END Tidal CO2 of 101!!!

[HappyParamedicRN]

Hi there,

Had an elderly male patient who presented in respiratory failure secondary to severe pneumonia coupled with COPD exacerbation. He lost conscousness when we put him in the truck, I intubated him and his end tidal co2 was 101 and the highest I could get him to satruate was 93 on 100%!

Problem - he had the longest expiratory phase of any patient I have ever had, so we could not hyperventilate him to blow of the CO2 because I was afraid of breath stacking and giving him a pneumo! I hung mag to open him up, since we are unable to nebulize down the ETT (long story).

Would you guys have done the same thing? Bagged him at a rate of 12, got his CO2 down to 73 in about a 10 minute ride. Any other thoughts? Anyone else ever seen a CO2 that high?

Happy

 

[abckidsmom]

Can't say I've ever seen an EtCO2 that high, the highest CO2 on a blood gas I've seen is about 88, on a 26 week premie we delivered in our STICU out of a patient we unparalyzed for labor. It was a bad situation.

 

[MSDeltaFlt]

With a history of COPD wbaf's his normal PaCO2? sometimes a PaCO2 of 73 just might be their normal.

 

[Smash]

Hi there,

Had an elderly male patient who presented in respiratory failure secondary to severe pneumonia coupled with COPD exacerbation. He lost conscousness when we put him in the truck, I intubated him and his end tidal co2 was 101 and the highest I could get him to satruate was 93 on 100%!

Problem - he had the longest expiratory phase of any patient I have ever had, so we could not hyperventilate him to blow of the CO2 because I was afraid of breath stacking and giving him a pneumo! I hung mag to open him up, since we are unable to nebulize down the ETT (long story).

Would you guys have done the same thing? Bagged him at a rate of 12, got his CO2 down to 73 in about a 10 minute ride. Any other thoughts? Anyone else ever seen a CO2 that high?

Happy

Yep, plenty. Intubated a guy just a week or two ago, asthmatic, his EtCO2 pre-intubation was about 18, post intubation was 120mmHg. I've seen plenty with EtCO2s like that.

The thing is, with these patients, hypoxia kills, hypercapnia... well, happens. His CO2 won't kill him, and it's not a good idea to try to work it down in such a short space of time. Ventilate very slowly, allow plenty of time for expiration (last weeks guy was getting 4/min) and don't worry about any numbers except SpO2, which at 93% is actually pretty good.

If you hyperventilate you are only going to cause volutrauma, barotrauma and decreased cardiac output and greatly increase the risk that a bleb will blow in his fragile old lungs; a chest tube is no COPDers friend.

 

[zmedic]

Just to not confuse some of the readers, it is important to differentiate between an initial post intubation CO2 and the steady state. So if someone holds their breath their CO2 will be very low because the CO2 being released at the alveoli are just staying down there and aren't being exhaled. Then the person breaths out and they have a super high CO2 until they take a few breaths and it is back down to normal. So while a CO2 of 120 right after intubation tells me that patient wasn't ventillating well on their own, to know how acidemic they were I would want to know what their CO2 was after a minute of bagging.

 

[usalsfyre]

Used to run on an older (30s) CFer that would commonly call with an ETCO2 in the 120 range, but his baseline sat around 60-70.

 

[46Young]

I'm assuming that you didn't have access to an in-line neb to deliver nebulized meds down the tube. Vagal tone can be increased by as much as 50% in pts with COPD, so the albuterol/atrovent combo is indicated. No solu-medrol? Mag has been controversial in treatment of COPD. It's thought to produce bronchodilation through the counteraction of calcuim-mediated smooth muscle constriction. It apparently has Class B evidence to support it's use in significant exacerbations, but we don't currently have it in our protocols for COPD. I've seen it work well for asthma pts time and time again.

Previous posts have addressed the EtCO2 question. I would be most concerned with tightly controlling it with head trauma pts, to aid in maintaining CPP in the field with our limited capabilities.

Also, if the pt was that bad off upon arrival, why didn't you work him at the residence rather than move him to the bus first? I understand that the ambulance provides a more controlled environment, but a critical pt needs to be worked on the spot so that they don't crash during the move to the ambulance, this pt being an example of that. I developed this mindset when I worked in NY. We had apartments with elevators, walkups of five floors or more in some cases, and other situations that make a quick snatch and grab into a process that can take five to ten minutes or more. I'm not concerned that we need to open our IV kit or med pouch in the house. Probably 95% of our pts will be fine with no more than vitals, EKG, and O2 until they're in the back. The other 5% or so need treatment on the spot.

 

[MrBrown]

Brown would not worry about it esp given his hx of COPD.

No Brown would not be hyperventilating him, the good old ambo trick of "more is better" does not apply here. Bad numbers are not always bad and should not attempt to be corrected by Sparky the ambo.

Where are those funny looking people who drive round in a blue Skoda dressed in orange "DOCTOR" jumpsuits when you need them?

 

[usalsfyre]

Just thoughton a couple of things that would have been probably helpful here, one being a mannometer (when was the last time you saw that on a 911 unit) to monitor what exactly was going on pressure wise. The other being PEEP. With PEEP you increase the amount of time available for gas exchange, giving more opportunity to unload CO2, as well as helping to reverse atelectisis that is common in low VT states. However, it does increase the potential for barotrauma, so you must use carefully. YMMV

 

[Smash]

Just to not confuse some of the readers, it is important to differentiate between an initial post intubation CO2 and the steady state. So if someone holds their breath their CO2 will be very low because the CO2 being released at the alveoli are just staying down there and aren't being exhaled. Then the person breaths out and they have a super high CO2 until they take a few breaths and it is back down to normal. So while a CO2 of 120 right after intubation tells me that patient wasn't ventillating well on their own, to know how acidemic they were I would want to know what their CO2 was after a minute of bagging.

110mmHg

 

[bonedog]

Permissive Hypercapnia... check it out