2010 PSOW Conference - BFD Capnography & 12 Lead

Capnography for EMS Understanding the Power Of Knowledge

BENEFITS of ETCO2
Non-invasive
Cost effective
Easy to use
Gives important information
Gives it fast, reliable
Way more sensitive than Pulse Ox

Measure of exhaled CO2
End tidal CO2 gives a number
Capnography gives a number and a waveform
Waveform is more reliable and can give additional information

Methods
ETCO2 detector that goes on ET Tube
Nasal Cannula that measures CO2
Can be used much more frequently
Not just for intubations anymore!!

Methods
Infrared light aimed thru exhaled gas
Washout of light from CO2 gives measurement

Physiology
Pulse oximetry measures oxygen saturation on hemoglobin
Drops late, trouble has already occurred
Is not sensitive to ventilation
Diffusion of oxygen into blood at alveoli
Often measured at peripheral location

Physiology
Capnography measures exhalation Carbon Dioxide and provides a real time graph
Changes quickly with patient condition
Best method to monitor ventilation
Indirect measure of body perfusion

Physiology
Carbon dioxide is by-product of metabolism (The smoke from the fire)
Normal ETCO2 = 38-42 mmHg
Normal perfusion means normal blood getting to lungs and off-loading CO2
Normal ventilation allows CO2 to be removed and measured

Physiology
Normal perfusion & Hyperventilation cause lower ETCO2
Hypoventilation causes higher ETCO2
Poor perfusion causes lower ETCO2
Trends are critical
Waveform can give information
May see no changes in pulse ox

When should Capnography be used??
All intubations
MANDATORY, not using is malpractice
Graph with persistent pattern means tube is in trachea ( # only can be false positive)
Use to guide rate for eucapnea (40 mmHg)
Use for goal directed ETCO2
Watch ETCO2 trend

All severely injured patients
Measurement of ETCO2 and the trend gives information about systemic perfusion
If ETCO2 starts falling, shock is present and is getting worse.
Rapid transport, ?? Fluids,
Trauma Center
Can give up to 20 minutes of warning

Cardiac Arrest
Predictor of outcome
With good CCR ETCO2 stays below 16, not likely to survive
Increasing ETCO2 levels predict success, perfusion is improving
We intubate late--initial ETCO2 will be very useful as to how we are doing

Hyperglycemic patient
NC ET capnography
See if ETCO2 is 29 or lower
This is due to Kussmal Respirations
Severe dehydration with decreased perfusion
If so, DKA likely
DKA needs WO Normal saline all the way to the hospital

Dyspnea
All patients with Dyspnea should have NC ETCO2 measured.
Asthma, COPD, pneumonia
If CO2 in high despite breathing hard, respiratory failure is developing
If ETCO2 is increasing, they are getting worse, if getting lower, they are improving

Dyspnea
ETCO2 is a much better indicator if CPAP is needed.
ETCO2 above 55 or so
ETCO2 climbing
ETCO2 will climb before the patient notably gets worse
Shark fin wave form means they are working hard to exhale

Permissive Hypercapnea Tight, intubated asthmatic Bag slow to allow extra time to exhale Allow CO2 to rise into 60’s.

Asthma Patient

COPD Patient on Oxygen Monitor ETCO2 to see if they start retaining. If so, back off on oxygen or add CPAP.

Sedation Patients
Any patient sedated should be on ETCO2. Will monitor ventilation closely and warn early of inadequate breathing.
Way more sensitive than pulse oximetry.
Use if narcotics or Benzodiazepines were administered

QUESTIONS ON CAPNOGRAPHY??
Easy to use
Start using a lot and get experience with it.
Great tool and easy to learn
Visit: Capnography.com or one of the other numerous web sites on this topic!!

Importance of 12 lead ECG Allows diagnosis earlier, thus saving time to definitive treatment Average is 15 minutes nationally

12 lead placement

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.

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

Cardiac Anatomy in Relation to Coronary Artery 18

What Does This 12-Lead ECG Show? L1 L2 L3 aVR aVF aVL V1 V2 V3 V4 V5 V6

Right Ventricular lead V4R

Right coronary Artery II, III, AVF- inferior wall Right ventricle Nodal tissue RV infarct, SCD, heart blocks

Left Coronary (LAD)
V1 - V4 Anterior wall
Main part of left ventricle
Pulmonary congestion
SCD
Cardiogenic shock

Circumflex
I, AVL, V5, V6
Lateral wall
SCD

Transmitting EKG’s Always on Med Pair radio Never cell phone As ALS may send positive or suspicious tracings only

12 Lead EKG by radio
Must call hospital on radio and wait for answer
Must talk before you send
Here comes a 12 lead
Then send it.

QUESTIONS??

2010 PSOW Conference - BFD Capnography & 12 Lead

by PSOW on Sep 30, 2010

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