To Bag or not to Bag?

[ShesanEMT]

I agree, (w/HaleEMT) the patient is conscious and breathing on their own (albeit rapidly) and sufficiently. I think the bvm would not be easily tolerated in this case. Of course if the LOC changed and breathing rate deteriorated, appropriate interventions would follow.

 

[Bosco836]

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?

Hello Brown,

Hopefully I can help to address your question.

The logic behind our teaching (at least in Ontario, Canada) is that if someone is breathing less than 8 times a minute or more than 28 times a minute, chances are their breathing is not effective.

One of our books provides the following example: If the average person breathes in 500mL of air with each breath, and breaths about 15 times a minute (on average) - they will be breathing in approximately 7.5L of air each minute. Having said that, in order to get (approx.) 500mL of air....one must inhale for a second or two and exhale for another second or two. With that in mind, if someone is breathing at 30-40 breaths a minute, they likely are not taking in enough oxygen, despite the rapid breathing (as each breath may only have 100-200 mL of air, resulting in an inadequate oxygen supply (or so the theory goes...).

Conversely, if a person is breathing at less than 8 times a minute (especially if unconscious and/or obvious signs of poor perfusion), they likely are not able to draw adequate oxygen levels (unless they are taking huge breaths and even then....it seems rather unlikely).

Having said that, tools, such as the PulseOx can help us to back up our decision weather to bag or not...and, as previously stated, one must exercise some common sense, and take into account factors like, the appearance of the patient, the rhythm and quality of the respiration's (not just rate), whether or not coaching the breathing (especially if its too fast) will be beneficial (i.e. if the patient is unconscious, its highly probable that coaching isn't going to do much good).

Hopefully the above explanation will help to answer your question with respect to the rationale about as assisting with ventilations.

Best regards,

 

[Frozennoodle]

@jjesus That's why I didn't bag them . It didn't even cross my mind once I saw the patient and got him up at 99%. That's why I was kinda asking here because it took me by surprise they would say that and that maybe I missed something in what I described that might have indicated a BVM.

 

[Hockey]

You know what I just realized and is sad...?

I've only had to bag one live person. And she had a trach. God that was such an awkard time. Trying to control her breathing but it wasn't working and kept pushing the bag off.

 

[JPINFV]

Let's try an experiment people.

Breath in over 5 seconds, hold it for 5 seconds, breath out, hold it for 5 seconds, repeate. See how long you can go.















The catch? You're obviously going to die soon since you're only breathing 4 times a minute, therefore someone should bag you even if you are feeling fine! Perform an assessment and treat based off that assessment!

 

[jjesusfreak01]

You know what I just realized and is sad...?

I've only had to bag one live person. And she had a trach. God that was such an awkard time. Trying to control her breathing but it wasn't working and kept pushing the bag off.

I've bagged once, it was a dead person (does v-fib count), and then the medics used this shocky thing and they were slightly less dead...so i've bagged a dead and live person, though it was the same person. Things turned out better than expected.

 

[Hellsbells]

To the OP I wouldn't worry too much about your colleagues armchair quarterbacking on this call, its probably the sign of an inferiority complex on her part.

What did the hospital do for this pt on arrival? Did they start BVM vents?

 

[Frozennoodle]

To the OP I wouldn't worry too much about your colleagues armchair quarterbacking on this call, its probably the sign of an inferiority complex on her part.

What did the hospital do for this pt on arrival? Did they start BVM vents?

The hospital put him in a trendelenburg and gave him like a 1000cc bolus and left him on my non-rebreather. After about 20 minutes they called in respiratory and dropped a king airway into him while he still had a gag reflex. I treated his airway and SOB and left his hypovolemia alone mainly because I had nothing to treat it with short of elevating his legs and draining fluid into his lungs compromising his breathing further. I transported in a high fowlers. I assume he started to desat when they treated for his blood pressure pumping all the fluids into the guy with fluid in his chest but I didn't see his vitals.

 

[usalsfyre]

One of our books provides the following example: If the average person breathes in 500mL of air with each breath, and breaths about 15 times a minute (on average) - they will be breathing in approximately 7.5L of air each minute. Having said that, in order to get (approx.) 500mL of air....one must inhale for a second or two and exhale for another second or two. With that in mind, if someone is breathing at 30-40 breaths a minute, they likely are not taking in enough oxygen, despite the rapid breathing (as each breath may only have 100-200 mL of air, resulting in an inadequate oxygen supply (or so the theory goes...).

Except in Kussmaul respirations the patient may have a >500ml tidal volume 30-40 times a minute. Trying to bag this respiratory pattern is going to do more harm than good.

Conversely, if a person is breathing at less than 8 times a minute (especially if unconscious and/or obvious signs of poor perfusion), they likely are not able to draw adequate oxygen levels (unless they are taking huge breaths and even then....it seems rather unlikely).

See JPINFV's post above about breathing 4 times a minute.

Having said that, tools, such as the PulseOx can help us to back up our decision weather to bag or not...and, as previously stated, one must exercise some common sense, and take into account factors like, the appearance of the patient, the rhythm and quality of the respiration's (not just rate), whether or not coaching the breathing (especially if its too fast) will be beneficial (i.e. if the patient is unconscious, its highly probable that coaching isn't going to do much good).

Hopefully the above explanation will help to answer your question with respect to the rationale about as assisting with ventilations.

Best regards,

Learn the rates for class and testing purposes. Then promptly forget them, along with most of what you were taught about airway and the respiratory system, as EMS classes do a crappy job of teaching it. Try to tailor your treatment to each individual patient, as is noted above. You will find that you VERY rarely bag conscious people, or even people who are breathing on their own.

 

[usalsfyre]

You know what I just realized and is sad...?

I've only had to bag one live person. And she had a trach. God that was such an awkard time. Trying to control her breathing but it wasn't working and kept pushing the bag off.

It was probably VERY uncomfortable for the patient. Asynchronous ventilation with a positive pressure source is severe badness. Either sedate, or try to take the patient's vent with them.

 

[usalsfyre]

The hospital put him in a trendelenburg and gave him like a 1000cc bolus and left him on my non-rebreather. After about 20 minutes they called in respiratory and dropped a king airway into him while he still had a gag reflex. I treated his airway and SOB and left his hypovolemia alone mainly because I had nothing to treat it with short of elevating his legs and draining fluid into his lungs compromising his breathing further. I transported in a high fowlers. I assume he started to desat when they treated for his blood pressure pumping all the fluids into the guy with fluid in his chest but I didn't see his vitals.

Sounds like you did fine. Remember the initial treatment for cardiogenic shock is still fluid.

I'm curious why the hospital used a King airway, especially with a gag present.

 

[usafmedic45]

Asynchronous ventilation with a positive pressure source is severe badness. Either sedate, or try to take the patient's vent with them.

....or if the patient is conscious and coherent, let them bag themselves.

 

[Frozennoodle]

Sounds like you did fine. Remember the initial treatment for cardiogenic shock is still fluid.

I'm curious why the hospital used a King airway, especially with a gag present.

That sir, I do not know.

 

[usafmedic45]

Sounds like you did fine. Remember the initial treatment for cardiogenic shock is still fluid.

I'm curious why the hospital used a King airway, especially with a gag present.

I'm trying to figure out how the hell the would get a King into a patient like that. Was the patient Jenna Jameson?

 

[usalsfyre]

I'm trying to figure out how the hell the would get a King into a patient like that. Was the patient Jenna Jameson?

Yeah, my first thought was actually WTF. I've been trying tact here lately, as I've been accused of being a bit ahhh, abrupt.

 

[Frozennoodle]

My partner told me it was a king airway. I never saw it. She also told me not to bring the NRB the nursing home had him on 15 LPM on one already. I look at the patient and see he is on a simple face mask at 4 LPM. I open the jump bag and grab the mask out and she tells me no why did you open the mask! He already has one! I said, "they have him on 4 on a simple face mask." I had to explain to her the difference between a NRB and a simple face mask in front a room full of lpns. So who knows what they used.

 

[usalsfyre]

My partner told me it was a king airway. I never saw it. She also told me not to bring the NRB the nursing home had him on 15 LPM on one already. I look at the patient and see he is on a simple face mask at 4 LPM. I open the jump bag and grab the mask out and she tells me no why did you open the mask! He already has one! I said, "they have him on 4 on a simple face mask." I had to explain to her the difference between a NRB and a simple face mask in front a room full of lpns. So who knows what they used.

No offense to you, and not a personal attack on your partner, but this reeks of fail. She's REALLY worried about opening a NRB (total cost less the five bucks)?

I HIGHLY doubt is was a King.

 

[Amycus]

Just had one of the few, rare instance today where our PT was getting bagged. Got called for an OD, in and out of consciousness- arrive on scene, Fire starts bagging the guy after dropping an NPA (4 times a minute, pale skin color), I sliced off his sleeve so I could grab some vitals, and out of nowhere BAM this guy woke up...full color, breathing normal rate/rythem, etc.

It's amazing what a bit of proper oxygenation can do for someone.

 

[Frozennoodle]

No offense to you, and not a personal attack on your partner, but this reeks of fail. She's REALLY worried about opening a NRB (total cost less the five bucks)?

I HIGHLY doubt is was a King.

No offense taken. She's not the brightest crayon in the box. I just did it and showed her the difference.

 

[exodus]

For those who bag patients who are alive and have agonal breaths and don't want to cross into their breaths... Watch the valve just before the elbow. With a good enough seal, you will see the valve move slightly, when it does, squeeze gently. This works best with a trach because the seal is much easier to manage, but can be done on the face.