vents and cpr

mskate · Oct 12, 2008

if i do not have a monitor and i have a brady rate of 20 and she is symptomatic or doesnt look right, I will start compressions and speed her up a bit, i wont let her ride that low. If you have drugs, give them. If it is only you there and you are alone, I'd up the vent rate and just use that so I could be free to compress and push drugs. She would still be getting her breaths.

PICNICRN, BSN, RN · Oct 12, 2008

If your patient becomes unresponsive/bradycardic/apneic/pulseless/ect. You would treat them like any other child in need of BLS/PALS. You would think airway first, maybe they have a plug, or have coughed out the trach? Regardless, you would bag the pt thier initial 2 breaths through the trach and if you get good chest rise, you would continue on with BLS from there. I guess you could then put her back on the vent and up the rate if you have absolutely no one to help you. But I do not think that American Heart has recommended uncoordinated breath/compression ratios yet, so you might not be in compliance on that note. They are still recommending 15 compressions THEN 2 breaths. Will it make a huge difference?? Dunno.

Do you have a line to give these meds through? And do you have the meds on hand?

My guess is if you are at school, you would be calling 911 and receive the assistance you will need.

smartnurse1982 · Oct 12, 2008

but what if their chest is rising with the vent, and it was( stated already nothing was wrong with the trach or vent)? bagging and the vent so seem like the same thing to me in that air is getting into the lungs {meaning there is a patent airway} by the way the school staff does not have the equipment to start an iv and the staff and i dont have any meds to give {i give meds in school that come from home}. this is the only kid in the whole school with a vent and only 1 other has a trach. might i add that the other nurses dont know about vents so i on my own basically

annreese · Oct 13, 2008

dealing with vented patients alot, in my experience the policy has always been to remove the vent and bag them. yes it takes another pair of hands, yes its inconvenient, but it removes the possibility of vent error. just because you have chest rise, doesn't mean there isn't another vent error, the pressure could be too high, tidal volume might not be right lots of things could be wrong. plus with a vent you can't feel the compliance like you can with a bvm or pocket mask, so its harder to tell if there an obstruction or other problem. I couldn't find the aha recommendation on this but that would be my advice.

mskate · Oct 13, 2008

but what if their chest is rising with the vent, and it was( stated already nothing was wrong with the trach or vent)? bagging and the vent so seem like the same thing to me in that air is getting into the lungs {meaning there is a patent airway} by the way the school staff does not have the equipment to start an iv and the staff and i dont have any meds to give {i give meds in school that come from home}. this is the only kid in the whole school with a vent and only 1 other has a trach. might i add that the other nurses dont know about vents so i on my own basically

It is sounding to me like, you work as a school nurse of some sort and there is a kid there that is vent dependent and is trached? You are worried about what to do in case of a cardiac arrest or problems in that event when someone is vented. You dont have IV supplies? Do you have a crash cart of PALS/ACLS meds and algoriths?

In this situation, call 911 immediately. If you are not in a hospital, you need to get the kid to one and have somsone on their way with IVs and drugs.

In a dream world, you will have meds, pharmacy, monitors, invasive lines, an MD, an RT, a recorder, a med pusher, a person to do compressions and a helper to hang ivs, etc....

In your world *if im understanding it right* - call 911.

ideally, if you have a second person to help - bag them. if you have someone who has a vent in your school, you need to have a way to check a pulse ox. make sure it is ok.

if you do not have someone to bag, if your volumes on your vent are ok, your pressures are OK and their sat is reasonable with good compressions - increase your vent to a rate of 15-20 and increase your fio2 to 100%.

if you have a monitor, put them on it. check a blood pressure.

if you have an AED, put them on it. do what is says.

make sure you have a pulse. if it a low rate, if it is not adequate, give drugs.

if you dont have iv access, sometimes you can do some this IO or ET. if you have no drugs, do compressions and check your aed to double check.

make sure you have your ambulance on the way and continue to check pressures, monitors, hr, bp, sats, etc... until help arrives.

PICNICRN, BSN, RN · Oct 13, 2008

Well then, If you are getting good chest rise, and you were by yourself, all you can do is increase your rate and compress yourself unitl EMS comes and takes over.

My only concern is with the uncoordinated compression/ventilation ratio that using the vent would provide. I know that American Heart is coming out with a change that will recommend NO LONGER pausing compressions for ventilations I just do not know if they have implemented this in their BLS/PALS course this year or if it is for next year. Does anyone know??

Either way, bagging or using the vent... you can't make things worse in this situation:uhoh3:

Blee O'Myacin, BSN, RN · Oct 13, 2008

Well then, If you are getting good chest rise, and you were by yourself, all you can do is increase your rate and compress yourself unitl EMS comes and takes over.
My only concern is with the uncoordinated compression/ventilation ratio that using the vent would provide. I know that American Heart is coming out with a change that will recommend NO LONGER pausing compressions for ventilations I just do not know if they have implemented this in their BLS/PALS course this year or if it is for next year. Does anyone know??
Either way, bagging or using the vent... you can't make things worse in this situation:uhoh3:

I took PALS last winter and we were not pausing compressions unless we were checking a rhythm. And we were not pausing compressions for ventilation unless it was one person CPR. In the few pedi codes I've worked in the ER, things never went according to plan and it was always a respiratory issue, then it quickly became cardiac. We start compressions on a child at a brady rate under 40bpm - if bagging doesn't bring up the heartrate. HTH

Blee

chare · Oct 13, 2008

the following is from the 2005 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care part 11: pediatric basic life support

in a victim of cardiac arrest with no advanced airway in place, pause after 30 compressions (1 rescuer) or 15 compressions (2 rescuers) to give 2 ventilations when using either mouth-to-mouth or bag-mask technique.
during cpr for a victim with an advanced airway (eg, endotracheal tube, esophageal-tracheal combitube [combitube], or laryngeal mask airway [lma]) in place, rescuers should no longer deliver "cycles" of cpr. the compressing rescuer should compress the chest at a rate of 100 times per minute without pauses for ventilations, and the rescuer providing the ventilation should deliver 8 to 10 breaths per minute. two or more rescuers should change the compressor role approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions.
if the victim has a perfusing rhythm (ie, pulses are present) but no breathing, give 12 to 20 breaths per minute (1 breath every 3 to 5 seconds).

could not find information specifically on pediatric patients, however i did find the following in the 2005 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care part 6: cpr techniques and devices:

automatic transport ventilators (atvs)

. one prospective cohort study of 73 intubated patients, most of whom were in cardiac arrest, in an out-of-hospital urban setting showed no difference in arterial blood gas parameters between those ventilated with an atv and those ventilated with a bag-mask device (loe 4).

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disadvantages of atvs include the need for an oxygen source and electric power. thus, providers should always have a bag-mask device available for manual backup. some atvs may be inappropriate for use in children

in both the out-of-hospital and in-hospital settings, atvs are useful for ventilation of adult patients with a pulse who have an advanced airway (eg, endotracheal tube, esophageal-tracheal combitube [combitube], or laryngeal mask airway [lma]) in place (class iia). for the adult cardiac arrest patient who does not have an advanced airway in place, the atv may be useful if tidal volumes are delivered by a flow-controlled, time-cycled ventilator without positive end-expiratory pressure (peep). if the atv has adjustable output control valves, tidal volume should be adjusted to make the chest rise (approximately 6 to 7 ml/kg or 500 to 600 ml), with breaths delivered over 1 second. until an advanced airway is in place, an additional rescuer should provide cricoid pressure to reduce the risk of gastric inflation. once an advanced airway is in place, the ventilation rate should be 8 to 10 breaths per minute during cpr.

on my unit we typically remove them from the ventilator and manually ventilate with resuscitation bag and 100% oxygen. remember that hypoxic insult is the primary cause of cardiovascular failure in children. also remember the dope (dislodged tube, obstruction, pneumothorax, equipment failure) pneumonic for assessing a patient who acutely deteriorates during mechanical ventilation. removing them from the ventilator is a quick and effective way to rule out/correct equipment failure.

PICNICRN, BSN, RN · Oct 13, 2008

CHAR.........

Great info!!! Thanks!!! :yeah:

smartnurse1982 · Oct 13, 2008

actually i am not a school nurse but a pdn

PageRespiratory! · Oct 13, 2008

Manual resucitator should always be used during an emergent situation.