title: The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation.
abstract: BACKGROUND
  This study aimed to determine whether field end-tidal carbon dioxide CO2 (ETCO2) monitoring decreases inadvertent severe hyperventilation after paramedic rapid sequence intubation.
  
  
  METHODS
  Data were collected prospectively as part of the San Diego Paramedic Rapid Sequence Intubation Trial, which enrolled adults with severe head injuries (Glasgow Coma Score, 3-8) that could not be intubated without neuromuscular blockade. After preoxygenation, the patients underwent rapid sequence intubation using midazolam and succinylcholine. A maximum of three intubation attempts were allowed before Combitube insertion was mandated. Tube confirmation was accomplished by physical examination, qualitative capnometry, pulse oximetry, and syringe aspiration. Standard ventilation parameters (tidal volume, 800 mL; 12 breaths/minute) were taught. One agency used portable ETCO2 monitors, with ventilation modified to target ETCO2 values of 30 to 35 mm Hg. Trial patients transported by aeromedical crews also underwent ETCO2 monitoring. The primary outcome measure was the incidence of inadvertent severe hyperventilation, defined as arterial blood gas partial pressure of CO2 (pCO2) of less than 25 mm Hg at arrival, for patients with and those without ETCO2 monitoring. These groups also were compared in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival arterial blood gas data, and survival.
  
  
  RESULTS
  The study enrolled 426 patients and administered neuromuscular blocking agents to 418 patients. Endotracheal intubation was successful for 355 of these patients (85.2%). Another 58 patients (13.6%) underwent Combitube insertion. For 291 successfully intubated patients, arrival pCO2 values were documented, with continuous ETCO2 monitoring performed for 144 of these patients (49.4%). Patients with ETCO2 monitoring had a lower incidence of inadvertent severe hyperventilation than those without ETCO2 monitoring (5.6% vs. 13.4%; odds ratio, 2.64; 95% confidence interval, 1.12-6.20; p = 0.035). There were no significant differences in terms of age, gender, clinical presentation, Abbreviated Injury Score, Injury Severity Score, arrival partial pressure of oxygen (PO2) and pH, or survival. The patients in both groups with severe hyperventilation had a significantly higher mortality rate than the patients without hyperventilation (56 vs. 30%; odds ratio, 2.9; 95% confidence interval, 1.3-6.6; p = 0.016), which could not be explained solely on the basis of their injuries.
  
  
  CONCLUSIONS
  The use of ETCO2 monitoring is associated with a decrease in inadvertent severe hyperventilation.
authors.affiliation: Department of Emergency Medicine, University of California, San Diego, CA 92103-8676, USA. davismd@cox.net
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Davis
authors.forename: James V
authors.initials: JV
authors.lastname: Dunford
authors.forename: Mel
authors.initials: M
authors.lastname: Ochs
authors.forename: Kenneth
authors.initials: K
authors.lastname: Park
authors.forename: David B
authors.initials: DB
authors.lastname: Hoyt
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D001785:Blood Gas Monitoring, Transcutaneous; D002140:California; D006259:Craniocerebral Trauma / Q000145:classification / Q000150:complications* / Q000401:mortality; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D006985:Hyperventilation / Q000209:etiology* / Q000517:prevention & control; D007442:Intubation, Intratracheal / Q000379:methods*; D008297:Male; D010092:Oximetry