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Now there are a few very helpful external tools used for monitoring the oxygenation of a patient. One of the most popular and most frequently used is the pulse oximeter. It can be a measurement tool that measures the oxygen saturation and trends in that oxygen saturation. The way that the pulse oximeter works is that it measures the percent of hemoglobin that is fully saturated or bound with oxygen molecules. It’s very important to remember that oxygen saturation does not equate to oxygen delivery to the tissues and the pulse ox does not provide information about the effectiveness of ventilation or the elimination of carbon dioxide. An effective pulse oximeter needs pulsatile blood flow in order to determine oxygen saturation. A pulse ox will display an inaccurate reading unless the pulse rate matches the ECG monitor. And even then, we should be watching and monitoring other ways to determine the oxygenation and gas exchange of the patient. It’s important to reevaluate the patient if the pulse oximeter signals a decrease in oxygen saturation, indicates a weak or absent signal, has an inaccurate pulse rate or doesn’t detect a pulse at all. Don't imagine that it's just a failure of the pulse ox, it actually could be a true monitoring of a change in the condition of our patient. Now it’s important that if we see that failing pulse oximeter that we re-evaluate the child to determine if the patient is stable or if they need additional care. If for some reason an infant probe is unavailable, we can use an adult probe around the hand or the foot of an infant. Capnography should be attached in order to monitor the concentration or partial pressure of carbon dioxide in the expired air. Normal expired air in a person who has proper circulation and respiration contains 35-40 mmHg of CO2 on the digital readout. If CPR was being performed and a sudden sustained rise in CO2 to 35-40 mmHg occurs, this would be an indication of a return of spontaneous circulation. When CO2 is absent as measured with capnography, it means either the endotracheal tube is in a wrong position or there is no circulation. The goal with CPR is to see a reading of greater than 10 mmHg. If the end tidal CO2 reading is less than 10 mmHg, CPR compression depth and rate should be adjusted in order to improve circulation. If a child is unable to maintain an effective airway, oxygenation or an adequate ventilation on their own, intubation with an Endotracheal Tube should be considered. It's vital that all ACLS and PALS providers know their limitations and their areas of proficiency. If a provider knows that they may be called upon to intubate a patient, they should be sure to take advantage of any and all opportunities to improve their experience and skills in order to proficiently be able to secure an advanced airway if the need arises. In the case that an intubated patient begins to deteriorate, we should be ready to check the following in order to rule out a treatable problem. I'd ask questions like, "Is the tube displaced out of the trachea or has it gone into the right or left main stem bronchus?" "Has an obstruction developed caused by thick secretions, blood, a foreign body or pus?" "Or is the tube being kinked?" "Has the patient developed a simple or tension pneumothorax?" Or, "has the equipment failed due to a disconnection in the O2 supply from the ventilation system, a lean in the ventilator, a power supply failure or even a malfunction of the valves in the bag or circuit?" ...can all cause cause this kind of failure. So if there is a mechanical failure, we must remember to go back to the basics and even begin to manually ventilate the patient with a bag valve mask if the patient is on a ventilator. Watch for signs of correction which include good chest rise and fall with ventilations. We should also be getting good lung sounds upon auscultation including listening over the stomach in order to rule out an accidental esophageal intubation. Check all your monitors including capnography, the ecg, pulse ox and the heart rate. Be sure to suction the ET tube if an obstruction is suspected and if it's kinked due to the patient being agitated or waking up, that's when we should consider sedatives and analgesics with or without a neuromuscular blocker in order to reduce the agitation and control ventilation and oxygenation. It’s important to remember that if we cannot confirm proper tube placement in the airway, direct visualization of the tube passing through the glottis is advised. If the provider suspects that the cause of the deterioration is that the tube is misplaced or not working correctly, removal of the original tube and ventilation with a bag mask device may be the best route of treatment until a properly advanced airway solution can be completed. Lastly, if the patient is complicating their oxygenation and ventilation due to agitation after all other causes are ruled out, then the provider may consider medicinal treatments in order to correct the problem. If an analgesic is decided upon, one might consider fentanyl or morphine. For sedation, one could consider lorazepam, or midazolam. Lastly, Succinylcholine may be used if a neuromuscular blocking agent must be used. If a paralytic agent is used, the provider must know that they can adequately oxygenate and ventilate the patient with a basic airway management solution.
In this lesson, we're going to look at some helpful tools for monitoring and oxygenating patients, beginning with …
The pulse oximeter is one of the most popular and frequently used tools to monitor oxygenation. It measures the oxygen saturation in the patient and any trend in oxygen saturation.
It works by measuring the percentage of hemoglobin that's fully saturated or bound with oxygen molecules.
Warning: It's important to note that oxygen saturation does not equal oxygen delivery to tissues, and the pulse oximeter doesn't provide any information on the effectiveness of ventilation or the elimination of carbon dioxide.
An effective pulse oximeter needs pulsatile blood flow in order to determine oxygen saturation and will display an inaccurate reading unless the pulse rate matches the ECG monitor. Which is why it's a good idea to look for other ways to determine the oxygenation and gas exchange of the patient.
Reevaluate the patient if the pulse oximeter:
Pro Tip #1: It's important to not make assumptions when there's a failure in the pulse oximeter, as what's deemed an equipment failure may be indicating an actual change in the patient's condition.
If you encounter such a problem, reevaluate the patient and determine if the patient is stable or requires additional care. And if you don't have an infant probe, use an adult eProbe positioned around the infant's hands or feet.
A capnography is used to monitor the concentration or partial pressure of carbon dioxide in the expired air.
Normal expired air in a person with proper circulation and respiration contains 35-40 mmHg of CO2, and this will be indicated on the digital readout. If CPR is being performed and you find a sudden and sustained rise in CO2 to 35-40 mmHg, this is likely an indication of spontaneous circulation.
Pro Tip #2: When CO2 is absent, as measured with the capnography, either the endotracheal tube is in an incorrect position or there is no circulation in the patient.
The goal with CPR is to see a reading of greater than 10 mmHg. If the reading is less than that, CPR rate and depth should be adjusted to improve circulation.
Intubation with an endotracheal tube should be considered whenever a patient is unable to maintain an effective airway, oxygenation, or adequate ventilation on their own.
Warning: It's vital that all PALS providers know their limitations, as well as their areas of proficiency and expertise, if you might be called upon to intubate a patient. Which is why you should always take advantage of any opportunities to hone your skills and get more experience in securing advanced airways. At some point, the need will arise.
If an intubated patient's condition begins to deteriorate, check the following to rule out treatable problems:
Pro Tip #3: If you encounter a mechanical failure, go back to the basics and begin to manually ventilate the patient using a bag valve mask if the patient is on a ventilator.
There are some signs of correction to look for in the patient and in the equipment readings, including:
Suction the endotracheal tube if you suspect an obstruction. If the tube is kinked because the patient woke up or is agitated, consider using sedatives and analgesics with or without neuromuscular blockers.
If you cannot confirm proper tube placement in an airway, direct visualization of the tube passing through the glottis is recommended.
Pro Tip #4: If you suspect that the cause of a patient's deterioration is due to a misplaced tube or equipment failure, remove the original tube and ventilate the patient using a bag mask device, as this might be your best course of treatment until you find an appropriate advanced airway solution.
If you have a patient who is complicating their oxygenation and ventilation because they've become agitated, after ruling out all other possible causes, consider medicinal treatment to correct the problem.
Warning: If you're intending to use a paralytic agent, you must be certain that you can adequately oxygenate and ventilate the patient using basic airway management solutions.