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Advanced Emergency Nursing Blog from AENJ
The concepts, concerns, clinical practices, researches, and future of Advanced Emergency Nursing.
Friday, November 21, 2014

Unfortunately, most people learn most of what they think they know about firearms usage, ballistics, and gun handling from the entertainment industries. When stories are devised for entertainment, errors, or lies, are tolerated for “dramatic effect” and greater profits in a very competitive high-stakes industry with ever-evolving demands for yet more “cool” and bigger bang explosions. Truth, good sense, and science have nothing to do it with it.


True cowboys carried five rounds in their simple six-shooter for safety; the TV cowboys of our youth fired many more without reloading. The stunt man who is “shot” has a wired harness to yank him backwards off his feet. There’s no such thing as a handgun that is not detectable at the airport. Silencers don’t.  You can’t dance away from bullets as in Matrix, nor outrun an explosion.


All firearms-related events must be explained by laws of physics, mechanical and chemical engineering, and variables such as climatic effects and altitude, misadventure, human anatomy, physiology, and psychology. Very few conclusions can be drawn from the impressions of initial exam and treatment.


Because of skin elasticity, and wounding variables, it is not possible from wound appearance to judge the caliber of the missile. With measurements by thousandths of an inch, laboratory examination and measurement is more accurate.


Likewise the small hole is not necessarily the entry, nor is the large wound the exit. A contact wound may have gasses reflected backwards from a hard surface that blows the wound outwards. A round may dissipate its energy within the body and make only a small exit wound or none.


Projectiles do not travel in a straight line, neither in air nor through human tissue. The bullet may take an erratic path within the body as it meets different densities, or even be embolized. Be suspicious and thorough. Check for pulses and vascular insufficiency, or murmur. Sonography/radiography may help localize.


There is a vast difference in wounding effect between handguns and rifles or shotguns. There is no perfect weapon; and stopping a determined or drugged assailant may require many wounds; even wounds which will ultimately be fatal may not slow the aggression.


Wounding locations may not be what was initially perceived or stated due to movement during reaction time from detection of danger, response to assault, or delay in noting the ending of the fight. Natural psycho-physiological responses may alter perceptions during the life-threatening event.


It is critically important to document the physical findings in a plain-seeing, plain-speaking, non-judgmental manner that will not color or taint future investigations. In short, describe the simple appearance of wounds and findings, and the body’s response, without any forensic conclusions.


Avoid using wounding holes in clothing or tissue as the start of cutting with shears or incising tissue. Photograph whenever possible. Remember the confusion from JFK’s tracheotomy in the neck wound, and information recorded (or not recorded) in the chart.


Use paper bags, NOT plastic bags, for removed clothing, or to bag hands and feet, due to the “hot-house environment” created within the plastic that will degrade organic matter.

Call investigators and evidence technicians as soon as possible for best preservation and chain-of-custody evidence trail for all possible evidence. One must be prepared to state who had the evidence, when and for how long, and to whom and how it was transferred, at all times.


Recovered projectiles are preferably handled with gloved fingers, rather than toothed forceps that may alter evidentiary striations.


Accurate time entries are important to document.


It is not possible during acute resuscitation or at any time before a complete investigation, or even trial, to know who is innocent, guilty, or what occurred during the altercation. If you think your patient is the perpetrator, he may well be

an innocent, or even an off-duty or undercover officer. Do not compromise your care.


If there is active shooting around you, move, duck, get behind impenetrable cover, and leave by the safest way as soon as possible. Bullets, splinters, secondary missiles, do not discriminate or have a conscience; there is no self-destruct for a projectile in flight –it will not care whom it hits or discern if it was deserved or not. Police officers have poor hit probability, ricochets may occur, suppressive fire may be used (“keep ‘em pinned down”), or even ‘spray and pray.” Being a health care worker does not protect you from fire coming your way.


You are not safer in an area that is posted as a “gun-free zone.” Many potential, and defenseless, victims draw crazy “active killers.” 92% of recent events have occurred in such areas. Regardless, the number of such terror attacks is far less than public perception, is decreasing, and outnumbered by less obvious dangers.


The Eddie Eagle GunSafe® Program, an effective and suitable safety program for young children, is provided by the National Rifle Association, It only promotes safety, not gun use.


Discussion of safety issues have led to safety rules for firearms in different forms  for many years. The most durable and concise modern expression is the Four Rules of Gun Safety by Col. Jeff Cooper, a USMC officer, academician, firearms trainer and expert. Any accidental or negligent shooting is a violation of one or more of these rules.


1. All guns are always loaded. Even if they are not, treat them as if they are.

2. Never let the muzzle cover anything you are not willing to destroy. (For those who insist that this particular gun is unloaded, see Rule 1.)

3. Keep your finger off the trigger till your sights are on the target. This is the Golden Rule. Its violation is directly responsible for about 60 percent of inadvertent discharges.

4. Identify your target, and what is behind it. Never shoot at anything that you have not positively identified,


The Eddie Eagle GunSafe® Program, an effective and suitable safety program for young children, is provided by the National Rifle Association, It only promotes safety, not gun use.


Simple Ballistics
Duke Orthopaedics presents Wheeless' Textbook of Orthopaedics: Gun Shot Wounds
Simple Reviews
Prehospital Care  Blog of medical and trauma care by Orthopaedic Surgeons in an austere environment in association with Society of Military Orthopedic Surgeons

Norouzpour, A., Khoshdel, A. R., Modaghegh, M. H., & Kazemzadeh, G. H. (2013). Prehospital Management of Gunshot Patients at Major Trauma Care Centers: Exploring the Gaps in Patient Care. Trauma Monthly, 18(2), 62.

PMID: 24350154 [PubMed] PMCID: PMC3860682

Tactical Combat Casualty Care (ppt)

Dan S. Mosely, Maj USA MC FS  20 Jun 05

Treatment Reviews

Bruner, D., Gustafson, C. G., & Visintainer, C. (2011). Ballistic injuries in the emergency department. Emergency medicine practice, 13(12), 1-30.

PMID 22232864 EB Medicine: Full text

Motamedi, M. H. K., Ebrahimi, A., & Shams, A. (2013). Current trends in the management of maxillofacial gunshot injuries: a critical review. Annals of Oral & Maxillofacial Surgery, 1(1), 8.

Rohit Shahani, MD, MS, MCh  & Jan David Galla, MD, PhD Penetrating Chest Trauma Treatment & Management  Medscape Updated: Dec 13, 2013

Dicpinigaitis, P. A., Koval, K. J., Tejwani, N. C., & Egol, K. A. (2006). Gunshot wounds to the extremities. BULLETIN-HOSPITAL FOR JOINT DISEASES NEW YORK, 64(3/4), 139.

de Barros Filho, T. E. P., Cristante, A. F., Marcon, R. M., Ono, A., & Bilhar, R. (2014). Gunshot injuries in the spine. Spinal cord. Spinal Cord (2014) 52, 504–510; doi:10.1038/sc.2014.56; published online 29 April 2014

Evolution of Care and Survival

In Medical Triumph, Homicides Fall Despite Soaring Gun Violence

By Gary Fields and Cameron McWhirter.  The Wall Street Journal Updated Dec. 8, 2012 12:12 a.m. ET

Hostile Fire Environments

Murphy’s Law of Combat Operations 
[includes coarse military humor]

Firearms in the Entertainment Industry
Horman, GS. 10 Movie Myths Dispelled “American Rifleman July 16, 2012

Pappalardo, Joe Anatomy of the Perfect (Undead) Headshot  Popular Mechanics website ©2014 Hearst Communication, Inc.

Seymour, Mike The Art of Wire Removal 10/27/07
{How stuntmen’s wires are removed from the image that you see on screen.}
Gun Safety
Gun Control Controversy

GunFacts.Info website 119 pp pdf

Lott, John R. New CPRC Report: Errors in Bloomberg’s latest report on Mass Shootings October 2, 2014 Crime Prevention Research Center

Lott, John R., Jr .Report from the Crime Prevention Research Center

The Myths about Mass Public Shootings: Analysis

October 9, 2014 Revised 36pp pdf

The Facts about Mass Shootings  It’s time to address mental health and gun-free zones. By John Fund. National Review Online December 16, 2012 4:00 PM


      Tom Trimble, RN CEN
All opinions are solely those of the author.

Saturday, October 18, 2014

Much of what we do is to educate, whether patients, peers, or other staff. How often have we encountered the self-assured “newbie” staff member who is genuinely clueless, yet confidently not knowing what is not known? And there are those who always instinctively do the right thing, yet feel they are not masterful.

A1999 paper, by the two eponymous authors from Cornell University, describes the phenomena. Essentially, “If you’re incompetent, you can’t know you’re incompetent. […] the skills you need to produce a right answer are exactly the skills you need to recognize what a right answer is. —David Dunning (as cited in Wikipedia article, below).

An example would be the recent ACLS graduate who tells the airway manager, who is ventilating the patient well without a leak, that he/she is holding the mask “upside-down”. This deliberate choice is known to the expert, but not well-published in basic literature. The so-called “merit badge courses” may contribute to this than a more comprehensive training program.


Unfortunately, there is a popular tendency to use the reference as a pejorative and jocular epithet. To apply such an indignity is without merit. Inevitably, in our complicated profession, we will encounter workers with different backgrounds and experiences. As those who continually share and teach, we owe it to the person to better their knowledge, and to better understand the intricacies of a more nuanced practice. It isn’t always possible to so immediately, but a simple “I’d like to explain it, later” will do.


Wikipedia Article: Dunning-Kruger Effect

Wikipedia Article: Four Stages of Competence

RationalWiki Article: Dunning-Kruger Effect

Lee, Chris. Revisiting why incompetents think they’re awesome

Dunning-Kruger study today: The uninformed aren't as doomed as the Web suggests. Ars Technica blog. May 25 2012, 9:00am PDT




Tom Trimble, RN CEN
All opinions are solely those of the author.

Wednesday, September 17, 2014

Because of your professional skills, you’ve been asked “to arrange first aid” for a group or cause in which you believe. You’re eager to help and believe that you can do the best possible job of it.


Your planning must consider the needs and resources, the number and type of attendance, location, potential risks, and liabilities, and the level of care that you intend to provide, scope of practice, and necessary supervision. There will be different considerations for an informal youth group, or a large public event (especially one in which intoxicants are common), and even by weather.


It is not possible for this column to give sufficiently deep and comprehensive advice or legal opinion; it’s our purpose to provoke thinking and planning points for which you may need local authoritative advice or legal counsel. Remember, too, that regardless of Good Samaritan laws, your own actions may be thought to be acting in a professional capacity as a provider or as an agent of the event organizers. You should review your professional liability and malpractice coverage to determine your personal risks. Does the organization’s umbrella policy provide coverage for this kind of event?


Plaintiff’s allegations will include their view of:

  • Your obligation to the victim/plaintiff;
  • And asserting that you failed to meet that obligation (duty)
  • The alleged causation of harm sustained;
  • Their assertion of Negligence/Willful Disregard/Gross Neglect (You knew, or should have known …).


Your Defense arguments might include:

  • Lack of relationship or obligation (might be modified by host or business invitee duties, or by paid admission);
  • Assumption of risk or contributory negligence by the plaintiff;
  • That Prevention/Mitigation efforts were reasonable and prudent;
  • That applicable Standards of Care were not breached.


If it is a large public event, with foreseeable risks, and admission is charged of other value exchanged, then it may be wise to contract for needed services from licensed and insured providers: Venue operators, Security firm; event medical crews or EMS stand-by providers; to provide some shielding to your group as to liability. Coordination and planning with official emergency services is very useful. Community services have an established routine, authority, and controlled scope of practice, and protocols, that help protect them, you, and the patients encountered.


If a high level of care or resource-intensive capability (mass attendees, large area, many defibrillators) is needed, or substantial numbers of qualified volunteers, especially for a high-visibility public fund-raiser, consider approaching a hospital or professional group to sponsor/donate/provide equipment, staff, funding, etc., in exchange for advertising/visibility/PR. Additionally, staff would have licensing and certifications all verified lessening the amount of work in oversight.


In what manner will care be made available? A central first aid station? Multiple stations? Roving teams? (In large events, or with severe weather stress, some providers could be actively patrolling to find persons at risk before they go down.) How will you be notified of needs elsewhere on the property? Who will respond?


Communications and transportation are important considerations. Calls for help, dispatching of responders, summoning transporters, interfacing with public services or destination hospitals, will require reliable communications and persons to coordinate/track calls, etc. Internal mobility for teams may require golf carts or ATVs, and stretcher capability, if it would be hard for conventional ambulances or fire trucks to navigate.


Recruit, in depth, and have co-coordinators, so that “the show can go on” regardless of no-shows, can’t-do-its, or personal emergencies. Make sure that everyone understands the goal, the mission, the plan, and the back-up plans. Any team member should be able to perform in your absence.


Prevention is better than cure. Water, cooling stations, people-spotters, patrolling, can be essential. Be alert to safety hazards and deal with them immediately. No chains on exit doors. No fire hazards. Ensure the venue operator fulfills the safety obligations. If water activities are available, ensure that there will be trained Lifeguards without other responsibilities, suitably equipped, and with relief staff available.


If you are the Camp Nurse for a youth group, you should have medical exam & history records for the youth, their leaders, and staff. On “Visitors’ Day,” you will have more people on the grounds, and no foreknowledge of their history and needs.


I hope that this discussion raises questions, gives insights, prompts reflection upon larger issues not otherwise immediately apparent, and inspires you to successful comprehensive planning for a great event.


Tom Trimble, RN CEN
All opinions are solely those of the author.

Thursday, September 04, 2014
This is the fifth part of our series on "Early Modern Resuscitation."

Part I: Oral Airways, early resuscitation, and recognition of airway care.

Part II: Mouth-to-Airway (adjunct)
Part II Erratum: Erratum in Mouth-to-Airway (adjunct)Part III: Early Modern Resuscitators
Part IV: Carbon Dioxide As A Resuscitative Gas
Part V: Oxygen Powered Resuscitators

From the earliest experiments with oxygen, it was apparent that oxygen supported combustion, metabolism, and revived the nearly asphyxiated. It was not a practical resuscitative aid until production could be commercially successful (~1895) and made portable in compressed form.


Simple free-flow oxygen to the patient would require manual artificial respiration to enhance ventilation.


The next step would be to have some a demand valve (low flow) to conserve O2 otherwise wasted during exhalation.


Using positive pressure to ventilate had many efforts through the twentieth century.


In the late 19th century, anesthetists could use bellows foot pumps to give ventilation, e.g., the Fell-O’Dwyer, but weren’t suitable for or thought of for lay use.


The Lungmotor was similar to a bicycle pump but double-acting creating a negative pressure exhalation.


In 1907, Dräeger of Lubeck, Germany, introduced an automatic pressure-cycled resuscitator, and later had a US subsidiary. It, and subsequent inventions by others, would inflate to a pressure thought to be safe, then cycle to an exhalation negative phase thought to be safe, and then recycle.


Ongoing objections over the years questioned the sensitivity and accuracy of the pressure sensing, especially for children and infants, or in the dynamic situation of airway obstruction and changing closing pressures. In obstruction, the machine was to rapidly cycle creating an audible “chattering” effect, which indicated the obstruction should be cleared, and ventilation resumed. Cardiac compressions rendered these obsolete, as the thoracic pressures would trigger recycling so that volume could not be delivered. With this latest opprobrium, these devices were condemned by the medical profession.


The Demand Valve was the answer to this, appearing in 1964.Upon manual triggering, or by a demand breath, rapid  (160 lpm) oxygen would flow, allowing for inflation between compressions, or for a demand breath sufficient flow to obviate the sense of suffocation.


It wrongly frightened some medical personnel as it was operated by a 50 psi wall source or from a step-down regulator from a tank (some thought the patient received wall 50 psi or 1500 psig from the tank directly to the lung. In fact, the pressure delivered was limited to ~50 cm/H2O, relieving the excess, but holding that amount for CPR. It was extremely well-liked by field personnel, but virtually unknown in hospitals. Light and handy, it had sufficient flow to ventilate in spite of leaks common in the mobile environment with an unsecured airway, rather than volume-limited like a bag (which needed an offside hand to squeeze, making mask application awkward single-handed and was bulky; if you were lucky, there was a trigger attachment that allowed two-handed mask application; but agency buyers seldom obtained them). It was manually time-cycled, so attention was needed to volume delivered. Unfortunately, rapid flow and high volumes could reach high quick peak inspiratory flow pressures, that could (absent a perfect airway) be diverted to the stomach easily overwhelming the gastroesophageal sphincter. Vomiting did occur frequently, in such cases, and medical condemnation followed. Manually triggered flow rate was reduced to 40 LPM while patient-actuated demand flows remained fast. FROPVD is a later acronym for flow restricted oxygen powered ventilation device.


Ironically, in this era, BVMs had problems with oxygen enrichment due to valve and bag designs and seldom achieved a high FIO2. Using a demand valve as a bag refilling device, seldom done, meant a true 100% and a quiet resuscitation room as there was no loud continuous flow of oxygen. The antipathy between field personnel with demand valves and hospital staff with bags was so great that there was seldom any agreement. Better access to federally funded grant specification writing groups meant that hospital physicians would “win.”


There were other ‘shoot in the foot” episodes. Esophageal Obturator Airways [EOA] and Esophageal Gastric Tube Airways [EGTA] precluded gastric inflation, and oxygen was delivered via periglottal ports; but were awkward to intubate “around.” The mask portion was clumsy as it was high and hard requiring expert mask-fitting skills. However, they could be used easily and well with the assist of head-straps which were never sold as part of the complete “kit” but only as an uncataloged “spare part.” When medical authorities were informed of this (and that patients could be delivered with a normal ABG), it was decided to ignore this  as a manuscript was in preparation “to get rid of them “ anyhow, in favor of endotracheal intubation..


As technology evolved, automatic resuscitator heads appeared again, but “the bloom being off the rose” did not find wide popularity. Automatic Transport Ventilators (ATV) also appeared, but likewise suffered as knobs and dials didn’t give visible feedback and cost concerns for both types of device favored ever-cheaper bags (as patents expired, and clones were marketed) instead of high acquisition, training, and sterilization costs.


Ironically, with the prevalence of poor hyperventilatory bag ventilation and its adverse effects recognized, it is now an ideal time to review how ventilation is delivered: a regular controlled rate and depth, sensitive to pressures, and ability to add PEEP and lung-sparing strategies is highly desirable. 




  1. Oxygen; Wikipedia
    **Oxygen, element and metabolic chemical.
  2. Joseph Priestly; Wikipedia
    **With Lavoisier, and Scheele, has early claim to discovering oxygen.
  3. Robert Boyle; Wikipedia
    **Early experiments on gases and metabolism
  4. How to light a grill in 2 seconds; YouTube
    **Oxygen does not explode, but does support combustion, even violently.
  5. Hypoxia, (medical); Wikipedia
    **Many forms of hypoxia occur, and each must be treated appropriately.
  6. An Experiment on a Bird in the Air Pump: Wikipedia
    **Experimental hypoxia.
  7. 1800-1920: Oxygen cylinders and chambers;
    **Early attempts to contain and use oxygen therapeutically.
  8. search for “historical medical uses of oxygen”
    **General searches such as this can net interesting images.
  9. The History of Dräeger
    **An in-house corporate history and profile, shows early respiratory developments from 1889-2010. Pulmotor is 1907.
  10. Resuscitation of man in battle, artificial respiration with oxygen. MEDICAL DEPARTMENT UNITED STATES ARMY IN WORLD WAR II
    CHAPTER I Resuscitation of Men Severely Wounded in Battle
    **The advancement of resuscitation within field military medicine.
  11. Martin, Lawrence, M.D.  Oxygen Therapy: The First 150 Years Curiosities, Quackeries, and Other Historical Trivia A CHRONOLOGY FROM PRIESTLEY TO HALDANE, BASED MAINLY ON ORIGINAL SOURCES With Editorial Comment Website updated 4/12/2011. Accessed July 28, 2014
    **Quoting original documents of fascinating history.
  12. Grainge, C. (2004). Breath of life: the evolution of oxygen therapy. Journal of the Royal Society of Medicine, 97(10), 489-493.
    **Developmental history.
  13.  Resuscitator: Wikipedia general article
  14. Emergency Care Research Institute [ECRI] Gas-Powered Resuscitators    Hazard [Health Devices Nov 1988;17(11):352-4]
    **Good review of concerns re Demand Valves, then and now.
  15. Personal Communication. ~1985.
  16. Geehr, E. C., Bogetz, M. S., & Auerbach, P. S. (1985). Pre-hospital tracheal intubation versus esophageal gastric tube airway use: a prospective study. The American journal of emergency medicine, 3(5), 381-385.
    ** Finds fault with EOA/EGTA, proposes ETI “gold standard.”
  17. Weiss, S. J., Ernst, A. A., Jones, R., Ong, M., Filbrun, T., Augustin, C., ... & Nick, T. G. (2005). Automatic transport ventilator versus bag valve in the EMS setting: a prospective, randomized trial. Southern medical journal, 98(10), 970-976.
    **Study finds EMS able to do more tasks, document better, perform physiological monitoring, with use of ATV.
  18.  Pepe, P. E., Copass, M. K., & Joyce, T. H. (1985). Prehospital endotracheal intubation: rationale for training emergency medical personnel. Annals of emergency medicine, 14(11), 1085-109
    **Support for prehospital ETI.

  19. Noordergraaf, G. J., Van Dun, P. J., Schors, M. P., De Jong, W., & Noordergraaf, A. (2004). Efficacy and safety in patients on a resuscitator, Oxylator EM-100, in comparison with a bag-valve device. The American journal of emergency medicine, 22(7), 537-543.
    **One of two small simultaneously published studies comparing bag-valve vs. Oxylator in intubated patients.
  20. Noordergraaf, G. J., Van Dun, P. J., Kramer, B. P., Schors, M. P., Hornman, H. P., De Jong, W., & Noordergraaf, A. (2004). Airway management by first responders when using a bag-valve device and two oxygen-driven resuscitators in 104 patients. European journal of anaesthesiology, 21(05), 361-366.
    **One of two small simultaneously published studies comparing bag-valve vs. Oxylator in intubated patients.
  21. White, Dan as PhillyDan in Paramedic BlogWhat Happened to Ventilation?” 2005
    **Opinion piece upon poor equipment choices, inadequate or dangerous ventilation, AHA’s support for “Hands Only, CPR”, etc.
  22. Strayer, Reuben MD – “Podcast 65 – A Primer on BVM Ventilation with Reuben Strayer” – 2012 –
  23. Weingart, S. D. (2011). Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. The Journal of emergency medicine, 40(6), 661-667.
    **Excellent article.
  24. Du Canto, James MD – (2012) Podcast 127 – The Oxylator with Jim DuCanto –
    **A recent take by an anesthesiologist on the advantages of an automatic resuscitator vs. the disadvantages of BVM ventilation.

ILLUSTRATIONS: (Links provided due to copyright issues)

Pulmotor: Google images for Pulmotor


Draeger Pulmotor (1907) at Wood Library-Museum of Anesthesiology


Lungmotor: The Life Saving Devices Company, Chicago, Illinois
Google image search for Lungmotor.


Lungmotor in:
Kennedy , Walter W.
Resuscitation of the Apparently Drowned. Public Health  Vol 5, No 6 June 1917

Infant Lungmotor {3 views} Wood Library-Museum of Anesthesiology [detail view]


Lungmotor Resuscitator from


Late-Model Stephenson Minuteman Resuscitator from


Artificial Respiration and the H-H Inhalator from

H-H Inhalator: Google image search for H-H Inhalator (not positive pressure) devised and promoted by Yandell Henderson, Ph.D, and partner Haggard.


1920's: Resuscitation: Pulmotor Resuscitator from


1940: Resuscitation: Vintage Hand Pump Resuscitator from

Concern for nerve gas attacks during WWII were very high, and although not used, caused much research on artificial respiration.


1940’S Emerson Resuscitator from


1940 -1950’s (sic) E-J Resuscitator from
Note the strings dangling from the flangeless wire airways.

1950’S: Resuscitation: MSA Pneolator from MSA had manufactured the obsolete H-H Inhalator; this probably replaced it with active positive-negative ventilation.


1953: Emerson Resuscitator Literature from


Emerson Resuscitator Utility Model 1960 from


1960s E-J Lytport Resuscitator from


1970's: Resuscitation: E & J Resuscitator Panel Mounted Resuscitator from Later model, to make lighter and more mobile, i.e., en route resuscitation.


E&J Resuscitator:  Google  search for E&J Resuscitator


Tom Trimble, RN CEN
All opinions are solely those of the author.


Tuesday, May 27, 2014
This is the fourth part of our series on "Early Modern Resuscitation."

Part I: Oral Airways, early resuscitation, and recognition of airway care.

Part II: Mouth-to-Airway (adjunct)
Part II Erratum: Erratum in Mouth-to-Airway (adjunct)Part III: Early Modern Resuscitators
Part IV: Carbon Dioxide As A Resuscitative Gas

There is insufficient space for a complete exposition of the theory and battles over carbon dioxide resuscitation. The select bibliography will provide ample links to extend your reading.


“Carbon Dioxide Resuscitation?” You think to yourself, What could that be?”

Does the name “Carbogen” ring a bell?


During the 1920s and 1930s, even later, the use of inhaled carbon dioxide in resuscitation was supported by the highest authorities. It was thought that the body’s “desire” to increase rate and depth of respiration to blow off CO2, was a useful stimulant.


Fahey indicates that the antecedent error of reasoning, widely held, in the naïve days of respiratory physiology investigations was an over-emphasis of respiratory failure in extremis that showed hypoxia and hypocarbia with shallow tachypnea. This was described as acarbia, and it was thought that giving carbon dioxide would drive greater minute volume and fix both "problems."


A variety of devices were used and concentrations delivered varied. Even after no longer having a role in resuscitation, CO2 was advocated for accelerating clearance of carbon monoxide poisoning into the 1950s and 1960s.


In 1927, H.W. Davies reported in the British Medical Journal of "A simple portable apparatus for the therapeutic administration of carbon dioxide." Essentially, the small cylinders of compressed carbon dioxide in "soda siphons" by the Sparklet Company for one's whisky were adapted to medical use as a respiratory stimulant. These became known as Sparklet Resuscitators; CO2 from either "C" or "J" size cylinders would be given to breathing victims with respiratory failure. 


Sparklet Resuscitator, cased set

©Tom Trimble, RN CEN; object from Author’s Collection

This is a cased kit of a Sparklet Resuscitator (J size),

with pressure chamber, regulator, tubing, reservoir

bag, flow stopcock, and funnel mask, with associated


Closer view of Sparklet Resuscitator

©Tom Trimble, RN CEN; object from Author’s Collection


Closer Detail View of Sparklet Resuscitator

Sparklet Resuscitator, price list

©Tom Trimble, RN CEN; object from Author’s Collection

Manufacturer's Price List for Sparklet Resuscitator


Carbogen, a trade name, was both O2 and CO2 mixed within a single cylinder, usually 3.5%, 5% (most commonly), or 7% CO2 and administered by anesthesia machine or other apparatus. It necessitated either switching cylinders from an oxygen device or having extra equipment; but when used outside a hospital was administered with an inhalator or resuscitator by rescue crews or in industrial or electrical, gas, or mining environments. Inhalators supplied free-flow or demand-controlled gas and manual artificial respiration would supplement respiratory effort, and resuscitators would cycle a positive-pressure or alternating positive-negative gas flows to the lung.


The therapeutic effect of CO2 inhalations in intermittent sessions was thought useful in pneumonia to increase respiratory rate and depth and to decrease atelectasis, and in clearance of carbon monoxide intoxication. Probably the only remaining clear indication for carbon dioxide inhalation would be Central Retinal Artery Occlusion, if seen immediately (<90 minutes), to attempt vasodilatation of that artery and thereby diminish the ocular infarct; however, the Cochrane Collaboration is unable to come to a conclusion as to its efficacy1.


If one person personified and dominated the era of CO2 resuscitation, it is Yandell Henderson, Ph. D., a Yale physiologist. He took up many clinical researches feeling that physiology should be an applied science contributing to the solution of human problems.  He was not a physician, but late in life received an honorary MD degree. He took part in high altitude respiratory physiology research on Pike’s Peak with J.S. Halstead from Oxford, who espoused a belief in carbon dioxide as the controlling agent of respiration and a postulated “acarbia” as the fundamental deficit. Halstead also maintained a theory that discrepancies in calculations were due to the lungs themselves “secreting” oxygen.


Henderson, it would seem, was an enthusiast, well-convinced of his opinions, with missionary zeal, who would firmly argue his positions and tirelessly campaign them. In 1920, he put forward his paper on CO2. In 1922, he and his colleague, Haggard, invented their H&H (or H-H) Inhalator. He opposed automatic pressure-cycled resuscitators (Pulmotor, and others) as being insufficiently sensitive to changes within the lungs, and insufficient in tidal volumes, but also at the extreme of pressures tolerated by the lungs and therefore liable to cause injury. He felt that Schaefer's method of artificial respiration was excellent and efficacious, supplemented when possible by Carbogen inhalation from the H&H Inhalator.


Henderson's contributions to study of physiologic effects include: mining; toxic gases; resuscitation; high altitude medicine; aviation medicine; vehicle exhausts, tunnel ventilation, and air pollution; protective appliances; US Army Chemical Warfare Service; and exercise physiology.


Select Bibliography:


  1. Fahey, D OStJ. The use of carbon dioxide in resuscitation.  St John History Volume 10 (2010-2011)
    **Australian review of Sparklet Resuscitators and CO2 therapy.
  2. Link to photograph of Yandell Henderson, Ph. D. Biographical Memoirs, V. 74 (1998) The National Academies Press. West, John B. Accessed May 17, 2014.
    **Most common Internet photograph of Henderson; from NAS memoir.
  3. Douglas, C. G., Haldane, J. S., Henderson, Y., Schneider, E. C., Webb, G. B., & Richards, J. (1913). Physiological observations made on Pike's Peak, Colorado, with special reference to adaptation to low barometric pressures. Philosophical Transactions of the Royal Society of London. Series B, Containing Papers of a Biological Character, 203(294-302), 185-318.
    **Paper resulting from Pike's Peak expedition with Halstead.
  4. Henderson, Y. (1916). Resuscitation Apparatus. Journal of the American Medical Association, 67(1), 1-5.
    **Commentary and review of resuscitation devices.
  5. Henderson, Y., Haggard, H. W., & Coburn, R. C. (1920). The Therapeutic Use of Carbon Dioxid After Anesthesia and Operation. Journal of the American Medical Association, 74(12), 783-786.
    **Henderson's foundation piece, establishing his teachings for years to come.
  6. Henderson, Yandell Ph.D. The Prevention and Treatment  of Asphyxia in the New-Born J. A. M. A.   90(8):383-386, February 25, 1928. From Neonatology on the Web. Accessed May 17, 2014.
    **Henderson's neonatal recommendations.
  7. Flagg, Paluel J. MD Treatment of Asphyxia in the New-Born.
    J.A.M.A.  91(11): 788-791, Sept. 15, 1928 From Neonatology on the Web.
    Accessed May 17, 2014.
    **Flagg's endorsement of Henderson's article.
  8. Neonatal Resuscitation, ca. 1944” Illustrations from The Art of Resuscitation, by Paluel J. Flagg, MD, provided by Neonatology on the Web.” Accessed May 17, 2014.
    **Photograph of neonatal resuscitation. In The Art of Resuscitation, Flagg names this as "Henderson's equipment."
  9. Flagg, P. J. (1944). The Art of Resuscitation. 453 pp. New York: Reinhardt Publishing Company
    **Flagg, "
    wrote seven books on anesthesia between the years 1919 and 1944,all entitled The Art of Anaesthesia" {c.f., Larson, below.} which were prominent. In this work, he indexes Henderson nine times, names him in text ten times, and cites references to him eight times. Text references are unfailingly respectful, even flattering.
  10. Link to photograph & brief biography of Dr. Paluel Joseph Flagg. Website of Catholic Medical Mission Board. Accessed May 17, 2014.
    **Prominent and influential anesthesiologist shared common views with Henderson.
  11. Larson, Merlin D. M.D. "Paluel J. Flagg and the “Art” of Anesthesia" CSA Bulletin. Arthur E. Guedel Memorial Anesthesia Center, San Francisco.
    **Monograph upon Flagg's work and writings.
  12. SHIPWAY, F. E. S. (1932). RESUSCITATION DURING ANÆSTHESIA AND OF THE NEWLY BORN. British Journal of Anaesthesia, 9(2), 69-79.|
    **Recommends 7% CO2.
  13. Apgar, V. (1953). A proposal for a new method of evaluation of the newborn. Curr Res Anaesth, 32, 260-267. From Neonatology on the Web. Accessed May19, 2014
    **Apgar's Score proposed; supports oxygen (without CO2) for neonatal resuscitation.
  14. Henderson, Y. (1932). Reasons for the Use of Carbon Dioxide with Oxygen in the Treatment of Pneumonia. New England Journal of Medicine, 206(4), 151-155.
    **Argues for increased minute volume to decrease atelectasis and clear secretions.
    **Journal report announcing the Sparklet Resuscitator.
  16. Historical Happenings Sparklets Bulbs - [no author stated] Open Airways-  St John Ambulance of South Australia -_07_July12
    **Brief account of CO2 cylinders found when moving museum.
  17. West, James B. Yandell Henderson April 23, 1873 - February 18, 1944 A Biographical Memoir by James B. West. 1998. National Academies Press Accessed May13, 2014.
    **Memoir of Henderson, fifty years after his death, by National Academy of Science, of which he was a member. His life, work, personality, honorary MD, politics, are discussed.
  18. Keys, T. E. (1974). Yandell Henderson (1873-1944). Anesthesia and analgesia, 54(6), 806-806.
    **Four paragraph “Historical Vignette” summarizing Henderson’s career.
  19. Pauly, P. J. (1994). Is liquor intoxicating? Scientists, prohibition, and the normalization of drinking. American journal of public health, 84(2), 305-313.  PDF.
    **Efforts to repeal Prohibition.
  20. Roizen, Ron. A Footnote to Pauly (1994): Yandell Henderson’s Lusitania Letters. 2012. From "Points: The Blog of the Alcohol and Drug History Society." Accessed May 15, 2014
    **Henderson's role in repealing Prohibition on beer, his cultural and political views.
  21. Multiple authors. BEDSIDE MEDICINE FOR BEDSIDE DOCTORS. California And Western Medicine November, 1928. Vol XXIV, No. V
    **Clinical notes upon CO2 therapy.
  22. Henderson, Yandell. New Treatment for Carbon Monoxide Poisoning. December, 1922. The Coal Industry, Volume 5. pp 526-528. Accessed May 19, 2014.
    **Argues for CO2 therapy to more rapidly clear CO intoxication.
  23. Carbonated Water Now Used In Gas Poisoning Treatment. The Evening Independent. St. Petersurg, Florida. January 10, 1925 p 20. Accessed May, 19, 2014.
    **Newspaper publicity account of "Weiss Beer" usage, and CO2 therapy by Henderson.
  24. Douglas, T. A., Lawson, D. D., Ledingham, I. M., Norman, J. N., Sharp, G. R., & Smith, G. (1961). Carbogen in experimental carbon-monoxide poisoning. British medical journal, 2(5268), 1673.
    **Researches to establish or refute CO2 therapy in CO intoxication.
  25. Henderson, Y. (1925). A Lecture ON RESPIRATION IN ANAESTHESIA: CONTROL BY CARBON DIOXIDE*. British medical journal, 2(3390), 1170.
    **Henderson's views on CO2 as the control of breathing.
  26. Henderson, Y. (1943). The return of the pulmotor as a" resuscitator": a back-step toward the death of thousands. Science, 98(2556), 547-551.|
    **Henderson’s vehement denunciation of automatic resuscitators, trade practices, and his personal difficulties attempting to suppress them.
  27. Parsloe, C. To Caesar what Is Caesar's. Canadian Journal of Anaesthesiology. 1994. 41:1. pp 74-80.
    **Correcting priority of attribution to maxim supported by Henderson as to CO2 controlling respiration; explains Mosso's usage; clarifies "Acapnia."
  28. Paul, John R. Dr. Yandell Henderson. Transactions of the American Clincal and Climatological Association. 1946; 58: li–lii PMCID: PMC2242328
    **An "in memoriam" piece; notes personality, accomplishments, honorary MD.
  29. Bhargava, C. A. CARBONDIOXIDE FOR RESUSCITATION & OXYGEN THERAPY. Indian J. Anaesth. 2003; 47 (2) : 146-147
    **Shows devices and problematic history of CO2 and equipment.
  30. Wrigley, M., & Nandi, P. (1994). The Sparklet carbon dioxide resuscitator. Anaesthesia, 49(2), 148-150.
    **Authors show a “C” cylinder Sparklet Resuscitator, recount the general history, and outline the history of CO2 in resuscitation, note Waters’s caution re hypercarbia.
  31. Donald, K. W., & Paton, W. D. (1955). Gases administered in artificial respiration. A Report to the Medical Research Council by Its Committee* for Research on Breathing Apparatus for Protection against Dangerous Fumes and Gases. British Medical Journal, 1(4909), 313.
    **"For these reasons it is recommended that in first-aid practice carbon dioxide should not be administered with oxygen in the resuscitation of subjects requiring and receiving artificial respiration." UK authoratative declaration against Carbogen.
  32. Wineland, A. J., M.D. (1935) MECHANISM OF CARBON DIOXID THERAPY* WITH SPECIAL REFERENCE TO THE LUNGS. (sic) California State and Western Medicine. May, 1935. Vol. 42, No.5. pp 354-357
    **Describes his reasons and method of administration, monitoring patient; reviewer comments warn of use if hypercapnic which induces further depression.
  33. Genaud, P. E. M. (1956). Gases Administered in Artificial Respiration. British medical journal, 2(4985), 176.
    **Commenting on Donald & Paton's report to the MRC; notes U.S. Army Chemical Corps abandoned Carbogen in 1952.
  34. Fisher, J. A., Iscoe, S., Fedorko, L., & Duffin, J. (2011). Rapid elimination of CO through the lungs: coming full circle 100 years on. Experimental physiology, 96(12), 1262-1269. PDF
    **A review of eliminating CO with CO2, O2 alone, hyberbaric O2, and proposing a method of inducing hyperpnea and maintaining normocapnia by supplementation.



                      Tom Trimble, RN CEN


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    Tom Trimble
    Tom Trimble, RN CEN is the Online Editor of AENJ.

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