One rescuer ventilation question

[mycrofft]

Some BVM's don't re-expand very quickly when they are too cold, limiting the amount of air per stroke.

Also ( remember we are talking under 10 deg F right?), exhalation can freeze in the duckbill valve making it "sticky" (resists opening, then POPs open).

Friction joints where female tubing or whatnot is jammed onto a male receptor don't work when the tubing is stiff like cement. Without care, the male connector can even snap.

And, anyone practice working a BVM with gloves on? Snow gloves? Can't get a good grip on the pt's facial bones for a seal I bet.

We lacked covered heated storage for every unit, in Nebraska where I worked. In the winter sometimes we'd jump start them and park them in the garage to thaw out while the other units were out. Grab an armful of warm blankets before going out for the pts.

 

[Summit]

Numask is a nice alternative to the pocket mask... unless there is extreme trauma...

 

[mycrofft]

Quote:
Originally Posted by mycrofft View Post
There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...

One of the big lies of omission we perpetrate for the patients' sake; a code due to respiratory failure may initially reflect cardiac irritability related to cardiomyopathic anoxia, but after five minutes or so the brain starts going. A defib might, might bring back a damaged heart for a bit, but it won't do a thing for arrest secondary to cerebral anoxia, i.e., biological death.

I might just be too tired but I didn't understand what you were trying to get at with that. ENDQUOTE Robb



Hands only CPR was mentioned, and that in codes initiated by respiratory failure ventilation is paramount.

My input: in respiratory arrests, some will revive if they are temporary (glottis closed due to water in airway, electrical shock, airway embarrassment) but if electrical activity in the heart is ineffective (no pulse, unconscious due to myocardial infarction, intoxication or anoxia ) you will need full CPR because that oxygenated blood will stay in the lungs and not get to where it is needed...the brain and heart. That needs to start promptly,not after dithering.

I nominate a change in CPR training: No pulse and no breathing, full CPR. (Radical, right?).

 

[Brandon O]

I nominate a change in CPR training: No pulse and no breathing, full CPR. (Radical, right?).

Research suggests more people tend to die this way.

Lots of things make sense but aren't true.

 

[Bullets]

The answer to this:

Eventually, the next step in any algorithm is "failed? well... keep trying until they're dead." But you want to make space before you hit that point.

With due respect, I'm not sure how understandable this is for the medics. Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"

Is this:

BVM with OPA -- if failed --> start compressions because you spent to much time on airway and failed .

and also this:

throw them on a NRB. Effective CPR is your first priority.

My mouth will never ever ever ever ever ever touch a patients face, nor will it come within a few inches required to use a pocket mask. I used to carry a pocket mask in my patrol bag, i have since thrown it away. BVM is the only means by which i will attempt ventilation.

Why would i ever be alone in a cardiac arrest? Where is my partner?

 

[Brandon O]

My mouth will never ever ever ever ever ever touch a patients face, nor will it come within a few inches required to use a pocket mask. I used to carry a pocket mask in my patrol bag, i have since thrown it away. BVM is the only means by which i will attempt ventilation.

Right on -- but I hope you're very good at using it and you know alllll the tricks.

Why would i ever be alone in a cardiac arrest? Where is my partner?

Perhaps you won't be, and your airway plan always presumes extra hands available. That's okay if it reflects your own circumstances. (I wasn't really talking about cardiac arrest though, since airway management isn't usually the priority there.)

 

[Household6]

Why would i ever be alone in a cardiac arrest? Where is my partner?

I have been, twice in the last month, and collectively more times than I can count..

Our service had us on-duty for 12 hours, and on-call for the next 12. We can leave the station when we're on-call, but we have to maintain an 8 minute response back to the garage.. Often, it's quicker for us to just show up on scene, and radio the on-call to meet us there.

It actually works pretty good. The on-call personnel are scattered around town, first responders are scattered around the rural areas.

 

[Carlos Danger]

Managing a difficult airway with nothing but a BVM and your wits is a uniquely BLS experience. Our typical airway algorithm is "1. BVM with OPA -- if failed --> 2. Soil self, call ALS, run screaming"

This is exactly why I feel very strongly that every BLS provider should be trained on and carry a SGA of some type.

In a perfect world, we would all be very adept at all that BLS airway management requires: positioning, suctioning, maintaining a mask seal, placing NPA's and OPA's, generating adequate pressure, but not too much, etc.

In the real world though, we don't get to practice it nearly enough. And it's not a level of care thing at all, because paramedics, on the whole, are no better at it than EMT's.

SGA's provide an effective, safe, much-needed, rather easy-to-use tool. I cannot fathom why any medical director would not support his BLS personnel using them.

 

[Handsome Robb]

Quote:
Originally Posted by mycrofft View Post
There's a shelf life for respiratory etiology codes after which you're doing CPR because the heart isn't going to restart otherwise. However...

One of the big lies of omission we perpetrate for the patients' sake; a code due to respiratory failure may initially reflect cardiac irritability related to cardiomyopathic anoxia, but after five minutes or so the brain starts going. A defib might, might bring back a damaged heart for a bit, but it won't do a thing for arrest secondary to cerebral anoxia, i.e., biological death.

I might just be too tired but I didn't understand what you were trying to get at with that. ENDQUOTE Robb



Hands only CPR was mentioned, and that in codes initiated by respiratory failure ventilation is paramount.

My input: in respiratory arrests, some will revive if they are temporary (glottis closed due to water in airway, electrical shock, airway embarrassment) but if electrical activity in the heart is ineffective (no pulse, unconscious due to myocardial infarction, intoxication or anoxia ) you will need full CPR because that oxygenated blood will stay in the lungs and not get to where it is needed...the brain and heart. That needs to start promptly,not after dithering.

I nominate a change in CPR training: No pulse and no breathing, full CPR. (Radical, right?).

compressions are an integral part of CPR...and CCR. There's no question about that. However, cardiocerebral resuscitation is designed for arrests with a cardiac etiology where compressions and defibrillation are the only proven things to make any difference. With a respiratory etiology you can pump away on the chest all you want with perfect compressions but if you don't optimize ventilation and oxygenation to correct the hypoxia, which caused the cardiac irritability and eventually cardiac arrest, you're signing that patient's death warrant.

 

[Brandon O]

SGA's provide an effective, safe, much-needed, rather easy-to-use tool. I cannot fathom why any medical director would not support his BLS personnel using them.

No real arguments here. It's not elegant to use them as a substitute for imperfect bagging, but it's better than no alternative at all.

 

[Carlos Danger]

No real arguments here. It's not elegant to use them as a substitute for imperfect bagging, but it's better than no alternative at all.

Not elegant or ideal, for sure. But far better than the algorithm you described that most BLS providers are limited to.

 

[mycrofft]

compressions are an integral part of CPR...and CCR. There's no question about that. However, cardiocerebral resuscitation is designed for arrests with a cardiac etiology where compressions and defibrillation are the only proven things to make any difference. With a respiratory etiology you can pump away on the chest all you want with perfect compressions but if you don't optimize ventilation and oxygenation to correct the hypoxia, which caused the cardiac irritability and eventually cardiac arrest, you're signing that patient's death warrant
.

Agreed!!
==============================================

Brandon O:

Quote:
Originally Posted by mycrofft View Post
I nominate a change in CPR training: No pulse and no breathing, full CPR. (Radical, right?).

Research suggests more people tend to die this way.

Lots of things make sense but aren't true.

Please cite one. I bet there are, but I bet we can deconstruct them. Too many armchair people trying to make their living and maybe get some notoriety by publishing stuff or getting onto a bandwagon and making citations which only support their premise.

Hands-only is to spark bystanders to DO something that short window when CPR may make a difference, instead of grossing out and turning away. Just like spineboarding in the Seventies and Eighties, hands-only may get a life of its own without anyone to tell them the emperor has no clothes.

But, we digress.

 

[Brandon O]

Please cite one. I bet there are, but I bet we can deconstruct them.

Here's a few.

http://www.ncbi.nlm.nih.gov/pubmed/18374452
http://www.ncbi.nlm.nih.gov/pubmed/18334691
http://jama.jamanetwork.com/article.aspx?articleid=186668

 

[mycrofft]

Thanks sir!