SPUR® II ADULT RESUSCITATORSINGLE PATIENT USE RESUSCITATOR

Description of Event or Problem

PATIENT WAS TRANSPORTED TO ICU WITH PLAN TO INTUBATE IN ICU FOR RESPIRATORY DISTRESS. ALL INTUBATION EQUIPMENT AND SUPPLIES WERE READY, PROCEDURE BEGAN AND MD ATTEMPTED INTUBATION. AS MD WAS ATTEMPTING INTUBATION PATIENT WAS STEADILY DESATURATING. WHEN SPO2 HIT APPROXIMATELY 75% INTUBATION ATTEMPT WAS HALTED, RESPIRATORY THERAPIST (RT) GRABBED THE BVM/AMBU BAG AND RT AND THE MD ATTEMPTED TO MANUALLY VENTILATE PATIENT. FLOW METER WAS ON 10 LPM, MD WAS HOLDING FACE/MASK SEAL AND I WAS GIVING MANUAL BREATHS WITH BVM. THE BVM WAS NOT INFLATING, NOR WAS IT GIVING ANY RESISTANCE OR BACK PRESSURE. THE BVM FELT LIMP AND WAS NOT SELF INFLATING. NO CHEST RISE WAS OBSERVED AND SP02 WAS CONTINUING TO FALL. WE BOTH COLLECTIVELY ATTEMPTED TO CHECK SEAL WITH PATIENTS FACE BUT BVM WOULD STILL NOT INFLATE AND WAS STILL LIMP WHEN GIVING MANUAL BREATHS. MD TOOK OVER GIVING MANUAL BREATHS WHILE RT TROUBLESHOOTED. RT INCREASED O2 TO 15 LPM WITH NO CHANGE IN PERFORMANCE AND THEN QUICKLY HOOKED IT UP TO A NEW FLOW METER WITH HELP FROM RN. STILL NO CHANGE WAS OBSERVED. IT WAS CLEAR THE BVM WAS NOT WORKING SO RT GRABBED A NEW BVM AND HOOKED THAT UP TO THE ORIGINAL FLOW METER AT 15 LPM. THE NEW BVM WAS WORKING BUT PATIENT LOST HIS PULSE AT THAT TIME AND CPR WAS INITIATED. PATIENT WAS INTUBATED DURING CPR AND ROSC WAS ACHIEVED. PATIENT WAS PLACED ON VENTILATOR AND STABILIZED. THE ICU TEAM DEBRIEFED AND WE DISCUSSED THE ISSUE WITH THE MALFUNCTIONING BVM. UPON INSPECTION THE BVM IN QUESTION WAS THEN WORKING PROPERLY. RESPIRATORY THERAPIST SUSPECT THAT A VALVE WAS STUCK OPEN OR OTHERWISE MALFUNCTIONING, PREVENTING MANUAL VENTILATION. TEAM AGREED THAT THAT WAS MOST LIKELY CAUSE OF MALFUNCTION.