, and also much quicker than a NRB alone.

It's not really the NC that I have a problem with, just the general intubation. They allowed the PT to desat, and then blew air into her stomach with a BVM while not doing much to increase her SPO2 and prepare her for her RSI. Even if you don't buy hi flow NC or Ap-Ox, you really shouldn't be laying your Pt's fat and then using a BVM to pre-oxygenate. That's my main concern.

 

[E tank]

To an extent, but I've seen it work very well, and also much quicker than a NRB alone.

It's not really the NC that I have a problem with, just the general intubation. They allowed the PT to desat, and then blew air into her stomach with a BVM while not doing much to increase her SPO2 and prepare her for her RSI. Even if you don't buy hi flow NC or Ap-Ox, you really shouldn't be laying your Pt's fat and then using a BVM to pre-oxygenate. That's my main concern.

Send 'em the link to this thread

 

[Handsome Robb]

The largest obstacle I realistically see to doing this DSI is maintaining a good mask seal for however many minutes you going to do it. If anyone saw the accompanying video by Dr.Kovacs (sp?) on Weingart's podcast post with the chest wall cut away so you could see the lung, PEEP seemed to do a great job at keeping the lung inflated and preventing repeated alveolar cycling, but then again, as soon as that mask is manipulated and seal is lost, the lung deflates.

When we DSI there is one person assigned to holding a mask seal. That's their one and only job, nothing else. We also generally use a CPAP mask with our "tower of power" (HME then EtCO2 then Smart BVM) which allows use to get a better seal and gives you a bit of wiggle room. It's also much more comfortable for the provider to hold a continuous seal than a normal BVM mask is. Is it perfect? No, but we've been having good success with it.


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[Carlos Danger]

To an extent, but I've seen it work very well, and also much quicker than a NRB alone.

It's not really the NC that I have a problem with, just the general intubation. They allowed the PT to desat, and then blew air into her stomach with a BVM while not doing much to increase her SPO2 and prepare her for her RSI. Even if you don't buy hi flow NC or Ap-Ox, you really shouldn't be laying your Pt's fat and then using a BVM to pre-oxygenate. That's my main concern.

It certainly sounds like a CF. God knows I've experienced plenty of those myself.

I guess the point that I would make here is that there is more than one way to skin a cat. It's not at all that I "don't buy" putting an NC under a NRB or apneic oxygenation, it's just that you will have patients in whom those techniques do nothing to help, and by the same token, there is nothing wrong with masking in order to improve an Sp02, if you are good at masking. By your description, this ED staff clearly did a poor job, but that doesn't mean that the way they did it (or tried to do it) is always wrong.

 

[DPM]

... By your description, this ED staff clearly did a poor job, but that doesn't mean that the way they did it (or tried to do it) is always wrong.

My problem was the lack of awareness that things were going south, and then a lack of insight or even open mindedness when a problem was highlighted. It's incredibly frustrating for me to see other professionals not following best practice.

 

[Carlos Danger]

My problem was the lack of awareness that things were going south, and then a lack of insight or even open mindedness when a problem was highlighted.

I agree 100%.

It's incredibly frustrating for me to see other professionals not following best practice.

This is the point I was trying to get at. Just be careful labeling the way you do things "best practice" just because they've worked for you. It implies that every other way of doing things is inferior, and that is rarely true.

 

[DPM]

...be careful labeling the way you do things "best practice" just because they've worked for you. It implies that every other way of doing things is inferior, and that is rarely true.

Absolutely. I don't really care how you pre-oxygenate, but you have to do it!

 

[UnkiEMT]

Absolutely irrespective of the debate that's ongoing, but to address the original question: Absolutely no one in healthcare trusts anyone else in healthcare. Once I burned out and took a turn at ALS IFT, this point has been driven home to me in an undeniable way. Not only do the higher level of care hospitals distrust the lower level of care hospitals, but the inverse is true.

Given that hospitals tend to think of us as being roughly equivalent to side show acts, do you really think any one of them trust you?