Tuesday, May 3, 2016

DIY NRB Capnography Device for the Paramedic

In today's times, money is tight. Agencies cannot always afford to buy the nasal cannula EtCO2 device. Because of this, it is important that you have an understanding on how make your own EtCO2 device.

For this particular post, I am going to focus on the use of a non-rebreather with the EtCO2 device.

Capnography is a critical tool in patient treatments. Capnography can used in various situations, to help guide the diagnosis, how well the treatments are working, and overall how the patient is doing. For example, if you run on a difficulty in breathing patient, Capnography can be used to determine the patients real-time respiratory rate, their exhaled CO2 level (EtCO2), and even provides a waveform, to help determine the respiratory status of the patient.

This particular post is not going to go into detail on the entire usage of capnography, indications, etc., but this post is geared to show you how to make your own capnography device using four simple tools. If you would like to read more about EtCO2, visit paramedicstudentcentral.webs.com for the PDF PowerPoint presentation.

To start, you will need a non-rebreather (NRB), EtCO2 capnography device (the device used for ET Tubes), oxygen, and a capnography capable monitor.

I have personally tried a few different ways, on how to set up the capnography device for the best reading and waveform outcome. The method that I prefer to use is where you stick the capnography tube into the NRB.

Place the patient on a NRB, with high-flow oxygen. Never withhold oxygen, in order to do this. To do this, take the capnography device, and cut off the end where the attachment is to attach it to the ET Tube. Now, you will have the attachment that goes into the monitor, and just a long tube. Attach the attachment device to the monitor. Now, take the other end of the capnography tube and slide it into one of the small holes on the NRB (where the rubber valve is). It should come out to looking like this:
(click photo to enlarge)

You want to try to get the capnography tube to be as close to the pt's lips are possible. Personally, I set it up so that the end of the capnography tube sits just inside the lip. After you have your placement, if needed, you can place a piece of tape on the tube and tape it to the NRB.

The capnometry and respiratory rate may no be as accurate as it would be with a real commercial device, but the waveform itself will be easily identifiable. Here is an example waveform of the DIY NRB Capnography with oxygen at 15-lpm:

(click photo to enlarge it)

A second way that you can do this, is by following the same steps and equipment as above, but instead of cutting off the EtCO2 ET Tube attachment, you cut a hole into the NRB (preferably cut out one of the valves), and slip the capnography device into the NRB. It should look like this:
(click picture to enlarge it)

The main issue that I have with this method, besides the capnometry number may not be accurate, is that the waveform doesn't seem to be as clear as compared to the first method.

Notice how the waveform is choppy, when you compare it to the first method:
(click picture to enlarge it)

I am not sure if the waveform is so choppy because of the oxygen back flowing into the capnography tubing, or if I just am not placing the device deep enough into the NRB. I will be running more trial runs (on my less critical patients, since I like the first method the most), to see if I can come up with a good way to run the second method.

I have tried different methods to DIY NRB capnography, but to me, the first method seems to work the best. As always, follow your companies and medical control authorities protocols.


NEVER WITHHOLD OXYGEN FROM A PATIENT WHO NEEDS OXYGEN,  JUST TO DO THIS DIY SETUP.

*NOTE: My posts are usually always sourced. However, this entire post is a "my opinion" post. Their are videos on youtube to show you how to do this DIY, but I have yet to see actually research performed. Again, this post is my opinion, based on my experience. ALWAYS follow your company policies and procedures, as well as your medical control authorities protocols.

Tuesday, February 2, 2016

Vertebrae and Their Functions

Break down on the vertebrae and their functions in the human body.


(click picture to enlarge)

Source: http://mercerislandchiropractic.com/wp-content/uploads/2012/02/VertebralSubluxationandNerveChart_0.jpg

Dopamine Cheat Sheet Chart


Here is a Dopamine cheat sheet that I had found online, while trying to learn the Dopamine calculation again.


(click on picture to enlarge)

Source:http://cchealth.org/ems/pdf/phcm_drug2012.pdf

Ketones vs. Lactic Acid

Ketones and Lactic Acid are important lab values when trying to determine the chemistry of a patient. Both Ketones and Lactic Acid can help to guide your thinking, on what is wrong with a patient, and what you need to do, in order to try to resolve the diagnosis of the patient. However, in the prehospital setting, there is nothing that we can do for these patients. The hospital is able to help the patient more, because they are able to obtain the lab values and have an endless supply of medications that they can administer to the patient. During an ALS transfer (hospital to hospital), the paramedic may need to monitor the medications that are being administered to the patient. At the same times, if a paramedic is transferring a patient from a nursing home, where the labs have been drawn, and taking the patient to the ER, the paramedic should have an understanding on what Ketones and Lactic Acid is and how they effects the body. In some cases, Ketones and Lactic Acid labs values can help to determine how severe the patient is, and if they need more advanced care and be transported at a higher-level of priority.

First, let's look at Ketones. Ketones is a substance that is made when the body has to break down fat, in order to make energy. Normally, the body will break down carbohydrates, but in some cases (diabetics, lack of carbohydrate intake, anorexia, dieting, dehydration), the body has to break down the fat in the body, in order to get the energy that it need to continue.

Ketones can be tested via the blood and the urine. Normally, their should be no ketones noted in the body (MedlinePlus 1). However, if there are Ketones in the body, the labs can be broken down into three different categories: small, moderate, and large (MedlinePlus 1). Small value would be <20mg/dL; Moderate value would be 30-40mg/dL; and a Large value would be >80mg/dL (MedlinePlus 1).

Now, lets talk about Lactic Acid. Lactic Acid is an acid that is produced when the carbohydrates in the body are broken down. The common causes of a high Lactic Acid is when their is a lack of oxygen in the body, thus causing the body to breakdown the carbohydrates for energy (MedlinePlus 2). In a normal case, when oxygen levels are normal, the body will break down the carbohydrates into water and CO2. Lactic Acid build up is caused by strenuous exercise, sepsis, heart failure, and liver issues (MedlinePlus 2). Unlike Ketones, Lactic Acid will always be in the body. The normal value of Lactic Acid in the body is 4.5 - 19.8 mg/dL (MedlinePlus 2). If a Lab Value is greater than 19.8mg/dL, than the patient is in lactic acidosis.

Both Ketones and Lactic Acid lab values are vital to help with the diagnosis and severity of a patient. Even though lab values do not do much for paramedics in the prehospital setting, they are still vital components to know when taking a patient to the ER (say from a nursing home), or performing an ALS transfer (from hospital to hospital); these lab values will help guide the paramedic in determining how critical the patient is, and if they needed higher level of care, and a higher level of priority.



Sources:
Ketones: https://www.nlm.nih.gov/medlineplus/ency/article/003585.htm

Lactic Acid: https://www.nlm.nih.gov/medlineplus/ency/article/003507.htm

Wednesday, December 9, 2015

Renin-Angiotensin System

(click to enlarge)

http://antranik.org/the-renin-angiotensin-aldosterone-reflex/

Five Types of Shock

Their are five types of shock: cardiogenic, hypovolemic, neurogenic, anaphylactic, and septic. We will break down each type of shock and provide greater detail.

Cardiogenic Shock
Inability of the heart to pump enough blood throughout the body. This is a result of left ventricular failure (caused by an MI or CHF). Due to the reduced BP caused by cardiogenic shock, the heart muscle becomes more damaged due to the lack of coronary artery perfusion...this can eventually lead to complete pump failure. Cardiac output, as well as the cardiac ejection fraction, is also decreased.

During the assessment, rales or rhonchi will be heard in the lungs, and white- or pink-tinged foamy sputum may be present.

Ensure that the airway is open and patent. ADM oxygen and assist ventilation if needed. Keep the patient warm since their body may no longer be able to keep them warm and organs functioning. Obtain IV access, cardiac monitoring, and 12-lead ECG.

Hypovolemic Shock
Patient goes into shock due to a loss of intravascular fluid volume caused by: internal/external bleeding, traumatic injury, long bone or open fractures, dehydration, diarrhea, vomiting, plasma loss from burns, excessive sweating, and DKA.

During assessment, the patient may alerted, unresponsive, pale, cool, diaphoretic, normal to hypotensive, pulse normal to rapid (bradycardia in late stage), decrease in urine output, cardiac dysrhythmias.

Ensure that the airway is open and patent. ADM oxygen and assist ventilation if needed. Keep the patient warm since their body may no longer be able to keep them warm and organs functioning.  Control and major bleeding. Obtain IV access, fluid bolus (NS or LR), cardiac monitoring, and 12-lead ECG.

Neurogenic Shock 
Results from an injury to the brain or spinal cord, which results in an interruption of the nerve impulses to the arteries. The arteries will lose tone and dilate, causing hypovolemia; no change in volume, just that the container is now larger.

Assessment may reveal warm, red skin, and dry skin (due to malfunction of the sweat glands). Hypotension and bradycardia.

Ensure that the airway is open and patent. ADM oxygen and assist ventilation if needed. Keep the patient warm since their body may no longer be able to keep them warm and organs functioning. Spinal immobilization, obtain IV access, fluid bolus (NS), cardiac monitoring, and 12-lead ECG.

Cushing Triage: Hypertension, Bradycardia, Irregular Respirations

Anaphylactic Shock
When an allergen enters in the body, the immune system respond to try to rid of that allergen. However, in some cases, the immune response is so great, that it is called anaphylactic.

Assess for dyspnea, tachypenia, wheezing, laryngeal edema, rashes, edema, hives, cyanosis, tachycardia, seizures, altered LOC.

Patient's in anaphylactic shock needed immediate and aggressive treatment. Ensure open and patent airway. ADM oxygen. Epi 1:1000 should be adm IM. Benadryl to help prevent any more histamine to be released int he body, Solu-medrol for steroid response, albuterol for the bronchioconstriction.

Septic Shock
When an infection enters into the body, causes a system wide failure or dysfunction of the organs.

During assessment look for, fever, tachycardia, hypotension, tachypnea, altered LOC.

Ensure an open and patent airway. ADM oxygen. IV access with fluid bolus of NS. ECG monitoring and 12-lead ECG. Dopamine may need to be adm in order to maintain a blood pressure.

In the elderly and very young, a fever may not be present. Try to identify if the patient had a fever or if they are hypothermic...both are indicative of sepsis when combined with the other criteria listed above.

Information obtained from: Essentials of Paramedic Care. Second Edition - UPDATE.

Acid Base?

My Wednesday parter is currently in his medic class. Today, during shift, he pulled out him homework, and asked if I knew anything about acid base. Now, I have been out of school for about 3 years now, so of course I had forgotten a lot of the material that was covered. I had to reread part of the section in his medic book. After reading the sections, and looking some other information up, I am now able to recall how to determine acid base based on the lab values.

You know how it goes, respiratory acidosis/alkalosis and metabolic acidosis/alkalosis...blah blah blah. We never really understand how important this is, on the medic level, unless we work in the ER or on a SCT/CCT truck. However, acid base is very important, because if the patient is acidic, than we either have to change the way that they breathing or we need to administer sodium bicarb. On the other side, if they are alkalosis, than we need to change the way that they are breathing; in EMS we can't fix alkalosis patients.

If you are in metabolic acidosis/alkalosis, you go into respiratory compensation. Where if you are in respiratory acidosis/alkalosis, than your kidney's take over, trying to compensate.

Since today's topic with my partner was interesting, and since I learned some tricks, and it made me think, I felt that a post was needed, because I am sure that I am not the only one who forgot about acid base.

----------------

Normal pH: 7.35 - 7.45
Normal pCO2:  35 - 45 mmHg
Normal HCO3: 21 - 25 mEq/L
Normal CO2: 35-45


If pH is >45 and pCO2 is decreased....then you are in respiratory alkalosis
If pH is <35 and pCO2 is elevated...then you are in respiratory acidosis
If pH is >45 and HCO3 is elevated...then you are in metabolic alkalosis
If pH is <35 and HCO3 is decreased...then you are in metabolic acidosis

(click on picture to enlarge)