May Capnography Log - Learning Something New Every Day
Trending - May 2006
Below is a trend summary from a CHF patient.
It is amazing we had this feature on our monitors for some time and I at least never knew about. I have been trying to spread the word, and have only found one other medic who knew about it.
For any of you with Lifepack 12's out there, do the following:
Hit Print on the options menu
Hit Report, which on ours is defaulted to Code summary.
You should get a trend summary option. Hit that.
Then hit print again on the options menu and the trend summary should print out.
I have found one monitor that doesn't have the trending software on it. Yours may or may not, but if it does, that's how to get it.
Looking at this trend summary, you can see the gradual reduction in heart rate (3rd graph), as well as the early SAT readings and later ones(4th graph). Next time I will try to get the capnography(5th graph) on in the room, rather than waiting to get out to the ambulance, as well as trying to keep the pulse SAT on.
Monitoring During Hand Held Treatments --May 6, 2006
I learned today you cannot use capnography on a person getting a handheld treatment. They have their mouths wrapped around the mouthpiece and so all the CO2 is coming out the extension. The CO2 cannula picks nothing up and all you get is a straight line and the apnea alarm going off every two minutes. You can of course monitor them before and after every treatment, but if you want to monitor them during the treament, you have to do the neb through a mask.
I used capnography twice today. First on an asthmatic COPDer, who had no wheezing, just chest congestion and chest pain. She had a small shark fin that showed only minute changes after the one treatment I gave her. Her numbers were around 35.
The second time was on a COPD/pneumonia lethary. Very decreased lung sounds. Blood pressure of 90/60 with poor cap refill. He was breathing about 22 times a minute with a number is the low to mid twenties. He had a shark fin. I wish I could print out the screen forms as they are so much more compact than the printout. The shapes look completely different.
Mouth Closed - May 7, 2006
Had a call for decreased mental status in an elderly DNR patient with a COPD history. He was breathing in a strange way. He wouldn't open his mouth, so his exhalation would puff up his cheek's like a frog, then the air would go up out his nose. It produced a capnography wave similar to a bronchospasm. When I made him open his mouth to breath, his wave form straightened up.
How do you spell that? - May 15, 2006
No indications for capnography for a few days. I should probably put together a list of indications for capnography. I went to a university medical school bookstore today and asked if they had any books on capnography. The manager said "What was that word?" I had to spell it for her. They had nothing in stock, just one you could order, which I already have. I'm trying to gather articles on capnography for our next journal club. The only good ones I can find pertain to intubation. The medical advisor to the club emailed me asking where are the articles on asthma and nonintubated patients. I told him I'll keep looking.
Dehydration - May 19, 2006
79 yer old woman at the doctor's office, weak and not eating for three days with vomiting. Short of breath. Clear lungs. Has a pacemaker. The cops had her on a nonrebreather, but the nurse had taken off so she could use the bathroom. She didn't appear to be having much trouble breathing and was initially Satting at 98. Down in the ambulance, her SAT dropped to 90 and she started too seem a little short of breath. I put her on a cannula and then when she still seemed short of breath, I put her back on a nonrebreather. Her capnography was consistently 20 throughout with a good wave form. Her respiratory rate varied from a low of 28 to the 50s. The rapid ventilations would make her number low, but it was low even when she wasn't breathing that fast. Her BP was okay, although she was dizzy when she stood. She didn't feel like talking much in the way that people who are sick and worried don't like to talk. I am curious what else may have been going on. I guess I am learning that capnography is just a single factor to try to add to the big picture and that capnography as with other vitals, the trend is often more important than the number, although the number can also be quite significant.
May 28, 2006 - Conversations
Back safely from the Medical Mission to the Dominican so I hope to start posting more on capnography. The night medic told me he had a COPDer with ETC02 in the 60's and an odd shaped wave-form, but he didn’t print the strip. I am going to try to enroll other medics in sharing their experiences with me and saving strips. The more strips I get and stories I hear, I can try to figure out what is normal and what is not for specific conditions and situations. He has been having the same experience I have where no one in the ED has any idea what the funny looking thing under the patient's nose is and what the capnography numbers and shapes look like.
I had a couple conversations with the nurse anesthetists on the medical trip about capnography and I was telling them how if I got a number 15 or above to start I was happy. One looked puzzled and said we always try to keep our number much higher. I said I'm taking about dead people.
Just before I left on the trip I received the following book I bought used from Amazon:
I will try to go through the book and post my notes as I go. It is not particuarly geared towards EMS.
May 29, 2006 - Weak Heart
Put it on three people today and yesterday. I got normal readings and wave-forms from a 22 year old diaylsis patient who was lethargic and vomiting and an 80 year old male with lung cancer. I got an upright wave form, but a low number reading of 25 in an 80 year old male with a weak heart (1/3) capacity according to wife, and who's defib had fired six times until I got some amio in him and stopped it. Poor cardiac output low number. Makes sense. He ended up at 29.
May 30, 2006 - Pneumonia
85 year old witha history of aspiration pneumonia. Audible rhonci, except for moments when he has coughed and he seems to have cleared some of the gook in his lungs. Respiratory rate 24. SAT of 80% went up into the 90's with a nonrebreather. BP 80/40. HR - 112. No pedal edema. NO CHF or COPD history. Breathes as well flat as sitting up.
His initial wave form is okay:
Then as the rhonci gets more audible, his wave form changes to a shark fin or a climbing wave form.
Then when he clears the gook for a moment, his wave form straightens out.
His capnometer was around 25. Poor cardiac output as evidenced by his pressure.