Medical Tidbits‎ > ‎

2015/01/21 - Medical Tidbits: EtCO2 for all intubated / ventilated patients

Greetings from the warm city of New Orleans …

 

Prior to coming onboard as medical director there was a huge push by Drs Miramontes and Goliver with the use of EtCO2 for all intubated / ventilated patients.  Since then we have continued this push and there are many valuable reasons for having EtCO2 on all intubated / trached / supraglottic airway devices, even if you are BVMing a patient.

 

Let’s start with the easiest – confirmation of airway.  EtCO2 is the “Gold Standard” for airway confirmation.  This is such a true statement that the Ohio Board of EMS will be requiring all EMS agencies to use EtCO2 within the next several years on all patients with an advanced airway in place.  We can tell if the CO2 levels remain low that the endotracheal tube is not in the proper place.

 

Return of spontaneous circulation – another leading trend is the assistance with determining ROSC or even termination of cardiac resuscitative measures.   During cardiac arrest scenarios prior to ROSC there will be an elevation in the CO2 level … this means that the body is starting to expel all of the built up acid in the body through the pulmonary system and early indicator that you are performing appropriate cardiopulmonary resuscitative measures.  An EtCO2 less than 10 after 20 – 25 minutes of resuscitative measures is an indicator of poor outcome and resuscitative measures can thus be terminated.  This is also true if we have a falling EtCO2 level during resuscitative measures.  Starting in the 40’s and drop below 10 is indication that either we are not performing appropriate cardiac resuscitation or that the individual will not have a good outcome.

 

Indications that paralytic agents are starting to “wear off”.  We can see the shark finning on EtCO2 which is one of the several wave patterns that helps with determining that paralyzed patients are starting to breathe a little bit on their own.  This can also be a reminder that if you have not given sedation medications to the patient that you should give sedation medication (this would also include giving a dose of fentanyl for the pain of having an ETT / supraglottic device in place).

 

Sepsis – new trends have come out of Orlando Regional Medical Center where they have started to show that patients with Sepsis criteria

·         (2 SIRS plus source equals sepsis, with SIRS criteria being – temperature > 100.4 < 36, HR > 90 bpm, RR > 20 / min or arterial PCO2 level < 32 mmHg or WBC > 12000 or < 4000 or > 10% immature bands).  Septic shock of course is sepsis with low blood pressure. 

·         In patients with ≥ 2 SIRS criteria, an EtCO2 measurement of ≤ 25 mmHg is strongly correlated with lactate levels > 4 mM/L and increased mortality.

 

Tim and Pat go through EtCO2 during competencies and Tim has a great lecture on EtCO2 that if you have not heard then you need to sit down and listen to (or ask him to give you the powerpoint presentation). 

 

LifeFlight and Life Star guidelines – “ALL” ventilated patients must have EtCO2.  This is the standard of care and an expectation that the medical directors have for care of patients.   1 missed tube or accidentally dislodged tube that is caught early is well worth the price that we pay for having this equipment on hand.

 

Remember … share the care, work as a team.  What you do really does matter.

 

Quote I heard yesterday at the NAEMSP advanced topics lecture … “there is no G^% D*&^ low hanging fruit … only hard work”, Michael Copass – Seattle EMS)

 

Until next month

Comments