# Combitube ?



## rhan101277 (May 21, 2011)

So I assisted with a code the other night and it seems that the combitube was really positional.  I would get some end tidal co2 for a while then it would go away.  It went away more toward the end, I double checked lung sounds and I had them bilaterally along w/ chest rise/fall.  Maybe the cells were dead and not doing any gas transfer.

Has anyone ever worked a code where the waveform went away, but you still had bilateral breath sounds.  Treat the patient not the monitor right.  It is possible there maybe have been an obstruction in the ETC02 measuring device.

Thoughts?


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## Shishkabob (May 21, 2011)

Happens sometimes with me, be it with ETT or a King. 

I just confirm placement by other means and go on.


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## rhan101277 (May 21, 2011)

Linuss said:


> Happens sometimes with me, be it with ETT or a King.
> 
> I just confirm placement by other means and go on.



Thanks, glad it just doesn't happen w/ me.


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## usafmedic45 (May 21, 2011)

Did you check to make sure both cuffs were fully inflated?  The most common cause (in my experience at least and assuming you're using the right port) for lack of a good reading is a lot of leak, especially if the tube is in the esophagus.


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## MSDeltaFlt (May 23, 2011)

rhan101277 said:


> So I assisted with a code the other night and it seems that the combitube was really positional.  I would get some end tidal co2 for a while then it would go away.  It went away more toward the end, I double checked lung sounds and I had them bilaterally along w/ chest rise/fall.  Maybe the cells were dead and not doing any gas transfer.
> 
> Has anyone ever worked a code where the waveform went away, but you still had bilateral breath sounds.  Treat the patient not the monitor right.  It is possible there maybe have been an obstruction in the ETC02 measuring device.
> 
> Thoughts?



You were working a code.  Meaning your pt was dead.  Remember capnometry and capnography both require cardiac output, which is something a dead person is kind of lacking a bit.  They're good to use but are by no means an absolute. Use those tools along with clinical assessments as well.


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## truetiger (May 23, 2011)

+1 for what MSDeltaFit said. You can actually use quantitative capnography as a quality indicator of compressions. Were the changes in ETCO2 correlating with the quality of compressions?


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## adil (May 26, 2011)

in my department all emt's like to intubite by using combi


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## Smash (May 26, 2011)

If there is good quality CPR being performed you should still get a wave form. Crappy numbers, but still a waveform, unless you are just trying to resus a truely dead person who has been that way for a while. 

No waveform should make you think of dislodgment or obstruction first. The British NHS recently did a massive review of all emergency (i.e. Not in theatre) intubations throughout the country and found that there was a reasonably large and worrying problem of clinicians thinking that there would be no waveform at all in an arrest, so not checking placement. 

Do what the other guys have said, recheck placement with all your other indicators, make sure the tube isn't obstructed with blood or vomit, check your equipment and if no response, replace the tube.


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## medictruth (Jun 10, 2011)

To me its a piece of equipment that can fail, trust your gut.


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## usalsfyre (Jun 10, 2011)

medictruth said:


> To me its a piece of equipment that can fail, trust your gut.



The Combitube, or the EtCO2?

While EtCO2 can fail, I'm fairly certain no one who's had an unrecognized esophageal tube  has thought "my gut says it's in the goose, but f@ck it, we're gonna use it anyway".


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## jwk (Jun 10, 2011)

usalsfyre said:


> The Combitube, or the EtCO2?
> 
> While EtCO2 can fail, I'm fairly certain no one who's had an unrecognized esophageal tube  has thought "my gut says it's in the goose, but f@ck it, we're gonna use it anyway".



Ditto - "trusting your gut" is exactly why EtCO2 monitoring is around in the first place.


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## MotorCity (Jul 1, 2011)

I hope you have a good gut. 

How many times have you seen someone put an iv in and "oh it's good". 5 minutes later grandmas hand is as big as a baseball.


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## lightsandsirens5 (Jul 1, 2011)

Smash "smashed" it. I can't believe how many people I've seen who assume there won't be any waveform in a full arrest pt. 

And I can only say what the others have said. Attempt confirmation by other means. Replace the tube if need be.


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## lightsandsirens5 (Jul 1, 2011)

rhan101277 said:


> Treat the patient not the monitor right.



No offense and nothing personal, but every time I hear this, I want to go and chime myself.  

Sorry, that is all.


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## usalsfyre (Jul 1, 2011)

lightsandsirens5 said:


> No offense and nothing personal, but every time I hear this, I want to go and chime myself.
> 
> Sorry, that is all.



Me too. My response?

"If the monitor is worthless, why am I carrying 20 lbs of useless kit around?"


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## lightsandsirens5 (Jul 1, 2011)

usalsfyre said:


> Me too. My response?
> 
> "If the monitor is worthless, why am I carrying 20 lbs of useless kit around?"



I know it is bad form for a red name to carry on a thread hijack, but.....

I can't stand the number of people who completely disregard the machine. I would say that in a loud, chaotic environment the automatic cuff is going to get a much more precise reading. Yet so many people say screw that that piece of junk can't take a good bp to save a life! Never mind that someone spent millions of dollars and thousands of hours researching, developing and building that machine. 

I totally agree with you. If it isn't valuable, why the heck does my boss have to spend a buttload of money on this monitor and why the heck do I have to carry it around? Why should I not lean towards believing the machine? If I get a sat of 80 even though my pt looks fine, I'm looking for why I have that sat. If I have a sinus tach on the 3 lead, but a pulse of 40, I not have an incredibly valuable piece of information that I would not have if I wasnt "treating" the monitor. It is high time we started believing the machine is correct and then being wary of circumstances that say otherwise instead of begrudgingly using it and the spending half our time trying to prove it wrong so we can dc the machine. 

:-S 

I'm sorry. Back to your regularly scheduled topic.


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## lightsandsirens5 (Jul 1, 2011)

lightsandsirens5 said:


> No offense and nothing personal, but every time I hear this, I want to go and chime myself.
> 
> Sorry, that is all.



That was supposed to be choke, not chime. 

Freaking autocorrect.


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## firetender (Jul 1, 2011)

lightsandsirens5 said:


> I know it is bad form for a red name to carry on a thread hijack, but.....


 
I look at the "red" thing like I'm the only guy in the room wearing pajamas. But wait, there's two of us here wandering around like someone busted our nap! 

(somebody explain this to me)


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## tom.watkins (Jul 17, 2011)

Had something similar happen the other day; had a pt with CBG of 399, and was having, and I quote, some "messed up breathing", (per RN). So here ya go: CBG-399 after 7 units of humalog; kussmaul respirations; and was going back and forth between tri and bigeminy. I thought this might be a good teaching moment and threw on a etco2 NC just to show my partner and fire what happens with acidosis. Unfortunately, the pts co2 was basically jumping between 16 and 60, with no real pauses in any shorter range. I decided just to VOMIT, and let the er fix it, since I don't carry insulin anyway. Moral of the story, machines can mess up, but humans aren't infallible either. I just treat when I can, trust my machines as far as I can throw them, and when all else fails, I have my EMT punch it.


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## WTEngel (Jul 17, 2011)

While I think ETCO2 is useful in the non intubated patient (i.e. esophageal tracheal tube, LMA, tracheal tube, etc.) it is worth noting that the jury is still deliberating on this issue. 

In the most recent ECC guidelines update they mention that while the use of ETCO2 in the non intubated patient is useful, the true measure of what it actually shows us in this patient population is up for debate.

Consistently expecting the same quantitative data readings that we get with intubated patients just has not been proven or fully studied yet.


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## usalsfyre (Jul 17, 2011)

WTEngel said:


> While I think ETCO2 is useful in the non intubated patient (i.e. esophageal tracheal tube, LMA, tracheal tube, etc.) it is worth noting that the jury is still deliberating on this issue.
> 
> In the most recent ECC and ILCOR guidelines update they mention that while the use of ETCO2 in the non intubated patient is useful, the true measure of what it actually shows us in this patient population is up for debate.
> 
> Consistently expecting the same quantitative data readings that we get with intubated patients just has not been proven or fully studied yet.



There's probably some differences to be expected in quantitative data (which let's face it, is of limited utility without a baseline ABG anyway) but what I care more about is the capnograph tracing.


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## WTEngel (Jul 17, 2011)

I agree, without a baseline gas along with a tube that we know the exact location of (ET tube) the waveform is really the only thing of significance to me.

While I agree that trending the numbers you get initially is a good way to measure resuscitative efforts, I'm afraid that capnography is quickly becoming another set of numbers that people are under educated on and want to arbitrarily manage. 

That's really one of the best take away points of the thread usla. Without a good gauge of where that patient "lives" normally and a good gas to compare against, ETCO2 can sometimes be just as misleading as SPO2 or any number of other parameters some providers randomly choose to fixate on.


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## usalsfyre (Jul 17, 2011)

WTEngel said:


> While I agree that trending the numbers you get initially is a good way to measure resuscitative efforts, I'm afraid that capnography is quickly becoming another set of numbers that people are under educated on and want to arbitrarily manage.
> 
> That's really one of the best take away points of the thread usla. Without a good gauge of where that patient "lives" normally and a good gas to compare against, ETCO2 can sometimes be just as misleading as SPO2 or any number of other parameters some providers randomly choose to fixate on.



There's a school of thought (that I personally subscribe to) that says except for cases of respiratory failure, post-intubation put the patient's ETCO2 back to where you found it pre-intubation. Even then, I would err on the hypercapenic side of normal while maintaining oxygenation. Hypercapnia takes a long time to kill somebody.


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## cfd3091 (Jul 18, 2011)

truetiger said:


> +1 for what MSDeltaFit said. You can actually use quantitative capnography as a quality indicator of compressions. Were the changes in ETCO2 correlating with the quality of compressions?


+2 on compressions


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