VentMedic Posted April 7, 2008 Posted April 7, 2008 The wiggle room is for Medics using BVM's vs those of us who like the vent. For some reasons some Medics do not like using vents. I personally love having the constant control rather than have someone (cough.. a FF) setting rate and volume. I was also wondering earlier in this thread why the student EMT was bagging a pt to CT Scan and a transport vent was not used. I would hope there was a vent waiting for them in radiology and she didn't have to bag through the CT Scan. If not, the RT should look for better working conditions or be nicer to the EMT students that are bagging in CT Scan for her. :wink:
DwayneEMTP Posted April 7, 2008 Posted April 7, 2008 DwayneEMTB wrote: [align=left:66ecac9b8b] I think I was bagging to slow because the RT said the pt need to be breathing 14 times a minute.[/align:66ecac9b8b] DwayneEMTB wrote: [align=left:66ecac9b8b] Ok here is what I think with out an advanced airway the pt may not get all the air that they need. Because maybe the airway is not open all the way or not all of it is going into the lungs.With an advanced airway you want to vent once every 7-8 seconds because it is like breathing normally. Because the tube goes directly from the mouth to the lungs. [/align:66ecac9b8b] Good. When using the mask you can/do lose some around the mask as well as down the esophagus, and as you mention there can be anatomy that interferes with ventilation compliance. When you have a tube, those issues are resolved. Also you are ventilating with a much higher concentration of O2 than is found in the ambient atmosphere. As well, bagging with a tube compared to normal resting respirations create a higher tidal volume, normally. (It seems...though I could be off in the ditch here.) And lastly, and this is my thinking, it's not something I've seen addressed before...It seems to me that the O2 requirements of an obtunded patient would be lower that those of even a relaxed, healthy person. What say you Vent? Is LOC considered when addressing ventilation needs? Not meaning to imply you have a "coma" or "Normal Mentation" button or anything...but is there a documented physiologic difference in O2 demand between the two? And if so, can you predict the difference in the needs of the two, all other things being equal? (Ok, I know they're never equal...but what if?) (I know, I know...where's the education! I'm following the links you PM'd me as fast as I can...I'll catch up...I promise! :wink: ) Dwayne
VentMedic Posted April 7, 2008 Posted April 7, 2008 Don't make me write about the OxyHemoglobin Dissociation Curve! Work of breathing and oxygen consumption can also be influenced if the patient has to fight the ventilator or the person doing the ventilations. It can also depend on the patient's pain and sedation medication since not all sedation meds soothes pain. Then you have that little thing with the disease process(es). Cardiac output and perfusion play a big role and we may start monitoring SvO2 as soon as a sepsis protocol is initiated which could be from multiple things like a lactate level or bilateral infiltrates. In the hospital, we may watch the size of our tidal volumes and give a higher rate to keep a good minute volume. Many, many factors go into Critical Care medicine. One statement can not sum it up for any specific rule for any one patient. We also have to be versatile enough to give and take on the ventilator and drips when RTs and RNs are running through a protocol. I may have to back off the vent as much as possible without losing too much ventilaton/oxygenation if the patient becomes hemodynamically unstable until the RNs catch up with one or several pressors and/or fluids he/she is hanging. Once the right stuff is hanging, the ventilator can go for its goal again. If I need a more stable BP or MAP to get into the oxygenation zone, the RN will have to work his/her magic with the pressors and fluids again. It may go on like that for several hours or even days. It is really a fascinating symphony of actions/reactions to do a full press resuscitation for sepsis, burns or cardiogenic shock in the ICU.
sportygirl Posted April 7, 2008 Author Posted April 7, 2008 VentMedic wrote: Many, many factors go into Critical Care medicine. One statement can not sum it up for any specific rule for any one patient. So what you are saying is that every pt is different? So it can make a big difference on how to treat the pt and what rules to flow. Right? So would something like COPD, CHF or something make a difference? This information is very helpful to me because two weeks a go we had our respiratory lecture. Thanks very much!
CBEMT Posted April 7, 2008 Posted April 7, 2008 A comment I heard one time was that in the field, you can not over hyper-ventilate a patient. The more the better. *speechless*
Ridryder 911 Posted April 7, 2008 Posted April 7, 2008 VentMedic wrote: So what you are saying is that every pt is different? So it can make a big difference on how to treat the pt and what rules to flow. Right? So would something like COPD, CHF or something make a difference? The point exactly! As Vent has demonstrated that each patient should be thoroughly assessed and treated accordingly. Vent has demonstrated the eloquent point of being a practitioner and having the knowledge and skills to treat each disease state and how the patient might respond to the therapy. That patients and the disease state might be categorized but; should always be treated per individual case by case. Again, the need to learn ..."outside the box"... R/r 911
firedoc5 Posted April 7, 2008 Posted April 7, 2008 *speechless* What? They're down, usually for a period of time. Their PaO2 is very low. What's wrong with bringing them in with a Pa02 of 100+? Just a thought. I'm not saying to bag them once a second. Watch the chest. It'll raise as you bag them, and lower when you are not. Wait 2-3 seconds and bag again. Through my experience, how many ALS squads actually count with each compression and vent. on the count of five? Since normally we had minimal staff and took turns during the entire code. When it came time for whoever was "running" things to do compressions they were usually too busy to giving instructions and making sure everything else was getting done and getting done right. Even though compression count may not have been verbally called out, I'd say that vents would be done on an average of every three compressions. Luckily there would be at least one other medic that could push drugs and other "P" skills, but clearly there was the one medic calling the shots.
VentMedic Posted April 8, 2008 Posted April 8, 2008 What? They're down, usually for a period of time. Their PaO2 is very low. What's wrong with bringing them in with a Pa02 of 100+? Just a thought. I'm not saying to bag them once a second. Watch the chest. It'll raise as you bag them, and lower when you are not. Wait 2-3 seconds and bag again. Through my experience, how many ALS squads actually count with each compression and vent. on the count of five? Hyperventilate - lower PaCO2 Hyperoxygenate - raise PaO2 EMS is Hyperventilating Resuscitation Patients http://www.merginet.com/index.cfm?pg=cardi...yperventilating The goal is to hyperoxygenate. If you hyperventilate, you raise intrathoracic pressure and drop the BP as well as the cardiac output defeating the hyperoxygenation goal. You also can vasoconstrict cerebral perfusion and shift the pH to extreme alkalosis which is just as bad if not worst than acidosis. Again, this is the reason for the new rate for ETT ventilations as I mentioned earlier.
sportygirl Posted April 8, 2008 Author Posted April 8, 2008 Vent Wrote: ASK QUESTIONS OF THOSE WHO MAY KNOW the answers when they are within reach! Use the licensed professionals as resources. Ok so now some questions? What is some of the terms that you have been using? But the one things that I can't figuer out is how bagging once every 5 seconds= 12 Resps per min, and if you bag once every 7-8 seconds it is faster but if I do the math and bag once every 7 seconds it is like 8 breaths a minute? That is where I am confused because the RT said that pt need 14 breaths a min so how many times is it? Vent Wrote: Don't stop learning. You have just been introduced to one tiny snowflake in the blizzard world of medicine. Ok you told me of the storm and how to get ready for it. And I am waiting for the first snowflake.
Scaramedic Posted April 8, 2008 Posted April 8, 2008 Ok so now some questions? What is some of the terms that you have been using? But the one things that I can't figuer out is how bagging once every 5 seconds= 12 Resps per min, and if you bag once every 7-8 seconds it is faster but if I do the math and bag once every 7 seconds it is like 8 breaths a minute? That is where I am confused because the RT said that pt need 14 breaths a min so how many times is it? That is a rate of squeezing the BVM every 4.2857142857142857142857142857143 seconds. But since the laws of physics and the ability of the human mind cannot do a rate like that with a BVM the closest you can get is a breath every 4 seconds. That equals out to a rate of 16 or you can go every five seconds for a rate of 12. This patient should have been on a vent, then you have much more control on rate, volume, PEEP, etc. Ok you told me of the storm and how to get ready for it. And I am waiting for the first snowflake. At times it is going to seem like a whiteout, to continue with the snow analogy, but you can slog your way through until it makes sense.
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