Capnography for EMS

Understanding the PowerOf Knowledge

BENEFITS of ETCO2

• Non-invasive• Cost effective• Easy to use• Gives important information• Gives it fast, reliable• Way more sensitive than Pulse Ox

Measure of exhaled CO2

• End tidal CO2 gives a number• Capnography gives a number and a

waveform• Waveform is more reliable and can

give additional information

Methods

• ETCO2 detector that goes on ET Tube

• Nasal Cannula that measures CO2– Can be used much more frequently

– Not just for intubations anymore!!

Methods

• Infrared light aimed thru exhaled gas• Washout of light from CO2 gives

measurement

Physiology

• Pulse oximetry measures oxygen saturation on hemoglobin– Drops late, trouble has already

occurred– Is not sensitive to ventilation– Diffusion of oxygen into blood at alveoli– Often measured at peripheral location

Physiology

• Capnography measures exhalation Carbon Dioxide and provides a real time graph– Changes quickly with patient condition– Best method to monitor ventilation– Indirect measure of body perfusion

Physiology

• Carbon dioxide is by-product of metabolism (The smoke from the fire)

• Normal ETCO2 = 38-42 mmHg• Normal perfusion means normal

blood getting to lungs and off-loading CO2

• Normal ventilation allows CO2 to be removed and measured

Physiology

• Normal perfusion & Hyperventilation cause lower ETCO2

• Hypoventilation causes higher ETCO2

• Poor perfusion causes lower ETCO2• Trends are critical• Waveform can give information• May see no changes in pulse ox

When should Capnography be used??

• All intubations– MANDATORY, not using is malpractice– Graph with persistent pattern means

tube is in trachea ( # only can be false positive)

– Use to guide rate for eucapnea (40 mmHg)

– Use for goal directed ETCO2– Watch ETCO2 trend

All severely injured patients

• Measurement of ETCO2 and the trend gives information about systemic perfusion– If ETCO2 starts falling, shock is

present and is getting worse.– Rapid transport, ?? Fluids,– Trauma Center– Can give up to 20 minutes of warning

Cardiac Arrest

• Predictor of outcome• With good CCR ETCO2 stays

below 16, not likely to survive• Increasing ETCO2 levels predict

success, perfusion is improving• We intubate late--initial ETCO2 will

be very useful as to how we are doing

Hyperglycemic patient

• NC ET capnography• See if ETCO2 is 29 or lower

– This is due to Kussmal Respirations– Severe dehydration with decreased

perfusion

• If so, DKA likely• DKA needs WO Normal saline all

the way to the hospital

Dyspnea

• All patients with Dyspnea should have NC ETCO2 measured.

• Asthma, COPD, pneumonia• If CO2 in high despite breathing

hard, respiratory failure is developing

• If ETCO2 is increasing, they are getting worse, if getting lower, they are improving

Dyspnea

• ETCO2 is a much better indicator if CPAP is needed.– ETCO2 above 55 or so– ETCO2 climbing– ETCO2 will climb before the patient

notably gets worse– Shark fin wave form means they are

working hard to exhale

Permissive Hypercapnea

Tight, intubated asthmaticBag slow to allow extra time

to exhaleAllow CO2 to rise into 60’s.

Asthma Patient

COPD Patient on Oxygen

Monitor ETCO2 to see if they start retaining. If so, back off on oxygen or add

CPAP.

Sedation Patients

• Any patient sedated should be on ETCO2. Will monitor ventilation closely and warn early of inadequate breathing.

• Way more sensitive than pulse oximetry.

• Use if narcotics or Benzodiazepines were administered

QUESTIONS ON CAPNOGRAPHY??

• Easy to use• Start using a lot and get experience

with it.• Great tool and easy to learn

• Visit: Capnography.com or one of the other numerous web sites on this topic!!

Importance of 12 lead ECG

Allows diagnosis earlier, thus saving time to definitive treatment

Average is 15 minutes nationally

12 lead placement

Measurement of Measurement of ST-Segment Deviation ST-Segment Deviation

STEMI: STEMI: 1 mm ST-segment elevation in 2 leads.*1 mm ST-segment elevation in 2 leads.*NSTEMI/UA: NSTEMI/UA: 0.5 mm ST-segment ischemic depression in 2 leads.*0.5 mm ST-segment ischemic depression in 2 leads.**Anatomically (regionally) contiguous leads.*Anatomically (regionally) contiguous leads.

Localizing Ischemia or Injury Localizing Ischemia or Injury

aVF inferioraVF inferiorIII inferiorIII inferior VV33 anterior anterior VV6 6 lateral lateral

aVLaVL lateral lateralII inferiorII inferior VV22 septal septal VV55 lateral lateral

aVRaVRI lateralI lateral VV1 1 septal septal VV4 4 anterior anterior

Cardiac Anatomy in Relation to Cardiac Anatomy in Relation to Coronary ArteryCoronary ArteryCardiac Anatomy in Relation to Cardiac Anatomy in Relation to Coronary ArteryCoronary Artery

18

What Does This 12-Lead ECG Show?What Does This 12-Lead ECG Show?

L1

L2

L3

aVR

aVF

aVL

V1

V2

V3

V4

V5

V6

What Does This 12-Lead ECG Show?What Does This 12-Lead ECG Show?

L1

L2

L3

aVR

aVF

aVL

V1

V2

V3

V4

V5

V6

Right Ventricular lead V4R

Right coronary Artery

II, III, AVF- inferior wallRight ventricle

Nodal tissueRV infarct, SCD, heart

blocks

Left Coronary (LAD)

• V1 - V4 Anterior wall• Main part of left ventricle• Pulmonary congestion• SCD• Cardiogenic shock

Circumflex

• I, AVL, V5, V6• Lateral wall• SCD

Transmitting EKG’s

Always on Med Pair radioNever cell phone

As ALS may send positive or suspicious tracings only

12 Lead EKG by radio

• Must call hospital on radio and wait for answer

• Must talk before you send• Here comes a 12 lead• Then send it.

QUESTIONS??