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Utility of Prehospital Quantitative End Tidal CO2?

Published online by Cambridge University Press:  23 January 2013

Christopher J. Cooper ,
James J. Kraatz ,
David S. Kubiak ,
James W. Kessel  and
Stephen L. Barnes
Christopher J. Cooper*
Affiliation:
Acute Care Surgery, University of Missouri, Columbia, Missouri USA
James J. Kraatz
Affiliation:
Bronson Trauma Surgery Services, Kalamazoo, Michigan USA
David S. Kubiak
Affiliation:
Burn and Wound Program, University of Missouri, Columbia, Missouri USA
James W. Kessel
Affiliation:
Acute Care Surgery, University of Missouri, Columbia, Missouri USA
Stephen L. Barnes
Affiliation:
Acute Care Surgery, University of Missouri, Columbia, Missouri USA
*
Correspondence: Christopher J. Cooper MD Division of Acute Care Surgery University of Missouri One Hospital Drive, MC205 Columbia, MO 65203 USA E-mail [email protected]
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Abstract

Introduction

End tidal CO2 (ETCO2) has been established as a standard for confirmation of an airway, but its role is expanding. In certain settings ETCO2 closely approximates the partial pressure of arterial CO2 (PaCO2) and has been described as a tool to optimize a patient's ventilatory status. ETCO2 monitors are increasingly being used by EMS personnel to guide ventilation in the prehospital setting. Severely traumatized and burn patients represent a unique population to which this practice has not been validated.

Hypothesis

The sole use of ETCO2 to monitor ventilation may lead to avoidable respiratory acidosis.

Methods

A consecutive series of patients with burns or trauma intubated in the prehospital setting over a 24-month period were evaluated. Prehospital arrests were excluded. Absence of ETCO2 transport data and patients without an arterial blood gas (ABG) within 15 minutes of arrival were also excluded. Data collected included demographics, place and time of intubation, service performing intubation, ETCO2 maintained en-route to hospital, and ABG upon arrival. Further data included length of stay, mortality, and injury severity scores.

Results

One hundred sixty patients met the inclusion criteria. Prehospital ETCO2 did not correlate with measured PaCO2 (R2 = 0.08). Mean ETCO2 was significantly lower than mean PaCO2 (34 mmHg vs 44 mmHg, P < .005). Patients arriving acidotic were more likely to die. Mean pH on arrival for survivors and decedents was 7.32 and 7.19 respectively (P < .001). Mortality, acidosis, higher base deficits, and more severe injury patterns were all predictors for a worse correlation between ETCO2 and PaCO2 and increased mean difference between the two values. Decedents and patients presenting with a pH <7.2 demonstrated the greatest discrepancy between ETCO2 and PaCO2. The data suggest that patients may be hypoventilated by prehospital providers in order to obtain a prescribed ETCO2.

Conclusion

ETCO2 is an inadequate tool for predicting PaCO2 or optimizing ventilation in severely injured patients. Adherence to current ETCO2 guidelines in the prehospital setting may contribute to acidosis and increased mortality. Consideration should be given to developing alternate protocols to guide ventilation of the severely injured in the prehospital setting.

CooperCJ, KraatzJJ, KubiakDS, KesselJW, BarnesSL. Utility of Prehospital Quantitative End Tidal CO2?. Prehosp Disaster Med. 2013;28(2):1-6.

Keywords

acidosisend tidal CO2prehospitaltraumaventilation
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 28 , Issue 2 , April 2013 , pp. 87 - 93
Copyright
Copyright © World Association for Disaster and Emergency Medicine 2013

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References

1.Caplan, RA, Vistica, MF, Posner, KL, Cheney, FW. Adverse anesthetic outcomes arising from gas delivery equipment: a closed claims analysis. Anesthiology. 1997;87(4):741-748.CrossRefGoogle ScholarPubMed
2.Bhavani-Shanker, K, Moseley, H, Kumar, AY, Delph, Y. Capnometry and anesthesia. Can J Anaesth. 1992;39:617-632.CrossRefGoogle Scholar
3.Cheney, FW, Posner, KL, Lee, LA, Caplan, RA, Domino, KB. Trends in anesthesia related death and brain damage: a closed claims analysis. Anesthesiology. 2006;105:1081-1086.CrossRefGoogle ScholarPubMed
4.Rozycki, HJ, Sysyn, GD, Marshall, MK, Malloy, R, Wiswell, TE. Mainstream end-tidal carbon dioxide monitoring in the neonatal intensive care unit. Pediatrics. 1998;101:648-653.CrossRefGoogle ScholarPubMed
5.Morley, TF, Giaimo, J, Maroszan, E, Bermingham, J, Gordon, R, Griesback, R, et al. Use of capnography for assessment of the adequacy of alveolar ventilation during weaning from mechanical ventilation. Am Rev Respir Dis. 1993;148(2):339-344.CrossRefGoogle ScholarPubMed
6.Ward, KR, Yealy, DM. End-tidal carbon dioxide monitoring in emergency medicine, Part 2: Clinical applications. Acad Emerg Med. 1998;5(6):637-646.CrossRefGoogle Scholar
7.Silvestri, S, Ralls, GA, Krauss, B, Thundiyil, J, Rothrock, SG, Senn, A, et al. The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system. Ann Emerg Med. 2005;45(5):497-503.CrossRefGoogle ScholarPubMed
8.Falk, JL, Rackow, EC, Weil, MH. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. N Engl J Med. 1988;318(10):607-611.CrossRefGoogle ScholarPubMed
9.Liu, SY, Lee, TS, Bongard, F. Accuracy of capnography in nonintubated surgical patients. Chest. 1992;102(5):1512-1515.CrossRefGoogle ScholarPubMed
10.Soto, RG, Fu, ES, Vila, H Jr, Miguel, RV. Capnography accurately detects apnea during monitored anesthesia care. Anesth Analg. 2004;99(2):379-382.CrossRefGoogle ScholarPubMed
11.Krauss, B, Hess, DR. Capnography for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2007;50(2):172-181.CrossRefGoogle ScholarPubMed
12.Fuke, S, Miyamoto, K, Ohira, H, Ohira, M, Odajima, N, Nishimura, M. Evaluation of transcutaneous CO2 responses following acute changes in PaCO2 in healthy subjects. Respirology. 2008;14:436-442.CrossRefGoogle Scholar
13.Wimberley, PD, Pedersen, KG, Thode, J, Fogh-Anderson, N, Sorensen, AM. Transcutaneous and capillary PCO2 and PO2 measurements in healthy adults. Clin Chem. 1983;29:1471-1473.CrossRefGoogle ScholarPubMed
14.Sanders, MH, Kern, NB, Costantino, JP, Stiller, RA, Strollo, PJ. Accuracy of end-tidal and transcutaneous PCO2 monitoring during sleep. Chest. 1994;106:472-483.CrossRefGoogle ScholarPubMed
15.Warner, KJ, Cuschieri, J, Garland, B, Carlbom, D, Baker, D, Copass, MK, et al. The utility of end-tidal capnography in monitoring ventilation status after severe injury. J Trauma. 2009;66:26-31.Google ScholarPubMed
16.Chesnut, RM, Marshall, LF, Klauber, MR. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34:216-222.CrossRefGoogle ScholarPubMed
17.Warner, KJ, Cuscheri, J, Copass, MK, Jurkovich, GJ, Bulger, EM. Emergency department ventilation effects outcome in severe traumatic brain injury. J Trauma. 2008;64:341-347.Google ScholarPubMed
18.Davis, DP, Idris, AH, Sise, MJ, et al. Early ventilation and outcomes in patients with moderate to severe traumatic brain injury. Crit Care Med. 2006;34:1202-1208.CrossRefGoogle ScholarPubMed
19.Salomone, JP, Pons, PT, McSwain, NE, et al, eds. Prehospital Trauma Life Support, 6th ed. St. Louis, Missouri USA: Mosby; 2006.Google Scholar
20.Shankar, KB, Moseley, H, Vemula, V, Ramasamy, M, Kumar, Y. Arterial to end-tidal carbon dioxide tension difference during anesthesia in early pregnancy. Can J Anaesth. 1989;36:124-127.CrossRefGoogle ScholarPubMed
21.Fletcher, R, Johnson, B. Deadspace and the single breath test for carbon dioxide during anaesthesia and artificial ventilation. Effects of tidal volume and frequency of respiration. Br J Anaesth. 1984;56:109-119.CrossRefGoogle ScholarPubMed
22.Hopper, AO, Nystrom, GA, Deming, DD, Brown, WR, Peabody, JL. Infrared end-tidal CO2 measurement does not accurately predict arterial CO2 values or end-tidal to arterial PCO2 gradients in rabbits with lung injury. Pediatr Pulmonol. 1994;17(3):189-196.CrossRefGoogle ScholarPubMed
23.Prause, G, Hetz, H, Lauda, P, Pojer, H, Smolle-Juettner, F, Smolle, J. A comparison of the end-tidal-CO2 documented by capnometry and the arterial pCO2 in emergency patients. Resuscitation. 1997;35:145-148.CrossRefGoogle ScholarPubMed
24.Belpomme, V, Ricard-Hibon, A, Devoir, C. Correlation of arterial PCO2 and PETCO2 in prehospital controlled ventilation. Am J Emerg Med. 2005;23:852-859.CrossRefGoogle ScholarPubMed