1. Capnography in Cardiac Arrest NO TRACE = WRONG PLACE
Professor Tim Cook Royal United Hospitals, Bath
Advisor on Airway to RCoA

2. A capnograph trace IS STILL SEEN in cardiac arrest
NO TRACE = WRONG PLACE

3. The cases referred to here involve identifiable patients, their families, clinicians and hospitals. Please consider this respectfully.

5. 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

6. 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.

7. 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, Search for:
Mr Peter Saint
Mrs Sharon Grierson

8. 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

9. Capnogram during cardiac arrest and CPR is an attenuated trace IT IS NOT A FLAT TRACE
This is during CPR

10. Capnogram during oesophageal intubation IS A FLAT TRACE
No waveform = No ventilation = TT in wrong place

11. 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

12. 2018 Never Events
Undetected oesophageal intubation

13. 2018 Never Events

14. 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

15. Actions for Airway Leads
Share this information Available on RCoA and DAS websites
Suggest
send to all by
present at next departmental meeting

16. Summary

17. Capnogram during CPR is an attenuated trace

18. ACT NOW Flat capnograph trace
= Oesophogeal intubation until PROVEN otherwise
ACT NOW

19. Capnography
NO TRACE = WRONG PLACE
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20. ©2018 Royal College of Anaesthetists / Difficult Airway Society