1. Manual resuscitators case study Manual resuscitators case study by Elizabeth Kelley Buzbee RRT RCP-NPS RCP Kingwood College Respiratory Care department

2. Your patient is an 18 year old WM who has just had an accident on his motorcycle. He was not wearing a helmet He comes into the ER. What do you want to do first?

3. answer Assess his respiratory rate. If his respiratory rate is less than 8 bpm, or he is not breathing we need to start manual resuscitation Check his heart rate and if he has no pulse, start CPR

4. Your patient has a respiratory rate of zero. You need to start manual resuscitation. What type of patient interface do you use?

5. answer You use a mask, but as soon as possible we need to intubate him so that we can bag the endotracheal tube

6. How do you test the bag for proper function?

7. answer Occlude the patient connector and squeeze the bag; you should feel some resistance because the gas cannot go anywhere Check the 02 flow meter and check the 02 line. Make sure there is a reservoir on the inlet of the bag

8. Due to the nature of this patient’s injuries, you must protect his spinal cord by what procedure?

9. answer to protect the spinal cord, you do not hyper extend the head; rather from the head of the bed, you place index fingers on the angles of the lower jaw. Pull the jaw forward without tilting the head or twisting it. This is the jaw thrust

10. When you put the mask on the patient’s face you see that the mask doesn’t extend down to the patient’s mouth.

11. answer Adjust the mask so that the eyes aren't touched & seal is present. If the mouth is still not covered, the mask is too small, get one that fits over the nose and the mouth

12. You get a good mask and when you press on the inflatable seal, you see that the mask is tight. When you squeeze the bag, you expect what to happen?

13. answer Gas should flow into the patient’s mask and his chest should rise

14. When you press on the bag, you see that the chest doesn’t rise. What do you do?

15. answer Check the bag against your hand for leaks. Repositions the mask on the face and bag again…if that doesn’t work –Reposition the head and bag again –Reposition the head a third time and bag again –Check the mouth for obstructions like blood or teeth. Sweep the mouth, or suction debris from the mouth –Get the patient intubated as soon as possible

16. While you are bagging at a rate of 12 bpm, you watch the chest rise and fall. The patient vomits into the mask. What do you do?

17. answer Take the mask off the face, shake out the vomitus and get someone to suction the mouth. Ask the doctor if we can intubate the patient so that we can avoid this next time

18. The doctor places a 7.5 endotracheal tube between the patient’s vocal cords and you inflate the cuff, now you:

19. answer Take the mask off the bag and apply the endotracheal tube adaptor to the bag and give breathes

20. now you see that the chest rises when you squeeze and falls when you release the bag. What respiratory rate do you pick?

21. answer Respiratory Rate between 10- 12 bpm Bag once every 5 seconds so that there is time for the patient to exhale

22. While you are bagging the patient, another RCP listens to breath sounds. He tells you that he hears bilateral breath sounds and that they are equal and clear. You:

23. answer You are pleased. That is what you want to hear.

24. Case study # 2 Your patient is a 55 year old WF with a long history of pulmonary disease. She has been breathing harder and faster all day and now her respiratory rate is at 40 bpm and it is shallow. Her skin is blue and her heart rate is fast [135 bpm]. When a blood gas is drawn, you see that the 02 is dropping and the C02 is rising. The doctor wants to intubate this lady What do you do?

25. answer You need to mask bag her because the act of intubation is an invasive procedure that requires some pre-oxygenation

26. When you test the bag, you notice that after you squeeze the bag, it takes 10 seconds to re-inflate. What is the problem?

27. answer The inlet to the bag is obstructed so that the recoil is too slow—get another bag

28. When you hyperextend her head, you notice that her false teeth are rattling around in her mouth. What do you do?

29. answer Remove the false teeth because they are an obstruction in the upper airway

30. You see that the manual resuscitator has no reservoir on the inlet. Is this a problem?

31. answer You cannot get Fi02 of 80-100% even with a high flow rate if you don’t have an 02 reservoir

32. You are pleased to see that the manual resuscitator’s one-way valve is a _________ because that is the easiest for the patient to open with her breathing

33. answer Duck bill

34. The doctor intubates this patient with a 7.0 endotracheal tube and inflates the cuff. You bag at a rate of 12 bpm, and when you listen to the chest you hear distant breath sounds & wheezing over the entire chest. The exhalation goes on right up until you squeeze the bag for the next breath. You do what?

35. answer Slow down the breathing from 12 bpm to 10 and listen again. If the patient exhales until the next breath he will air trap and that can lead to barotrauma If he is still exhaling till then next breath slow down to 8 bpm. Ask for a drug to combat the bronchospasm

36. You know that while you are bagging this adult patient that the possible tidal volumes you can get with this bag are:

37. answer 800-1200 ml

38. Someone increases the 02 flow rate from 10 lpm to 15 lpm. If the bag was not made correctly, this excessive flow rate would do what?

39. answer Jam the valve open so that the one way valve cannot work properly

40. When you start bagging your patient, you noticed that there was a certain amount of pressure against your hand as you squeezed. Now you notice that the pressure seems to have increased and that it is harder to bag the patient. What do you do?

41. answer Listen to breath sounds. If wheezing, then patient’s driving pressures are rising. Give bronchodilator & slow down to prevent airtrapping If wheezing, then patient’s driving pressures are rising. Give bronchodilator & slow down to prevent airtrapping If breath sounds show diminished breath sounds in the basal [bottom] of the lung and no wheezes, the patient’s lung compliance may risen—the lung is stiffer