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

 

Sincerely,
 
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. 

 

REFERENCES:

 

  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; HardluckAsthma.blogspot.com
    **Early attempts to contain and use oxygen therapeutically.
  8. Images.google.com 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
    GENERAL SURGERY 
    Volume II GENERAL SURGERY Chapter 1 Part I RESUSCITATION, CONTROL OF PAIN, AND ANESTHESIA
    CHAPTER I Resuscitation of Men Severely Wounded in Battle
    Henry K. Beecher, M. D.* THE EVOLUTION OF METHODS OF RESUSCITATION IN THE MEDITERRANEAN THEATER OFFICE OF THE SURGEON GENERAL 
    DEPARTMENT OF THE ARMY WASHINGTON, D. C., 1955
    **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 – EMCrit.org
    **NOT TO BE MISSED!
  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 – EMCrit.org
    **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

http://woodlibrarymuseum.org/museum/item/96/draeger-pulmotor

 

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 EMSMuseum.org

 

Late-Model Stephenson Minuteman Resuscitator from EMSMuseum.org

 

Artificial Respiration and the H-H Inhalator from EMSMuseum.org

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 EMSMuseum.org

 

1940: Resuscitation: Vintage Hand Pump Resuscitator from EMSMuseum.org

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 EMSMuseum.org

 

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

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

 

1953: Emerson Resuscitator Literature from EMSMuseum.org

 

Emerson Resuscitator Utility Model 1960 from EMSMuseum.org

 

1960s E-J Lytport Resuscitator from EMSMuseum.org

 

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

 

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

 

Sincerely,
 
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
CLICK FOR LARGER IMAGE.

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

documents.


Closer view of Sparklet Resuscitator

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

CLICK FOR LARGER IMAGE

Closer Detail View of Sparklet Resuscitator

Sparklet Resuscitator, price list

©Tom Trimble, RN CEN; object from Author’s Collection
CLICK FOR LARGER IMAGE

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.
  15. DAVIES, H. W. (1927). A SIMPLE PORTABLE APPARATUS FOR THE THERAPEUTIC ADMINISTRATION OF CARBON DIOXIDE. British Journal of Anaesthesia, 4(3), 148-153.
    **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.

                 Sincerely.

 

                      Tom Trimble, RN CEN

 

                      All opinions are those of the author.

     


    Monday, May 26, 2014
    To those who have served and sacrificed,
    To those who have served and suffered,
    To those who stayed and supported,
    Advanced Emergency Nursing Journal offers its respectful reverence, its gratitude, and a deep appreciation for what you've done for the sake of others.
    Thank you.

    Saturday, May 03, 2014

    Although told several times, the story of the development by Henning Ruben of the prototypical modern manual resuscitator, the self-refilling bag with unidirectional non-rebreathing valves which now dominate the world of resuscitation, is still not well-known.

     

    What were its recent antecedents? What further developments occurred?  Review of the Wellcome Library movies on YouTube (1945) [links below in references] is instructive as to resuscitative methods of the 1930s and 1940s: Manual methods; gas bag or bellows operated by hand or machine; an anesthesia gas machine; or iron lung.

     

    Joseph Kreiselman’s portable concertina-like bellows was invented and deployed in the US military from 1943 followed by the UK’s Porton Resuscitator, postwar, from its secret chemical research facility and used industrially into the early 1960s. Kreiselman later did much work on neonatal resuscitation and warming beds.

     

    Child-sized Kreiselman Resuscitators
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Remember to maintain Triple Airway Maneuver and push bellows down without losing head tilt collapsing airway or creating leak.

     

    Bellows resuscitators are awkward as it is difficult to maintain a patent airway as the downward compression of the bellows tends to collapse the airway; if uneven, the axial loading of the bellows tends to cause mask leak; as well, mask-hold is inherently one-handed, and sensing of compliance is poor. Latterly, equipment standards decried use of a bellows and favored the self-refilling bag.

     

    Some European bellows units were separated by tubing from the mask, even having belt clips to allow compression against the first aider’s body or two-handed mask-hold with additional rescuers.

    Bellows Resuscitator, Chirana, 1969, Czech Military
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Czech Military resuscitation kit, 1969, mfr. Chirana.
    Note metal belt bracket to support one-handed
    inflation. Rubber parts dusted with talc for preservation.

     

    1953 was the first evolution of Ruben’s self-refilling bag with non-rebreathing valves (“How the BVM beganq.v). It went to market in 1956 with a foam-rubber filled bag that allowed re-expansion and pressure limitation; subsequent breakdown of the foam and sterilization problems led to further modifications.

     

    Ruben’s AMBU evolved through several valves and material changes to improve performance. Other challengers came to the burgeoning market with different designs, valves, and materials, many of which functioned inadequately when evaluated. Ruben’s insistence upon including a portable foot-operated aspirator did much to establish portable suction, not requiring power or oxygen supply,  in field care. Chemical-resistant BVMs with a cartridge respirator filter are made for military and toxic environments.

     

    AMBU Mark III RDIC resuscitator, modern U.S. military version for chemical, biological, nuclear environments.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    AMBU Mark III (mil) RDIC resuscitator for U.S. Military
    use in Chemical, Biological, Nuclear environments.

     

    Laerdal’s design, notable for a duckbill or fishmouth valve suggested by James Elam, also evolved with new masks, folding capability, better reservoirs, and silicone for ability to sterilize. Now off-patent, there are disposable clones readily availability. Laerdal also offered a Freon-powered aspirator (no longer made due to ecological concerns) and electrical aspirator units.

     

    Laerdal Resusci-Folding-Bag II
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Collapsable PVC bag, clear acrylic masks. Reservoir tubing replaced
    by reservoir bag with over/under pressure relief valves. Note valve can
    remain on patient with extension tubing from mask for awkward transports.

     

    Laerdal RFB II kit, with additional supplies. Freon-powered aspirator.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Laerdal RFB II kit with Freon-powered aspirator,
    additional supplies.

     

    Gordon’s Rescue Breather has a modern counterpart in Draeger’s Orotubus, a metal-lined flanged mouthpiece with a securing strap, nasal clamp, and thumb-hooks to provide better Triple Airway Maneuver; the 22 mm connector allows fitment of a BVM or transport ventilator.

    Orotubus by Draeger

    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.

    Metal-reinforced bite-block, blow pipe fits 22mm connectors.
    Note sturdy thumb-hooks and strap to help maintain Triple
    Airway Maneuver, nose clamp.

    The Johnson & Johnson Resuscitube is no longer on the market. A myriad of pocket-masks and face-shields have supplanted it.

    Orotubus from Draeger. Looking within.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Rescuers view of Orotubus. Metal-reinforced bite block, only latex
    contacts patient.

     

    Mouth-to-Mask units with expiratory-diversion and air inlet valves at the mask with mouthpiece tubing for the respiratory rescuer have the advantage of placing the rescuer at the patient’s vertex for better monitoring and posture; having the inlet at the mask end allows for the first ~150 ml of air to the lung to be 21% O2 and the trailing portion of the inflation in the dead space is rebreathed by the rescuer to minimize hypocapnea. It does require professional skill in using a mask and maintaining the airway.

     

    Fyr-Fyter brand of Globe Mouth-to-Mask Resuscitator by Monaghan.

    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.

    Fyr-Fyter brand of Globe Mouth-to-Mask Resuscitator by Monaghan. Cased set of resuscitator, manual bulb aspirator,

    oral airway, directions.

     

    Detail view of Globe Resuscitator cased set.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Detail view of Globe Resuscitator boxed set.
    Rescuer's inlet valve above mask, allowed
    rescuer to rebreathe his own CO2 to prevent
    hypocapnia; first portion of breath given to
    patient would be 21% O2.

    There was a variant of the Wendl nasopharyngeal airway by Rusch that had a long tubing to allow Mouth-to-NPA ventilation.

     

    The “automatic resuscitators” of yore, which alternated pressure-cycled positive and negative pressure, or steady flow, and provided suction by oxygen venturi  (rapidly depleting the oxygen tank), lost place in the market when condemned as incompatible with external cardiac massage. Manually-triggered

     

    Stephenson Minuteman Resuscitator.
    ©Tom Trimble, RN CEN; object from Author's Collection
    Click for larger image.
    Stephenson Minuteman Resuscitator, a light and modern automatic
    cased unit with double yoke for two D-cylinders, provides alternating
    positive & negative pressure-cycled breathing, constant flow, or oxygen
    powered venture suction. Note metal wire flangeless oral airways with twill-tape near regulator. Mask has perished with age.

     

    Oxygen-powered Demand Valves supplanted them and faced criticism and modifications due to excessive flow-rates and higher pressure-relief limits. Some are still sold, but must be used cautiously to avoid gastric insufflation.

     

              Sincerely,

     

                     Tom Trimble, RN CEN

     

    All opinions are those of the author.

     

    This is the third 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

     

     

    References and Links:

     

    Trimble, Tom, RN CEN  How the BVM began The Advanced Emergency Nursing Blog October 20, 2013 http://journals.lww.com/aenjournal/blog/aenj-blog/_Layouts/listform.aspx?PageType=4&ListId={EFBFD26E-FC13-47C7-AF4A-03A6CAC13BF4}&ID=29  from the website of Advanced Emergency Nursing Journal <http://AENJournal.com> Accessed 04/24/2014

    **Our short summary of the development of the self-refilling bag for respiratory support.

    Resuscitation set, Europe, 1801-1850 - Science Museum, London. Wellcome Images Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/ Accessed 04/24/2014

    ** An Eighteenth-Nineteenth century bellows kit for artificial ventilation, or for insufflating the rectum with tobacco smoke.

     

    Fell-O’Dwyer Apparatus. Wellcome Library, London
    Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
    Accessed 04/24/2014

    **For anesthetic delivery at the level of the vocal cords; also used by O’Dwyer during Diptheria epidemic to avoid tracheostomy. Fell then collaborated with O'Dwyer to add his foot-powered positive pressure insufflator. (c.f., image of Fell-O'Dwyer apparatus.)

     

    Wellcome Library Movies of Artificial Respiration (hospital-based) from 1940s showing in six parts several methods in context of anaesthesia training.

    <https://www.youtube.com/watch?v=3DzTBN-yrMc&list=PL05EC1F6712CA2BB1>

    Part:

    1. The Drinker Respirator (Iron Lung) Time 3:26
    2. The Both Respirator (variation of cabinet respirator; shows how to manually operate in emergency) Time 2:46
    3. Partial Enclosure Methods:
      The Paul-Bragg Pulsator (a thoracic compression vest)
      The Burstall Respirator (negative pressure to the chest) Time 5:16
    4. The Biomotor Respirator (alternating positive and negative pressure to the abdomen) Time 3:13
    5. {Methods of Postural or Visceral Shift}
      Eve’s Rocking Method, using the Riley’s Rocking Stretcher
      The Barrel
      The Sling Time 3:42
    6. {Using Positive Pressure Oxygen}
      The McKesson Respirator (automatic cycling pressure operated)
      The Oxford Respirator (manually cycled valve for positive pressure [open-exhaust])  Time 3:05

     

    Wellcome Library’s Anaesthesia Series includes:

      • Endotracheal anaesthesia: No. 5 (1944) broad review including how to make and clean your own ETTs. Note metallic oral airway, straight laryngoscope blades, uncuffed tubes with throat packing, cuffed tubes, lack of gloves. Learn BNTI, check airflow by hearing and movement of cotton wisp by exhalation, NTI with direct laryngoscopy & Magill’s Forceps; open-mask ether or ether-can to ETT by hose with airvent in can. Time 24:05
      • Respiratory and Cardiac Arrest: No. 9 (1945) Silvester’s artificial respiration on OR table, mouth-to-mouth, turning and clearing of vomitus, NPA for obstruction, wooden wedge to open teeth in trismus, suction, and oral airway, then O2 insufflation, and mask breathing. Open chest cardiac massage, intracardiac injection, stimulant drugs, IV saline, further care
      • The development of endotracheal anaesthesia (1965)” interviewing Sir Ivan Magill. Time 15:29

     

    Henderson, Yandell (1943). The return of the pulmotor as a" resuscitator": a back-step toward the death of thousands. Science, 98(2556), 547-551.

    **A scathing denunciation of “suck and blow” resuscitators and marketing practices by the preeminent physiologist of his time focused upon respiration and asphyxia.

     

    Kreiselman, J. (1943). A new resuscitation apparatus. Anesthesiology, 4(6), 608-611.
    **Published description of his bellows resuscitator.

     

    Kreiselman, Joseph. (1946). U.S. Patent No. 2,399,643. Resuscitator. Washington, DC: U.S. Patent and Trademark Office.

    **Patent for the resuscitator.

    Kreiselman, Joseph. (1945). U.S. Patent No. 2,366,630. Bassinet organization. Washington, DC: U.S. Patent and Trademark Office.

    **Applying his Infant Resuscitator to a warmer for neonates.

    Ruben, H. (1959). Self-contained resuscitation equipment. Canadian Medical Association journal, 80(1), 44.
    **Ruben’s description of essential portability of resuscitation equipment. Note novelty of use without a pressurized cylinder. Photos of early AMBU bag & foot-pump suction in use.

     

    Fahey, D. G. (2010). The self-inflating resuscitator--evolution of an idea. Anaesthesia and intensive care, 38, 10-15.

    **Nice summary history: photo of early AMBU and other devices; reports Elam & Safar’s involvement with Laerdal’s BVM, Resusci-Anne.

    Mitchell, H. W. (1965). Ambulances and emergency medical care. American Journal of Public Health and the Nations Health, 55(11), 1717-1724.
    **Relatively early account of then status of prehospital care, before EMS movement took place.

     

    Safar, P., & Brose, R. A. (1965). Ambulance design and equipment for resuscitation. Archives of Surgery, 90(3), 343-348.

    **Calls for updated resuscitation equipment; BVMs, rather than resuscitators, suction, etc.

    Evaluation: Manually Operated Resuscitators (1971) Emergency Care Research Institute. No authors listed. Health Devices. 1971 Apr;1(1):13-7.pp 13-17 PMID: 5209569
    **Possibly the first institutional safety review of BVMs (i.e., not a case report or letter to the editor). ECRI states “The Institute’s first evaluation of 18 brands of manually operated resuscitators found nine to be ineffective and started ECRI as an independent evaluator and provider of medical-device-related information and guidance.C.f., Evaluation of Manually Operated Resuscitators

     

    CARDEN, E., & HUGHES, T. (1975). An evaluation of manually operated self-inflating resuscitation bags. Anesthesia & Analgesia, 54(1), 133-138.
    **Critical exam of poor FIO2 delivery, valve-jamming, rebreathing, reservoir designs.

     

    CARDEN, E., & FRIEDMAN, D. (1977). Further studies of manually operated self-inflating resuscitation bags. Anesthesia & Analgesia, 56(2), 202-2 06.

    **Documents improvements in BVMs previously investigated and found deficient in FIO2.

    Abdo Khoury, M. D., Hugonnot, S., Cossus, J., & De Luca, A. From mouth to mouth to Bag-Valve-Mask ventilation: Evolution and characteristics of actual devices. A review of the literature. In press?  Download from Hindawi Publishing without additional data availability.
    **Review by French authors of of BVM design and functioning.

     

    Farrington, J. D. (1967). Death in a ditch. Bull Am Coll Surg, 52(3), 121.
    **Classic pre-EMS document describing rescue care by rural volunteer squads. Popularized extrication and spinal immobilization. Inspired much rescue training.

     

    National Research Council (US). Committee on Trauma, & National Research Council (US). Committee on Shock. (1971). Accidental death and disability: The neglected disease of modern society. National Academies.

    **Landmark document calling for comprehensive prehospital care reform from the (authoritative, independent) government-chartered National Academy of Sciences – National Research Council, thereafter a bedrock citation.

    Rockwood Jr, C. A., MANN, C. M., Farrington, J. D., HAMPTON JR, O. P., & MOTLEY, R. E. (1976). History of emergency medical services in the United States. Journal of Trauma and Acute Care Surgery, 16(4), 299-308.

    **Recounts early improvements in prehospital care, by its shakers and movers.

     

    About the Author

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

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