Guidelines Administrative Practice X Clinical Practice Professional Practice

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1 Guidelines Administrative Practice X Clinical Practice Professional Practice End Tidal CO 2 (EtCO2) Monitoring Using the Zoll Monitor/Defibrillator Page 1 of 4 Scope: Outcome: Respiratory Therapists (RT), Anesthesia Providers, Code Team Leaders (Physicians, Physician Assistants, APRNs), RNs End Tidal CO 2 (EtCO2) monitoring will be utilized for patients with artificial airways during cardio-pulmonary resuscitation. Supportive Data: Primary interventions during cardiopulmonary resuscitation (CPR) include external ventilation after establishing airway patency, and precordial compression. It is precordial compression that maintains forward flow of blood in amounts that temporarily sustain the viability of major organs and especially the heart and the brain. EtCO2 evaluation provides a competent and technically simple, noninvasive monitor that highly correlates with cardiac output under conditions of constant ventilation during CPR. EtCO2concentrations during CPR are primarily dependent on pulmonary blood flow and therefore reflect cardiac output. Healthy person, normal cardiac output, metabolism/body temperature and no significant ventilation-perfusion gradient typically results in a P et CO 2 of mmhg. During low flow states, such as shock or closed chest compressions during cardiac arrest, the P et CO 2 primarily reflects systemic perfusion. The failure to maintain ETCO 2 at >10 mm Hg during adult CPR reflects poor cardiac output and strongly predicts unsuccessful resuscitation. The 2010 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care recommend monitoring EtCO2 during CPR to assess blood flow in 2 ways: (1) to improve chest compression performance if EtCO2 is <10 mm Hg during CPR and (2) to consider an abrupt sustained increase to a normal value (35 to 40 mm Hg) as an indicator of the return of spontaneous circulation (ROSC). The expert panel recommends that when available, EtCO2 should be the primary physiological metric when neither an arterial nor a central venous catheter is in place at the time of the cardiac arrest and CPR. The expert panel also recommends titrating

2 Page 2 of 5 CPR performance to a goal EtCO2 of >20mm Hg while not excessively ventilating the patient. Content: A. Bedside Equipment: Zoll monitor/defibrillator with the Capnostat 5 CO 2 sensor cable attached to the yellow CO 2 connector at the back of the zoll unit. a. Note: Zoll monitor/defibrillator must be in MANUAL mode in order to display EtCO2 waveform and value. End Tidal CO2 (EtCO2) Adapter- available in anesthesia intubation box and/or equipment pyxis in inpatient units under Zoll Airway Adaptor or End Tidal CO2 Adaptor. a. These are single use items. B. Caregiver Roles and Responsibilities: 1. Respiratory Therapy (RT)/Anesthesia Provider Attach EtCO2 airway adapter to sensor cable. Zero EtCO2 airway adapter according to instructions in Using the EtCO 2 Option on Zoll monitor/defibrillator monitor section below. Once zero process done, attach EtCO2 airway adapter to airway device. Ensure EtCO2 waveform and value is displayed on Zoll monitor screen. Evaluate EtCO2 waveform for accuracy and note value. Report EtCO2 values/changes to Providers/Code Team Leaders. 2. Code Team Leader Monitor EtCO2 value during CPR in conjunction with RT/Anesthesia. Provide orders for interventions as needed with clinical changes. 3. RN Assist RT to ensure EtCO2 waveform and value is displayed on Zoll monitor screen. Ensure visualization of waveform by RT/Anesthesia and Team Leader. Coordinate care between disciplines.

3 Page 3 of 5 C. Using the EtCO 2 Option on Zoll monitor/defibrillator: 1. Ensure attachment of the Capnostat 5 CO 2 sensor cable into the yellow CO 2 connector at the back of the Zoll unit. 2. Attach the EtCO2 airway adapter to the sensor cable by aligning the arrow on the bottom of the airway adapter with the arrow on the bottom of the sensor. Press the two together until they click. 3. C02 Warm Up message will display on the Zoll monitor. Warm up may take up to 1 minute. a. If unit displays Check CO 2 Adapter message, evaluate the following: i. Verify proper connection of sensor cable to back of Zoll unit. ii. Verify proper connection of EtCO2 airway adapter to sensor. iii. Verify EtCO2 airway adapter windows are clean and dry. iv. If the above are verified and message is still present, the EtCO2 airway adapter needs to be re-zeroed. 4. Zeroing is recommended: a. The first time an EtCO2 airway adapter is connected to the sensor on the Zoll unit. b. When the message Zero CO 2 Adapter appears. c. To troubleshoot the Check CO 2 Adapter message. 5. Do not zero EtCO2 airway adapter while in line with the patient s airway. If zeroing is necessary after monitoring has begun: a. Remove EtCO2 airway adapter and sensor. b. Wait 20 seconds for CO 2 to dissipate. c. Attempt to re-zero. d. If not successful, obtain second EtCO2 airway adapter and repeat zero process. 6. Process for zeroing the EtCO2 airway adapter to the sensor: a. Place the EtCO2 airway adapter into the sensor and keep away from all sources of CO 2. b. Press the PARAM soft key, then the CO 2 soft key. c. Press Zero soft key. Process takes about seconds. d. Once complete, the message Zero Done will be displayed.

4 Page 4 of 5 7. Attaching EtCO2 airway adapter to the airway circuit: a. Resuscitation bag: place the EtCO2 airway adapter between the endotracheal tube and the resuscitation bag or the mask and resuscitation bag. b. If the ResQPOD is being used, the EtCO2 airway adapter is placed between the ResQPOD and the ventilation source. c. Ventilator circuit: place the EtCO2 airway adapter between the elbow and the ventilator circuit wye. d. Position the EtCO2 airway adapter with its window in a vertical, not a horizontal position. This keeps patient secretions from pooling on the window. e. Clean or replace the EtCO2 airway adapter if excessive secretions are observed. f. Remove the EtCO2 airway adapter from circuit while delivering aerosolized medications. 8. Once EtCO2 airway adapter and sensor are attached to the airway, a waveform and EtCO2 value along with a respiratory rate will be displayed in yellow as the third parameter on the Zoll monitor. a. Please note: Copious secretions or blood in the EtCO2 airway adapter can interfere with EtCO2 readings. D. Documentation: RN recorder will document EtCO2 values on cardiac arrest flowsheet. If EtCO2 monitoring is used during transport, the RT will document value in the monitoring parameter on the Respiratory Care Flow Sheet. E. Special considerations: Inadequate chest compressions is usually accompanied by a very low, P et CO 2 < 10 mmhg reading that increases linearly with improved compressions. Disorders that cause significant ventilation-perfusion mismatch (i.e. pulmonary embolism, ARDS) or decreased production of CO 2 (hypothermia) can cause low P et CO 2. Administration of several medications during cardiac arrest can affect P et CO 2 levels: o Sodium Bicarbonate: can cause a transient rise in P et CO 2 as it dissociates into water and CO2. o Vasoconstrictors (epinephrine and vasopressin): will cause a decrease in P et CO 2 as systemic vascular resistance increases and total cardiac output declines.

5 Page 5 of 5 Key Word Search: end tidal, CO2, zoll, airway, CPR Issued: December 2013 Proponent: Medical Emergency Response Committee (MERC), Dr. Jason Gluck Replaces: NEW Approved by: Nursing Policy and Procedure, Reviewed: Revised: June 2014