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The basics  are paramount!

Proper BVM technique / Basic Techniques

Use two handed mask seal if staffing allows

Understand the device you are using, mask pressure my be adjustable with a syringe.

Success starts before the call with a proper truck and equipment  check

Small volume BVM devices are becoming the new standard, to prevent over inflation

Regardless of size of BVM its the operator making sure that just enough volume to get rise of the chest the target

New BVM devices may limit filling of the bag device to keep ventilation rate lower and more appropriate

Capnography can and should be put inline between bag and the mask if just mask ventilating the patient. 

The capnography provides rates on your capnograph. Pay attention!

Consider throwing an inline capnography set in with every BVM to remind providers to utilize

Consider using a inline filter between every patient and the BVM to prevent exposure to the providers

Capnography must be allowed to calibrate before sampling Co2

Don't forget the BLS airways OPA / NPA

Consider PEEP valve with every BVM kit. Consider its use if patient is not oxygenating without, needed if manually resuscitating  a patient who was previously vented patient

PEEP and CPAP create the same physiological effect at the alveoli level

If you started with CPAP, and the patient requires ventilation, add PEEP

Hang around after dropping a patient off at an ER, what they do immediately thereafter may be things you should have already done

If supplied oxygen from the BVM is insufficient, you can augment with nasal cannula beneath the mask

Oxygenation is a passive process, the trigger for the body to breath is a rise in Co2. We breath to rid ourselves of the Co2 waste product. Higher concentrations of supplied oxygen will diffuse naturally to areas of lower concentration and keep sats up. 

Put a nasal cannula on the patient to keep the patient oxygenated between the interval of removing the BVM mask and the introduction of and advanced airway. This is apenic oxygenation. Flow rate can be 15 LPM.

Pulse ox value is delayed. Don't wait for desat, its already happened by the time you see it. 

Hyperoxygenation builds a safety net

Trending of pulse ox and capnography is the necessary to see what effect interventions are having on the  patient

There is not an obligation to always use a advanced technique if the basic is working

Natural breathing is not positive pressure. The chest goes out and diaphragm down creating a negative intrathoracic pressure "sucking" (equalizing) outside and inside pressures. 

This temporary negative pressure in the chest also helps suck blood back to the chest from the extremities

Transitioning to positive pressure ventilation takes away that augmentation of blood pressure and may have systemic effects

Adding medications to this situation may worsen hemodynamics

Start simple management and build to complex

Preparation - prepare for failure

Positioning is different for placing supraglottics vs visualizing the airway for ETI

Resuscitate then intubate

• Stabilize airway

• Get access

• Fluid resuscitate as necessary

• Get medications prepared

• Have backup plan called for and prepared 

"Cheat" - Use adjuncts to help

Bougie can be an option, must train with it to be proficient

Know your tools, practice with other things

Assessment tools may help you decide how difficult airway management may be

Prepare suction, may need to keep suction catheter in the airway during airway attempts

The Protocols

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