the 100% directionless thread

I honestly can't remember the last time that I saw capnography not used during an out-of-hospital intubation or transport of an intubated patient.

MonkeyArrow said:
My ER. Only half joking.
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I have transported patients to and from ED's and ICU's in dozens of hospitals over the years. I've worked as either a RN or CRNA in a 5 or 6 different facilities. I rotated through 10+ different hospitals during my anesthesia training......and I don't remember ever seeing capnography used in hospital, outside of the OR.
 
Remi said:
and I don't remember ever seeing capnography used in hospital, outside of the OR.
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Why do you think that is, Remi? Do they have something else to use (bedside X-ray, say)?
 
Remi said:
I honestly can't remember the last time that I saw capnography not used during an out-of-hospital intubation or transport of an intubated patient.



I have transported patients to and from ED's and ICU's in dozens of hospitals over the years. I've worked as either a RN or CRNA in a 5 or 6 different facilities. I rotated through 10+ different hospitals during my anesthesia training......and I don't remember ever seeing capnography used in hospital, outside of the OR.
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Yeah, it is something I am trying to get our medical director to get more aggressive with as a ED-wide standard. We have the freaking cannulae and adapters right there in the resus bay next to the BP cuffs and electrodes where all our intubations end up, but aside from a couple of more aggressive docs, I've never seen it used. We use colorimetric end tidal immediately post-intubation, of course followed by stat CXr and then the advanced metrics of the ventilator within 5 minutes of passing the tube. So, I mean probably not the worse thing in the world but it drives me up a wall.
 
EpiEMS said:
Why do you think that is, Remi? Do they have something else to use (bedside X-ray, say)?
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X-ray to confirm placement and then ABG to modify vent settings.
 
EpiEMS said:
Why do you think that is, Remi? Do they have something else to use (bedside X-ray, say)?
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Yep:

DesertMedic66 said:
X-ray to confirm placement and then ABG to modify vent settings.
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Modern ICU vents give you a lot of information about ventilation, and if the patient is sick, you are probably drawing blood gases regularly and even also, and can always do a CXR. Really does probably obviate the need for capnography in most cases. Because of that I think many people in medicine really think of Etc02 as just a way to prove tracheal placement on intubation. They just don't think it's worth the cost of the monitor modules and the sampling lines.

On the other hand, I would feel naked without it in the OR even though I have volume and pressure waveforms and all the pressure measurements (and loops, if I want to look at them) on my anesthesia machine, but I'm also monitoring other gases as well. When I do intubations in the ICU and ED, they only have the colorimetric devices and even when I know the tube is placed properly, I still feel like I'm missing something important when I'm doing my immediate post-intubation assessment and have no C02 waveform to look at.
 
Remi said:
Modern ICU vents give you a lot of information about ventilation, and if the patient is sick, you are probably drawing blood gases regularly and even also, and can always do a CXR. Really does probably obviate the need for capnography in most cases. Because of that I think many people in medicine really think of Etc02 as just a way to prove tracheal placement on intubation. They just don't think it's worth the cost of the monitor modules and the sampling lines.

On the other hand, I would feel naked without it in the OR even though I have volume and pressure waveforms and all the pressure measurements (and loops, if I want to look at them) on my anesthesia machine, but I'm also monitoring other gases as well. When I do intubations in the ICU and ED, they only have the colorimetric devices and even when I know the tube is placed properly, I still feel like I'm missing something important when I'm doing my immediate post-intubation assessment and have no C02 waveform to look at.
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I was one of the few, or only, nurses in the unit that regularly used capnography. I used it on every intubated patient and NC-ETC02 on most of my recently extubated patients. Not many providers, RN to MD, were very comfortable with interpretation so they just didn't use it. I hated getting called to a room with a crashing patient and not having end tidal.

It also didn't help that the ETC02 modules for our monitors were like $12k a piece and constantly breaking.
 
Given all of the experts, and high end equipment available at any given hospital for endotracheal tube confirmation versus a paramedics "instincts" and prowess, there is absolutely no reason why we--the paramedic--should not utilize the one and only tool proven to guarantee ETT placement and guide treatments such as post resuscitative care in the field.

Any paramedic who cannot comprehend this idea should not be a paramedic, let alone be allowed to intubate in this day and age. End of story.
 
I honestly don't know why it's not mandatory in EDs as well. Waveform capno gives us a real-time, objective and remote measurement of ventilations, tube condition, placement and metabolism that we can literally put on a remote screen anywhere in the hospital- how is that not a valuable thing to have? Blood gasses, even at frequent intervals, don't do that. SpO2 and cardiac monitoring don't do that.
 
It seems to be becoming more and more commonplace in most of our ED's, even the CAH's. I would say so much so that more often than not, as long as their detectors are phlegm-free, I'll just use the hospitals since they're compatible with our monitors.
 
In completely unrelated news to the above discussion, CPR training today went pretty well, was actually more engaging/interesting than last week's "Practice the Heimlich all day" lol

Besides the normal mannequins, they had a couple of the really fancy ones that connect to a computer and show you how well or poor your compressions and ventilations are (shows you your rate, depth, and recoil, and time off chest). The departments SOG is continuous, non stop chest compressions, 1 ventilation every 10th compression, switching out the person on the chest every minute...the dept AEDs have a little timer and even a metronome to facilitate this....so many of us (me included) started of doing chest compressions at rates of 150 or higher! The metronome is set for 110 non, and it really does feel so slow, almost takes practice to not go too fast...

Cool thing is that the dept Medical Director was on hand, helping out. She even showed me a better way of holding the BVM mask that was not only more comfortable, but I went from struggling to provide enough tidal volume (air was leaking out around the mask and not going into the "patient") to reliably being in the blue on the computer, all in all pretty good for an AHA refresher lol!
 
RocketMedic said:
I honestly don't know why it's not mandatory in EDs as well. Waveform capno gives us a real-time, objective and remote measurement of ventilations, tube condition, placement and metabolism that we can literally put on a remote screen anywhere in the hospital- how is that not a valuable thing to have? Blood gasses, even at frequent intervals, don't do that. SpO2 and cardiac monitoring don't do that.
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Well, it is somewhat redundant when you can mirror the vent settings anywhere in the hospital. All intubated patients are going to be placed on a vent, and the advanced metrics there will certainly show if the tube has been misplaced or dislodged.
 
MonkeyArrow said:
Well, it is somewhat redundant when you can mirror the vent settings anywhere in the hospital. All intubated patients are going to be placed on a vent, and the advanced metrics there will certainly show if the tube has been misplaced or dislodged.
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ETCO2 is so much more than just ET tube placement. A patient can be synchronous with no vent alarms but still profoundly hypercapnic. Or just as importantly as a marker for perfusion.
 
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