October Log

Presumption - Hiccup

I did a presumption involving a fresh death and questionable DNR detailed in the story Understand. I had never used capnography before on a presumption, but ever the field scientist, tried it(putting a capnography cannula on the patient): 1) to document the apnea, 2)to give myself some time to think of what I was going to say about the unusual circumstances surrounding the case when I called in for permission to not begin CPR, and 3) out of pure curiousity. I immediately saw the flat line of apnea, but then a few minutes later was startled by the appearence of the number 7 in the capnometer without a wave form. I figured later that the 7 probably came from a stomach hiccup or some type of passive gas escape. Here's the trend summary.

Note: the slight bumps in HR are due to the patient's pacemaker.

I don't know if it is necessary to document apnea in a presumption. All we are currently required to do is run a six second strip of asystole in three leads, but in any sort of nonstandard presumption(perhaps traumatic arrest patients), I don't think it could hurt to have a trend summary of RR, ETCO2, and HR. The future is going toward not transporting traumatic arrests in most cases. In light of the occasional story of a patient waking up later, the trend summary might be good documentation and use less paper than a minute plus long strip of asystole.

I would also use this on freshly desceased DNRs.

COPD - Hypoxic drive

Called for a man with lung cancer and COPD. He was satting in the low 80's on his home 02 with slight wheezing. We put him on a nonrebreather when his sats didn't improve with a few more liters by cannula. While his SAT went up to 100%, his end tidal also went from 37 up to 52, and his respirations dropped slightly. The point of all this is for all the debate about the hypoxic drive and not giving COPDers too much 02, if you are at a nursing home or a doctor's office and they tell you not to give over 2 liters while you are putting a mask, you can just say, not to worry, you are monitoring the patient's ventilations with capnography.

Here's the trend summary (HR, SP02, ETC02, RR):

Initial capnograph:

On nonrebreather:

"Quick Look"

When I have a patient who looks sick, but I am not certain how sick, I like to put the capnography on right away and that can either relax me if the numbers and wave form are good or kick me into high gear if they are bad. Bob Page put it very well in his class calling this "The Quick Look of Life" or as he titled his lecture, "Slap the Cap!"

Here's two patients who I encountered in back to back calls the other day.

1. 39 year old female in third floor walkup, lying across bed in cockroach infested apartment. Complaining of chest pain, breathing rapidly. Skinny emaciated with distended abdomen, diaylsis port and a pacemaker. History of asthma. Lungs clear above, slight crackles in bases. Hasn't been to diaylsis for a week.

RR- 62 ETCO2 - 22

"Stair chair," I said to my partner.

At the hospital they weighed intubation, but ended up giving her emergency dialysis. Her PH was 7.3

2. 80 year old patient altered mental status, altered breathing, possible aspiration. You can hear the rhonci from the doorway. DNR, supportive care only. Staff at Nursing home says patient's pulse - 112, BP 160/100.

Here's the quick look.

RR - 32 ETCO2 -14

We couldn't feel a pulse or get a BP.

Here's his ECG:

Certainly helps illustrate the case for ETCO2 as a measure of cardiac output.

At the hospital his PH was 7.1. They called his doctor and family to see how aggressive they wanted him treated, and ended up trying to pace him, which didn't work until after they gave him calcium. It seems he was extremely hyperkalemic. I would have liked to have seen what his ETCO2 did when they finally got a pressure. When we saw him an hour later he was still puffing away, trying to blow off CO2.