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Capnometry and Capnography in the Emergency Department
Reuben Strayer McGill Emergency Medicine
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MUHC Capabilities
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Basic Physiology of CO2
.03% Three forms Classical use of [CO2] Alveolus Continuum
Ward 1998
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Measuring CO2
Capnometry & Capnography
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Measuring CO2
Ward 1998
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Measuring CO2
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PetCO2 vs. ScvO2
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Measuring CO2
.03% Three forms Classical use of [CO2] Alveolus Continuum Infrared
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Measuring CO2
Mainstream vs. Sidestream
Santos 1994
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Miller’s Anesthesia, 6th ed.
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Time lag
Sullivan 2005
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Capnograph
Ward 1998
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The PetCO2 Value
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CO2 production
Delivery of blood to lungs
Sanders 1989
Alveolar ventilation
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The PetCO2 Value
Decreased central drive Muscle weakness Diffusion problems
Increased PetCO2
Fever Burns Hyperthyroidism Seizure Bicarbonate Rx ROSC Tourniquet
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The PetCO2 Value
Overventilation Hypothermia Sedation Paralysis
Decreased PetCO2 Decreased CO
Ventilating nonperfused lung (dead space)
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The PetCO2 Value
Dead space ventilation
Ward 1998
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The PetCO2 Value
Shunt perfusion
Ward 1998
Santos 1994
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a-ADCO2
3-5 mmHg
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Interpretation of the capnogram
No CO2 Low PetCO2
Failure to ventilate
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Ward 1998
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Interpretation of the capnogram
No CO2 Low PetCO2
Failure to ventilate
Failure to circulate
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Interpretation of the capnogram
Ward 1998
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Interpretation of the capnogram
No CO2 Low PetCO2
Failure to ventilate
Failure to circulate
Changes in the slope of phase II and III
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Interpretation of the capnogram
Kinked ETT
Ward 1998
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Interpretation of the capnogram
Obstructive lung disease
Ward 1998
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Interpretation of the capnogram
Curare cleft
Ward 1998
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Interpretation of the capnogram
Cardiogenic oscillations
Cuff leak Ward 1998
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Use in the confirmation of tracheal intubation
Prehospital BVM
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Use in the confirmation of tracheal intubation
Leong 2005
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Use in the confirmation of tracheal intubation
Supraglottic ETT Cardiac arrest Do not rely on capnometry exclusively auscultation of breath sounds absence of gastric sounds observation of chest motion appropriate compliance of the bag-valve assembly tube condensation absence of gastric contents in the tube palpation of the tube cuff in the suprasternal notch use of a lighted stylet use of an esophageal detector device chest radiography bronchoscopy pulse oximetry
6 breaths Li 2000
Montauk 1996 Li 2006
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Use in displaying the respiratory rate
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Use in displaying the respiratory rate
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Use in displaying the respiratory rate
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Use in displaying the respiratory rate
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Use in displaying the respiratory rate
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Use in displaying the respiratory rate
In search of a reliable RR
Transthoracic impedance
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Use in displaying the respiratory rate
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Use in displaying the respiratory rate
Biro 1994 Greenberg 2006
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Use in displaying the respiratory rate
tcPCO2
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Use in CPR
CO2 production, alveolar ventilation, and pulmonary perfusion
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Use in CPR
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Use in CPR
Santos 1994
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Use in CPR
CO2 production, alveolar ventilation, and pulmonary perfusion PetCO2 reflects the adequacy of CPR Long downtimes Obstructive causes of cardiac arrest
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Use in CPR
Rosen’s Emergency Medicine, 4th ed.
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Use in CPR
Pseudo-PEA
Rosen’s Emergency Medicine, 4th ed.
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Use in CPR
CO2 production, alveolar ventilation, and pulmonary perfusion PetCO2 reflects the adequacy of CPR Long downtimes Obstructive causes of cardiac arrest Bicarb & epi
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Use in CPR
Rosen’s Emergency Medicine, 4th ed.
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Use in CPR
CO2 production, alveolar ventilation, and pulmonary perfusion PetCO2 reflects the adequacy of CPR Long downtimes Obstructive causes of cardiac arrest Bicarb & epi
Guiding the termination of resuscitative efforts
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Use in CPR
Koetter 1999
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Use in CPR
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Use in CPR
CO2 production, alveolar ventilation, and pulmonary perfusion PetCO2 reflects the adequacy of CPR Long downtimes Obstructive causes of cardiac arrest Bicarb & epi
Guiding the termination of resuscitative efforts Summary
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Use as a PaCO2 surrogate
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Use as a PaCO2 surrogate
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Use as a PaCO2 surrogate
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Use in procedural sedation
Chest rise
Hasel 2003
Cote 1991
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Use in procedural sedation
Stemp 2005
Walker 2004
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Use in procedural sedation
McQuillen 2000
McNulty 1990
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Use in procedural sedation
Chest rise
Not good enough
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Use in the management of asthma
Yaron 1996
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Use in the diagnosis of pulmonary embolism
PE makes dead space vs. the A-a gradient
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Use in the diagnosis of pulmonary embolism
Ward 1998
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Use in the diagnosis of pulmonary embolism
Kline 1998
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Use in the diagnosis of pulmonary embolism
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Use in the measurement of cardiac output
VO2 = (CO x CA) - (CO x CV)
CO = VO2 / (CA - CV) Cardiac Output = Oxygen Consumption / Arteriovenous Oxygen Difference
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Conclusion
CO Physiology
The Capnograph
Confirming ETT placement Displaying respiratory rate Guiding CPR PaCO2 surrogate Procedural sedation Asthma PE Cardiac output
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