Cardiovascular Critical Care II
| (a) | Physical assessments include visually inspecting chest rise bilaterally and listening to |
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the epigastrium (breath sounds should be absent) and lung fields (should be equal and
adequate).
| (b) | Exhaled CO2 or esophageal detector devices are a reasonable and objective means of |
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confirmation if continuous waveform capnography is not readily available.
| (c) | Continuous waveform capnography is the most reliable and objective way to ensure, |
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confirm, and monitor correct endotracheal tube placement. Although not specifically
studied with supraglottic airways, readings should be similar to endotracheal readings.
| (d) | False-positive CO2 detection (CO2 detected not from ventilation) is rare, whereas false- |
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negative CO2 detection (no CO2 detection when ventilation is occurring) is more common.
Most common cause of false-negative CO2 detection is a reduction in blood flow or CO2
delivery to lungs (e.g., lack of quality chest compressions, pulmonary embolism, severe
airway obstruction). Partial pressure of end-tidal CO2 (PETCO2) less than 10 mm Hg
during CPR suggests ROSC is unlikely, and maneuvers such as improving the quality of
chest compressions, adding vasopressor therapy, and others, should be considered.
Post-intubation airway management
| (a) | Airway should be marked (from front of teeth/gums) and secured (with tape or commercial |
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device), avoiding compression around the neck, which could impair venous return from the
brain.
| (b) | Chest radiography is suggested for confirmation of location of end of endotracheal tube in |
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relation to the carina.
| (c) | Slower ventilator rates (6–12 breaths/minute) have been shown to improve hemodynamics |
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Circulation 2004;109:1960-5; Resuscitation 2004;61:75-82).
vi.
After placement, continuous chest compressions should be given at a rate of 100-120
compressions per minute. A breath should be delivered every 6–8 seconds (8–10 breaths/
minute), making sure to avoid over-ventilation, which could decrease venous return and cardiac
output.
Patient Case
F.V. is a 63-year-old woman with a history of diabetes, heart failure with preserved ejection fraction, hyper-
tension, and obstructive sleep apnea who presents to the ED with chest tightness and “feeling funny.” In
the ED, F.V. loses consciousness and develops pVT. Chest compressions are initiated immediately, pads
are placed, and bag-mask ventilation is given at a compression/ventilation ratio of 30:2 for two cycles. The
monitor confirms the rhythm of pVT. The defibrillator is charged, the patient is cleared, and the first shock is
delivered. Chest compressions resume, and during the next pulse check, the patient is intubated. F.V. still has
no pulse, and chest compressions are continued. Which is the most accurate statement about F.V.’s resuscita-
tion after advanced airway placement?