2010 PSOW Conference - BFD Capnography & 12 Lead


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  • Key Concept: ST-segment deviation (elevation or depression) is measured 0.04 second after the juncture of the QRS complex and ST segment. The TP segment, not the PR interval, is used for baseline reference. Ask participants to point out the important segments and baseline for measurement of ST-segment deviation. How much ST-segment deviation is important for ST-segment elevation MI, ST-segment depression consistent with unstable angina or non – ST-segment MI? Discussion Points: The TP segment and end of PR interval are used as the baseline for measurement of ST-segment deviation. The PR interval is often abnormal in pericarditis, conditions that affect atrial repolarization, and atrial infarction. When possible, the TP segment is preferred in ACS. ST-segment deviation is measured between 0.04 and 0.08 second from the J point, the juncture between the QRS complex and the ST segment. Exercise stress testing uses 0.08 second after the J point for measurement, set by sensitivity and specificity patterns. For ACS, 0.04 second is used: one small box. ST-segment elevation MI qualifies for reperfusion therapy when  1 mm of ST-segment elevation is present in 2 contiguous leads. Early lytic trials used 2 mm in the precordial leads. ST-segment ischemic depression is considered significant if  1 mm at 0.04 second after the J point. But  0.5 mm is equally prognostic when the reader can identify ST-segment changes as ischemic.
  • Key Concept: Experienced providers should be proficient in ECG identification of the major ECG presentations of ACS. Use this slide and the following slide to review and assess their skills. Ask which coronary arteries supply the above distributions, ie, left anterior descending coronary artery = anterior; generally circumflex coronary artery = lateral (although a high large diagonal or intermediate ramus may supply this area); occlusion of right coronary artery = inferior wall MI. Teaching Point : The circumflex coronary artery may be electrically silent in  60% of patients with ACS. You are convinced a patient is experiencing ACS with persistent ischemic-type pain. What should you do? Extension of the anterior leads, eg, V 7 , V 8 , V 9 , may be helpful, but echocardiography will demonstrate a wall motion abnormality if significant ischemia/infarction is present. This noninvasive technique is also useful in assessing other acute cardiovascular problems, eg, pericardial effusion and aortic dissection involving the proximal aorta. Order it when in doubt. Hemodynamically unstable patients benefit from immediate diagnostic angiography. (See ACLS Provider Manual, Case 6, and ACLS: Principles and Practice, Chapter 17.)
  • Now review the anatomy discussed in the previous table. Note that the LAD supplies the largest amount of myocardium. The more proximal the occlusion the greater the change of cardiogenic shock and congestive heart failure. Ask what might be expected from an inferior wall MI. Emphasize the SA and AV nodal supply and discuss the possible development of bradyarrhythmias. Do not give too much away on the hemodynamic consequences or spend time discussing them because they are the key concepts for Case 2.
  • Answer: Inferior wall MI.
  • Answer: Lateral wall MI.
  • 2010 PSOW Conference - BFD Capnography & 12 Lead

    1. 1. Capnography for EMS Understanding the Power Of Knowledge
    2. 2. BENEFITS of ETCO2 <ul><li>Non-invasive </li></ul><ul><li>Cost effective </li></ul><ul><li>Easy to use </li></ul><ul><li>Gives important information </li></ul><ul><li>Gives it fast, reliable </li></ul><ul><li>Way more sensitive than Pulse Ox </li></ul>
    3. 3. Measure of exhaled CO2 <ul><li>End tidal CO2 gives a number </li></ul><ul><li>Capnography gives a number and a waveform </li></ul><ul><li>Waveform is more reliable and can give additional information </li></ul>
    4. 4. Methods <ul><li>ETCO2 detector that goes on ET Tube </li></ul><ul><li>Nasal Cannula that measures CO2 </li></ul><ul><ul><li>Can be used much more frequently </li></ul></ul><ul><ul><li>Not just for intubations anymore!! </li></ul></ul>
    5. 5. Methods <ul><li>Infrared light aimed thru exhaled gas </li></ul><ul><li>Washout of light from CO2 gives measurement </li></ul>
    6. 6. Physiology <ul><li>Pulse oximetry measures oxygen saturation on hemoglobin </li></ul><ul><ul><li>Drops late, trouble has already occurred </li></ul></ul><ul><ul><li>Is not sensitive to ventilation </li></ul></ul><ul><ul><li>Diffusion of oxygen into blood at alveoli </li></ul></ul><ul><ul><li>Often measured at peripheral location </li></ul></ul>
    7. 7. Physiology <ul><li>Capnography measures exhalation Carbon Dioxide and provides a real time graph </li></ul><ul><ul><li>Changes quickly with patient condition </li></ul></ul><ul><ul><li>Best method to monitor ventilation </li></ul></ul><ul><ul><li>Indirect measure of body perfusion </li></ul></ul>
    8. 8. Physiology <ul><li>Carbon dioxide is by-product of metabolism (The smoke from the fire) </li></ul><ul><li>Normal ETCO2 = 38-42 mmHg </li></ul><ul><li>Normal perfusion means normal blood getting to lungs and off-loading CO2 </li></ul><ul><li>Normal ventilation allows CO2 to be removed and measured </li></ul>
    9. 9. Physiology <ul><li>Normal perfusion & Hyperventilation cause lower ETCO2 </li></ul><ul><li>Hypoventilation causes higher ETCO2 </li></ul><ul><li>Poor perfusion causes lower ETCO2 </li></ul><ul><li>Trends are critical </li></ul><ul><li>Waveform can give information </li></ul><ul><li>May see no changes in pulse ox </li></ul>
    10. 10. When should Capnography be used?? <ul><li>All intubations </li></ul><ul><ul><li>MANDATORY, not using is malpractice </li></ul></ul><ul><ul><li>Graph with persistent pattern means tube is in trachea ( # only can be false positive) </li></ul></ul><ul><ul><li>Use to guide rate for eucapnea (40 mmHg) </li></ul></ul><ul><ul><li>Use for goal directed ETCO2 </li></ul></ul><ul><ul><li>Watch ETCO2 trend </li></ul></ul>
    11. 11. All severely injured patients <ul><li>Measurement of ETCO2 and the trend gives information about systemic perfusion </li></ul><ul><ul><li>If ETCO2 starts falling, shock is present and is getting worse. </li></ul></ul><ul><ul><li>Rapid transport, ?? Fluids, </li></ul></ul><ul><ul><li>Trauma Center </li></ul></ul><ul><ul><li>Can give up to 20 minutes of warning </li></ul></ul>
    12. 12. Cardiac Arrest <ul><li>Predictor of outcome </li></ul><ul><li>With good CCR ETCO2 stays below 16, not likely to survive </li></ul><ul><li>Increasing ETCO2 levels predict success, perfusion is improving </li></ul><ul><li>We intubate late--initial ETCO2 will be very useful as to how we are doing </li></ul>
    13. 13. Hyperglycemic patient <ul><li>NC ET capnography </li></ul><ul><li>See if ETCO2 is 29 or lower </li></ul><ul><ul><li>This is due to Kussmal Respirations </li></ul></ul><ul><ul><li>Severe dehydration with decreased perfusion </li></ul></ul><ul><li>If so, DKA likely </li></ul><ul><li>DKA needs WO Normal saline all the way to the hospital </li></ul>
    14. 14. Dyspnea <ul><li>All patients with Dyspnea should have NC ETCO2 measured. </li></ul><ul><li>Asthma, COPD, pneumonia </li></ul><ul><li>If CO2 in high despite breathing hard, respiratory failure is developing </li></ul><ul><li>If ETCO2 is increasing, they are getting worse, if getting lower, they are improving </li></ul>
    15. 15. Dyspnea <ul><li>ETCO2 is a much better indicator if CPAP is needed. </li></ul><ul><ul><li>ETCO2 above 55 or so </li></ul></ul><ul><ul><li>ETCO2 climbing </li></ul></ul><ul><ul><li>ETCO2 will climb before the patient notably gets worse </li></ul></ul><ul><ul><li>Shark fin wave form means they are working hard to exhale </li></ul></ul>
    16. 16. Permissive Hypercapnea Tight, intubated asthmatic Bag slow to allow extra time to exhale Allow CO2 to rise into 60’s.
    17. 17. Asthma Patient
    18. 18. COPD Patient on Oxygen Monitor ETCO2 to see if they start retaining. If so, back off on oxygen or add CPAP.
    19. 19. Sedation Patients <ul><li>Any patient sedated should be on ETCO2. Will monitor ventilation closely and warn early of inadequate breathing. </li></ul><ul><li>Way more sensitive than pulse oximetry. </li></ul><ul><li>Use if narcotics or Benzodiazepines were administered </li></ul>
    20. 20. QUESTIONS ON CAPNOGRAPHY?? <ul><li>Easy to use </li></ul><ul><li>Start using a lot and get experience with it. </li></ul><ul><li>Great tool and easy to learn </li></ul><ul><li>Visit: Capnography.com or one of the other numerous web sites on this topic!! </li></ul>
    21. 21. Importance of 12 lead ECG Allows diagnosis earlier, thus saving time to definitive treatment Average is 15 minutes nationally
    22. 22. 12 lead placement
    23. 23. Measurement of ST-Segment Deviation STEMI:  1 mm ST-segment elevation in 2 leads.* NSTEMI/UA:  0.5 mm ST-segment ischemic depression in 2 leads.* *Anatomically (regionally) contiguous leads.
    24. 24. Localizing Ischemia or Injury aVF inferior III inferior V 3 anterior V 6 lateral aVL lateral II inferior V 2 septal V 5 lateral aVR I lateral V 1 septal V 4 anterior
    25. 25. Cardiac Anatomy in Relation to Coronary Artery 18
    26. 26. What Does This 12-Lead ECG Show? L1 L2 L3 aVR aVF aVL V1 V2 V3 V4 V5 V6
    27. 27. What Does This 12-Lead ECG Show? L1 L2 L3 aVR aVF aVL V1 V2 V3 V4 V5 V6
    28. 28. Right Ventricular lead V4R
    29. 29. Right coronary Artery II, III, AVF- inferior wall Right ventricle Nodal tissue RV infarct, SCD, heart blocks
    30. 30. Left Coronary (LAD) <ul><li>V1 - V4 Anterior wall </li></ul><ul><li>Main part of left ventricle </li></ul><ul><li>Pulmonary congestion </li></ul><ul><li>SCD </li></ul><ul><li>Cardiogenic shock </li></ul>
    31. 31. Circumflex <ul><li>I, AVL, V5, V6 </li></ul><ul><li>Lateral wall </li></ul><ul><li>SCD </li></ul>
    32. 32. Transmitting EKG’s Always on Med Pair radio Never cell phone As ALS may send positive or suspicious tracings only
    33. 33. 12 Lead EKG by radio <ul><li>Must call hospital on radio and wait for answer </li></ul><ul><li>Must talk before you send </li></ul><ul><li>Here comes a 12 lead </li></ul><ul><li>Then send it. </li></ul>
    34. 34. QUESTIONS??