Hi folks! Remember a few blogs ago the CRUX article by Dr Shim. Well he is back with this nice short article on bagging for RSI and better tools for ventilation
No Bagging for RSI
The whole idea of no bagging after pushing the drugs in RSI was because of what?
It wasn’t because we didn’t want to give more oxygen to a patient,
It wasn’t because we wanted the co2 to rise
It was because of one thing… we didn’t want to inflate the stomach thus potentially putting the patient at risk of aspiration and potentially impeding diaphragm movement.
But surely you could bag gentle enough to prevent this from happening…right?
Sorry but it’s just been evident over the years that especially when we miss the first time with what ever device we want to put in, our anxiety increases significantly no matter how experienced we are. How does this translate to our bagging?
Ummm duuhh. We all grab the bag slap it on the face often with one hand (cuz we’re told to do it that way…again wrong) and push hard and fast!
I am in the same camp as Dr. Ruben Strayer (video of two handed BVM found at EMCRIT). I think we need to get away from talking about one handed bagging. However even with two person bagging (one operator with 2 handed mask seal and other bagging) I disagree with Ruben that “anyone can bag the patient”. Yes anyone can squeeze the bag but to do it gently so as not to deliver too high a flow rate and PIP not to mention the appropriate respiratory rate is not so simple.
So what happens then…exactly what we didn’t want to happen in the first place. We inflate the stomach and we usually hyperventilate the patient.
Ok so we suck at this. So how do we do it better.
Enter the Oxylator..
This little gizmo was developed in my home country CANADA eh?
It is a brilliant piece of machinery and simplicity.
It’s pressure limited so you can dial in a low pressure to begin with starting at 15 cm H2O. And probably more importantly its flow limited to 30 lpm. As Dr. Jim Ducanto pointed out to me, it’s likely the fast flow rates that cause the gastric insulflation as opposed to the absolute PIP. Deliver 30 cm of water pressure quickly vs slowly and gently can mean the difference between a ballooned stomach or not. That being said both of these parameters when delivered in high enough values are the co offenders of forcing air into the stomach and both of these offenses often happen when things get tough. The oxylator mitigates these problems by allowing you to limit the pressure and limit the flow rate to no more than 30 lpm.
It tells you when you have an open airway. It tells you when you have an obstructed airway and it tells you when you have a leak. It doesn’t get stressed, it makes you purposely think about increasing the pressure and by how much, it tells you still suck at applying the mask. Although by itself the oxylator tells us we have a patent airway I still firmly believe ETCO2 should be used as a secondary assurance that we are exchanging gas. My weapon of choice is something called the EMMA ETCO2 device. It’s light, it’s portable, so you can take it to any code, aeromedical transport or trauma. It is positioned right where you are looking so you know how you’re doing. I show both of these tools in the accompanying video.
Dr. Harold Bob Shim
M.D., C.C.F.P.(EM), Dip. Sport Med.
Clinical Medical Director
Presidential Medical Wing
Great work Harold and thanks for sharing! I have no financial disclosures to any of these device manufacturers