Oxygen during code

[waterbottle10]

Confused about a topic today about hypoxic patient who received 100% oxygen, directly blowing at patients face, w resident forming a mask shape w/ hands, instead of bagging the patient. This is prob equipment related (?) but i was told that if you bag the patient, the oxygen wont go out the patients end, than if you just blow it. Anyone has any idea how this works and why bagging wont get the O2 to patients end? Thcx

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[jdh71]

Won't go out the patients end??

 

[waterbottle10]

of the oxygen tube

 

[Raryn]

Confused about a topic today about hypoxic patient who received 100% oxygen, directly blowing at patients face, w resident forming a mask shape w/ hands, instead of bagging the patient. This is prob equipment related (?) but i was told that if you bag the patient, the oxygen wont go out the patients end, than if you just blow it. Anyone has any idea how this works and why bagging wont get the O2 to patients end? Thcx

Your question makes no sense. Zero.

I have never heard of anyone making a mask shape with their hands to direct oxygen towards a patient.

We frequently will put a mask on the patient to oxygenate them, if they're breathing on their own. There are many different types of mask depending on how much oxygen you want to give the patient. There are also machines (CPAP, BPAP) that will provide varying concentrations of oxygen along with some positive airway pressure to assist in breathing. All of those options (except BPAP) will only oxygenate, and will not ventilate the patient.

If they're not breathing on their own, we will bag them (... or intubate them). Oxygen goes through the bag just fine, and if the patient isn't breathing, you need to be able to actually breath for them, not blow oxygen vaguely in the direction of their face. Both of those options will also assist in ventilation.

 

[jdh71]

I still don't understand.

 

[jdh71]

Confused about a topic today about hypoxic patient who received 100% oxygen, directly blowing at patients face, w resident forming a mask shape w/ hands, instead of bagging the patient. This is prob equipment related (?) but i was told that if you bag the patient, the oxygen wont go out the patients end, than if you just blow it. Anyone has any idea how this works and why bagging wont get the O2 to patients end? Thcx

Look. I want to help. You seem to have a legitimate question and I don't want you to not clarify because you think I'll be a jerk. It's important that you understand some of these things and I have a sneaking suspicion someone is telling your horse**** which scares me.

So, please ask your question again and rephrase try to be as clear as possible.

 

[flipmd]

If this was during a real "Code" where the patient was pulseless (and hence not having respirations), your resident just killed the patient. Actually, wording it differently, your resident may have prevented the patient from being revived, if the patient had a chance at all. But I agree with jdh, it's either we don't understand the question, or your resident's advice is so out of this world no one here has heard about it before and it sounds so ludicrous we can't understand it.

 

[Siggy]

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest
Ann Emerg Med.
2009 Nov;54(5):656-662.e1. doi: 10.1016/j.annemergmed.2009.06.011. Epub 2009 Aug 6.

 

[jdh71]

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest
Ann Emerg Med.
2009 Nov;54(5):656-662.e1. doi: 10.1016/j.annemergmed.2009.06.011. Epub 2009 Aug 6.

Retrospective data. And the whole oxygen and bag mask issue is really confounded by their end point in my opinion because the important point in an out of hospital arrest is the CPR. And if you're dicking around with a bag mask out of the hospital and not giving lots of high quality CPR of course one would expect tires neurological outcomes. To extrapolate this data into the hospital though is, well . . . ******ed.

 

[Siggy]

Retrospective data. And the whole oxygen and bag mask issue is really confounded by their end point in my opinion because the important point in an out of hospital arrest is the CPR. And if you're dicking around with a bag mask out of the hospital and not giving lots of high quality CPR of course one would expect tires neurological outcomes. To extrapolate this data into the hospital though is, well . . . ******ed.

So high quality compressions is only important out of hospital, but we can dick around with a BVM inside the hospital? I didn't realize physiology changed based off of the location of the patient. Also, the end point (neurologically intact discharge) is the only end point that matters with a cardiac arrest. Who cares if you get a pulse back if the patient ends up gorked at best, dead 2 days later (or sooner) at worse. Now measuring that based off of phone and mail questioners is a different thing entirely.

Also, I'm not going to say that this is an authoritative end all, be all study, but, "OMG, the resident murdered the patient in a code" is a bit of hyperbole.

 

[jdh71]

So high quality compressions is only important out of hospital, but we can dick around with a BVM inside the hospital? I didn't realize physiology changed based off of the location of the patient. Also, the end point (neurologically intact discharge) is the only end point that matters with a cardiac arrest. Who cares if you get a pulse back if the patient ends up gorked at best, dead 2 days later (or sooner) at worse. Now measuring that based off of phone and mail questioners is a different thing entirely.

Also, I'm not going to say that this is an authoritative end all, be all study, but, "OMG, the resident murdered the patient in a code" is a bit of hyperbole.

Yes. With more highly trained people I see no reason not to use a bag mask in the hospital. I'm not suggesting there has been any change in physiology. The problem with extrapolating out of hospital to in hospital are the confounders. In the hospital with a handful of exceptions (every ass hole can find one outlier) you have a patient that is seen/noted to be crimping or crump, professionals trained to the best of our ability to train this kind of thing are at the bedside in a relatively immediate fashion. Out of the hospital there is a ton of variability including downtime, quality of CPR if present at all, how long it took to get to the hospital, etc. There is clearly too many confounders in this retrospective data (which in this case is largely statistical analysis throwing **** against a wall and looking for what sticks) and to conclude anything about oxygen during a code in the hospital which can't be done in any serious fashion without controlling for variables and actually doing a prospective study. I don't know if the resident in the story "killed" anyone (wasn't an accusation I made) but I'm not convinced in any way, shape, or form he did the patient any favors either.

 

[Siggy]

An ICU team or an ED team, sure. ...and by "team" for maintaining a good seal, I mean RTs as bag-masking a patient simply isn't done during most codes ("let's stop compressions for an airway"). Your average med/surg team I'd rate below EMS providers. Also, provided properly trained paramedics (in contrast to EMTs), length of transport for a patient abscense confounding issues or ROSC shouldn't be transported anyways.

The reality is that without more coherant information about what was going on in the OP's situation, it's hard to judge one way or another (and I know you didn't make the accusation). If we're talking a v-fib/v-tach arrest where the team doesn't bother with ventilations pending the arrivial of the crash cart, then I think it could easily be argued a priori that it was a better route than stopping compressions for ventilations by someone inexpereinced with a BVM sans advanced airway. On the other hand, a cardiac arrest caused by hypoxia would be a different situation. I don't think that prehospital research is necesarrily inapplicable to the hospital and vice versa.

 

[Raryn]

An ICU team or an ED team, sure. ...and by "team" for maintaining a good seal, I mean RTs as bag-masking a patient simply isn't done during most codes ("let's stop compressions for an airway"). Your average med/surg team I'd rate below EMS providers. Also, provided properly trained paramedics (in contrast to EMTs), length of transport for a patient abscense confounding issues or ROSC shouldn't be transported anyways.

The reality is that without more coherant information about what was going on in the OP's situation, it's hard to judge one way or another (and I know you didn't make the accusation). If we're talking a v-fib/v-tach arrest where the team doesn't bother with ventilations pending the arrivial of the crash cart, then I think it could easily be argued a priori that it was a better route than stopping compressions for ventilations by someone inexpereinced with a BVM sans advanced airway. On the other hand, a cardiac arrest caused by hypoxia would be a different situation. I don't think that prehospital research is necesarrily inapplicable to the hospital and vice versa.

You realize that at an academic hospital the ICU team is made up of the exact same residents that the ward teams are, right? One month they'll be on one, the next month they'll be on the other. Usually you don't have the fellow or attending so involved they go to every code, unless someone happens to code during rounds.

In addition, that paper didn't say anything about making a mask shape with your hands to blow oxygen at the patient.

 

[Siggy]

You realize that at an academic hospital the ICU team is made up of the exact same residents that the ward teams are, right? One month they'll be on one, the next month they'll be on the other. Usually you don't have the fellow or attending so involved they go to every code, unless someone happens to code during rounds.

In addition, that paper didn't say anything about making a mask shape with your hands to blow oxygen at the patient.

So nurses and RTs don't respond to codes in your hospital? The residents start all of the IVs, bag the patient and everything else, push all of the medications, etc?

 

[jdh71]

An ICU team or an ED team, sure. ...and by "team" for maintaining a good seal, I mean RTs as bag-masking a patient simply isn't done during most codes ("let's stop compressions for an airway"). Your average med/surg team I'd rate below EMS providers. Also, provided properly trained paramedics (in contrast to EMTs), length of transport for a patient abscense confounding issues or ROSC shouldn't be transported anyways.

The reality is that without more coherant information about what was going on in the OP's situation, it's hard to judge one way or another (and I know you didn't make the accusation). If we're talking a v-fib/v-tach arrest where the team doesn't bother with ventilations pending the arrivial of the crash cart, then I think it could easily be argued a priori that it was a better route than stopping compressions for ventilations by someone inexpereinced with a BVM sans advanced airway. On the other hand, a cardiac arrest caused by hypoxia would be a different situation. I don't think that prehospital research is necesarrily inapplicable to the hospital and vice versa.

No one stops compressions for an "airway," especially if sats are being maintained with the bag masking.

I think the data above is inapplicable to the hospital, especially the end point data, and it's conclusions. It's "interesting" and the type of thing that could/should provoke a prospective study of these things (but the practicality of such isn't realistic, so won't happen), but ultimately has very little utility in any clinical setting outside of where the observations were made.

 

[Raryn]

So nurses and RTs don't respond to codes in your hospital? The residents start all of the IVs, bag the patient and everything else, push all of the medications, etc?

A crisis nurse (who is frequently the ICU charge nurse or some equivalent) and RTs respond to all the codes. Plus whomever is around on the floor as well to help out with chest compressions. I'd say that the code teams are fairly equivalent no matter where the patient codes, given that a code is simple as stink from a medication standpoint, so as long as everyone can follow basic orders and the person who is running it knows what they're doing...

(Codes in the ICU are easier to deal with because the rooms are bigger, equipment for post-code management such as putting in a central line and such is more available, and the patient doesn't have to be moved after the code rather than transferred to a different part of the hospital... but for the code itself at every hospital I've been at, the personnel are relatively irrelevant as long as you have an RT or two, an RN or two that aren't *completely* incompetent, and a line of people who can pound on the chest)

 

[waterbottle10]

Sorry bad wording. I think I figured it out somewhat. I think its cause the oxygen mask was connected to a connector if you you bag the oxygen will go the other way due to closed valve?

 

[Instatewaiter]

Confused about a topic today about hypoxic patient who received 100% oxygen, directly blowing at patients face, w resident forming a mask shape w/ hands, instead of bagging the patient. This is prob equipment related (?) but i was told that if you bag the patient, the oxygen wont go out the patients end, than if you just blow it. Anyone has any idea how this works and why bagging wont get the O2 to patients end? Thcx

Yeah that's not true at all. You're resident is a *****.

During a code where the patient is pulseless, they are also not breathing. Some air is getting into the lungs because of the chest compressions but not much. You bag the patient. The bag is full of O2. What you're bagging into the patient is high FiO2 (probably not 100% but much higher than ambient air)

 

[Instatewaiter]

So high quality compressions is only important out of hospital, but we can dick around with a BVM inside the hospital? I didn't realize physiology changed based off of the location of the patient. Also, the end point (neurologically intact discharge) is the only end point that matters with a cardiac arrest. Who cares if you get a pulse back if the patient ends up gorked at best, dead 2 days later (or sooner) at worse. Now measuring that based off of phone and mail questioners is a different thing entirely.

Also, I'm not going to say that this is an authoritative end all, be all study, but, "OMG, the resident murdered the patient in a code" is a bit of hyperbole.

No the issue is that the heart is the most important. Out of hospital you don't want people stopping compressions to deliver oxygen. There arent aneough people helping with the code and what happens is someone will try to do something with the airway and no one will be doing compressions.

The physiology didn't change. For about 4 minutes after loss of pulse, the oxygen tension in the alveoli is still high enough that if there is reasonable cardiac output from compressions, you can avoid anoxic injury. Hense, high quality compressions are stressed out of hospital. Ideally however you'd be able to maintain a high level of O2 tension in the airway and do compressions. So, in hospital it is high quality compressions by one part of the team while the other simultaneously deals wit the airway.

 

[Siggy]

No the issue is that the heart is the most important. Out of hospital you don't want people stopping compressions to deliver oxygen. There arent aneough people helping with the code and what happens is someone will try to do something with the airway and no one will be doing compressions.

The physiology didn't change. For about 4 minutes after loss of pulse, the oxygen tension in the alveoli is still high enough that if there is reasonable cardiac output from compressions, you can avoid anoxic injury. Hense, high quality compressions are stressed out of hospital. Ideally however you'd be able to maintain a high level of O2 tension in the airway and do compressions. So, in hospital it is high quality compressions by one part of the team while the other simultaneously deals wit the airway.

All the more reason to focus on uninterrupted (except for rhythm checks/defibrillations) compressions during the initial part of a code and not stopping for either intubation or stopping for breaths (otherwise we're looking at gastric inflation), especially if the patient is in a rhythm amenable to electricity. At 100 compressions/minute, that's a compression every 0.6 seconds. You aren't delivering breaths in that time frame, so at least part of each breath is going to have push back from the increase in interthoracic pressure from PPV.

Now if you're in PEA, then sure, get an airway since hypoxia is one possible source.

If you're in asystole, well, you're pretty much screwed anyways.


Also, there's this entire team of people that respond to out of hospital cardiac arrests who are, at least in theory, trained in using a BVM... and probably more proficient than your average hospital team member with the exclusion of the anesthesiologist and RT. At least to me, "out of hospital" refers to EMS, not the average schmuck with a ARC CPR card. Seriously, when was the last time the average IM... or even EM... resident used a BVM? No, directing someone else to use one isn't the same. ...and no, using one on one of those cheap CPR manikins isn't the same either.

 

[Instatewaiter]

All the more reason to focus on uninterrupted (except for rhythm checks/defibrillations) compressions during the initial part of a code and not stopping for either intubation or stopping for breaths (otherwise we're looking at gastric inflation), especially if the patient is in a rhythm amenable to electricity. At 100 compressions/minute, that's a compression every 0.6 seconds. You aren't delivering breaths in that time frame, so at least part of each breath is going to have push back from the increase in interthoracic pressure from PPV.

Now if you're in PEA, then sure, get an airway since hypoxia is one possible source.

If you're in asystole, well, you're pretty much screwed anyways.


Also, there's this entire team of people that respond to out of hospital cardiac arrests who are, at least in theory, trained in using a BVM... and probably more proficient than your average hospital team member with the exclusion of the anesthesiologist and RT. At least to me, "out of hospital" refers to EMS, not the average schmuck with a ARC CPR card. Seriously, when was the last time the average IM... or even EM... resident used a BVM? No, directing someone else to use one isn't the same. ...and no, using one on one of those cheap CPR manikins isn't the same either.

Tube while you're doing compressions. Don't stop for breaths. i don't give a **** how inflated the stomach is. The patient is dead while you're doing compressions.

I think you mean intra-thoracic pressure, unless you mean the pressure between your thorax and someone elses. Also, intrathoracic pressure is low compared to what the bag mask can deliver... which is why it is used. So it will overcome that intrathoracic pressure from compressions. The infrequent breaths allow the intrathoracic pressure to stay low to allow for venous return.

Finally I don't know what kind of shop you're at but IM and especially EM use the BVM quite regularly. Also, let's not act like this is some complex, hard to understand or use device. It is a frigin Squeezble tube and a one way valve... there's no complex physics here. Push against the face then squeeze.

 

[Siggy]

Finally I don't know what kind of shop you're at but IM and especially EM use the BVM quite regularly. Also, let's not act like this is some complex, hard to understand or use device. It is a frigin Squeezble tube and a one way valve... there's no complex physics here. Push against the face then squeeze.

http://www.ncbi.nlm.nih.gov/pubmed/17925412

There's also a ton of studies documenting over ventilation in emergency situations using a BVM.

But screw the literature. Screw the fact that hyperventilation occurs (both in terms of rate and volume). Screw the fact that the ACEP has a CME online where even the ACEP recognizes that "BVM ventilation is a difficult skill to master. There are many impediments to successful mask ventilation." It's the "frigin Squeezble tube and a one way valve..." Apparently the College for the specialty where the whole goal is management of emergencies thinks there's a little more finesse involved in order to to it appropriately.

Oh, and you also get a better seal with less resistance by lifting the jaw into the mask instead of smashing it against the face.

 

[Instatewaiter]

Again this isnt rocket science. If you are too stupid to use a bag valve mask, you're too stupid to be a doctor. If you're too stupid to realize by over ventilating you decrease venous return (as I alluded to in my previous post) you're too stupid to run the code or use the bag-valve mask.