Northwest Community EMS System – Continuing Education – page 1 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout Equipment Needed
Diana Neubecker RN BSN PM
4. BVM device
10. CPAP mask 11. Monitor w/ capnography
5. KLT airway 6. ET tube
Pg 4 - A
• Roundtable group discussion
• Pulse oximetry measures oxygenation, saturation of Hg Case Studies
Content is not new, is review of material taught in “Introduction to Capnography” class
Capnography
Case Studies
Capnography
3. Manikin head
9. Neb device
Teaching Method
Pg 4 - A i
• Respiratory rate • ETCO2 value Case Studies
Capnography
• At cellular level, O2 used w/ glucose from digestion (Krebs cycle), to create energy in the form of ATP, CO2 produced as byproduct
• Capnography measures ventilation, elimination of CO2
Pg 4 - B
• Produced in tissues as a result of aerobic metabolism
Case Studies
8. NRB O2 mask
2. Spont breathing capno cannula
– NOT powerpoint lecture
Capnography
7. RQP/ITD
– If ZOLL - adapter
Case Studies
CAPNOGRAPHY Case Studies
1. Assisted vent capno sensor
Capnography
Case Studies
Capnography
Continuing Education February 2012
• Waveform
1
Northwest Community EMS System – Continuing Education – page 2 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout Pg 4 - C
Pg 4 - D
•D 35 – 45 mmHg
Case Studies
• don’t count for full minute, etc.
Capnography
• pts don’t always breathe at a regular rate Case Studies
Capnography
• ??? RR
Pg 4 - E
•E i a Fever, Sepsis, Hyperthyroidism
CO2 elimination by respiratory system
Case Studies
• Ventilation
Capnography
Case Studies
Capnography
CO2 produced by cellular metabolism
CO2 transport in vascular system
• D ii HypOcarbia/hypOcapnia
Pg 4 - E i
• Metabolism
• Perfusion
•D i HypERcarbia/hypERcapnia
•E i b Hypothermia, Sedation, Hypothyroidism
Pg 4 - F
Pg 5 - G Baseline Alpha angle Plateau
ETCO2 value
Case Studies
Capnography
Case Studies
Capnography
• Rectangular/squared
Expiration
Inspiration
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Northwest Community EMS System – Continuing Education – page 3 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout
Assisted ventilation
• Hi
Yes
• Hia
Prevent lethal hyperventilation
• Hib
Will decrease
• Hic
Will increase
• H ii
Yes
• H ii a To assure correct placement
Case Studies
• H
Pg 5 - H ii a
Capnography
Case Studies
Capnography
Pg 5 - H
Yes, area of high risk/liability
– Yes
During pt movement
Yes
• Respiratory distress • Altered mental status Case Studies
Capnography will not detect R mainstem intubation
Pg 6 - I
Capnography
Case Studies
Capnography
Pg 6 - H ii b
Pg 6 - J
Pg 6 - J i & ii
•1J i
• 1 J ii Case Studies
• NWC EMSS QI results show capnography often NOT used
Attach to BVM device pre-connect/tape to bag Capnography
Case Studies
Capnography
• Engineering control to remind PM’s to use
With O2 delivery devices NC, NRBM
3
Northwest Community EMS System – Continuing Education – page 4 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout HANDSHANDS-ON DEMO
Video
Place oral-nasal capnography cannula & pulse ox on volunteer PM and have PM: 1. Hold breath as long as possible – note:
2. Hyperventilate – note: • Immediate decrease in waveform height and closer distance between waveforms
Show Video #1 (3 minutes)
Case Studies
• No change in pulse ox
Capnography
• Delay in change of RR & ETCO2 value (device averages 30 sec for readings)
Case Studies
Capnography
• Immediate loss of waveform
Pg 6 - 23
Pg 6 - 23 B
• RQP/ITD closest to pt Case Studies
• 23 A i Step-down adapter Colormetric ETCO2 detector can be used (if adapter not available)
• Yes Capnography
• 23 A Yes Case Studies
Capnography
• 23 OP/NPA, BVM capnography sensor, RQP/ITD
Case Studies
Capnography, RQP & MASK pass around room (all take apart & put together)
HANDSHANDS-ON DEMO
Capnography
Case Studies
Capnography
HANDSHANDS-ON DEMO
• Capnography closest to bag
Capnography, RQP & ET/KLT pass around room (all take apart & put together)
4
Northwest Community EMS System – Continuing Education – page 5 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout Pg 7 - C
Pg 7 - D
Initial capnography
due to resp etiology
Case Studies
higher when arrest is
Capnography
Case Studies
Capnography
readings may be
During CPR, ETCO2 is a measure of cardiac output
Pg 7 - D i – iii
•D i
Pg 7 - E • E
Decrease
– Respiratory rate • Ei
Increase Decrease
• D iii) a
Increase
• E ii
Case Studies
• D iii
– To avoid hyperventilation
Capnography
Case Studies
Capnography
• D ii
– Increases intrathoracic pressure – Decreases venous return to heart – Decreases coronary perfusion pressure
– Decreases survival
Pg 7 - F
Pg 7 - G
• F
• G
NO
Less than 10 mmHg for 20 minutes
Skin color – central (e.g., tongue)
Case Studies
• Fi
Capnography
Case Studies
Capnography
Readings (high or low) unreliable • Gi Hypothermic pt
5
Northwest Community EMS System – Continuing Education – page 6 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout
H Yes
• Yes, often about 30-60 seconds prior to ROSC
•
Hi ETCO2 is indication of cellular level function
• ETCO2 will suddenly & dramatically increase Case Studies
•
Pg 8 - I
Capnography
Case Studies
Capnography
Pg 7 - H
• Usually increase of >10 mmHg (e.g., 30 increases to 40+)
• J NO
Case Studies
• When ROSC occurs, CO2 delivery to lungs increases.
Pg 8 - J
Capnography
• Cardiac arrest results in CO2 delivery to lungs, even if normal levels of CO2 produced in tissues. Case Studies
Capnography
Pg 8 - I i
• Ja Hyperventilation likely to cause hypotension and rearrest during this period of stunned myocardium
Pg 8 -K
Pg 8 - L
May decrease ~5 mmHg,
• ETCO2
desired temp is reached
Case Studies
delayed & seen when
Capnography
prehospital; decrease is Case Studies
Capnography
unlikely to be seen
• ECG
6
Northwest Community EMS System – Continuing Education – page 7 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout Video
Pg 8 – 24 A - B
• 24 A Waveform shape Case Studies
Show Video #2 (3 minutes)
Capnography
Case Studies
Capnography
• 24 Place pt on capnography
• 24 B Sharkin, increased alpha angle
• 24 D Severe asthma attack
• 24 E Yes • 24 F Yes Case Studies
• 24 C Anything causing obstruction to exhalation e.g., tongue, secretions, kinked ETT
Pg 9 – 24, EE-F
Capnography
Case Studies
Capnography
Pg 8 – 9, 24 CC-D
• 24 F i Administer albuterol via nebulizermask set-up, and place oral-nasal cannula on pt under mask
HANDSHANDS-ON DEMO
Pg 9 - 25
• 25 A Pts w/ COPD often normally have increased ETCO2 values Case Studies
use manikin apply oral-nasal capno cannula under neb mask
Capnography
Case Studies
Capnography
• 25 Increased
• 25 B If value increasing – pt getting worse If value decreasing – getting better
7
Northwest Community EMS System – Continuing Education – page 8 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout Pg 9 - 25 C
Pg 99-10, 26 A - C • 26 HF
Case Studies
• 25 C i Demonstrates obstruction to exhalation
• 26 A Squared/rectangular
Capnography
Case Studies
Capnography
• 25 C Sharkin Increased alpha angle
• 26 B Fluid in alveoli impairing ventilation • 26 C O2 via CPAP, ASA, NTG q 3-5 min
Pg 10 - D
HANDSHANDS-ON DEMO
on manikin apply capnography oraloral-nasal cannula under CPAP mask
Case Studies
•Di Apply oral-nasal cannula on pt under CPAP mask
Capnography
Case Studies
Capnography
•D Yes
Pg 10 - E
Pg 10 - F • F
•E
ETCO2 values may decrease – as perfusion decreases
Case Studies
•Ei Possible CPAP failure & need for intubation
Capnography
Case Studies
Capnography
Values may increase - as ventilation is improved
• Fi ETCO2 values are determined by metabolism, perfusion, and ventilation
8
Northwest Community EMS System – Continuing Education – page 9 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout Pg 10 - 27
Pg 11 - D i
• 27 – Capnography
• 27 D – most likely shark fin
Case Studies
• 27 C – exacerbation of COPD
Capnography
• 27 B – exacerbation of HF Case Studies
Capnography
• 27 A – waveform shape
Pg 11 - 28
If shark fin waveform, and pt has PMH of HF consider co-existing pneumonia or COPD; may also require treatment for HF
Pg 11 - 29
• 29 ETCO2 value
Alcohol, acidosis, anoxia Trauma, temperature, toxin, tumor Endocrine, epilepsy, Infection
Uremia
Case Studies
O2 deficit, overdose, opiates
Psych, poisoning, polypharmacy Stroke, seizure, SAH, sepsis, shock
Capnography
Insulin
Case Studies
Capnography
encephalopathy, electrolyte
Pg 11 - 30
Pg 11 – 30, B
• Pts can be apneic for 3 minutes before pulse ox levels fall Case Studies
Capnography
Case Studies
Capnography
• 30 ETCO2 value • 30 A Capnography
• 29 A Respiratory failure
• May be even longer if on supplemental O2
9
Northwest Community EMS System – Continuing Education – page 10 of 10 February 2012 – Capnography Case Studies – Diana Neubecker IMPORTANT NOTE: this document is the KEY for class handout Pg 12 - 31
Pg 12 - 32 • 32
• 31
HYPERventilation
or deeper than “just to” chest rise
• 32 A Case Studies
Only if ventilating faster than 10/m
Capnography
• 31 A Case Studies
Capnography
HYPOtension or HYPERventilation
Probably Assess ventilation rate & depth
Pg 12 – 32, B
Pg 12 – 32 C
• High CO2 results in cerebral vasodilation, increased cerebral blood flow and increased ICP Case Studies
• 11 B i Low CO2 causes cerebral vasoconstriction
• No
Capnography
Case Studies
Capnography
• 11 B Hyperventilation can cause or worsen cerebral ischemia and worse neurological outcome
Contact Diana Neubecker RN BSN PM NWC EMSS InIn-Field Coordinator Case Studies
What is the most important thing you learned from this class?
eucapnia are recommended.
QUESTIONS?
Capnography
Case Studies
Capnography
Review
• Ventilation rates to achieve
[email protected] 847 618 4488
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