Waveform Capnography | ACLS-Algorithms.com

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  1. Orly says

    If a pulse is felt and the person is ventilated through a breathing machine but the etco2 is sub 30 do we need to perform cardiac compressions? Or rely on the pulse thatan there is adequate circulation?

    • Jeff with admin. says

      It is unlikely that you will be able to palpate a pulse before you see a rise in ETCO2. The sudden increase in ETCO2 is typically the first sign of ROSC and will be seen prior to being able to palpate a central pulse. If you see a rise in the ETCO2 finish the round of CPR and perform a pulse check.

      If you cannot palpate a pulse then continue for another cycle of CPR. Then recheck the pulse. Also realize that the initial ETCO2 reading might be higher than normal (35-45 mm Hg) because of the accumulation of CO2 in the cardiopulmonary system during cardiac arrest.

      Rely on the pulse check, but if ETCO2 is available, it can be used to assess CPR quality and monitor for ROSC.

      Kind regards,
      Jeff

  2. Jennifer says

    If we see a spike in etco2 is that enough to stop compressions and do a rhythm /pulse check? Or do we finish our round of compressions and check after our 2 mins as usual?

    • Jeff with admin. says

      You finish the round of CPR and check the pulse after the two minute cycle. It can take time for the heart to begin to pump efficiently and completing the cycle of CPR helps to ensure that adequate circulation has been established. Kind Regards, Jeff

  3. Sarah says

    If we had a code situation and a physician was not present to intubate but we were able to deliver excellent ventilation so via BVM, could we attach the ETCO2 device between the mask and the bag to give an indication of our chest compression and ventilation adequacy, until such time intubation was able to take place ?

  4. Eric Amistad says

    Do we need to actively decrease EtCO2 to 35-40 during ROSC? Like bringing back 50 to 35-40? How do we ventilate? Do we increase the rate of ventilation?

    • Jeff with admin. says

      An EtCO2 level of 35-45 indicates that ventilation is adequate. An elevated EtCO2 level is typically an indication of hypoventilation or increased metabolic activity.

      If you are delivering a normal number of ventilations and your EtCO2 level is high then you would want to identify why the EtCO2 level is remaining high and treat that cause.

      Here are a couple of articles that go a little deeper on the subject if you would like to read:

      Waveform Capnography 1

      Waveform Capnography 2

      Kind regards,
      Jeff

  5. Sharon says

    I have heard instructors state that the ETCO2 will show a sudden rise to 50-70 when rosc occurs and then decrease to 35-40. Is this accurate information?

    • Jeff with admin. says

      It is likely that the ETCO2 may be higher than normal when ROSC occurs. This is because there is a buildup of CO2 in the lungs and body during the cardiac arrest when metabolic processes are not functioning optimally. Once ROSC occurs and the CO2 is washed out of the lungs with the reestablished metabolic processes the CO2 will drop down to the normal level of 35-40 mmHg.

      Kind regards,
      Jeff

  6. Toban says

    Since it is now considered standard of care, will waveform capnography be incorporated into the Megacode simulations?

    • Jeff with admin. says

      Yes this is correct. For any scenario in which the patient is intubated, there will be questions about waveform capnography.

      For the purposes of cardiopulmonary resuscitation, the patient must be intubated for proper measurement of ETcO2.

      Kind regards,
      Jeff

  7. Steven Chadwick says

    Does administration of bicarb during acls effect the ETCO2 ranges given for good compressions?
    Just looking at it from a physio standpoint you would think you would get an increase in ETCO2 throwing off the ranges.

    • Jeff with admin. says

      Bicarbonate given during CPR could potentially give a slight increase in the end tidal CO2. I do not think that it would be significant enough to give you a false reading of good or bad compressions.Kind regards, Jeff

    • Coty says

      You won’t note any significant change (~5mmHG) but the big thing is recognizing when to give Bicarb and when not to. We no longer administer Bicarb for acidosis secondary to extended down time, now it’s usage is limited to tricyclic antidepressant overdose and suspected electrolyte imbalance. Studies have actually shown that when given IVP there is an initial decrease in pH due to cellular metabolism often lowering the patient’s pH below the threshold for sustainable life before the bicarbonate begins to slowly raise the pH, hence why it is now often referred to as a drip. In drip form this noted drop is not present.

      • Jeff says

        It’s important to remember that the CV system does not function well in a severely acidotic state. Therefore, there’s nothing “wrong” with IVP of bicarb, however improvements in cardiovascular function are transitory as bicarb is rapidly metabolized. Anecdotally, IVP w/gtt probably achieves best results in my experience. Honestly, while I’m a “data driven” practitioner (RT) I’m not familiar with any well executed (randomized, blinded, controlled) trials which have looked at this.

    • Coty says

      You’re not necessarily looking for an increase to norm range with ROSC. In my experience I’ve noted EtCO2 increases to around 25mmHG with ROSC. The important thing is to note the time of change, complete your round of CPR and then assess for pulse. If you have a perfusable rhythm and increase in EtCO2 with good capnography then chances are you have ROSC.

      • Jeff says

        Agree – Please don’t focus on numbers; especially “normal values.” If someone is performing compressions CPR and your EtCO2 is 6; you switch practitioners and it’s 50, you now have effective compressions, (and likely need better ventilation). Furthermore, we will never magically see a return to normal values with ROSC for two reasons:
        1.) ROSC may occur DURING compressions, and;
        B.) It’s highly likely that ANY lab value is going to be “normal” after requiring CPR.

  8. Kim says

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