Capnography for Paramedics: December Log

Cannula Placement

I had a 60 year old dialysis patient with a high fever and altered mental status, hypotension and a low Sat. I put the end tidal on and got a reading of 11, which didn't seem right. I noticed he was a mouth breather with a large upper lip. I shifted the mouth piece downward and walla, the end-tidal was 53. This has happened several times now. See the September log for a photo of the problem, as well as the exampe in the December 11 call below. I put the patient on a nonrebreather. At the hospital when I was giving my report to the doctor, I mentioned the patient's ETCO2 was 53, to which she snapped, he probably doesn't need to be on a nonrebreather then. ??? There is no COPD history here. This is a patient with a fever of 102.8, which might account for the high ETCO2 and a cannula air SAT in the 80s.

Seizure/Hypoventilation

Called for a seizure. We found a postictal 80 year old man. No prior historyof seizure, who they said fell the night before, but hadn't appeared injured. Out in the ambulance he started seizing again. I managed to get a 24 gauge in his arm just as he stopped seizing. I had the ETC02 on and was watching his respirations now. He didn't look like he was breathing. It was more sort of burping.

I'm not certain what the little bumps represented -- the burps possibly, but I believe now I just had the cannula too deep in his nose and not enough over his mouth. I repositioned it, as he started taking deeper breaths. His end tidal was 80.

His breathing was very irregular, sporadic.

I kept waiting for him to snap out of it, but he wasn't coming around. I tried bagging him for a little bit, and then decided just to intubate him. I attached the capnography filter to the top of the ET tube, put in the stylet and went in. Saw the chords, saw good wave form on the monitor and I was good. I bagged him and got his ETCO2 down to 35.

He started bucking the tube a little so I gave him some versed.

At the hospital they said he had been in the hospital for a subdural hematoma a month before, so he may have been bleeding again.

Here's the trend summary for ETCO2 and RR:

Note: The apnea period includes a period where his nasal monitor is off and the ET tube isn't in yet. I have to unplug one filter, plug in the other and then I won't start getting a reading until I go in with the tube.

What lesson did I learn from the capnograpy? It alerted me that he was hypoventilating and his respiratory pattern was sporadic and ineffective. I was much more aggresive with the airway than I might have been based just on naked eye observations.

Circling the Drain

Called for difficulty breathing to a nursing home. The woman is in her 80’s and breathing rapidly and shallowly. They have her on a non-rebreather at 4 lpm. They say they can’t get her SAT above 80. They can’t tell me how long this has been going on, but they seem to think it all started this afternoon. Her lungs are very junky. She looks like she is getting very tired.

We go lights and sirens. I am having trouble getting the ECG leads to stick. I can't get a rythmn, but my concern right now is her breathing. She is declining fast. I get out my intubation kit. Her resps are almost agonal now. I disconnect her nasal cannula ETCO2 monitor and hook the ET capnography filter to end of the ET tube and slip in a thin stylet.

I see her chords and pass the tube. I look at the monitor I have no wave form. I must have missed I think. I pull back a little, and then again go through the chords. I have no wave form, but I am not certain now she is breathing. She in fact is apneic. I grab the ambu bag and give it a squeeze and up pops a wave form. I’m in. I secure the tube and start bagging. Her End tidal is 30, but then it soon drops to 17.

The monitor is still not reading the leads. She looks like she is dead. The end tidal is very low. I reach over and do some compressions. I shout to my partner, but he is already out of the ambulance.

He opens the back door. Standing behind him are the patient’s daughter and another family member. His eyes widen when he sees I am doing CPR. He turns and waves to the crew of an ambulance parked in the lot. With their help we get the patient on a board, slaps some pads on – the patient is asystole -- I can check my lung sounds – equal right and left, nothing in the belly, and get a round of drugs in, one epi and one atropine, and then we are wheeling her in.

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Here’s the trend summary I printed out after the call, which pretty much tells the story of her declining respirations.