EM Quick Hits 45 ETCO2 in Cardiac Arrest, Organ Donation, Paraphimosis, Medicolegal Myths, QI Corner

Topics in this EM Quick Hits podcast Anand Swaminathan on continuous quantitative end-tidal CO2 monitoring in cardiac arrest (2:30) Tahara Bhate in QI Corner - sorting out the the dizzy patient (10:00) Andrew Healey on organ donation do's and don'ts (20:00) Sarah Foohey on foodcourt hacks - paraphimosis, rectal prolapse, food bolus obstruction (28:10) Jennifer C. Tang on 4 medicolegal myths (35:55) Podcast production, editing and sound design by Anton Helman, January 2023 Podcast content, written summary & blog post by Anton Helman and Sarah Foohey, January 2023 Cite this podcast as: Helman, A. Swaminathan, Bhate, T. Healey, A. Foohey, S. Tang, JC. EM Quick Hits 45 - ETCO2, Organ Donation, Paraphimosis, Medicolegal Myths, QI Corner. Emergency Medicine Cases. January, 2023. https://emergencymedicinecases.com/em-quick-hits-january-2023/. Accessed September 17, 2024. Value of continuous waveform quantitative end-tidal CO2 monitoring in cardiac arrest * A sudden decrease or loss of ETCO2 may indicated the need for CPR to be started * ETCO2 is an indirect assessment of quality of chest compressions (location, rate, depth); adequate chest compressions correlate with ETCO2 pressures of ≥20mmHg. * A rise of ETCO2 >20mmHg is highly specific for ROSC in patients with PEA arrest; on average, patients with ROSC after CPR had an average ETCO2 level of 25 mmHg in one meta-analysis * An up-trending ETCO2 during resuscitation suggests continuing resuscitative efforts unless there is overwhelming clinical evidence to the contrary * Confirmation of airway placement and subsequent guide for adequate delivery of breaths using BVM or supraglottic device and ventilation rates for ETT with more immediate feedback than oxygen saturation monitoring * A general "rule" is that if the ETCO2 is consistently <10mmHg for 3-5 minutes after 20 minutes of high quality CPR and resuscitative efforts, ROSC is unlikely to be achieved; however this is not a sensitive test and should be used only as an adjunctive data point in decisions of termination of resuscitation efforts * There are multiple potential confounders that can elevate or decrease ETCO2 levels (see chart below), so extreme or trending values may be more useful than unwavering mid-range levels * A sudden flattening of the ETCO2 waveform may be due to cardiac arrest, ventilator disconnection, esophageal intubation, capnography obstruction or dislodged airway device Factors Affecting EtCO2 Source: EMSWorld Expand to view reference list * Kodali, B. Urman, R. Capnography during cardiopulmonary resuscitation: Current evidence and future directions. J Emerg Trauma Shock. 2014 Oct-Dec: 7(4): 332-340. * Crickmer M, Drennan IR, Turner L, Cheskes S. The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity. Resuscitation. 2021 Oct;167:76-81. * Skulec, R., Vojtisek, P. & Cerny, V. Correlation between end-tidal carbon dioxide and the degree of compression of heart cavities measured by transthoracic echocardiography during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Crit Care 23, 334 (2019). * Wang, AY. Initial end-tidal CO2 partial pressure predicts outcomes...