Standard Operating Procedure SOP ID
Clinical Effectiveness Group
1st February 2013
31st January 2015
Clinical Publication Category
Mandatory - No deviation from document permissible
This Standard Operating Procedure (SOP) outlines the correct procedure for using the EMMA Emergency Capnometer to confirm the presence of end tidal CO2 (ETCO2) during patient ventilation and to confirm correct endotracheal tube placement.
This SOP must be read in conjunction with Clinical Guideline (CG11) - End Tidal CO2 Monitoring and Clinical Guideline (CG03) - Airway Management.
It is the responsibility of all ambulance clinicians to adhere to this SOP.
The EMMA Emergency Capnometer is a quantitative carbon dioxide mainstream monitor comprised of a sensor body that snaps in place on top of a disposable airway adapter. The unit measures, displays and monitors carbon dioxide concentration and ventilator/respiratory rate.
The measurement of ETCO2 is provided via an infrared micro bench. A microprocessor continuously calculates ETCO2 concentrations from the infrared light absorption measured through the optical window of the Airway Adapter. The features of the EMMMA are indicated in Figure 1.
Figure 1- Device Features
The device has three displays; respiratory rate, ETCO2 and the CO2 bar graph.
Respiratory Rate Display
3.5.1 The respiratory rate display, indicates the respiratory rate (RR) or ventilatory rate (depending if the patient is spontaneously breathing or being ventilated) as breaths per minute (3-150 bpm) using red numbers. 3.6
3.6.1 The EMMA displays ETCO2 in kPa (0.0 - 9.9 kPa) as red numbers.
CO2 Bar Graph
3.7.1 The 14-segment red bar graph shows the current CO2 value. Table 1 illustrates the relationship between the bar graph and the concentration of CO2 in kPa. The bar graph is intended to be used as an adjunct to the two quantitative numeric displays. The bar graph is non-linear, using smaller units of measure at the bottom and larger units of measure at the top. 3.7.2 Table 1 - Bar Graph Interpretation Segment 13 12 11 10 9 8 7 6 5 4 3 2 1 0
KPa Greater than or equal to 9.0 Greater than or equal to 8.0 Greater than or equal to 7.0 Greater than or equal to 6.0 Greater than or equal to 5.0 Greater than or equal to 4.0 Greater than or equal to 3.0 Greater than or equal to 2.0 Greater than or equal to 1.5 Greater than or equal to 1.0 Greater than or equal to 0.75 Greater than or equal to 0.5 Greater than or equal to 0.25 Greater than or equal to 0.0
Apply device as indicated by Clinical Guideline (CG11) - End Tidal CO2 Monitoring. It is mandatory that one of the three forms of ETCO2 monitoring available within the Trust (Easy Cap, EMMA or Mobimed) are utilised whenever a BVM is used by an ambulance clinician to ventilate via a face mask, supra-glottic airway, ET tube or surgical airway. Where a unit is not available at the commencement of the airway intervention or ventilation, the rationale for this must be recorded in the procedural exclusion section of the PCR and an incident report submitted.
Whilst ETCO2 monitoring must commence at the earliest opportunity, the choice of initial device is at the discretion of the senior clinician on-scene. The Easy Cap and EMMA device are the most rapid to deploy, whilst the Mobimed provides the benefits of full waveform capnography.
Directions for Use
Attach the EMMA airway adapter to the EMMA emergency capnometer. The adapter is designed so that it only connects when in the proper orientation (Figure 2); the optical window on the airway adaptor should line up with the optical sensor on the capnometer. It is possible to position the airway adapter in the breathing circuit first and then fit the EMMA device.
Figure 2 - Inserting the Airway Adaptor
The adult/paediatric airway adaptor is to be used for use on patients’ aged either 1 years or older or weighing 10kgs or higher. The infant airway adaptor is to be used for use on patients aged under 1year or 10kgs weight. The adult/paediatric airway adapter must not be used with infants, as it adds 6mls of dead space to the ventilation circuit.
If contamination of the device is unlikely from any fluid traces within the airway, attach the airway adaptor directly to the BVM mask, SGA, ET tube or surgical airway, so that EMMA is facing upwards. If contamination is possible, place a standard in-line bacterial filter between the BVM mask/SGA/ET tube and the airway adaptor.
Check that the EMMA is properly fitted and before it is connected to the patient press the power on button. A start-up sequence will be initiated to check for proper functioning.
When the unit is ready the ETCO2 display indicates 0, the Respiratory Display indicates “-“, the first segment of the bar graph and the green battery status indicator are illuminated.
If the ETCO2 display shows a non-zero value, ensure that there has not been an accumulation of CO2 between the EMMA unit and the airway adapter; remove and reattaching the airway adapter. If the ETCO2 still displays a non-zero value, perform the zeroing procedure: • Avoid breathing near the airway adapter before or during the zeroing procedure. The presence of ambient air in the airway adapter is of crucial importance. • Start the EMMA by pressing the on button. • Make sure that a new airway adapter is correctly attached.
• Press and hold down simultaneously the ‘On’ and ‘Alarm Silence’ buttons until the ETCO2 display shows “10” and the RR displays “C0”. Keep both buttons depressed while the ETCO2 Display starts counting down (displaying 9, 8, 7, 6) until ‘0’ is displayed. Zeroing is complete. 6.8
Connect the catheter mount/BVM/ventillator to the top end of the airway adaptor. The device is now ready be used to measure ETCO2. Continue to ventilate patient and monitor the ETCO2 reading provided by the unit.
The EMMA is recommended to be operated at temperatures between -5 to 40°C.
The battery status indicator is normally lit with a steady green light. When the battery is low, the indicator starts blinking. This occurs approximately 30 minutes prior to the depletion of standard alkaline batteries.
To ensure the device remains in operation, spare AA batteries must be stored within every EMMA carry case.
EMMA switches off automatically 15 seconds after the airway adaptor is removed or if a no breath condition is detected two minutes after the alarm silence button is pressed.
To insert the batteries press the battery cover release button into the EMMA body until the battery cover pops off (Figure 2).
Figure 2 - Opening the Battery Compartment
Open the battery compartment and insert two AAA batteries. Make sure that the batteries are fitted according to the indicated polarity. After installation snap battery cover back into place.
Cleaning and Decontamination
After each use dispose of the airway adaptor as contaminated waste and wipe entire exterior surface of the EMMA with a detergent wipe.
10.1 In line with Trust Policy, a Patient Clinical Record must be completed and annotated appropriately to identify the utilisation of the device and the confirmation of endotracheal tube placement. Any deviation from this SOP must be recorded, with any potential or actual adverse event reported through the incident reporting system.