Capnography in Cardiac Arrest NO TRACE = WRONG PLACE Professor Tim Cook Royal United Hospitals, Bath Advisor on Airway to RCoA
A capnograph trace IS STILL SEEN in cardiac arrest NO TRACE = WRONG PLACE
The cases referred to here involve identifiable patients, their families, clinicians and hospitals. Please consider this respectfully.
NAP4 - oesophageal intubation 9 cases (5%) 3 Anaesthesia: 2 deaths 4 ICU: 2 deaths 2 ED: 2 deaths 6 deaths 1 brain damage 2 prolonged stay ICU
A NAP4 case A middle-aged patient with a known history of asthma and latex sensitivity was scheduled for elective peripheral surgery. Airway assessment was not recorded. Pre-oxygenation was not performed. Propofol by infusion and fentanyl were used for induction of anaesthesia, after which ventilation with bag and mask rapidly became impossible. Hypoxia and cardiac arrest ensued and anaphylaxis was suspected. Tracheal intubation was hampered by grade 3 laryngeal view. After intubation the capnograph trace was flat (ascribed to a loss of cardiac output) and ventilation was very difficult (ascribed to severe bronchospasm). No action was taken to actively exclude oesophageal intubation. Cardiac output was restored with adrenaline but the flat capnograph trace persisted, prompting urgent re-intubation. This was successfully achieved, despite a persistent grade 3 view, with a McCoy laryngoscope and bougie. Oxygen saturation was below 70% for 20 minutes. At the time of the report, the patient remained in a persistent vegetative state.
Recent cases Mr Peter Saint Mrs Sharon Grierson Two recent patient deaths associated with oesophageal intubation have been highlighted in Coroner’s Reports. These are publically available on the judiciary website, www.judiciary.uk. Search for: Mr Peter Saint Mrs Sharon Grierson
This is 5 mins after CPR was stopped Capnogram during cardiac arrest is an attenuated trace IT IS NOT A FLAT TRACE This is 5 mins after CPR was stopped
Capnogram during cardiac arrest and CPR is an attenuated trace IT IS NOT A FLAT TRACE This is during CPR
Capnogram during oesophageal intubation IS A FLAT TRACE No waveform = No ventilation = TT in wrong place
Assume oesophageal intubation until PROVEN otherwise Actions Assume oesophageal intubation until PROVEN otherwise Remove tracheal tube and re-intubate (in most circumstances) ventilate by other means where necessary exclude blocked tube or circuit
2018 Never Events Undetected oesophageal intubation
2018 Never Events
Actions for Airway Leads This is vital information for All anaesthetists All intensivists All emergency physicians Paediatricians who intubate Cardiac arrest teams Pre-hospital teams Advanced paramedic practitioners It may also be useful for the whole surgical team
Actions for Airway Leads Share this information Available on RCoA and DAS websites www.rcoa.ac.uk www.das.uk.com Suggest send to all by email present at next departmental meeting
Summary
Capnogram during CPR is an attenuated trace
ACT NOW Flat capnograph trace = Oesophogeal intubation until PROVEN otherwise ACT NOW
Capnography NO TRACE = WRONG PLACE Spread the message
©2018 Royal College of Anaesthetists / Difficult Airway Society