C02 during resuscitation

[GoldenBeaR6]

So, I ran my first code last night. Patient was tubed by a medic and I assisted with compressions and ventilations. He was hooked up to the LP12 for capnography. I believe the C02 reading should ideally be kept around 35mmHg. Just to double check, higher levels mean faster ventilations and lower mean slow down right? Is that an appropriate means to check that the rate of ventilations is OK?

 

[MasterIntubator]

You pegged it. That is the beauty of having a numerical feedback system in realtime, you can self pace.... and it feels great to be able to think on your own. Huh?

Last code I had, the initial EtCO2 was 88.... after a few minutes, it adjusted down to a more normal range <insert your reference ranges here>.

Don't become too much of a number hound.... as long as it stays an exceptable range, the cells will do the body as right as they can. When they start coming back to life.... then those high/low normal ranges become more important... ( at least until the next AHA theoretical meeting )

 

[VentMedic]

You pegged it. That is the beauty of having a numerical feedback system in realtime, you can self pace.... and it feels great to be able to think on your own. Huh?

Last code I had, the initial EtCO2 was 88.... after a few minutes, it adjusted down to a more normal range <insert your reference ranges here>.

Don't become too much of a number hound.... as long as it stays an exceptable range, the cells will do the body as right as they can. When they start coming back to life.... then those high/low normal ranges become more important... ( at least until the next AHA theoretical meeting )

Careful... He did say during a code. If the number is 18 mmHg before ROSC, you don't want him to bag at a rate of 0 -1 to get that number to 35 mmHg in belief it is "hyperventilation".

Also, you still have to take the underlying diseases into consideration for V/Q mismatching and deadspace. You also do not want someone to over bag to where there is stacking and hyperinflation.

 

[VentMedic]

Are you talking about during the code while the patient is in cardiac arrest or after ROSC?

To learn more about capnography:

http://elearning.respironics.com/index_f.asp

It is free and sign on is easy. You will find a few CE training modules on that sight that is informative. Of course, if you have had some college level A&P the phyisology for acid-base and shunting would be easier but you can still get something from it.

Here is another good site:
http://www.capnography.com/

For cardiac arrest:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC374377/

Many clinical studies have now established that the PETCO2 can predict the outcome of the resuscitation effort. For example, failure of closed-chest resuscitation to increase the PETCO2 above 10 mmHg has been reported to predict an extremely low likelihood of restoring spontaneous circulation [6,7]. Conversely, higher PETCO2 levels are associated with increased likelihood of successful resuscitation. In one study, successfully resuscitated victims all had a PETCO2 level of at least 18 mmHg before the return of spontaneous circulation [7].

Read the whole article to get a good understanding as well as the highlighted links to other studies. The other articles to the right are also worth reading.

As for as the ventilation rate for someone not in cardiac arrest, an ETCO2 of 35 mmHg is the low end of normal for a patient with NORMAL lungs and no underlying factors to skew the gradient between the lungs or alveolar level and the blood. Hence, this concerns ventilation to perfusion matching. If you are too over zealous to correct, you can compromise cardiac output by decreasing venous return. If ROSC has just been established, be very cautious with the way you ventilate by not stacking breaths or trying to "normalize" numbers too quickly.

Also, when working a code with the patient in cardiac arrest you still want to do the AHA recommended rate for an intubated patient regardless of how low the ETCO2 reading is. Do not slow to attempt to get that 10 mmHg up to 35 mmHg.

 

[MasterIntubator]

Just wanted to give enough to spark thier interest to search and learn more on thier own.
But vent is correct... you just have your foot in the door... but its your good foot.

 

[VentMedic]

Just wanted to give enough to spark thier interest to search and learn more on thier own.
But vent is correct... you just have your foot in the door... but its your good foot.

I provided some links because I didn't want them to start with some of the EMS blogspots for ETCO2 information. There are enough legit and carefully scrutinized resources out there. Capnography has widely use clinically for over 25 years and that includes one of the model I transported with on CCT/Specialty over 20 years ago. There is a wealth of information for it but it is good to check the source.

 

[GoldenBeaR6]

I'll definitely do some reading. just for info on the call, we got there very quickly and patient was reported as gurgling when called in. 47 y/o male. no pulse, no breathing upon arrival. monitor showed v-fib. CPR, intubated, and shocked 6 times. converted to PEA with rate around 30/min. no pulses palpable. continued CPR to hospital. when we left the ED, he had pulse of 110, BP 130/90, and some respiratory effort. who knows how much O2 his brain got, but we gave him a chance I suppose.

 

[VentMedic]

I'll definitely do some reading. just for info on the call, we got there very quickly and patient was reported as gurgling when called in. 47 y/o male. no pulse, no breathing upon arrival. monitor showed v-fib. CPR, intubated, and shocked 6 times. converted to PEA with rate around 30/min. no pulses palpable. continued CPR to hospital. when we left the ED, he had pulse of 110, BP 130/90, and some respiratory effort. who knows how much O2 his brain got, but we gave him a chance I suppose.

Did you notice what the ETCO2 reading was during CPR?

 

[GoldenBeaR6]

no idea on scene. in the truck, the lowest i saw was 22 and highest 48, probably averaged around 29-32

 

[VentMedic]

no idea on scene. in the truck, the lowest i saw was 22 and highest 48, probably averaged around 29-32

Read the article I posted earlier about cardiac arrest and the chances for ROSC as well as survivability predictor. This person could have a decent chance depending on the cause of the arrest.

 

[Hal9000]

Are you talking about during the code while the patient is in cardiac arrest or after ROSC?

To learn more about capnography:

http://elearning.respironics.com/index_f.asp
.

This link is excellent; I would recommend it to others. Thanks.

 

[Aidey]

Something with ETCO2 I've learned also is that when all cellular metabolism stops, the ETCO2 reading will get pretty low. So your ETCO2 reading of 6mmHg may not be because you are bagging the pt too fast, it may be because your pt has moved from mostly dead to very dead.