Bag-mask resuscitators with integrated manometry help reduce the risk of pulmonary injury during manual ventilation. All such devices must function as intended while preventing carbon dioxide rebreathing, as unintended hypercapnia can be harmful in critically ill patients. We describe a case of carbon dioxide rebreathing in a patient suspected of having a brain injury after blunt trauma who was manually ventilated with a widely available bag-mask resuscitator with integrated manometry after emergent intubation. This case highlights the importance of vigilant monitoring of end-tidal carbon dioxide and appropriate troubleshooting and investigation of unexplained findings to mitigate and prevent adverse patient outcomes.
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