Capnography in ems.ppt

Oxygenation: –  oxygen is inhaled into the lungs and carried into the

blood

 Ventilation: – CO2 is transported back from the blood to the lungs

& exhaled

Relationship between CO2 & respiratory rate (RR):   Increased RR = decreased CO2 =

HYPERventilation (ETCO2 < 35)   Resp. alkalosis

  Decreased RR = increased CO2 = HYPOventilation (ETCO2 > 45)

  resp. acidosis

CAPNOGRAPHY = ““THE VENTILATION VITAL SIGN””:   INTUBATED APPLICATIONS:

Verification of ETT placement

  NON-INTUBATED APPLICATIONS:

anaphylaxis

post-ictal

biofeedback monitor

3 QUESTION TO ASK EVERY TIME CAPNOGRAPHY IS USED:

1. IS THE ET TUBE IN THE TRACHEA (rise and fall of detectable CO2)?

2. WHAT IS THE ETCO2 VALUE (height of the waveform)?

35 – 45 mm/hg   ETCO2 Less Than 35 mmHg =

– "Hyperventilation/Hypocapnia"

  ETC02 Greater Than 45 mmHg = – "Hypoventilation/Hypercapnia"

    B-C is the exhalation upstroke where dead space gas

   D-E is the inspiration washout.

  Phase I (A) = Respiratory Baseline   Phase II (B)= Expiratory upstroke   Phase III (C)= Expiratory plateau   (D)**ETCO2 Peak level   Phase IV (E) = Inspiratory downstroke

CAPNOGRAPHY WAVEFORM ANALYSIS:

  ““Square box”” waveform; baseline CO2 = 0;   ETCO2 = 35-45 mm Hg

  DISLODGED ETT: – 

 – Replace ETT

  ESOPHAGEAL INTUBATION: – 

ETCO2.

 –  Re-intubate

  CPR: –  “Square box” waveform; baseline CO2 = 0;

ETCO2 = 10-15 mm Hg (possibly higher) with adequate CPR

 –  Change rescuers if ETCO2 drops < 10

  Monitoring ETC02 measures cardiac output, thus monitoring ETCO2 is a good way to measure the effectiveness of CPR. In 1978, Kalenda “reported a decrease in ETC02 as the person performing CPR fatigued, followed by an increase in ETCO2 as a new rescuer took over, presumably providing better chest compressions.” –Gravenstein, Capnography: Clinical Aspects, Cambridge Press, 2004 “Reductions in ETCO2 during CPR are associated with comparable reductions in cardiac output....The extent to which resuscitation maneuvers, especially precordial compression, maintain cardiac output may be more readily assessed by measurements of ETCO2 than palpation of arterial pulses.” -Max Weil, M.D., Cardiac Output and End-Tidal carbon dioxide, Critical Care Medicine, November 1985

  ”” with/without prolonged expiration = – 

 – 

epinephrine)

  ROSC: – 

–  Check for pulse; contact BIOTEL for drip authorization

  Return of Spontaneous Circulation (ROSC) ETCO2 can be the first sign of return of spontaneous circulation (ROSC). During a cardiac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses. End-tidal CO2 will often overshoot baseline values when circulation is restored due to carbon dioxide washout from the tissues. A recent study found the ETCO2 shot up on average 13.5 mmHg with sudden ROSC before settling into a normal range.-Grmec S, Krizmaric M, Mally S, Kozelj A, Spindler M, Lesnik B.,Resuscitation. 2006 Dec 8

  RISING BASELINE = – Patient is rebreathing CO2:

  Check equipment for adequate oxygen inflow   Allow intubated patient more time to exhale

  HYPOVENTILATION: –  ? RR; Prolonged waveform; baseline CO2 = 0;

ETCO2 > 45 mm Hg

 – 

  HYPERVENTILATION: – ? RR; shortened waveform; baseline ETCO2

= 0; ETCO2 < 35 mm Hg   Management:

– Biofeedback if conscious, decrease assisted ventilation rate if unconscious/intubated

–  **Important exceptions: Severe metabolic acidosis (DKA, sepsis, salicylate poisoning, acute renal failure, methanol ingestion, tricyclic overdose) will cause tachypnea (?? RR), but ETCO2 will be HIGH. **In other words, if RR is high, but ETCO2 is also high, consider the above diagnoses. This is NOT normal!

  PATIENT BREATHING AROUND ET TUBE:  Adult: Broken cuff or tube is too small Pediatric: tube is too small

  reintubate

Assisting Intubation   Continuous end-tidal CO2 monitoring can confirm a tracheal intubation.   A good wave form indicating the presence of CO2 ensures the ET tube is in the trachea.

  2005 study comparing field intubations that used continuous capnography to confirm intubations versus non-use showed zero unrecognized misplaced intubations in the monitoring group versus 23% misplaced tubes in the unmonitored group. -Silverstir, Annals of Emergency Medicine, May 2005

  “When exhaled CO2 is detected (positive reading for CO2) in cardiac arrest, it is usually a reliable indicator of tube position in the trachea.” - The American Heart Association 2005 CPR and ECG Guidelines

  THE END!!!

Oxygenation: – What is oxygenation?

 Ventilation: – What is ventilation?

Relationship between CO2 & respiratory rate (RR):   HYPERventilation =

– What is relationship of RR? – What is relationship of CO2? – ETCO2 < _____?

  HYPOventilation – What is relationship of RR? – What is relationship of CO2? – ETCO2 > _____?

CAPNOGRAPHY = ““THE VENTILATION VITAL SIGN””:   INTUBATED APPLICATIONS: 1. 2. 3.

4.

CAPNOGRAPHY = ““THE VENTILATION VITAL SIGN””:   INTUBATED APPLICATIONS:

Verification of ETT placement

Capnography Applications in CCT

  NON-INTUBATED APPLICATIONS: 1. 2. 3. 4.

Capnography in CCT

  NON-INTUBATED APPLICATIONS:

anaphylaxis

post-ictal

biofeedback monitor

CAPNOGRAPHY IS USED: 1. IS THE ____________________?

2. WHAT IS THE _________________?

3. WHAT IS THE ________________?

3 QUESTION TO ASK EVERY TIME CAPNOGRAPHY IS USED:

1. IS THE ET TUBE IN THE TRACHEA (rise and fall of detectable CO2)?

2. WHAT IS THE ETCO2 VALUE (height of the waveform)?

35 – 45 mm/hg 1.  What is the normal range of ETCO2? 2.  ETCO2 <_____ ? = _____________? 3.  ETCO2 >_____ ? = _____________?

35 – 45 mm/hg   ETCO2 Less Than 35 mmHg =

– "Hyperventilation/Hypocapnia"

  ETC02 Greater Than 45 mmHg = – "Hypoventilation/Hypercapnia"

CAPNOGRAPHY WAVEFORM ANALYSIS:

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

CAPNOGRAPHY WAVEFORM ANALYSIS:

  ““Square box”” waveform; baseline CO2 = 0;   ETCO2 = 35-45 mm Hg

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  DISLODGED ETT: – 

 – Replace ETT

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  ESOPHAGEAL INTUBATION: – 

ETCO2.

 –  Re-intubate

Pt is pulseless

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  CPR: –  “Square box” waveform; baseline CO2 = 0;

ETCO2 = 10-15 mm Hg (possibly higher) with adequate CPR

 –  Change rescuers if ETCO2 drops < 10

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  ROSC: – 

–  Check for pulse; contact BIOTEL for drip authorization

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  ”” with/without prolonged expiration = – 

 – 

epinephrine)

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  RISING BASELINE = – Patient is rebreathing CO2:

  Check equipment for adequate oxygen inflow   Allow intubated patient more time to exhale

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  HYPOVENTILATION: –  ? RR; Prolonged waveform; baseline CO2 = 0;

ETCO2 > 45 mm Hg

 – 

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  HYPERVENTILATION: – ? RR; shortened waveform; baseline ETCO2

= 0; ETCO2 < 35 mm Hg   Management:

– Biofeedback if conscious, decrease assisted ventilation rate if unconscious/intubated

–  **Important exceptions: Severe metabolic acidosis (DKA, sepsis, salicylate poisoning, acute renal failure, methanol ingestion, tricyclic overdose) will cause tachypnea (?? RR), but ETCO2 will be HIGH. **In other words, if RR is high, but ETCO2 is also high, consider the above diagnoses. This is NOT normal!

  Is ETT in Trachea?   What is ETCO2 value?   What is the shape?   What is management?

  PATIENT BREATHING AROUND ET TUBE:  Adult: Broken cuff or tube is too small Pediatric: tube is too small

  reintubate

  THE END!!!