FAST FACT – This is based on the Burns: The Practical Stuff video and post.
Full reference available in full post.
Category: Clinical
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Video – Burns: The Practical Stuff
Uploaded to YouTube in April 2019; Filmed 2018 Content warning: This video may contain sensitive content.
This video demonstrates the assessment and management of burns, using equipment that is recommended within the locality at the time of production. Remember to check your local, current guidelines before putting anything into practice. Produced by HCPs and students.
This video demonstrates use of burn gel wraps, which may no longer be used in your ambulance Trust. Please check your local guidelines regarding this. According to the British Burn Association:
Burn gel wraps may be used to provide analgesia, but only after adequate cooling has
Varley et al (2014)
occurred as they do not actively remove heat from the woundRemember to follow good IPC in real life.
The transcript below has been slightly edited, with titles added, to make it easier to read.
Further recommended reading: The British Burn Association First Aid Clinical Practice Guidelines
Transcript
You must read the full disclaimer at www.article999.co.uk/disclaimer and check your local guidelines before putting into practice any of our content.
BURNS: The practical stuff
This video contains content some might find sensitive.
Treatment
With all assessments and interventions, use an aseptic technique, especially because ‘burns are prone to infection’
Purcell, 2003: 217Airway
The patient’s airway might worsen. Here’s why:
‘A burned patient may have a patent airway on the initial evaluation. […] In the time that follows, the face, as well as the airway, will likely swell.’
NAEMT, 2016: 411… So, consider HEMS for RSI.
Breathing
The patient’s breathing might worsen. Here’s why:
Is there a chest wall burn?
‘Burns constrict the chest wall similarly to having several leather belts progressively tightening around the patient’s chest. As time progresses, the patient cannot move the chest wall to breathe.’
NAEMT, 2016: 412So, consider HEMS and ventilatory support where needed.
Other considerations:
Inhaled toxins ‘can produce asphyxiation’
NAEMT, 2016: 412If:
El-Helbawy & Ghareeb, 2011
– LOC in a fire with ‘heavy smoke’
– trapped patient in a fire
consider O2Circulation
Swelling might get worse. Here’s what to do about it:
‘Distal limb perfusion may be critically reduced’; ‘Burned extremities should be elevated during transport to reduce the degree of swelling in the affected limb’
NAEMT, 2016: 412A complication of swelling:
Fluid loss occurs from swelling and evaporation
NAEMT, 2016: 416Giving Fluids – Pros and Cons
Consider IV fluids, especially if the burn is >10% of the body (AACE, 2016: 265-266). Keep watching for info on how to determine this.
Give fluids with caution. Too much -> ‘cardiac failure, […] infectious complications, acute respiratory distress syndrome, and even death’.
Too little -> ‘hypovolemic shock, organ failure’
(NICE, 2016)
Judicious fluid management of children with severe burn injury can improve the respiratory outcome measures of these children
Duran and Sheridan, 2016Cannulating – Essentials
When cannulating, ‘placement through the burn is appropriate [only] if no alternative sites are available’
NAEMT, 2016: 412What about heat?
Patients with burns are not able to maintain their own body heat
NAEMT, 2016: 413…So, give blankets
ECGs
ECGs are required for electrical burns (AACE, 2016: 265) but consider them for all burns as ‘cardiac dysrhythmias’ result from the release of ‘muscle potassium’ (NAEMT, 2016: 418) and studies have shown disturbances in the cardiac functions of in-hospital burn patients (Jeschke et al, 2008).
Disability
Do your BMs
Hyperglycemia may occur in burns patients and has a higher risk of ‘morbidity and mortality in critically ill patients’ (Wolfe et al, 1979; Mecott et al, 2010).
Pain management in children
In children, ‘a multi-modal approach to pain and sedation can improve the neurological status of severely burned children’
Duran and Sheridan, 2016Expose/Examine
Cooling the burn:
Cool with a wet compress
Purcell, 2003: 217‘Cooling gels such as Burnshield are often used by paramedics. These are useful in cooling the burn and relieving pain in the initial stages.’ *
Be aware of the risk of ‘heat loss’
Hudspith and Rayatt, 2004*This guidance is changing. Check your local guidance first, and consider the use of cling-film after running water.
Documentation during examination:
Assess and document:
‘Burn depth & features’ (Purcell, 2003: 217)
Other considerations:
Anticipate Swelling. Take off jewelry. Be aware that these and clothing ‘retain residual heat’ (NAEMT, 2016: 413).
Cooling – more details
Irrigate early to cool and prevent further burning.
Chemical burns: 15 mins min (AACE, 2016: 265)
All burns: Max 20 mins (AACE, 2016: 266)
This is most effective ‘within 20 minutes of the injury’ (Hudspith and Rayatt, 2004).
Don’t use ice cold water as ‘intense vasoconstriction can cause burn progression’ (Hudspith and Rayatt, 2004).
When using cling film
Discard ‘the first few centimetres’ to be aseptic
‘lay this on the wound rather than wrapping the burn’ to anticipate swelling
(Hudspith and Rayatt, 2004)
Consider using wet dressings instead in chemical burns (Allison and Porter, 2004)
Estimating total burns
Consider the use of tools to estimate the total body percentage of the burns (NICE, 2016; Mersey Burns, 2013).
Transport
Using those tools [such as Mersey Burns] will help determine the right treatment centre for the patient and the treatment priority.
Time critical features:
- major abcd problems
- airway burns
- history of hot air or gas inhalation
- respiratory distress
- burns that completely encircle the chest, neck, or limb
- significant facial burns
- burns >10% total body area
- ‘presence of other major injuries’
(AACE, 2016: 266)
References
Association of Chief Ambulance Executives (AACE), 2016. UK Ambulance Services Clinical Practice Guidelines. Bridgwater: Class Professional Publishing
Allison, K. and Porter, K. 2004. Consensus on the prehospital approach to pain management. Emergency Medicine Journal. 21 (1), pp. 112-114
Duran, C. and Sheridan, R.L. 2016. Current Concepts in the Medical Management of the Pediatric Burn Patient. Current Trauma Reports. 2 (4), pp. 202-209
El-Helbawy, R.H. and Ghareeb, F.M. 2011. Inhalation injury as a prognostic factor for mortality in burns patients. Annals of Burns and Fire Disasters. 24 (2), pp.82-88
Hudspith, J. and Rayatt, S. 2004. First aid and treatment of minor burns. BMJ. 328 (7454), pp. 1487-1489
Jeschke, M.G. et al. 2008. Pathophysiologic response to severe burn injury. Anals of surgery. 126, pp. 37-51
National Association of Emergency Medical Technicians (NAEMT). 2016. PHTLS. Prehospital Trauma Life Support, 8th Edition. Burlington: Jones and Bartlett Learning.
NICE, 2016. Mersey Burns for calculating fluid resuscitation volume when managing burns. Available at: https://www.nice.org.uk/advice/mib58/chapter/summary (Accessed 06/04/19)
Purcell, D. 2003. Minor Injuries. A Clinical Guide. Edinburgh. Elsevier.
St Helens and Knowsley Teaching Hospitals NHS Trust, 2013. Mersey Burns. Available at: https://merseyburns.com (Accessed 06/04/19)
*Stiles, K. and Goodwin, N. 2018. British Burn Association: First Aid Clinical Practice Guidelines. Available Online: https://www.britishburnassociation.org/wp-content/uploads/2017/06/BBA-First-Aid-Guideline-24.9.18.pdf (Accessed 29/03/21)
*Varley, A. et al. 2014. British Burn Association: First Aid Position Statement. Available Online: https://www.nbt.nhs.uk/sites/default/files/attachments/British%20Burn%20Association%20First%20Aid%20Position%20Statement.pdf (Accessed 29/03/21)
Wolfe, R.R. et al. 1979. Glucose metabolism in severely burned patients. Metabolism. 28 (10), pp. 1031-1039
*Added to post 29/03/21
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An Easy Way to Remember How to Identify Left and Right Bundle Branch Blocks
Dubin, 2000, pp: 191-198 Easily remembered as: In English we read from left to right, but the ECG prints a view of the heart from right (V1-V2) to left (V5-V6).
Reference
Dubin, D. (2000) Rapid Interpretation of EKG’s. 6th edition. Florida: COVER Publishing Company.
Like it? Hate it? Spot a mistake? Let me know in the comments below ->
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Quizzes Now Available On Selected Videos. Test your Knowledge
The first video in the series is Ventilator V2, which was posted some time ago on the website & on YouTube. You may view the original video & more information here.
Please follow this link to view the quiz:
https://ed.ted.com/on/RyhGsz57You may now complete a quiz to test your knowledge instead of or as well as watching the entire video. Each wrong answer will optionally link you to the relevant part of the video.
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PARAMEDIC-2 Trial Results
‘For more than 50 years, treatment strategies have included the use of various drugs, but there is limited evidence that such treatments are effective’ (Perkins et al, 2018).
Now the PARAMEDIC-2 trial results are in…
- 8014 patients of the 10, 623 initially selected were included in the trial.
- Of these, 4015 were given adrenaline and 3999 a placebo.
- Of those who were given adrenaline and survived until discharge, 39 (31.0%) out of 126 patients had a ‘severe neurological impairment’ and of those who were given the placebo, the same was true for ’16 of 90 patients [17.8%]’
(Perkins et al, 2018).
Exclusions to the trial
- ‘…those with anaphylaxis, pregnant women and children’ (below age 16).
- After the pilot, life-threatening asthma as a suspected cause of the cardiac arrest was added as an exclusion because of ‘the potential overlap between the presentation of asthma and anaphylaxis’.
- Anaphylaxis was excluded because adrenaline is considered potentially ‘beneficial’ for this condition
(Warwick Clinical Trials Unit, 2018).
The trial only looked at the effects of the use of adrenaline during out-of-hospital cardiac arrest and not at the use of adrenaline during ROSC, which is a protocol that some Trusts follow (Warwick Clinical Trials Unit, 2018). In addition, this does not cover any treatment initiated by the hospital if the patient was transported there.
Conclusions
‘the benefits of epinephrine that were identified in our trial are small, since they would result in 1 extra survivor for every 112 patients treated. This number is less than the minimal clinically important difference that has been defined in previous studies.29,30 Among the survivors, almost twice the number in the epinephrine group as in the placebo group had severe neurologic impairment’ (Perkins et al, 2018).
Limitations
Perceived limitations include: ‘Information about the quality of CPR was limited to the first 5 minutes of cardiac arrest and involved fewer than 5% of the enrolled patients.’ (Perkins et al, 2018)
Further limitations to consider could be:
- time to CPR
- patient’s co-morbitities that weren’t already considered in the study
More information
Warwick’s Clinical Trials Unit have produced an infographic with more information here.
View the University of Warwick’s press release here.
References
NIHR, 2018. Investigating the role of adrenaline in cardiac arrest. Available Online: https://www.nihr.ac.uk/news/investigating-the-role-of-adrenaline-in-cardiac-arrest/8931 (Accessed 19/07/18)
Perkins, G.D. et al, 2018. A randomized trial of epinephrine in out-of-hospital cardiac arrest. New England Journal of Medicine. doi: 10.1056/NEJMoa1806842
Warwick Clinical Trials Unit, 2018. Available Online: https://warwick.ac.uk/fac/med/research/ctu/trials/critical/paramedic2/faqs/ (Accessed 19/07/18)
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Cheat Sheets: Scene Overview
Scene Overview
Harris, 2016; Pilbery & Lethbridge, 2016 *This can be made available in alternative formats & colours on request* And more…
Harris, 2016; Pilbery & Lethbridge, 2016 *This can be made available in alternative formats & colours on request You may find varying suggestions for what to consider in what is usually referred to as your ‘scene assessment’ (Harris, 2016: 1; Pilbery & Lethbridge, 2016: 126) or ‘end of bed […] assessment’ (Spurr, 2014). This is a cheat sheet to assist you in identifying these important factors. There are a few examples within each category, forming part of what is surely an endless list. Harris (2016: 1-3) also recommends considering use of PPE, considering vehicle position, and considering CBRNE incidents. Pilbery & Lethbridge (2016: 127) recommend considering outside/inside temperature, terrain that is not reachable by land ambulance, and referring to major incident guides where applicable. Major incidents are not covered within this cheat sheet, but this sheet may guide you through the initial thought process prior to announcing a major incident…
Final Note & References
This is a cheat sheet which is designed to complement your scene assessment. This cheat sheet is in the author’s own words but ideas have been used from the below texts. Any copies of the above cheat sheets should be paired with the below references.
Harris, G. 2016. ‘General principles of assessment’ in A.Y. Blaber and G. Harris, ed. 2016. Assessment Skills for Paramedics, 2nd ed. Berkshire: Open University Press, pp. 1-13
Pilbery, R. and Lethbridge, K. 2016. Ambulance Care Practice, Bridgwater: Class Professional Publishing
Spurr, J. 2014. End-of-Bedogram: The Art Formally Known as Intuition, Available Online: http://injectableorange.com/2014/03/end-bedogram-art-formally-known-intuition/ (Accessed 26/03/18)
Feedback? Comments? Please post below…
This post is yet to be peer reviewed. Please get in touch if you have any comments. -
Free Ventilator Downloads from Smiths Medical
So far, Article 999 has a reasonable collection of information and videos about positive pressure breathing and ventilators used in prehospital emergency care. Smiths Medical is behind the PneuPac ParaPac. They have kindly given their permission to share the following documents, which are available for those who want to read more, find out about other available ventilators, or find an answer not available here.
BabyPAC self-assessment checklist
Medical Care under extreme Conditions
An introduction to Oxygen Therapy
Emergency and Transport Ventilation an introductory guide
Add feedback below ↓
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Ventilators: How?
A shorter version of Ventilators: Why, What, How, When? featuring how-to use the ventilator demonstrations only. Made by UK Paramedics, this demonstrates how to use the PneuPac ParaPac ventilator.
Read more:
Ventilators: Why, What, How, When?
How do I get the ventilator off the racks?
What is the relief pressure dial on the ventilator?
The Discovery of Negative and Positive Pressure Ventilation – Fast Fact
What is positive pressure breathing?
What is Negative Pressure Breathing?
Disclaimer
You must read the full disclaimer at www.article999.co.uk/about/ (disclaimer tab) before putting into place anything you see here. Useful information is available in the text on this video, so if you only listen to the narration you will miss important facts. The ventilation settings mentioned in this video are what is recommended by Smiths Medical, current guidelines and some articles – however, as with all topics, there is always varying information available online & alternative expert advice, and no video can cater for all of that. Similarly, this video is intended to demonstrate how to use equipment & to introduce or remind you to the Why, What and When of ventilators – not to tell you that you should or shouldn’t be using it. That is dependent on local guidelines, your research & your choice as a clinician. This video merely highlights the varying advice regarding tidal volume settings, and in the text points out the potential problems with some of the figures. No specific volume is recommended.
Transcript
Article 999. Ventilators: Why, What, How, When?
This video has been made by UK Paramedics following guidelines. It is not endorsed by any author, organisation or Ambulance Trust. You must read the full disclaimer at www.article999.co.uk/about/ and refer to your local guidelines before putting into place anything you see here. This video is intended to demonstrate how to use the ventilator according to use guides and guidelines – not to tell you that you should or shouldn’t use it. That decision is up to you and should be dependent on local guidelines and your own research. This is what the textbooks, the manufacturer and a few articles say & is not intended to represent the expert opinions or experience of others within healthcare.
Remember hand hygiene, bare below the elbows and gloves in real life.
How?
- To remove the ventilator from the racks, pull the flap to the side and push the ventilator up. To put it back in, simply push it down and pull the flap to the side again.
- To connect to the gas supply, push the hose into the socket and twist. It’s the same when connecting to a portable oxygen cylinder.
- When you turn it on, the ventilator should complete a self check. The alarm lights should flash in sequence, there should be one burst of the high pressure audible alarm, and the orange indicator should flash for 60 seconds.
- Next, check the indicator shows white for O2.
- Connect the patient circuit [shown in video].
- Next on the list, adjust the ventilation parameters. Set the air mix control to no air mix for respiratory arrest or CPR. Set the relief pressure control to 40. Set the respiratory rate to 12. As for the tidal volume, it varies massively as you can see on the screen. It depends on whether you opt for an average value or base it on the patient’s weight. Smiths Medical (2017) advise 800-900ml on their training video, [but this may not be advisable] but don’t worry too much about the slight differences in tidal volume because the PneuPac features a high pressure alarm that we’ll discuss shortly. The alarm will help you identify if the tidal volume is too high for your patient.
(Gregory & Mursell, 2010: 44; Pilbery & Lethbridge, 2016: 189; Baker, 2012; Smiths Medical, 2017)
The following demonstrate the variance in researched texts and guidelines – not necessarily the advised settings:
400-600ml Baskett, 1996 500-600ml Perkins et al, 2015 600ml Baker, 2016 800-900ml Smiths Medical, 2017 – may not be advisable due to risks of barotrauma. See below 6-8ml/kg Bocklage & Balk, 2017; Frakes, 2007 10ml/kg or 5-8ml/kg Baker, 2012 – depending on the extent of the risk of barotrauma 7. Next, temporarily occlude the patient connection. The relief pressure monitor should go to the maximum setting – i.e. 40cmh20.
(Gregory & Mursell, 2010: 44; Pilbery & Lethbridge, 2016: 189; Baker, 2012; Smiths Medical, 2017)
What do the audible warnings mean?
- Top left is the high pressure alarm
- Top right is low pressure
- Bottom left is the battery indicator
- The middle one tells you when breathing is detected by the ventilator
(Smiths Medical, 2017)
High pressure = excessive tidal volume, incorrect airway position, kinked ET tube, or incorrect ventilation settings.
If the pressure is reaching it’s max, there may be something wrong with the circuit.If you’ve checked the above and the alarm is still sounding, Smiths Medical (2017) advise that your tidal volume setting might simply be too high.
Low pressure = leakage or insufficient tidal volume/settings, faulty valve in the patient’s circuit
This alarm tends to occur when pressure drops below 10cmh20Earlier, I pointed out the alarm in the middle, at the bottom. This is SMMV. It’s an indicator that will flash green if the patient is breathing for themselves. The ventilator will assist if the patient breathes with less than 150ml of tidal volume. Between 150-400ml the ventilator will extent the exhalation time to allow the patient to complete their own breath, and above 400ml the ventilator will allow the patient to breathe and will not assist, but may still assist on the next breath if required (Smiths Medical, 2017; Baker, 2012).
Extra facts:
McCarty et al (2012) found that ‘ventilation rates and tidal volumes commonly exceeded Guideline recommendations. This resulted in […] excessive mean airway pressure’
Smiths Medical (2017) advise that peak inflation pressure should be below 20cmh20 when using a mask to ventilate due to the issues of too high pressure
Inspiration to Expiration should be 1:2 (Smiths Medical, 2017; Baker, 2012)
References
Baker, D. 2012. Emergency and Transport Ventilation, an introductory guide, Smiths Medical International Limited: Luton
Baker, D.J. 2016. Artificial Ventilation: A Basic Clinical Guide. Springer International: Switzerland
Baskett, P. et al. 1996. ‘Tidal volumes which are perceived to be adequate for resuscitation’, Resuscitation, 31 (3), pp. 231-4
Bocklage, T. & Balk, R.A. 2017. Setting the Tidal Volume In Adults Receiving Mechanical Ventilation: Lessons
Learned From Recent Investigations, Available Online: https://www.nbrc.org/wp-content/uploads/2017/07/Setting-the-Tidal-Volume.pdf (Accessed 17/12/17)
Frakes, M. 2007. Ventilation Modes and Monitoring, Available Online: http://www.rtmagazine.com/2007/02/ventilation-modes-and-monitoring/ (Accessed 17/12/17)
Gregory, P. and Mursell, I. 2010. Manual of Clinical Paramedic Procedures, West Sussex: John Wiley & Sons
McCarty, K. et al, 2012. Ventilation rates and tidal volume during emergency department cardiac resuscitation, Resuscitation, 83: 4, p45
Owen, R. and Castle, M. 2006. ‘EtCO2: the key to effective prehospital ventilation’, Emergency Medical Journal, 23 (7), pp. 578-579
Perkins, G.D. 2015. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation, Available Online: https://ercguidelines.elsevierresource.com/european-resuscitation-council-guidelines-resuscitation-2015-section-2-adult-basic-life-support-and/fulltext#back-bib0760 (Accessed 17/12/17)
Pilbery, R. & Lethbridge, K. 2016. Ambulance Care Practice, Bridgwater: Class Professional Publishing
Smiths Medical, 2017. ‘Pneupac – ParaPAC’, Pneupac Transport Ventilators – Breathe Easy, Available Online: https://www.smiths-medical.com/resources/pneupac-transport–ventilators—breathe-easy (Accessed 27/10/17)
With thanks to Smiths Medical for their correspondence and information
Music:
Dobroide, 2010. 20091229.ambulance.siren.wav. Available Online: https://freesound.org/people/dobroide/sounds/8713/ (Accessed 21/08/17)Productiontrax.com
Images:
Article 999’s own or licenses purchased via Adobe Stock & Dreamstime
Feedback is welcome & responded to. Stay tuned for more content!
Displayed on one of our ‘Fast Facts’ pages. Click on the image for the link & reference! -
Ventilators: Why, What, How, When?
Made by UK Paramedics, this video demonstrates how to use the PneuPac ParaPac ventilator.
Read more:
How do I get the ventilator off the racks?
What is the relief pressure dial on the ventilator?
What is positive pressure breathing?
What is Negative Pressure Breathing?
The Discovery of Negative and Positive Pressure Ventilation – Fast Fact
Disclaimer
You must read the full disclaimer at www.article999.co.uk/about/ (disclaimer tab) before putting into place anything you see here. Useful information is available in the text on this video, so if you only listen to the narration you will miss important facts. The ventilation settings mentioned in this video are what is recommended by Smiths Medical, current guidelines and some articles – however, as with all topics, there is always varying information available online & alternative expert advice, and no video can cater for all of that. Similarly, this video is intended to demonstrate how to use equipment & to introduce or remind you to the Why, What and When of ventilators – not to tell you that you should or shouldn’t be using it. That is dependent on local guidelines, your research & your choice as a clinician. This video merely highlights the varying advice regarding tidal volume settings, and in the text points out the potential problems with some of the figures. No specific volume is recommended.
Transcript
Article 999. Ventilators: Why, What, How, When?
This video has been made by UK Paramedics following guidelines. It is not endorsed by any author, organisation or Ambulance Trust. You must read the full disclaimer at www.article999.co.uk/about/ and refer to your local guidelines before putting into place anything you see here. This video is intended to demonstrate how to use the ventilator according to use guides and guidelines – not to tell you that you should or shouldn’t use it. That decision is up to you and should be dependent on local guidelines and your own research. This is what the textbooks, the manufacturer and a few articles say & is not intended to represent the expert opinions or experience of others within healthcare.
Remember hand hygiene, bare below the elbows and gloves in real life.
Why use the ventilator?
Research suggests that mechanical ventilators can reduce the variability of breath timings & as a result, capnography readings. They can also increase the likelihood of ‘effective ventilation’ (Owen and Castle, 2006)
To quote from Gregory & Mursell (2010: 47) ‘A high flow rate over a short inflation time inevitably produces a high peak airway pressure in an unprotected airway [as with BVM technique]. High peak airway pressure overcomes the pressure of the lower oesophageal sphincter and causes gastric inflation. […] Use of […] mechanical ventilation may help to overcome the high pressures involved. […] In an intubated patient or a patient with an LMA in situ, use of a mechanical ventilator has been shown to allow paramedics to accomplish extra tasks, document better, and provide better patient care’ (Gregory & Mursell, 2010: 47)
What?
This is a time-cycled, volume preset flow generator (Baker, 2012). In other words, the pressure can vary, volume is always the same, and the air must be delivered within a preset time, which helps to control the tidal volume.
There are many different types. One of the most common ones in UK ambulances at this time (Gregory & Mursell, 2010: 44) is the Pneupac paraPAC (Smiths Medical, 2017) but the ParaPac Plus may soon replace it.
Here are the useful parts:
The supply gas failure alarm
The inlet connection
The relief pressure control
The ‘main pneumatic switch’
Air mix control
Inflation pressure monitor
Frequency control
Tidal volume control
(Pilbery and Lethbridge, 2016: 189)How?
- To remove the ventilator from the racks, pull the flap to the side and push the ventilator up. To put it back in, simply push it down and pull the flap to the side again.
- To connect to the gas supply, push the hose into the socket and twist. It’s the same when connecting to a portable oxygen cylinder.
- When you turn it on, the ventilator should complete a self check. The alarm lights should flash in sequence, there should be one burst of the high pressure audible alarm, and the orange indicator should flash for 60 seconds.
- Next, check the indicator shows white for O2.
- Connect the patient circuit [shown in video].
- Next on the list, adjust the ventilation parameters. Set the air mix control to no air mix for respiratory arrest or CPR. Set the relief pressure control to 40. Set the respiratory rate to 12. As for the tidal volume, it varies massively as you can see on the screen. It depends on whether you opt for an average value or base it on the patient’s weight. Smiths Medical (2017) advise 800-900ml on their training video, [but this may not be advisable] but don’t worry too much about the slight differences in tidal volume because the PneuPac features a high pressure alarm that we’ll discuss shortly. The alarm will help you identify if the tidal volume is too high for your patient.
(Gregory & Mursell, 2010: 44; Pilbery & Lethbridge, 2016: 189; Baker, 2012; Smiths Medical, 2017)
The following demonstrate the variance in researched texts and guidelines – not necessarily the advised settings:
400-600ml Baskett, 1996 500-600ml Perkins et al, 2015 600ml Baker, 2016 800-900ml Smiths Medical, 2017 – may not be advisable due to risks of barotrauma. See below 6-8ml/kg Bocklage & Balk, 2017; Frakes, 2007 10ml/kg or 5-8ml/kg Baker, 2012 – depending on the extent of the risk of barotrauma 7. Next, temporarily occlude the patient connection. The relief pressure monitor should go to the maximum setting – i.e. 40cmh20.
(Gregory & Mursell, 2010: 44; Pilbery & Lethbridge, 2016: 189; Baker, 2012; Smiths Medical, 2017)
What do the audible warnings mean?
- Top left is the high pressure alarm
- Top right is low pressure
- Bottom left is the battery indicator
- The middle one tells you when breathing is detected by the ventilator
(Smiths Medical, 2017)
High pressure = excessive tidal volume, incorrect airway position, kinked ET tube, or incorrect ventilation settings.
If the pressure is reaching it’s max, there may be something wrong with the circuit.If you’ve checked the above and the alarm is still sounding, Smiths Medical (2017) advise that your tidal volume setting might simply be too high.
Low pressure = leakage or insufficient tidal volume/settings, faulty valve in the patient’s circuit
This alarm tends to occur when pressure drops below 10cmh20Earlier, I pointed out the alarm in the middle, at the bottom. This is SMMV. It’s an indicator that will flash green if the patient is breathing for themselves. The ventilator will assist if the patient breathes with less than 150ml of tidal volume. Between 150-400ml the ventilator will extent the exhalation time to allow the patient to complete their own breath, and above 400ml the ventilator will allow the patient to breathe and will not assist, but may still assist on the next breath if required (Smiths Medical, 2017; Baker, 2012).
When?
– AACE (2016) recommend considering ventilation if a ptn’s o2 sats <90 on high con o2,
if the RR is <10 or >30 bpm or if there is ‘inadequate chest expansion’ (p42) but the mechanical ventilator is to be used …
– for ’emergency and transport ventilation’ in 5kg + patients (Smiths Medical, 2017)Extra facts:
McCarty et al (2012) found that ‘ventilation rates and tidal volumes commonly exceeded Guideline recommendations. This resulted in […] excessive mean airway pressure’
Smiths Medical (2017) advise that peak inflation pressure should be below 20cmh20 when using a mask to ventilate due to the issues of too high pressure
Inspiration to Expiration should be 1:2 (Smiths Medical, 2017; Baker, 2012)
References
Baker, D. 2012. Emergency and Transport Ventilation, an introductory guide, Smiths Medical International Limited: Luton
Baker, D.J. 2016. Artificial Ventilation: A Basic Clinical Guide. Springer International: Switzerland
Baskett, P. et al. 1996. ‘Tidal volumes which are perceived to be adequate for resuscitation’, Resuscitation, 31 (3), pp. 231-4
Bocklage, T. & Balk, R.A. 2017. Setting the Tidal Volume In Adults Receiving Mechanical Ventilation: Lessons
Learned From Recent Investigations, Available Online: https://www.nbrc.org/wp-content/uploads/2017/07/Setting-the-Tidal-Volume.pdf (Accessed 17/12/17)
Frakes, M. 2007. Ventilation Modes and Monitoring, Available Online: http://www.rtmagazine.com/2007/02/ventilation-modes-and-monitoring/ (Accessed 17/12/17)
Gregory, P. and Mursell, I. 2010. Manual of Clinical Paramedic Procedures, West Sussex: John Wiley & Sons
McCarty, K. et al, 2012. Ventilation rates and tidal volume during emergency department cardiac resuscitation, Resuscitation, 83: 4, p45
Owen, R. and Castle, M. 2006. ‘EtCO2: the key to effective prehospital ventilation’, Emergency Medical Journal, 23 (7), pp. 578-579
Perkins, G.D. 2015. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation, Available Online: https://ercguidelines.elsevierresource.com/european-resuscitation-council-guidelines-resuscitation-2015-section-2-adult-basic-life-support-and/fulltext#back-bib0760 (Accessed 17/12/17)
Pilbery, R. & Lethbridge, K. 2016. Ambulance Care Practice, Bridgwater: Class Professional Publishing
Smiths Medical, 2017. ‘Pneupac – ParaPAC’, Pneupac Transport Ventilators – Breathe Easy, Available Online: https://www.smiths-medical.com/resources/pneupac-transport–ventilators—breathe-easy (Accessed 27/10/17)
With thanks to Smiths Medical for their correspondence and information
Music:
Dobroide, 2010. 20091229.ambulance.siren.wav. Available Online: https://freesound.org/people/dobroide/sounds/8713/ (Accessed 21/08/17)Productiontrax.com
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