MEDiCATE 19

Issue 19 | June 2016
MEDiCATE
Our Trusts clinical newsletter
Dr Rory McCrea
On tour… spending time with HART East

In this
edition
C ntents
2 Looking Back
A case review with an important safeguarding view
3 Opioids
What are they? What is the right dose?
7 Pippa on tour
A reflection on time with operational staff
8 Let’s chat
A chance to get to know a clinical manager
9 Hidden profession
What use is a pharmacist? Find out more!
3 PREVENT
What are we preventing? What does it mean?
14 Clinical Audit
What are the key points you need to know?
21 ETCO2
What do I need to know? Why is it important?

A Reflection on a clinical case
Last year, whilst working on an SRV, I attended an incident that highlighted the unique
position we are in to provide support to vulnerable people via the safeguarding referral
pathway.
Early evening, EOC dispatched me to a middle-aged female who was actively choking. When I
arrived at the property, no one answered the door, despite me ringing the doorbell and knocking
hard on the front door. The crew arrived close behind me, and we could see a female with learning
difficulties in the conservatory at the side of the house who waved happily at us. Finally, after a callback
from EOC, the patient’s elderly father came to the front door. He apologised profusely for the
delay due to his poor hearing, and explained that she was no longer choking, but that he had called
999 when it happened, as he hadn’t known what to do.
By this point, the patient had fully recovered, but it became apparent that she had a long history of
dysphagia causing her to choke on a fairly regular basis despite her father’s best efforts to avoid
food that might cause an issue. His wife had died many years before, and he had been his
daughter’s main carer ever since. She had quite severe disabilities with a complete lack of verbal
communication and very limited comprehension, and although her father did have some support—
day care and a cleaner once a week—it was clear his own frailties were becoming greater, and that
he wouldn’t be able to provide such a high level of support to her for much longer.
After I’d given him some practical first-aid instructions on how to deal
with a choking incident should it happen again, we had a discussion
around how he managed to care for her, as I was quite concerned
about the many risk factors in the situation such as the difficulty
accessing the property, the patient’s high risk of choking, her level of
vulnerability in being unable to summon help should her father become
ill, and the father’s frail health and difficulty in hearing. Consequently,
with consent from the father, I made the decision to refer both of them
to the safeguarding team for review via the Vulnerable Person Referral
Form in the hope that some of the risks could be reduced.
A few days later, I had feedback to say Social Services had already
completed an initial assessment, and that they had arranged for
further assessment regarding dysphagia risks and an increased
care package. It transpired that although the family had some input
from the learning disability team, they were unknown to adult social
care, so this referral enabled them to access some much-needed
support.
Naomi Murphy
Clinical Education Lead
Naomi Murphy Clinical Education Lead
Dr Rory
McCrea

What are opioids?
Opioids are a class of drugs that are commonly prescribed for their analgesic, or painkilling,
properties. They include substances such as morphine, codeine, oxycodone, and
methadone. Opioids may be classified as natural, semi-synthetic, fully synthetic, or
endogenous. Natural opioids such as codeine and morphine are derived from opiate
alkaloids contained in the resin of the opium poppy. Semi-synthetic opioids such as
oxycodone and hydrocodone are created by chemically altering the natural opioids. Fully
synthetic opioids such as methadone are synthesized from non-opioid substances in
laboratories. Endogenous opioids are naturally produced by the body and include
substances such as endorphins.
How do opioids work?
Opioids bind to specific proteins called opioid receptors that are located in the brain, spinal
cord, and gastrointestinal tract. Through this mechanism, opioids are able to block the
brain's ability to perceive pain. Instead, opioids tend to stimulate the pleasure centres of
the brain, inducing euphoria.
* Image borrowed from Wyeth library

When are opioids used?
Opioids are used in medicine because they can block the perception of pain. Patients
receiving palliative care frequently report pain as one of the most distressing factors as
they approach the end of life. About 70% of patients with advanced cancer and 65% of
patients dying from other non-malignant diseases commonly complain of pain 1 . Opioidbased
medicines are prescribed to these patients to reduce their pain and increase their
quality of life. The vast majority of patients receiving long-term opioid pain medication are
in advanced stages of their disease however they are also used to manage acute pain
such as fractures, abdominal and back pain.

What are side effects of opioids?
Opioid use carries several side effects. These include drowsiness, nausea, slower
breathing, and a general depression of the respiratory system. Further, opioids often cause
constipation(opioid-induced constipation (OIC)). OIC is an uncomfortable side-effect that
occurs in many patients who receive opioid treatments to relieve pain.
What about dosage?
Whilst we have the ability to administer up to 60mg as a STAT dose the key with opioids is
to start small and work your way up…
So if you patient has never used codeine before then 15mg is likely to be enough to
achieve good analgesia, if your patient is used to taking opioid analgesia – lets say a
patient with known back pain, normally on codeine but is away from home and lost their
own codeine – in this situation 30mg – 60mg is likely to be required to reach effective
treatment.
If in doubt - give our excellent colleagues on the PP desk a call
to discuss your patient.

Digital
patients?
Omnicell was originally a hospital based solution for
medicines security. As an innovative organisation
SECAmb procured the product and have utilised its
abilities to match the needs of a very different medical
setting where patients have shorter interactions and don’t
receive on-going care.
In the next few editions of MEDiCATE there will be a
series of Know How guides which will help you to use the
system in the way that matches its design for SECAmb.
Booking out Medicines.
When booking out medicines we need to tell the Omnicell where the item will ―live‖.
The way we do this is by selecting our medicines bag, controlled drug box or our vehicle if we are allocating the
spare cardiac arrest pouch. When carrying this out on the right of the Omnicell screen is a button which says
―add patient‖.
What is an Omnicell patient?
Omnicell patients for SECAmb are the controlled drug boxes, drugs bags or vehicles. We do not input any
actual patient details to our Omnicell as very often we only see our patients once. Hospitals use the system
differently because they create a file for their patients who they often see on multiple occasions and for
significantly longer interactions than ourselves. This allows them to calculate costs per stay and to claim the
funds for the episode from the Government.
All of SECAmb’s patients are global which means that you can see them from any Trust location in case you
needed to get medicines and were not at your local station.
Once we have selected where the item will live we can select which medicine or pouch we need. Once selected
we are able to remove the item by selecting ―remove drugs now‖ and the Omnicell will allow us access to the
medicines.

Pain is a complex collection of symptoms and fears often met by a lack of background
knowledge from frontline clinicians.
http://www.change-pain.co.uk/
has devised a number of free educational materials to help clinicians build their background
knowledge and confidence in dealing with and managing pain

Pippa
As many of you know I am often looking to come out and shadow operational staff. I welcome offers of shifts
from all areas as like to get to see the operational staff and see the challenges that face different localities.
Being able to work alongside yourselves helps me to understand and appreciate the impact of the decisions
and suggestions that I make around your medicines and so being able to visualise your roles is really
important to me.
On May bank holiday weekend I joined Ross – Paramedic & Mel – Student Paramedic. On their shift I was privileged
enough to witness almost the entire pain ladder in use across a number of patients and conditions.
We saw an elderly patient who had severe back pain. She was unable to mobilise to get out of bed and lived alone.
The patient was very resistant to taking any medication except for Paracetamol tablets which were having little impact
on her pain on this occasion. She declined a cannula for the crew to give her anything IV and would not use Entonox
as she didn’t like the feeling of being wobbly or dizzy. With reluctance she agreed to try Penthrox which she used
intermittently for her spasmodic pain reducing her pain score from 10 to 8. We were able to mobilise her onto the
chair with significant assistance and convey her to hospital continuing to use the Penthrox intermittently in order that
she could be reviewed and her regular analgesia assessed to ensure that she would be safe at home.
Later in the shift we had a call to another elderly patient who had been blown off of her feet by the increasing wind.
She was in an exposed area and growing increasingly cold so controlling her pain quickly to assess, immobilise and
move her was critical to ensuring she didn’t become hypothermic. The lady had osteoporosis and had previously
broken her hip. She had a pain score of 10 on arrival and she had visible shortening and rotation of her right leg.
Moving quickly but carefully she was assessed for other injuries but the potential fractured neck of femur was isolated
as her only injury. The lady was loaded with Entonox in order that we could quickly immobilise her with frac-straps
and then scoop her onto the trolley and move her off of the cold pavement into the safety of the DCA.
She was administered IV Paracetamol and other analgesia options were discussed with her. The lady was very
reluctant to accept Morphine, she explained that she was scared of finding it difficult to come off of Morphine which is
what had happened to her before. Mel and Ross worked to make her more comfortable, repositioning her legs in a
way that she felt was move comfortable and continued talking and reassuring the lady that this would be a single
dose to get her comfortable to travel and the patient agreed. She was given an initial 5mg while the last of the
assessment was carried out and prior to travel accepted a further 5mg which reduced her pain score to 5. The
patient declined any further doses on route as said that her pain was bearable at a score of 5.
I learned from this shift the impact of the various analgesia carried on different types of pain and how a dynamic risk
assessment can lead you to a decision which becomes the start of the patient care plan, and how the care plan then
develops to provide with the best possible outcome for the patient.
If anyone would be happy to allow me to observe a shift please let me know by emailing me so that I can arrange to
come and find you on a suitable day.

Lee Busher | Learning & Development
Q...What does your role involve?
I oversee the educational programmes for PPs and CCPs at the University
of Surrey, St Georges and Hertfordshire. I represent the Clinical Education
Department on the Cardiac Arrest Survival Team, Quality Improvement
Working Group and Clinical Equipment and Consumables Sub Group. I
am also a Response Capable Manager and regularly attend incidents.
Q...What is your background?
Nurse Practitioner working in a variety of settings including A&E, Police Custody Suites & as an Event Nurse.
I joined the Trust as a Clinical Supervisor before moving into Clinical Education. I’m an ALS instructor and
hold post-graduate qualifications in Medical Education & Clinical Leadership as well as being an honorary
lecturer at St Georges University. I am also just about to finish my paramedic training.
Q...What do you think the biggest
challenge our frontline staff face?
The biggest challenge for our staff is often the access to alternative referral pathways. Many staff report
finding it difficult to refer patients to community services in an attempt to avoid an unnecessary A&E
admission. This issue often leaves the crew little choice but to convey to A&E.
Q...What are your plans for the next 12 months?
I hope to move into Operations to help support localised pathways and influence the Cardiac Arrest Strategy,
affording patients and staff better access to the care they need and deserve. Operations is undergoing
significant change and I would like to be part of this
Q...If you could change one thing about the service, what
would it be?
I would like to chance the view of the way concerns are addressed within the Trust. We need to reinforce the
fact that the Trust has adopted a no-blame culture and ensure staff feel supported when making decisions
that are in the best interests of our patients, moving towards a safety culture.

The hidden
profession
Pharmacy is no longer the traditional “pill in bottle” professional that it used to be.
Over the last twenty years the pharmacy profession has grown hugely to offer a whole
host of new services.
The Pharmacist
Pharmacists undertake a four year Master’s degree program in order to qualify at their most basic level. The
degree is followed by a year as a pre-registration pharmacist before they can practice autonomously. Pharmacists
offer a host of skills in both community and hospital environments including:
Advice to other healthcare professionals, including doctors and nurses, on how to choose medicines and
use them correctly
Ensure that new medicines are safe to use with other medication
Advise on dosage and suggest the most appropriate form of medication such
as tablet, injection, ointment or inhaler
Make sure that patients use their medicines safely
Provide information to patients on how get the maximum benefit from the
medicines they are prescribed
Advise on the most effective treatments for a particular condition including
those for sale without prescription
Nationally there is a drive for Pharmacies to offer more service in the Primary
Care Setting and the Pharmacy team is developing in order to facilitate this need.
Pharmacists have access to shared Patient Care records and so are
able to offer a huge amount of advice and direction on the patient,
their usual medicines and their medical history. They will also liaise
with the GP to relay information passed to them by us and to arrange
medicine reviews and domiciliary visits should the patient need the service.
A large number of pharmacists also prescribe so are a handy alternative to getting your
patients the medicines they need!

Follow us
@SECAmb_Medicines
Want an item reviewed?
Email products@secamb.nhs.uk

What have we spent this year…
With a total medicine spend of £143,409.72 in two
months. Since April 2016 we have spent a
whopping £31,135.00 on tenecteplase.
Lee Busher
Learning & Development Lead

Want to understand more about illegal drugs or alcohol?
A number of staff have found the following free training package useful - taking
around 30 minutes to complete and can be done in small bite size chunks!
http://birminghampublichealth.co.uk/elearning.php
Safeguarding Patients and Medicines
Patients who are vulnerable may require additional support and interventions by staff to help keep them safe. This may include
ensuring that, on occasion, patients do not have unsupervised access to their own medication.
Whilst is appropriate to take patient medication with them when they are
transported to hospital those exhibiting suicidal ideation during a mental
health crisis are extremely vulnerable. Each patient must be individually
risk assessed with regards to whether you feel it would be safe to leave
their medication with them, or whether medication should be handed
over to hospital staff for safe-keeping. Transfers of medication to hospital
staff members should be noted on the PCR.
In line with the Trust’s Medicines Management Manual guidance, patient
medication should be placed in green medication bags (available on
vehicles) and clearly marked with the patient’s name and date of birth. If
it is identified that the patient having access to their medication may pose
a risk, this must be discussed with the receiving member of hospital staff
and a plan agreed for safe storage of medication.
By ensuring that we follow best practice guidelines whilst the patient is in our
care and highlighting concerns during handover we can work in partnership
with hospital colleagues to help keep our patients safe.
If you have any questions about patient vulnerability, please contact Jane Mitchell
(jane.mitchell@secamb.nhs.uk, or the safeguarding team
(safeguarding@secamb.nhs.uk)
if you have any questions regarding safe use and storage of medications, please
contact Paul Cloves (paul.cloves@secamb.nhs.uk) for further information.
Jane Mitchell Safeguarding Lead
Paul Cloves Medicines Management Lead

What is PREVENT?
This is part of the UKs counter terrorism strategy. Its aim is to give people the tools to identify someone who may be
vulnerable to becoming radicalised – either into terrorism (think IS activity) or other extremist activity (think far right
extremism, direct action animal rights activists etc.) before they end up being involved in a criminal act supporting
that view.
How will I know?
All patient facing staff will be receiving training as part of their classroom key skills sessions. This session has been
devised by the Home Office to be delivered to staff working in health settings and is designed to help staff
understand the purpose of PREVENT and how to identify and raise concerns about either patients or colleagues
they have
I have a worry – what do I do?
If you are worried, if it’s safe to discuss your concerns, let them know that you are worried that they may be being
taken advantage of, or be heading towards criminal activity and that you can make a referral to get them some
support. If it’s unsafe to have this discussion, you will need to weigh up the risk to the patient and the public before
deciding whether the information should be shared anyway. For a member of staff it would be worth speaking to a
trusted colleague or manager to support your discussion as the indicators you have picked up on may indicate other
welfare support might be needed… The referral should be made using the VP referral route – select Prevent as
your primary concern. The safeguarding team will contact you to discuss the case and decide next steps.
What does happen next?
The safeguarding team will raise the concern through the local multi-agency panel (CHANNEL) where the referral
will be discussed and a plan for offering support relevant to the concern will be formulated. This may involve local
voluntary organisations, religious leaders or social support.
If you have any questions regarding this topic, you can contact your CTL regarding when you might
receive the face to face training, or email safeguarding@secamb.nhs.uk if you have a specific question.

Since April 2011, all ambulance trusts in England have been measured and reporting against 11
ambulance quality indicators (AQIs), which allow our performance to be compared with that of
other services across the country. The indicators are split into ambulance system indicators
(including response times) and clinical outcome indicators (COI) for cardiac arrest (ROSC),
STEMI and stroke.
Within the Clinical Audit department we report performance for the following COIs. When
completing PCRs for ROSC STEMI and Stroke it is helpful to know what information is collected
to audit against compliance. Irrespective of what the narrative infers we can only report on what
is, or is not documented in black and white within the PCR.
For example, writing ‘FAST +ve’ in the free text box has to be judged as incomplete for the care
bundle as each element of face, arms, speech should be documented separately either using the
tick boxes or in full narrative.
A summary of the audit criteria to assist in PCR completion for the COIs are provided below.
CARDIAC ARREST
This indicator has two components:
1) ROSC ALL - All patients who had resuscitation (BLS or ALS) documented as commenced/continued by
ambulance service personnel following an out-of-hospital cardiac arrest.
2) ROSC Utstein - All patients who had resuscitation (BLS or ALS) documented as commenced/continued by
ambulance service personnel following an out-of-hospital cardiac arrest of presumed cardiac origin, where the
arrest was bystander witnessed and the initial rhythm was VF or VT.
STEMI
This indicator has two components:
1) The percentage of patients suffering a STEMI who are directly transferred to a centre capable of delivering
primary percutaneous coronary intervention (PPCI) and receive angioplasty within 150 minutes of emergency
call.
2) The percentage of patients suffering a STEMI who receive an appropriate care bundle. All of the following
must be documented to achieve compliance with the care bundle including if the patient refuses, is contraindicated
or is unable to comply:
Aspirin given
GTN given
Two pain scores recorded
Appropriate Analgesia given for all pain scores above 0

STROKE
This indicator has two components:
1) The percentage of Face Arm Speech Test (FAST) positive stroke patients (assessed face to face) potentially eligible
for stroke thrombolysis, who arrive at a hyperacute stroke centre within 60 minutes of emergency call.
2) The number of patients with symptoms of suspected stroke, or unresolved transient ischaemic attack, assessed face
to face who received an appropriate care bundle. All of the following must be documented to achieve compliance
with the care bundle including if the patient refuses, is contra-indicated or is unable to comply:
FAST assessment recorded (including the 3 separate components of face, arms, speech)
Blood glucose recorded
Systolic and diastolic blood pressure recorded
Clinical Performance Indicators (CPIs)
Increasingly CPIs are being used in healthcare settings to assess and monitor the delivery of care. The National
Ambulance Service Clinical Quality Group’s (NASCQG) technical sub group was established in 2007 and set about
defining a core set of National CPIs for key clinical topic areas.
The priority of the National CPI programme is to provide ambulance services with useful data for the continuous quality
monitoring and improvement of care delivery, in addition to the provision of a national benchmarking tool.
There are currently 6 CPIs that we audit against twice a year on a monthly rotation. Each topic has a care bundle
against which PCR documentation is reviewed.
Current CPI topics are Asthma, single limb fracture, febrile convulsion, elderly falls, and mental health.
In each edition of Medicate we will let you know which topic is going to be focused on and provide you with a list of
elements that require documentation in order to evidence completion of the care bundle. We will also begin feeding
back audit results beginning next month.
For the month of July Single Limb Fractures will be audited. This CPI has 4 elements and applies to all patients 18
years of age and over.
All of the following must be documented to achieve compliance with the care bundle including if the patient refuses, is
contra-indicated or is unable to comply:
Two pain scores recorded (pre and post treatment)
Analgesia administered
Immobilisation of limb recorded (all fractures should be immobilised unless patient refuses)
Assessment of circulation distal to fracture site recorded
If you would like to find out more about the national reporting programme for COIs and CPIs please send an
email to clinical.audit@secamb.nhs.uk

Notification:
New Cannula Pack:
Date of Alert: June 2016
Whom Responsible: ROM’s, OUM, COM’s, MRCM and VPP Managers
Action By: All Operational Staff
Action Timeframe: Immediate
New Vygon Cannula Pack:
As part of the Trusts ongoing commitment to patient safety and quality care the Clinical Equipment and
Consumables Sub Group have reviewed the cannula pack and made some additions to the content which has
meant a change to the company that produces them for us.
Vygon have worked with the Procurement Team and Infection Control Lead to produce a pack that now contains
all elements required to carry out a cannulation procedure except the cannula which will still be stored separately
due to logistical reasons.
Many of you will already have completed this year’s Key Skills session for the Aseptic Patient and have been
provided with further guidance / awareness of why the cannula pack forms an integral role in ensuring a clean /
aseptic field is maintained during the cannulation procedure and we hope that the new pack will enhance this.
We have taken on board comments from operational staff in regard to content and have added another
Tegerderm dressing for the patients that are sweating profusely and fixing the dressing in place first time round
becomes compromised.
For further information on the cannulation procedure please refer to the Infection Prevention and Control Manual
which can be found on the Intranet by following the link below;
http://www.secamb.nhs.uk/staff_zone/my_secamb/clinical_zone/infection_prevention__control.aspx
Any additional enquiries can be sent to Aide Hogan – Infection Control Lead:
Telephone - 07766511514
E-mail – Adrian.hogan@secamb.nhs.uk
The photo on the next page shows the full contents of the pack along with a list of contents:

Pack Contents:
1 x ChloraPrep® Frepp 1.5ml applicator
5 x Non-woven swabs 10 x 10cm 4ply white
1 x VENE-K® disposable silicone tourniquet
3 x Tegaderm dressing 7 x 8.5cm code 1633
2 x Clinell® 2% Chlorhexidine wipe
1 x Octopus 2 Vadsite type 6841.21
1 x Drape towel 45 x 35cm
1 x 10ml Pre-filled syringe with NaCl 0.9%
1 x Green sticker ANTISEPTICALLY INSERTED 1 x 4cm
1 x Red sticker EMERGENCY INSERTED 1 x 4cm
Out of date?
Got out of date CD’s that need disposing of?
Print off form from sharepoint or copy form the rear of the
medicines manual
Complete and email copy to CDorder@secamb.nhs.uk
Place another copy in CD safe
Logistics will then collect the out of date CD’s on the next
delivery providing there is a paramedic on station.

A message
from Health
Records
The safe collection scanning and storage of the PCRs you complete is important for our patients, the
Trust and also for the staff who write them. As well as being legal documents, which can be requested
as evidence at coroners court, PCRS are used as evidence internally to support safeguarding and
clinical improvement, investigation, audit, and to demonstrate the great care we provide.
In order to enable effective scanning and storage of this vital documentation please:
Don’t fold your PCR – this leads to delays in scanning (as they have to be unfolded) and a
reduction in scanning quality
Ensure all key information is clearly completed;
• Incident Date
• Incident Number (8 digit number only – missing the 2)
• Call Sign Letter
• Call Sign Number
• Station Base
• Condition Code
Without this there are delays in scanning and linking PCRs.
Complete forms as legibly as possible in black ball point pen only
Complete a new form for damaged (ripped) or soiled forms (bodily fluids/drinks/mud,) as these
forms cannot be scanned
Ensure PCRs are returned to station promptly and made available for regular collection.

Resuscitation 85 (2014) 1619–1620
Contents lists available at ScienceDirect
Resuscitation
j ournal
homepage: www.elsevier.com/locate/resuscitation
Clinical paper
PQRST – A unique aide-memoire for capnography interpretation
during cardiac arrest 6
Bård E. Heradstveit a,∗ , Jon-Kenneth Heltne a,b
a
Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
b
Department of Medical Sciences, University of Bergen, Bergen, Norway
a r t i c l e i n f o a b s t r a c t
Article history:
Received 9 May 2014
Received in revised form 14 July 2014
Accepted 14 July 2014
Keywords:
Cardiac arrest
Capnography
Survival
Education
PQRST
Mnemonic
The use of capnography is recommended during resuscitation. By implementing the mnemonic “PQRST”,
rescuers have a ready-made checklist to help them achieve the full potential of capnography. This
approach can facilitate efforts to both reduce the hands-off time and individualize the treatment, which
can lead to improved survival for our patients.
© 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
2.1. P – position of the tube
The use of capnography during advanced life support was
enhanced in recent guidelines. 1 Levels of end tidal carbon dioxide
may reflect both production in the cells and ventilation from
the lungs; however, assuming these variables are constant, the
levels may also reflect the cardiac output induced by chest compressions.
To implement capnography in a systematic manner, we
advocate the introduction of the mnemonic “PQRST” as a unique
aide-memoire when interpreting capnography for the resuscitation
team. In the following, we address these different aspects of
resuscitation, and interpretations of capnography data that may be
useful during resuscitation.
2. The mnemonic “PQRST”
P Position of the tube
Q Quality of chest compressions
R Return of spontaneous circulation (detection)
S Strategy for further treatment
T Termination of resuscitation
6 A Spanish translated version of the summary of this article appears as Appendix
in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.07.008.
∗ Corresponding author.
E-mail addresses: baard.heradstveit@helse-bergen.no (B.E. Heradstveit),
jon-kenneth.heltne@helse-bergen.no (J.-K. Heltne).
Capnography, in contrast to capnometry, displays the level of
carbon dioxide as a function of time. Grmec compared the use of
auscultation, capnometry, and capnography, and found that the latter
technique demonstrated superior sensitivity and specificity. 2
Moreover, when this method is selected, rescuers receive additional
information that immediately confirms correct tracheal tube
placement. Normally, positioning the tube is considered a primary
task, and later, it is forgotten. When the intubated patient is transported,
during cardiopulmonary resuscitation (CPR) or after the
return of spontaneous circulation (ROSC), various situations may
cause dislocation of the tube, and capnography monitoring can
immediately warn the rescuers.
2.2. Q – quality of CPR
Quality of chest compression during cardiac arrest (CA) influences
the level of end tidal carbon dioxide, as demonstrated by
Kalenda, in 1979. 3 When fatigue occurs, indicated by a drop in
capnography levels, he advocated that another person should take
over the chest compressions. Higher levels of end tidal carbon dioxide
are associated with a better outcome 4,5 ; thus, it is reasonable to
relieve the person performing chest compressions at every cycle,
and to limit the individuals performing compressions to those that
have achieved the highest levels. Qvigstad et al. 6 reported variations
in end tidal carbon dioxide when they moved the compression
http://dx.doi.org/10.1016/j.resuscitation.2014.07.008
0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.

1620 B.E. Heradstveit, J.-K. Heltne / Resuscitation 85 (2014) 1619–1620
site to three different locations; that finding indicated that a single
location may not be optimal for all patients. Capnography may
facilitate the detection of the best site for compression, but maybe
even more important, the early recognition of poor quality of chest
compressions.
2.1. R – ROSC
Return of spontaneous circulation is normally detected during
the analyzing phase. A sudden increase in end tidal carbon dioxide
is an early, reliable indicator of ROSC. 7 Implementation of carbon
dioxide detection is important, because checking the pulse to differentiate
between pulseless electrical activity and ROSC is difficult
and time consuming. 8,9 Any effort to reduce “hands-off” time 1 may
be in vain in the absence of the potential provided by capnography.
Although we clinicians are waiting for industry to establish software
that can analyze heart rhythm during chest compressions,
we already have a tool for detecting whether a given rhythm can
provide a pulse.
2.2. S – Strategy
Strategy is important for individualizing resuscitation, and for
evaluating a potentially treatable cause of the arrest. An early and
aggressive strategy is of vital importance particular in CA victims
with reversible causes. Approximately 70% of the out-of-hospital
cardiac arrests were assumed to be caused by myocardial infarction
or pulmonary embolism; that estimation led to a randomized
study for testing tenecteplase treatment for patients with witnessed
arrests. 10 By reducing pulmonary blood flow, a pulmonary
embolism will influence the end tidal carbon dioxide levels, as
described by Rumpf et al. 11 This influence would probably be more
important when the obstruction causes cardiac arrest. Reduced levels
of end tidal carbon dioxide have been described in patients
with a suspected pulmonary embolism. 12 Therefore, capnography
may assist clinicians in detecting patients suitable for fibrinolytic
therapy during CPR. However, low levels of end tidal carbon dioxide
may also indicate other causes, such as internal hemorrhage
or tension pneumothorax; thus, interpreting capnography can be
complicated. This situation also underlines the need for a thorough
clinical examination and an early treatment strategy for improving
survival.
2.3. T – Termination
Termination of resuscitation may become a self-fulfilling
prophecy. Nevertheless, Levine et al. 13 found that an end tidal carbon
dioxide level

Contributions made by:
Pippa Meakins
Pharmacy Technicians
Jane Mitchell
Safeguarding Lead
Darren Palmer
Paramedic Practitioner
Naomi Murphy
Clinical Education Lead
Brad Gander
Student Paramedic
Aide Hogan
Infection Control Lead
Amanda Allen
Head of Clinical Audit (interim)
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Paul Cloves
Lead for Medicines and
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Lee Busher
Learning and
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