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  1. Tools to Monitor Oxygenation

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In this lesson, we're going to look at some helpful tools for monitoring and oxygenating patients, beginning with …

Pulse Oximeter

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:

  • Signals a decrease in oxygenation saturation
  • Indicates a weak pulse rate
  • Shows an inaccurate pulse rate
  • Doesn't detect a pulse at all

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.

Capnography

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.

Endotracheal Intubation

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:

  • Is the tube displaced from the trachea?
  • Has the tube gone into the right or left main stem bronchus?
  • Has an obstruction developed due to thick secretions, blood, foreign objects, or pus?
  • Is there a kink in the endotracheal tube?
  • Has the patient developed a simple or tension pneumothorax?
  • Has the equipment failed? Possible reasons for equipment failure include:
    • A disconnection in O2 supply from the ventilation system
    • A lean in the ventilator
    • A power supply failure
    • A malfunction of the valves in the bag or circuit

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.

Looking for Signs of Correction

There are some signs of correction to look for in the patient and in the equipment readings, including:

  1. Check to see if the patient's chest is rising and falling with ventilations.
  2. Check to see if there are good lung sounds upon auscultation. (Listen over the patient's stomach to rule out accidental esophageal intubation.)
  3. Check all monitors including the capnography, ECG monitor, pulse oximeter, and heart rate monitor.

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.

When to Use Medications

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.

  • If using an analgesic, consider Fentanyl or Morphine
  • If using a sedative, consider Lorazepam or Midazolam
  • If using a neuromuscular blocker, consider Succinylcholine

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.