To Bag or not to Bag?

Frozennoodle

Frozennoodle

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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?
 
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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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.
 
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.
 
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?
Click to expand...

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.
 
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
 
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.
 
Frozennoodle said:
To answer the earlier question: I would describe his breathing as rapid and deep
Click to expand...

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
Click to expand...

If this person had all the information that you've given us, don't sweat it.
 
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.
 
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.
 
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.
 
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
 
Her theory was that by forcing the fluids out his lungs with positive pressure he would have been able to breathe easier
Click to expand...

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

*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! ......
 
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.
 
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?
 
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.
 
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.
Click to expand...

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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