05 capnography hottopics 3_08_quiz

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05 capnography hottopics 3_08_quiz

  1. 1. The Standard of Care Capnography Created by Joshua English, EMT-P James Pointer, MD Mike Jacobs, EMT-P
  2. 2. Objectives <ul><li>Understand why we use capnography </li></ul><ul><li>Understand the physiology of respiration/ ventilation </li></ul><ul><li>Define normal & abnormal EtCO 2 values/ waveforms </li></ul><ul><li>Understand the 4 major applications of EtCO 2 </li></ul><ul><ul><li>intubated applications (mainstream) </li></ul></ul><ul><ul><li>non-intubated applications (sidestream) </li></ul></ul>The Standard of Care Capnography
  3. 3. Why Capnography? <ul><li>Advanced Airway Management (Policy #10102) </li></ul><ul><li>All devices used to confirm tube placement must be documented on the PCR. </li></ul><ul><li>Esophageal Detection Device (EDD) </li></ul><ul><li>End tidal CO2 detector (ETCO2) colorimetric or capnography </li></ul><ul><li>“ Conclusion: No unrecognized misplaced intubations were found in patients for whom paramedics used continuous EtCO 2 monitoring. Failure to use continuous EtCO 2 monitoring was associated with a 23% unrecognized misplaced intubation rate. [Annals of Emergency Medicine 2005; 45:497-503]” </li></ul>The Standard of Care Capnography
  4. 4. Why Capnography? <ul><li>Verification of proper tube placement </li></ul><ul><li>There is simply NO BETTER WAY to confirm proper tube placement </li></ul><ul><li>than with waveform capnography…. PERIOD!!! </li></ul>no waveform = no tube!!! The Standard of Care Capnography
  5. 5. Why Capnography? <ul><li>Because respiration, ventilation and oxygenation are </li></ul><ul><li>VERY different concepts. </li></ul>O2 CO2 The Standard of Care Capnography
  6. 6. Why Capnography? <ul><li>It’s a window into the patient’s ventilatory status </li></ul>50 mmHg 50 mmHg The Standard of Care Capnography
  7. 7. Why Capnography? <ul><li>Core Concepts </li></ul><ul><li>What intubation verification method is most reliable? </li></ul><ul><li>How do oxygenation and ventilation differ? </li></ul>The Standard of Care Capnography
  8. 8. Physiology oxygenation alveoli perfusion metabolism back to lungs capillary vein Ventilation Transport Cell Metabolism O2 + oxygen glucose energy CO2 The Standard of Care Capnography
  9. 9. <ul><li>Factors that affect CO2 levels: </li></ul>Hyperventilation Hypoventilation Bronchospasm Effective drug therapy for bronchospasm Decreased cardiac output (during resuscitation) Increased cardiac output (during resuscitation) Decreased muscular activity Increased muscular activity DECREASE IN ETCO 2 INCREASE IN ETCO 2 The Standard of Care Capnography
  10. 10. Normal EtCO 2 Normal O2 CO2 The Standard of Care Capnography
  11. 11. Terminology Capnogram a real-time waveform record of the concentration of carbon dioxide in the respiratory gases Capnograph Capnogram waveform plus numerical value 38 mmHg CO2 The Standard of Care Capnography
  12. 12. Terminology EtCO 2 – End Tidal CO 2 The measurement of exhaled CO 2 in the breath Normal Range | 35-45 mmHg CO2 The Standard of Care Capnography
  13. 13. Normal Waveform A B C D E A TIME End of inspiration Beginning of exhalation End of exhalation Beginning of new breath Alveolar plateau 38 mmHg CO 2 The Standard of Care Capnography Clearing of anatomic dead space
  14. 14. Common Waveforms Normal mmHg RR 39 16 The Standard of Care Capnography
  15. 15. Common Waveforms Hyperventilation Hypoventilation mmHg RR mmHg RR 48 8 24 35 The Standard of Care Capnography
  16. 16. 4 Main Uses of Capnography <ul><li>Severity of asthma patients </li></ul><ul><li>Monitoring head injured patients </li></ul><ul><li>Cardiac arrest </li></ul><ul><li>Tube confirmation </li></ul>The Standard of Care Capnography
  17. 17. Terminology Sidestream An indirect method of measuring exhaled CO 2 in non-intubated patients Mainstream Direct method of measuring exhaled CO 2 with intubated patients The Standard of Care Capnography
  18. 18. Asthmatic Waveforms Shark Fin mmHg RR COPD patients have a difficult time exhaling gases This is represented on the capnogram by a shark fin appearance 45 18 The Standard of Care Capnography
  19. 19. EtCO 2 & Asthma Moderate Attack Mild Attack mmHg RR mmHg RR 28 38 36 20 The Standard of Care Capnography
  20. 20. EtCO 2 & Asthma Severe Attack mmHg RR Time To Get MOVING!!! The asthmatic who looks tired and has a shark fin appearance on the capnogram… IS HEADED FOR RESPIRATORY ARREST 49 9 The Standard of Care Capnography
  21. 21. The Head Injured Patient Carbon dioxide dilates the cerebral blood vessels, increasing the volume of blood in the intracranial vault and therefore increasing ICP Recognizing the head injured patient and titrating their CO 2 levels to the 30-35 mmHg range can help relieve the untoward effects of ICP The Standard of Care Capnography
  22. 22. The Head Injured Patient Titrate EtCO 2 mmHg RR Titration IS NOT hyperventilation. Intubating a head injured patient and using capnography gives a means to closely monitor CO 2 levels. 30 16 The Standard of Care Capnography Keep them between 30 and 35 mmHg
  23. 23. EtCO 2 and Cardiac Arrest The capnograph of an intubated cardiac arrest patient is a direct correlation to cardiac output Increase in CO 2 during CPR can be an early indicator of ROSC The Standard of Care Capnography
  24. 24. Termination of Resuscitation EtCO 2 measurements during a resuscitation give you an accurate indicator of survivability for patients under CPR Non-survivors < 10 mmHg Survivors > 30 mmHg ( to discharge) The Standard of Care Capnography
  25. 25. ET Tube Verification <ul><li>Verification of proper tube placement </li></ul><ul><li>There is simply NO BETTER WAY to confirm proper tube placement </li></ul><ul><li>than with waveform capnography…. PERIOD!!! </li></ul>no waveform = no tube!!! The Standard of Care Capnography
  26. 26. 4 Main Uses of Capnography <ul><li>Core Concepts </li></ul><ul><li>What is the characteristic shape of a capnogram for a COPD patient? </li></ul><ul><li>Describe how to determine the severity of an asthma attack using capnography? </li></ul><ul><li>What level should you maintain a severe head injured patient’s CO 2 at? </li></ul><ul><li>What are two ways that capnography can assist during CPR? </li></ul>The Standard of Care Capnography
  27. 27. Troubleshooting Inadequate Seal mmHg RR As air escapes around the cuff during BVM respirations the waveform will distort, alerting you to a possibly deflated or damaged ET cuff 39 16 The Standard of Care Capnography
  28. 28. Troubleshooting Obstruction mmHg RR An obstructed ET tube may have an erratic EtCO 2 value with a very irregular waveform 39 16 The Standard of Care Capnography
  29. 29. Troubleshooting Rebreathing mmHg RR A capnogram that does not touch the baseline is indicative of a patient who is rebreathing CO 2 through insufficient inspiratory or expiratory flow 42 16 The Standard of Care Capnography
  30. 30. QUIZ The Standard of Care Capnography
  31. 31. Hypoventilation mmHg RR The Standard of Care Capnography 48 8
  32. 32. Rebreathing mmHg RR The Standard of Care Capnography 42 16
  33. 33. Esophageal Tube The Standard of Care Capnography
  34. 34. Asthma mmHg RR The Standard of Care Capnography 36 20
  35. 35. Normal mmHg RR The Standard of Care Capnography 39 16
  36. 36. Questions? The Standard of Care Capnography

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