Capnography

[Spock]

Obtaining vital signs is a basic function of every patient interaction.  Any patient complaining of respiratory difficulty that requires the administration of oxygen should have ETCO2 measured.  Cost is not a factor:  You buy tires and put fuel in the truck so why don't you have the basic patient care modalities?  My service has had ETCO2 since 2000 and I have rewritten the SOG's for its use four times.  This is a no-brainer.

Let the tube be with you.

Spock 

[Off Label]

Obtaining vital signs is a basic function of every patient interaction.  Any patient complaining of respiratory difficulty that requires the administration of oxygen should have ETCO2 measured.  Cost is not a factor:  You buy tires and put fuel in the truck so why don't you have the basic patient care modalities?  My service has had ETCO2 since 2000 and I have rewritten the SOG's for its use four times.  This is a no-brainer.

Let the tube be with you.

Spock 

even non intubate ones? Why do you think its indispensable there?

[rock_shoes]

even non intubate ones? Why do you think its indispensable there?

I suspect he's referring to the nasal end tidal CO2 sets available for use with non-intubated patients. They're good for a waveform, respiratory rate, and trending but the absolute ETCO2 numbers aren't all that useful (not a closed system so typically gives a false low). 

[Spock]

The micro stream technology used with some monitors gives a remarkably accurate reading with the nasal cap ETCO2 plus it can also provide an indication of perfusion status.  Capnography has been demonstrated to be a more reliable and quicker monitor to detect hypoventilation than a pulse oximeter.  

Case study:  A 13 year old boy is injured in a zip line accident sustaining a significant blow to the occipital region of his head.  He is unconscious and bleeding profusely.  The crew arrives on scene, controls the bleeding, and immobilizes him on a spine board with a collar.  Yes, this was two years ago when we still did such things routinely.  They called for a helicopter and transported to the LZ.  I met the crew at the LZ and did a quick assessment.  The boy was still unconscious, skin pink, BP normal, saturation 100% on room air, and breathing about 20 times per minute but shallow.  I applied the nasal capnography and the first number was 60.  I didn't look to see if it went higher because I was grabbing the BVM.  The kid looked fine but the capnography proved otherwise.  I bagged him until the helicopter arrived and we RSI'd him.  

Capnography is not necessary for every patient you see, but it is an essential vital sign in the critically ill or injured.  I just don't buy the argument that "we don't use it because it is to expensive".  

May the tube be with you.

Spock

[1EMT-P]

Spock, I totally agree with you on the nasal cap ETC02. I have seen the nasal capnography used on patients that looked totally fine, but when the nasal capnography was applied it revealed a serious issue. Thanks for sharing your case study.

 

All the best,

 

[Off Label]

The micro stream technology used with some monitors gives a remarkably accurate reading with the nasal cap ETCO2 plus it can also provide an indication of perfusion status.  Capnography has been demonstrated to be a more reliable and quicker monitor to detect hypoventilation than a pulse oximeter.  

Case study:  A 13 year old boy is injured in a zip line accident sustaining a significant blow to the occipital region of his head.  He is unconscious and bleeding profusely.  The crew arrives on scene, controls the bleeding, and immobilizes him on a spine board with a collar.  Yes, this was two years ago when we still did such things routinely.  They called for a helicopter and transported to the LZ.  I met the crew at the LZ and did a quick assessment.  The boy was still unconscious, skin pink, BP normal, saturation 100% on room air, and breathing about 20 times per minute but shallow.  I applied the nasal capnography and the first number was 60.  I didn't look to see if it went higher because I was grabbing the BVM.  The kid looked fine but the capnography proved otherwise.  I bagged him until the helicopter arrived and we RSI'd him.  

Capnography is not necessary for every patient you see, but it is an essential vital sign in the critically ill or injured.  I just don't buy the argument that "we don't use it because it is to expensive".  

May the tube be with you.

Spock

so, are you saying that without the ETCO2, given that presentation, you would not have intubated that patient?

Spock, I totally agree with you on the nasal cap ETC02. I have seen the nasal capnography used on patients that looked totally fine, but when the nasal capnography was applied it revealed a serious issue. Thanks for sharing your case study.

 

All the best,

 

So, for the sake of the conversation, in what kind of patient, whose exam is not worrisome, will nasal ETCO2 demonstrate a problem?

Edited March 12, 2016 by Off Label

[1EMT-P]

 

 

I can think of several types of patients who can appear fine, but when you assess their ETCO2 you could find problems including Asthma, COPD, CHF, Heroin Overdose, Sedation & Seizures just to name a few.

 

[scubanurse]

I use ETCO2 on any patient I give narcs to, any respiratory distress patient, and any overdose patient.  It's not up for discussion in my mind, we have a tool that is useful and proven to improve patient outcomes, so why not use it?  Most nurses I work with do the same and the few who don't use it, can't give me a good reason as to why they won't. Every EMS system that transports to us has it as well and uses it in the same cases as described above.  We also always use the inline CO2 monitor for all tubed patients.

[Off Label]

I use ETCO2 on any patient I give narcs to, any respiratory distress patient, and any overdose patient.  It's not up for discussion in my mind, we have a tool that is useful and proven to improve patient outcomes, so why not use it?  Most nurses I work with do the same and the few who don't use it, can't give me a good reason as to why they won't. Every EMS system that transports to us has it as well and uses it in the same cases as described above.  We also always use the inline CO2 monitor for all tubed patients.

so, I'm not wanting to come off as someone who doesn't see the value of ETCO2 in the non intubated patient as a monitor only. What I strongly disagree with is the idea that it is a diagnostic tool in the non intubated patient. Intubated? That is another conversation.

Edited March 15, 2016 by Off Label

[1EMT-P]

Off Label can you please explain why you feel that nasal ETCO2 is not a diagnostic tool in the non intubated patient, but that it is in the intubated patient.