# CPR Save: Capnography as Performance Monitor



## 18G (Oct 30, 2011)

Nice to see emphasis placed on use of capnography as a performance monitor for CPR. 

http://www.reuters.com/video/2011/10/27/new-cpr-technique-revives-man-after-63-m?videoId=223945877


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## Shishkabob (Oct 30, 2011)

Gotta find the study, but it's been stated for a while that the chance of getting ROSC after EtCO2 falls below 10 mmHg is minimal.


Due to that, I've had arrests where I called it the moment I could, and have had arrest where we push on for some time after because EtCO2 is still adequate.  




The doctor wants non-Paramedics to have EtCO2 when they won't know how to interpret it or decide what to do based on the numbers?  Odd.  Just push hard and fast on the chest and play with the AED until a medic gets there with the rest of the stuff.  A first responder doesn't need to be the one making a determination on whether or not the EtCO2 is good or not and make care decisions based off of that.


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## NJEMS (Oct 31, 2011)

Linuss said:


> Gotta find the study, but it's been stated for a while that the chance of getting ROSC after EtCO2 falls below 10 mmHg is minimal.
> 
> 
> Due to that, I've had arrests where I called it the moment I could, and have had arrest where we push on for some time after because EtCO2 is still adequate.
> ...



Agreed, as a basic the only use I found in EtCO2 is deciding at what rate to bvm a patient


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## rhan101277 (Oct 31, 2011)

NJEMS said:


> Agreed, as a basic the only use I found in EtCO2 is deciding at what rate to bvm a patient



Only change ventilation rates, based on ETCO2, when dealing with herniation.


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## mycrofft (Oct 31, 2011)

*Linus, truer words are sayeth naught.*

To each level its own.
I might be teaching people to be EMS's "little red wagons", but they are good ones and there are a mess of them running around out there right now.


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## 18G (Oct 31, 2011)

rhan101277 said:


> Only change ventilation rates, based on ETCO2, when dealing with herniation.



Irregardless of herniation, a head injured patient should have their EtCO2 maintained at the low end of normal (35-37mmHg).  

I had a patient a few weeks ago... was a younger male pt. kicked in the head during a fight and initially refused EMS care. EMS was called back a little while later when pt. was unresponsive and seizing. Pt. had a subarachnoid bleed and was intubated in the ED and my unit was called to transfer this patient to a trauma center.

Long story short... transfer was about two hours with morning, rush hour traffic, and sending facility did not provide a vent. So we had no choice but to bag the patient for two hours. Using waveform capnography, we were able to maintain an EtCO2 of 35-37mmHg throughout care.    

When we got to the trauma center, I overheard one of the trauma docs comment, "his ABG's really aren't that bad for being bagged for several hours". I just wanted to use this experience as an example of how useful EtCO2 monitoring is and how important it is to pay close attention to assisted ventilation especially in a head injured patient.


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## usalsfyre (Oct 31, 2011)

Just a thought to keep in mind, you are right it's important to use ETCO2 for more than tube placement, but...

It's also important to note ETCO2 isn't a direct reflection on PaCO2 and may be greatly influenced by cardiac output and shunt physiology. Especially in complex medical and cardiac patients, just because the end tidal is good don't assume the gasses are good.


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## 18G (Oct 31, 2011)

usalsfyre said:


> Just a thought to keep in mind, you are right it's important to use ETCO2 for more than tube placement, but...
> 
> It's also important to note ETCO2 isn't a direct reflection on PaCO2 and may be greatly influenced by cardiac output and shunt physiology. Especially in complex medical and cardiac patients, just because the end tidal is good don't assume the gasses are good.



Agree. I was just referring to a young, isolated head injured patient. Although, EtCO2 has been shown to be very close to PaCO2.


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## usalsfyre (Oct 31, 2011)

18G said:


> Although, EtCO2 has been shown to be very close to PaCO2.


In the healthy patient the gradient is generally small, it's the patient with a sick heart and junk in their lungs that you can't trust it on.


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## 18G (Oct 31, 2011)

usalsfyre said:


> In the healthy patient the gradient is generally small, it's the patient with a sick heart and junk in their lungs that you can't trust it on.



Ditto.


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## rhan101277 (Oct 31, 2011)

18G said:


> Irregardless of herniation, a head injured patient should have their EtCO2 maintained at the low end of normal (35-37mmHg).
> 
> I had a patient a few weeks ago... was a younger male pt. kicked in the head during a fight and initially refused EMS care. EMS was called back a little while later when pt. was unresponsive and seizing. Pt. had a subarachnoid bleed and was intubated in the ED and my unit was called to transfer this patient to a trauma center.
> 
> ...



I bet your arm got tired.  We carry vents on our critical care units.  They are not as good as the ones in the ICU though.


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## 18G (Oct 31, 2011)

rhan101277 said:


> I bet your arm got tired.  We carry vents on our critical care units.  They are not as good as the ones in the ICU though.



lol.. it wasn't too bad actually. In the state I work Paramedic's aren't allowed to monitor propofol which the patient was on so an RN was onboard and him and I switched off. 

My company has vents, just not on every unit which I wish they did.


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## Farmer2DO (Oct 31, 2011)

18G said:


> Irregardless of herniation, a head injured patient should have their EtCO2 maintained at the low end of normal (35-37mmHg).



Actually, our medical director is insistent that he wants these patients kept at 38-42, with the perfect world constant goal of 40.




18G said:


> In the state I work Paramedic's aren't allowed to monitor propofol



Once intubated, I think propofol is safer than the other agents, in an appropriate patient.  Goes to show what happens when other groups (anesthesiologists) dictate our practice.  Another reason why EMS needs a degree ladder and more formal education:  having practice guidelines set more by EMS people.


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## usalsfyre (Oct 31, 2011)

Propofol, in my admittedly limited experience, sucks for transport. It works great in ICUs where you can limit sensory inputs. On the road or in the air, where you've got little control over what comes in, you end with an inadequately sedated patient on level of propofol that give them borderline hypotension. I prefer a midaz/fentanyl infusion myself.


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## 18G (Oct 31, 2011)

Farmer2DO said:


> Actually, our medical director is insistent that he wants these patients kept at 38-42, with the perfect world constant goal of 40.



The guidelines from the Brain Trauma Foundation actually recommend EtCO2 to be maintained between 35-40mmHg. Most of the literature I have read call for maintaining EtCO2 in the low-end. 

Do you know why your medical director is insistent on that range? Maybe he feels it gives a margin of error to prevent hyperventilation when targeting for 35mmHg?


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## 18G (Oct 31, 2011)

usalsfyre said:


> Propofol, in my admittedly limited experience, sucks for transport. It works great in ICUs where you can limit sensory inputs. On the road or in the air, where you've got little control over what comes in, you end with an inadequately sedated patient on level of propofol that give them borderline hypotension. I prefer a midaz/fentanyl infusion myself.




I like propofol and have observed great effect pre-hospital. It works well, easily titrated and managed. We also give benzo's as needed to manage sedation with the propofol during transport.


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## Smash (Oct 31, 2011)

usalsfyre said:


> Propofol, in my admittedly limited experience, sucks for transport. It works great in ICUs where you can limit sensory inputs. On the road or in the air, where you've got little control over what comes in, you end with an inadequately sedated patient on level of propofol that give them borderline hypotension. I prefer a midaz/fentanyl infusion myself.



I agree.  Props is good for induction in some cases (we use it for burns with a high GCS) but I like fentanyl/midaz or morphine/midaz for transport.  Something I see a lot is no analgesia concurrently with a propofol infusion, which is a bit nasty as props has no analgesic effect.


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## Smash (Oct 31, 2011)

18G said:


> I like propofol and have observed great effect pre-hospital. It works well, easily titrated and managed. We also give benzo's as needed to manage sedation with the propofol during transport.



If you are using propfol for sedation, why do you add benzos for sedation as well?  Wouldn't adding some analgesia make more sense than doubling up on sedation with no analgesia?


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## Farmer2DO (Nov 1, 2011)

18G said:


> The guidelines from the Brain Trauma Foundation actually recommend EtCO2 to be maintained between 35-40mmHg. Most of the literature I have read call for maintaining EtCO2 in the low-end.
> 
> Do you know why your medical director is insistent on that range? Maybe he feels it gives a margin of error to prevent hyperventilation when targeting for 35mmHg?



Specifically, I don't know.  But I do know that it's based on the literature that's out there, and that he's well read and has been involved in some of the research.  We have a pre-hospital RSI program in our region, and management of capno is one of his strong areas of interest.  He also worked his way up through the system; started as a commercial EMT-B and was a paramedic before he was a physician.  I have an incredible amount of respect for him.



Smash said:


> If you are using propfol for sedation, why do you add benzos for sedation as well?  Wouldn't adding some analgesia make more sense than doubling up on sedation with no analgesia?



Obviously, propofol isn't for everyone, but I think that infusions are better than bolus sedations, regardless of the agent.  I also firmly believe that everyone is most often best served by using 2 agents for sedation.  Usually midazolam and fentanyl or propofol and fentanyl.  I prefer the prop/fent for the short half life; I can often add 2 mg boluses of midazolam.  If the patient becomes hypotensive, I can lighten up on the propfol and the effects wear off pretty quick.  Just my personal opinion based on experience.  I agree that analgesia needs to be added to most patients with sedation.


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## Farmer2DO (Nov 1, 2011)

I just watched the video.  I think Dr. White wrote one of my textbooks.

Also, the guy narrating it needs to learn how to pronounce "defibrillation".  The Y is silent.  <_<

One of my pet peeves.


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