Page 154 - JSOM Fall 2020

APPENDIX F: POST CRICOTHYROTOMY/ENDOTRACHEAL INTUBATION CHECKLIST

POST CRICOTHYROTOMY/ENDOTRACHEAL • Calculate remaining medication and establish analgesia
INTUBATION CHECKLIST and sedation plan. A patient with a cricothyroidotomy
• Double check placement with waveform capnography may not require heavy continuous sedation.
or capnometry, placed directly on ET tube adapter. • Raise the head and torso to 30–45°
• Check proper tube depth (not main stem) by auscultat- • Filter and humidify the air with a heat moisture ex-
ing bilateral lung sounds changer. Place HME in-line distal to ETCO device.
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• Check that tube is secured (suture to skin + tie with girth • As needed, place in-line suction for the tube, and suction
hitch around neck, should be able to fit 2 fingers under the mouth for any excess secretions
the tube tie) • Check cuff pressure (palpate bulb—should be moder-
• Bag-valve-mask (BVM) with positive end-expiratory ately firm but still compressible)
pressure (PEEP) valve @ 5 of PEEP at proper volume • Place orogastric tube, if available.
(one hand moderate squeeze) and proper rate (one • Put a BVM + PEEP valve at the bedside if using a me-
squeeze every 5–6 seconds) chanical ventilator.
• Provide adequate analgesia and sedation (follow analge- • Decontaminate the mouth with chlorhexidine swab or
sia and sedation CPG) toothbrush without paste as per the nursing care plan.

APPENDIX G: WAVEFORM CAPNOGRAPHY AND PULSE OXIMETRY INTERPRETATION

WAVEFORM CAPNOGRAPHY (END-TIDAL CO [ETCO ]) During CPR (as an indicator of effectiveness of chest compres-
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AND PULSE OXIMETRY (SpO ) INTERPRETATION sions and return of circulation):
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Detection of ETCO is the most reliable way to continuously • ETCO < 10: there is no return of CO to the lungs (no
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monitor ventilation and therefore confirm placement of an ad- effective circulation). If CPR is initiated, it is ineffective
vanced airway (the only exception is during CPR when ETCO • ETCO = 10–20: EFFECTIVE CPR
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may be undetectable). Waveform capnography is the preferred • ETCO = 40 OR GREATER: You may see an abnor-
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method to detect ETCO , and with the development of small, mally high CO reading immediately after return of
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portable devices, is the recommended technique even in aus- spontaneous circulation (ROSC), for instance after a
tere field environments. Inexpensive colorimetric CO detec- successful defibrillation or return of effective cardiac
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tors are available; however, the color change method may be activity.
very difficult to visualize with poor lighting or night vision de-
vices. Waveform capnography measures the end-tidal carbon Monitor that can provide waveform capnography can provide
dioxide that passes through the device as the patient exhales much more insight into a patient’s ventilation and oxygenation
in real time since it is placed directly in-line with the endo- status. A quick reference to the most common waveforms is
tracheal tube. ETCO may also be attached to a face mask to helpful to understanding the status of a patient.
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verify normal and spontaneous breaths, if an advanced airway
has not been placed. With most portable, field capnographs, Pulse oximetry is also of use in monitoring the oxygenation
a number in mmHg will be appear on the display, which in- status of a patient. It can be an indirect measure of oxygen
dicates the value of the CO in the exhaled breath and can delivery to the tissues, and overall pulmonary function. Pulse
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be an immediate confirmation of correct tube placement. If oximetry monitors oxygenation by measuring absorbance
the airway was placed correctly, and the patient is ventilating differences between oxyhemoglobin and deoxyhemoglobin
normally, the capnograph should read between through the use of an infrared light. Pulse oximetry, however,
35 and 45mmHg. Some other examples include: has some important key limitations. A pulse oximetry read-
• ETCO = 0: the tube is not transmitting any CO : dis- ing indirectly reflects the patient’s central (pulmonary) oxy-
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connected, tube placed in wrong position or has become genation status by measuring the peripheral oxygenation. This
dislodged. This may also occur if the patient is dead and means that any intervention that addresses oxygenation in the
there is no gas exchange. lungs may not be detected by the pulse oximeter until 30–90
• ETCO < 35: Hyperventilation. The most common cause seconds after the intervention.
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is over-bagging the patient, but may also indicate pain or
anxiety. The only indication for “induced” hyperventila- Additionally, if the patient is suffering from carbon monox-
tion is severe traumatic brain injury with signs of acute ide or some other forms of poisoning, the pulse oximetry may
herniation, GOAL = 30–35 (no less than 30) read inaccurately. Also, a strong peripheral pulse and warm
• ETCO > 45: Retaining CO , ineffective ventilation may extremity are required to perfuse the capillary beds of the ex-
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indicate oversedation, primary lung problem, brain in- tremities and allow the pulse oximeter to obtain a valid mea-
jury, worsening obstructive disease (asthma). If the trend surement, therefore it may be difficult to measure in cold or
is rising, this is an indicator of need for active ventilation hypotensive patients.
assistance (BVM or mechanical ventilator)

152 | JSOM Volume 20, Edition 3 / Fall 2020