Download Medical Procedures/Equipment

TAB 500
MEDICAL PROCEDURES/EQUIPMENT
TABLE OF CONTENTS
Section
Oral Airway......................................................................................................................A
Nasopharyngeal Airway ..................................................................................................B
Tracheal Suctioning.........................................................................................................C
Intubation ........................................................................................................................D
Medication Facilitated Intubation……………………………………………………………..D(2)
Visualized Oraltracheal Intubation with C-spine Control ………………………................
E
King Supralottic Airway ...................................................................................................F
Needle Decompression...........................................................................................…..... G
Cricothyrotomy.................................................................................................................H
Nebulizer .........................................................................................................................I
In-line Aerosol Set.....................................................................................................…... J
KED............................................................................................................................…. .K
TubeChek-B................................................................................................................….. L
Pulse Oximeter.........................................................................................................…....M
Blood Glucose Meter......................................................................................…..............N
Traction Splint .................................................................................................................O
Transthoracic External Cardiac Pacing............................................................................P
Tab 500
Medical Procedures
TAB 500
MEDICAL PROCEDURES/EQUIPMENT
TABLE OF CONTENTS
Page 2
Photo Kit.........................................................................................................................Q
Restraint..……………………………..................................................
..............................R
Capnography..…………………………...............................................
..............................S
T
CPAP…………………………………………………………………………………………….
EZ-IO…………………………………………………………………………………………
.....U
ResQpod…………………………………………………………………………………
..…… .V
Saline Locks…………………………………………………………………
……………
….. ...W
Intranasal (IN) Medication Administration……………………………………………………X
Tab 500
Medical Procedures
A
OROPHARYNGEAL AIRWAY
The oropharyngeal airway (oral airway) is a disposable semi-circular device used to hold the
tongue away from the posterior wall of the pharynx. This airway should only be used in patients
without a gag reflex.
A.
Procedure
1.
2.
3.
4.
5.
6.
7.
Safe scene, standard precautions.
Measure oropharyngeal airway for proper size (from angle of the mandible to just
beyond the lips).
Clear mouth and pharynx of any foreign objects, blood, vomit or secretions.
Insert a tongue blade to displace the tongue inferiorly and anteriorly and insert the
airway posteriorly toward the back of the oropharynx following the normal curvature
of the oral cavity. If a tongue blade is unavailable, the airway may be inserted from
the side to the back of the tongue. Caution should be used not to catch the tongue,
as it will push the tongue back into the hypopharynx occluding the patient’s airway.
Select proper ventilator device and proper mask (Auto Vent or BMV).
Ensure seal around patient’s airway and ventilate.
Auscultate lung fields for adequate breath sounds.
Tab 500
Medical Procedures/Equipment A-1
B
NASOPHARYNGEAL AIRWAY
The nasopharyngeal airway is a flanged disposable airway that is soft and pliable. It is used to
maintain compromised airways on conscious and semi-conscious patients with a gag reflex. In
most of the population (approximately 90%), the airway is inserted into the right nares. In patients
with deviated septums, the airway will need to be inverted so the bevel is toward the septum and
then inverted again when the airway reaches the posterior wall. The airway should be measured
from the tip of the patient’s nose to the tragus of the ear. Lubrication may or may not be needed.
The airway should not be forced. The airway is contraindicated with severe head trauma, basal
skull fracture and nasal or maxillofacial fractures.
A.
Procedure
1.
2.
3.
4.
5.
Safe scene, standard precautions.
Measure nasal pharyngeal airway for proper size.
Clear airway of any foreign objects, blood, vomit or secretions.
Insert airway.
Administer appropriate ventilatory support or oxygen therapy.
Tab 500
Medical Procedures/Equipment B-1
C
TRACHEAL SUCTIONING
When possible, sterile techniques should be followed during tracheal suctioning. As time permits,
suctioning should not exceed ten (10) seconds per procedure.
A.
Procedure
1.
2.
3.
4.
5.
6.
7.
8.
9.
Safe scene, standard precautions.
Select appropriate suction equipment.
Explain procedure to patient if applicable.
Hyperventilate the patient for at least two (2) minutes prior to procedure.
Open sterile saline solution.
Lubricate catheter tip with saline.
Insert catheter to carina (until resistance is met).
Slowly withdraw catheter using rotating motion and apply negative pressure.
Hyperventilate patient.
Tab 500
Medical Procedures/Equipment C-1
D
INTUBATION
ADVANCED AIRWAY MANAGEMENT
A.
Adult Endotracheal Intubation
1.
Indications
a.
b.
Patients in deep coma, respiratory arrest or cardiopulmonary arrest.
Patients where complete obstruction of the airway appears imminent, i.e.,
respiratory burns, acute anaphylaxis, upper airway foreign body obstruction.
2.
Contraindications
a.
b.
3.
Precautions
a.
b.
c.
4.
Patients with an intact gag reflex.
Patients where irritation of the pharynx might cause laryngeal spasm - croup
or epiglottitis.
It is important not to take longer than 10 seconds per attempt. If it takes longer
than 10 seconds, you should stop. Oxygenate the patient before trying again.
Other techniques of airway management may be indicated if there is a
suspected injury to the cervical spine.
The importance of verifying successful endotracheal intubation by auscultation
of the chest following the procedure cannot be over emphasized. Accidental
intubation of the esophagus, resulting in prolonged hypoxia is usually always
fatal if not quickly reversed.
Complications
a.
b.
c.
d.
e.
Accidental intubation of the esophagus.
Insertion of the endotracheal tube too deep into trachea or right main stem
bronchus.
Oropharyngeal trauma.
Fractured teeth or dentures.
Spasm of the vocal cords.
Tab 500
Medical Procedures/Equipment D-1
Intubation, continued
5.
Required Equipment
Endotracheal tube
Lubricant
Stylet
10ml syringe
Laryngoscope blade
Laryngoscope handle
Magill forceps
ET holder
Stethoscope
Suction
Tube Chek
Capnography FilterLine
6.
Procedure
a.
b.
c.
d.
e.
f.
Oxygenate patient. Assemble equipment. If applicable, auscultate breath
sounds prior to intubation.
Assemble and check equipment.
(1)
Select appropriate size laryngoscope blade and handle.
(2)
Check light on laryngoscope to be certain it works and is screwed
tightly in.
(3)
Select appropriate size endotracheal tube, i.e. measure size to the
patient’s little finger or nares.
(4)
Check cuff of endotracheal tube, leave inflated for approximately 10
seconds. Use maximum amount of cc’s recommended by the
manufacturer. Leave syringe attached.
(5)
Tube should be lubricated.
Place victim’s head in sniffing position: (Maintain c-spine control if indicated).
Hold laryngoscope in left hand. Hold ET in right hand.
Position self over victim, open mouth, remove oral airway and do tongue jaw
lift.
Insert laryngoscope while directly visualizing:
(1)
Insert blade in right side of mouth moving the tongue to the left, or
(2)
Use mid-line technique following palate ¼ to ½ inch beyond uvula.
Landmarks for insertion; epiglottis, vocal cords and arytenoids cartilages.
Tab 500
Medical Procedures/Equipment D-2
Intubation, continued
g.
h.
i.
j.
k.
l.
Do not use teeth as fulcrum, elevate laryngoscope, advance endotracheal
tube through cords, withdraw laryngoscope and hold onto tube.
Inflate cuff by feeling pilot balloon tension. Look at syringe and visualize exact
amount of air injected. Use only enough air to create an effective seal (usually
4-6ml of air).
Confirm placement with Tube Check.
Place adult capnography FilterLine on the endotracheal tube then attach BVM
to FilterLine adapter and confirm tube placement.
Ventilate with BVM, assess effectiveness with stethoscope apices, midaxillary
line and epigastrium.
Secure with tape or ET strap.
B.
Pediatric Endotracheal Intubation
1.
Indications
a.
b.
2.
Contraindications
a.
b.
c.
3.
Patients in deep coma, respiratory arrest or cardiopulmonary arrest.
Patients where complete obstruction of the airway appears imminent respiratory burns.
Patients with an intact gag reflex.
Patients where irritation of the pharynx might cause laryngeal spasm.
Croup or epiglottitis.
Complications
a.
b.
c.
d.
e.
Accidental intubation of the esophagus.
Insertion of the endotracheal tube too far.
Oropharyngeal trauma.
Fractured teeth.
Spasm of the vocal cords.
Tab 500
Medical Procedures/Equipment D-3
Intubation, continued
4.
Required Equipment
Pediatric non-cuffed ET tube
Lubricant
Stylet
Laryngoscope blade
Laryngoscope handle
ET holder
Stethoscope
Suction
Capnography FilterLine
5.
Procedure
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Check laryngoscope and light
Select appropriate blade size for age of infant/child
Hyperventilate child
Insert laryngoscope blade properly
Do not use teeth as fulcrum
Insert endotracheal tube while maintaining visualization of vocal cords
Place pediatric Capnography FilterLine on the endotracheal tube then attach
BVM to FilterLine adapter and confirm tube placement.
Check tube placement following insertion
Ventilate infant/child with BMV
Auscultate chest
Secure tube
Take no longer than 10 seconds to attempt to re-ventilate
Tab 500
Medical Procedures/Equipment D-4
D–2
ADULT MEDICATION FACILITATED INTUBATION
This protocol is for use ONLY BY a PARAMEDIC who is operating in Fulton County.
A.
INDICATIONS
1.
Situations in which airway control is indicated (i.e. orotracheal intubation) due to:
A. Significant respiratory distress or impending respiratory failure in a patient who is
conscious and in whom Nasotracheal intubation is not an option.
B. Patient with altered mental status or who is otherwise unable to cooperate, and in
whom definitive airway control is indicated due to:
a. The potential for deterioration
b. Respiratory burns
c. Head trauma
d. Multi-system trauma
B.
CONTRAINDICATIONS
1.
2.
3.
D.
Patient in whom airway control may be established without the use of sedating
agents.
Patients with high potential for difficult airway due to:
a. Significant trauma to the mandible or mid face.
b. Significant oropharyngeal bleeding or emesis in hypopharynx, potentially
obscuring the airway.
c. Anatomic presentation that is likely to prevent airway visualization
Patients <16 years of age.
POTENTIAL COMPLICATIONS
1.
2.
3.
4.
5.
6.
7.
Accidental intubation of the esophagus.
Insertion of the endotracheal tube too deep into trachea or right main stem
bronchus.
Oropharyngeal trauma.
Fractured teeth or dentures.
Spasm of the vocal cords.
Bruxism
Hypotension
Tab 500
Medical Procedures/Equipment D (2)-1
Medication Assisted Intubation, cont.
E.
PROCEDURE
1.
2.
3.
4.
5.
6.
7.
8.
9.
Establish need for intubation/airway control with sedation, and establish that
contraindications are not present.
Administer oxygen @ 10-15 lpm via non-rebreather if patient is ventilating
spontaneously, or assist oxygenation and ventilation with a Bag-Valve-Mask and
supplemental oxygen if indicated and possible.
Initiate IV of 0.9%NaCl 1000 mL at situation appropriate rate.
Obtain baseline vitals.
Initiate cardiac monitoring and pulse oximetry
Assemble and check all necessary equipment (Suction, endotracheal tube with
functioning balloon, stylet, laryngoscope with functioning light source, endotracheal
tube placement confirmation device (bulb syringe, capnography, stethoscope…)
In patients suspected of having increased intracranial pressure, administer
Administer Versed (Midazolam) 5mg Slow IV push
Administer Etomidate 0.3mg/kg IV over one minute followed by 5-10cc flush/bolus
10.
11.
12.
13.
14.
15.
. Etomidate must be pushed SLOWLY to avoid bruxism.
If level of sedation is inadequate or patient develops bruxism or masseter muscle
spasm, administer repeat dose of Etomidate 0.3mg/kg IV over one minute followed
by 5-10cc flush/bolus.
Intubate patient promptly
Confirm tube placement:
a. No ventilatory sounds over stomach
b. Bilateral breath sounds and chest rise
c. Positive aspiration with bulb syringe
d. Presence of condensation in the ET tube with expiration
e. Continuous capnographic monitoring is MANDATORY
Secure ET
Continued/additional sedation with Versed (Midazolam) 0.05 mg/Kg or Valium
(Diazepam) 0.05 mg/Kg IV q 10-20 min as necessary to maintain appropriate level
of sedation.
MEDICAL CONTROL should be advised as soon as possible so they may prepare to
continue ventilatory support upon your arrival at the ER.
Tab 500
Medical Procedures/Equipment D (2)-2
E
VISUALIZED OROTRACHEAL INTUBATION WITH C-SPINE IMMOBILIZATION
A.
Procedures
1.
Safe scene, standard precautions.
2.
Need for c-spine control from scene/situation.
3.
Direct one EMT to provide manual in-line support from above patient’s head (c-spine
log roll if semi-prone).
4.
Perform global assessment - indicate need for ventilation.
5.
Perform visual scan of mouth performed with tongue-jaw lift.
6.
Insert oropharyngeal or nasopharyngeal airway.
7.
Provide ventilation with BVM.
8.
Connect reservoir and high flow oxygen to BVM.
9.
Complete rest of ABC’s.
10.
Auscultate left and right lung fields.
11.
Select proper size ET tube, test cuff with 10cc syringe. Leave syringe fixed to bulb.
12.
Select laryngoscope blade of choice, test laryngoscope and blade, test bulb for
tightness.
13.
Place pads under patient’s head, prn.
14.
Direct second EMT to take manual in-line support from forward presenting positionfacing patient on opposite side from EMT ventilating. EMT at head releases his/her
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
hold and moves away - BVM ventilation continues from side.
(While facing EMT providing manual immobilization). Sit on ground superior to
patient’s head, slide in with legs over patient’s arms until patient’s head is touching
medic’s pelvis.
Instruct EMT ventilating to hyperventilate and then clear airway removing
oropharyngeal airway.
Press patient’s head with thighs, using tongue jaw lift, insert laryngoscope blade in
manner suitable for blade. Without moving patient’s head, lean back and visualize
arytenoid cartilage and ½ of vocal cords.
Insert ET tube, proper depth.
Inflate cuff - remove syringe.
Place pediatric/adult Capnography FilterLine on the endotracheal tube then attach
BVM to FilterLine adapter and confirm tube placement.
Connect bag to ET tube and hyperventilate for two minutes while auscultating left
and right lung fields and over epigastrium without releasing hold on ET tube.
Confirm tube placement with Tube Check.
Secure tube in place if sounds are proper.
Monitor ventilation, periodically check breath sounds, and seek signs of
respiratory improvement. (Skin, mucosa, LOC)
Tab 500
Medical Procedures/Equipment E-1
F
KING SUPRAGLOTTIC AIRWAY
Indications:
A. An alternative to endotracheal intubation for airway management in patients greater than 4
feet tall to secure a patent airway and deliver ventilations.
1) Cardiac arrest from any cause.
2) Respiratory arrest with no gag reflex.
3) Unconscious patient with inadequate respiration and with no gag reflex.
4) Two unsuccessful attempts of endotracheal intubation.
Contraindications
A.
B.
C.
D.
Responsive patients with an intact gag reflex.
Patients with known esophageal disease.
Any patients that have ingested caustic substances.
Patients who are less than 4 feet tall.
Required Equipment
A. King airway (appropriate size)
B. Water soluble lubricant
C.
D.
E.
F.
60 ml syringe
Securing device
Gloves
Stethoscope
Procedure:
A. Scene safety and B.S.I.
B. Maintain ventilation with an oropharyngeal airway and bag-valve-mask
C. Determine and select appropriate airway for size of patient
1) Choose the correct tube size based on the patient’s height. (See Chart)
a. 4 to 5 feet tall = size 3
b. 5 to 6 feet tall = size 4
c. > than 6 feet tall = size 5
D. Prepare the non-visualized airway
1) Check inflatable cuffs for leaks
2) Prepare suction unit
3) Apply water soluble lubrication to the tip
4) Prepare suction unit
Tab 500
Medical Procedures/Equipment F-1
King Supraglottic Airway, continued
E. Apply chin lift and introduce the King airway in to the corner of the mouth.
F. Advance tip under the base of the tongue while rotating the tube back to midline.
G. Without excessive force, advance the tube until the base of the connector is aligned with the
patient’s teeth or gums.
H. Inflate cuff based on size.
1) Size 3 = 50ml
2) Size 4 = 70ml
3) Size 5 = 80ml
I. Attach the BVM. While gently bagging slowly withdraw the tube until ventilation is easy to
administer a large tidal volume with minimal airway pressure.
J. Adjust cuff inflation, if necessary, to obtain an airway seal at peak ventilation pressure.
K. Assess for proper tube placement.
1) Assess breath sounds
2) Assure chest rise and fall
3) Attach patient to continuous end tidal CO2 monitoring
4) Continue to reassess that tube is properly placed and that patient ventilation is easy and
free flowing with chest rise and adequate breath sounds
5) Secure airway
6) If at anytime the provider is unsure of proper placement – deflate cuff, remove and
use BVM for ventilation
Notes
A. The key to insertion is to get the distal tip of the King airway around the corner in the
posterior pharynx under the base of the tongue. A chin life along with the lateral approach
has been shown to help facilitate tube placement.
1) Alternatively, a laryngoscope or tongue depressor can be used to lift the tongue to the
anterior to allow easy advancement of the King tube into the proper position
2) Insertion can also be accomplished using a midline approach by applying a chin lift and
sliding the distal tip along the palate and into position in the hypopharynx. In this
instance, head extension may also be helpful
B. It is important to maintain the tube midline after it is advanced around the corner in the
posterior pharynx. Keeping the tip at the midline assures the distal tip is properly placed in
the hypopharynx/upper esophagus
C. Depth of insertion is the key to proper tube placement.
1) With deeper initial insertion only withdrawl is required to accomplish a patent airway. A
shallow inflation requires cuff deflation to advance the tube deeper.
2) As the tube is withdrawn the proximal opening will be the first align with the laryngeal
inlet. Since the proximal opening is closest to the proximal cuff there is less chance of
airway obstruction.
Tab 500
Medical Procedures/Equipment F-2
King Supraglottic Airway, continued
D.
E.
F.
G.
3) With drawl of the airway with the cuffs inflated results in retraction of tissues away from
the laryngeal opening encouraging a more patent airway.
During ventilation the epiglottis or other tissue can be drawn into the distal ventilatory
opening resulting in obstruction. Advancing the tube 1-2 cm or initiating deeper placement
normally eliminates the obstruction.
Ensure the cuff is not over inflated. Cuff pressure should be adjusted to 60 cmH2O or until
air does not leak around the cuff at peak inspiratory pressure.
Medications cannot be administered directly though this airway.
To remove the King airway:
1) Suction above the cuff in the oral cavity if indicated.
2) Fully deflate both cuffs before removal.
3) Remove the tube when the gag reflex has returned.
Tab 500
Medical Procedures/Equipment F-3
G
NEEDLE DECOMPRESSION
Needle decompression is rarely required in the pre-hospital setting. If indicated, however, it must
be recognized early and accomplished quickly. Tension pneumothorax is a life threatening
condition, which must be corrected early.
A.
Signs and Symptoms of Tension Pneumothorax
1.
Acute dyspnea (severe).
2.
Unilaterally absent or severely diminished breath sounds on the affected side.
3.
Subcutaneous emphysema.
4.
Signs and symptoms of shock without other apparent cause.
5.
Mediastinal shift with tracheal deviation (late sign).
6.
Distended neck veins. (JVD)
7.
Hyperresonant percussion (usually difficult in the pre-hospital setting).
B.
Required Equipment
1.
2.
3.
4.
5.
6.
7.
8.
9.
C
2 ¼”, 14g catheter (smaller catheter if pediatric)
3-5 ml syringe
Gloves
Providine iodine prep
IV set up
500ml IV bag saline
1" tape
4x4
Stethoscope
Procedure
1.
Safe scene, standard precautions.
2.
Administer oxygen 15 lpm by non-rebreather mask.
3.
Place patient in position of comfort, usually upright (only if c-spine has been ruled
out).
4.
Assess patient’s chest and respiratory excursions.
5.
Take vital signs (pulse oximeter).
6.
Bare the chest and observe chest wall movement, ventilatory efforts, accessory
muscles, agitation and anxiety.
Tab 500
Medical Procedures/Equipment G-1
Needle Decompression, continued
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
16.
18.
19.
Auscultate breath sounds in all fields.
Palpate the chest wall.
Check for symmetry of chest wall movement.
Check for JVD (jugular vein distension).
If assisted ventilation in progress, check for resistance when ventilating.
Check for tracheal deviation.
Identify (palpate) the second intercostal space, in the mid clavicular line on the side
of the pneumothorax.
Prep the site with Providine Iodine (do not palpate site after prepped).
Attach 14ga 2-1/4" catheter snugly to a syringe.
Place patient in an upright position if not already (only if c-spine injury has been ruled
out).
Insert needle into the skin and direct the needle over the third rib (vessels and nerves
are located on the inferior borders of the ribs).
Puncture the parietal pleura.
Aspirate as much air as necessary to relive the patient’s acute symptoms.
20.
21.
22.
23
Advance the catheter in place and apply a bandage or small dressing.
Drain 500ml IV bag to approximately 250ml and hook up to IV catheter. Clearly
mark bag as chest tube so it is not raised above the level of the puncture.
Reassess chest, respiratory excursion and vital signs.
1.
Observe chest wall movement ventilatory effort, accessory muscles, and
agitations/anxiety.
2.
Reassess blood pressure, Identify significance of BP changes.
3.
Auscultate breath sounds. Right and left at apices and mid-axillary line, one
hand width below axilla.
4.
Check for symmetry.
Ventilate with 100% oxygen assisting with ventilations if needed.
Tab 500
Medical Procedures/Equipment G-2
H
SURGICAL CRICOTHYROTOMY
CONSIDERATIONS:
The paramedic considering a cricothyrotomy must make a careful airway assessment
focused on:
(1)
Determining the patient's ability to maintain their own airway without further
interventions,
(2)
Need for non-surgical interventions such as obstructed airway procedures, manual
airway maneuvers, oral or nasal airways with positive pressure ventilation,
medication (Epinephrine, Benadryl) administration.
(3)
A need for surgical cricothyrotomy.
This decision will be affected by: extrication time, transport time, distance to transport hospital,
paramedic personal airway skills, and on-line Medical Control.
INDICATIONS:
Surgical Cricothyrotomy is a traumatic emergency procedure and should only be attempted when
total airway obstruction is present and other airway maneuvers have failed or are not feasible (i.e.,
facial trauma, foreign body obstruction, edema of the trachea or posterior oropharynx). The
urgency for this procedure may preclude contact with on-line Medical Control; however, on-line
Medical Control may be contacted for guidance when time permits and if no delay in ventilating
the patient will occur.
A.
Surgical Cricothyrotomy
1.
Safe scene, standard precautions, gloves (sterile if possible)
2.
Try to establish an airway using less invasive airway maneuvers.
3.
Patient must be in supine position with neck in a neutral position, c-spine control if
indicated.
4.
Palpate the thyroid notch, cricothyroid interval and sterna notch for orientation.
5.
Use aseptic technique as time and conditions will allow. In ideal situations, the site
should be prepped with Providine Iodine.
6.
Stabilize the thyroid cartilage with the left hand.
7.
Using a scalpel, make an incision over the lower half of the cricothyroid membrane,
approximately 1" to 1-1/2" in length. This should expose the cricothyroid membrane.
Tab 500
Medical Procedures/Equipment H-1
Surgical Cricothyrotomy, continued
8.
9.
10.
11.
12.
13.
Carefully incise through the membrane, up to 1 cm in length.
Using the scalpel handle of a second capped scalpel, insert it into the incision and
rotate it 90 degrees to open the incision into the airway or hemostats may be used to
widen the opening.
Insert a cuffed 6.0 endotracheal tube through the cricothyroid membrane incision.
Direct the tube distally into the trachea.
Inflate the cuff approximately 10ml and ventilate the patient, auscultating the chest
for adequate ventilations.
Secure the ET tube to prevent dislodging. Care should be taken not to cut or remove
the cricothyroid cartilage.
Attach to 100% oxygen by Auto Vent.
Complications of Surgical Cricothyrotomy are:
A.
B.
C.
D.
E.
F.
G.
Asphyxia
Aspiration
Creation of a false passage into tissues
Subglottic stenosis/edema
Laryngeal stenosis
Hemorrhage
Laceration of the esophagus
H.
I.
J.
Laceration of the trachea
Mediastinal emphysema
Vocal cord paralysis
Tab 500
Medical Procedures/Equipment H-2
Surgical Cricothyrotomy, continued
Pediatric Surgical Needle Cricothyrotomy
CONSIDERATIONS:
Under most circumstances an adequate airway is provided by repositioning of the head and jaw,
an oropharyngeal airway or endotracheal intubation. Occasionally a child with an upper airway
foreign body, severe oral/facial injuries, anaphylaxis or a laryngeal fracture will require this
procedure.
INDICATIONS:
THIS PROCEDURE IS TO BE USED ONLY IN A CHILD WHO HAS A TOTALLY
OBSTRUCTED AIRWAY AND ALL OTHER EFFORTS HAVE FAILED.
Equipment Needed:
1)
1-1/4" 14 ga. IV catheter w/flexible over the needle catheter
2)
Auto Vent or pediatric ambu bag
3)
20" IV extension set
4)
3ml syringe
5)
15mm adapter from 2.5 or 3.0 pediatric endotracheal tube
6)
Providine Iodine preps
7)
Alcohol preps
A. Pediatric Surgical Needle Cricothyrotomy
1.
Safe scene, standard precautions, gloves (sterile if possible).
2.
3.
4.
5.
6.
Try to establish an airway using less invasive airway maneuvers.
Patient must be in supine position with neck in a neutral position, c-spine control if
indicated.
Palpate the cricothyroid membrane anteriorly, between the thyroid cartilage and
cricoid cartilage. If time allows, prep the area with betadine swabs.
Use a 1-1/4" 14 gauge needle, 3ml syringe attached. Puncture the skin midline and
directly over the cricothyroid membrane.
Direct the needle at 45º angle distally. Insert the needle through the lower half of the
cricothyroid membrane. Aspiration of air confirms entry into the tracheal lumen.
Tab 500
Medical Procedures/Equipment H-3
Pediatric Surgical Needle Cricothyrotomy, continued
7.
8.
9.
10.
11.
Remove the syringe and withdraw the metal stylet while advancing the synthetic
catheter distally.
Attach the catheter hub to the IV extension tubing, attach the 15mm adapter to the
proximal end of the extension tubing and then to the pediatric ambu device. Ventilate.
Auscultate chest for adequate ventilation.
The catheter should be held by hand until the airway is turned over to the ER staff.
You should maintain a grip on the catheter at all times during transport to avoid
dislodging. Different methods of taping and immobilization of the catheter may be
necessary depending on circumstances but under no situations should the
paramedic relinquish their grip on the surgical airway catheter.
Make sure the systems attached to Auto Vent or 100% Oxygen using a pediatric
ambu bag.
Complications of the Surgical Cricothyrotomy are:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Incorrect placement missing the airway
Asphyxia
Aspiration
Creation of a false passage into the tissues
Subglottic stenosis or edema
Laryngeal stenosis or trauma
Hemorrhage
Laceration of esophagus
Laceration of the trachea
Mediastinal emphysema
11.
12.
Vocal cord trauma or paralysis
Delayed soft tissue infection
Tab 500
Medical Procedures/Equipment H-4
I
NEBULIZER
The oxygen powered hand held nebulizer is a method of administering Albuterol by aerosol. The
most ideal method of administration is by using the T-mouth piece that comes with the unit. If the
patient is too symptomatic to utilize the "T" device, an alternative method of administration is using
the aero mist oxygen mask. It should be noted that the aero mist oxygen mask is not an oxygen
delivery system. When the treatment is complete, the patient should be switched over to a
standard oxygen delivery system, i.e. nasal cannula. If intubation is required, the in-line aerosol set
should be utilized to administer the medication. (See Tab 500 J-1)
A.
Nebulizer
1.
Explain procedure to patient.
a.
Instruct patient to create a seal around the T-device.
b.
Instruct patient to inhale through their mouth and exhale through their nose as
much as possible.
2.
Open nebulizer and hook up oxygen supply tubing to the unit and the oxygen delivery
device.
3.
Pour the medication (single unit dose) into the chamber by either unscrewing the
top or by removing the "T" mouthpiece.
4.
Set liter flow at 8 liters.
5.
The procedure should last approximately ten (10) minutes. Upon nearing the end of
the treatment, the condensate will need to be moved down to the bottom of the bowl
so it can be drawn up the siphon tube. To do this, shake the chamber or strike the
chamber with your fingertip.
6.
Monitor patient pulse rate, EKG, oximeter, color and respiratory effort for
improvement or deterioration.
7.
Dosing of an aerosol treatment is a single unit dose, reassess treatment response
after completion of aerosol and administer a second unit dose if indicated. Any further
doses are only after contact with On-Line Medical Control.
Tab 500
Medical Procedures/Equipment I-1
J
IN-LINE AEROSOL SET
The in-line aerosol set is a method of delivering aerosolized medication to an intubated patient.
This is a single patient use device. The kit contains a valved tee, adapter and an accordion style
swivel elbow with an adapter at one end for the Auto Vent or BMV and an adapter at the other end
to attach to the endotracheal tube.
A. Procedure
1.
Remove both units from the package.
2.
Attach small end of tee to large end of swivel elbow.
3.
Add single unit dose of medication to cup of aerosol chamber and attach to tee
piece after removing cap.
4.
Attach smaller end of swivel end to endotracheal tube. (There is a removable cap at
this end for tracheal suctioning or for the introduction of medications directly into the
endotracheal tube.)
5.
Attach nebulizer cup to oxygen device and set at 8 liters per min.
6.
Ventilate the patient using the auto vent or BMV. If using the BMV, the Oxygen
reservoir tubing is not connected to an oxygen source.
7.
Continually reassess patient and lung sounds for improvement or deterioration.
8.
Dosing of an aerosol treatment is a single unit dose, reassess treatment response
after completion of aerosol and administer a second unit dose if indicated. Any further
doses are only after contact with On-Line Medical Control.
9.
Upon completion of treatment, Oxygen source should be connected to BVM if
utilized.
Tab 500
Medical Procedures/Equipment J-1
K
KED (Kendrick Extrication Device)
The KED is the device used to immobilize patients with suspected cervical spine injuries. This
device should be applied according to manufacture's recommended application. KED application
should be practiced often to become proficient in rapid application if indicated. It should be
considered to obtain pictures using the Photo Kit Protocol for mechanism of injury. (Tab 500 Q-1).
The KED requires a minimum of (3) three rescuers to apply.
A.
Application
1.
Safe scene, standard precautions.
2.
Direct personnel to take c-spine control.
3.
Evaluate c-spine control.
4.
Explain procedure to patient.
5.
Check P.M.S. (pulse, motor, sensory).
6.
Choose appropriate size collar.
7.
Apply collar (evaluate neck before application).
8.
Maintain c-spine control. Slightly lean patient forward and slip KED behind patient.
(Evaluate back while patient is forward).
9.
Maintain c-spine control, lean patient back.
10.
Pull leg straps down to patient's side.
11.
Wrap sides of board around patient and couple the bottom strap (leave loose).
12.
Couple the middle strap (leave loose).
13.
Adjust the board up under the armpits by using the adjusting handles.
14.
Maintaining neutral spinal alignment, gradually tighten the two lower straps.
Tab 500
Medical Procedures/Equipment K-1
KED, continued
15.
Couple and tighten the leg straps. This is done by passing the leg straps under the
patient's legs and coupling to the receiver on the opposite side of the KED. (If groin
injury suspected, the straps should be coupled to same side of the KED).
16.
If indicated, pad behind patient's head.
17.
Apply forehead strap.
18.
Apply chinstrap.
19.
Couple top torso strap and tighten.
20.
Check P.M.S. (pulse, motor, sensory).
21.
Move patient onto long board by sliding on long axis.
22.
Uncouple leg straps and lower legs.
23.
Recouple leg straps and leave loose.
24.
Secure patient to long board.
25.
Check P.M.S. (pulse, motor, sensory).
B. Points to Remember
1.
2.
3.
4.
KED should be checked before and after use.
KED should be cleaned after each use.
KED should be packaged ready to use. (i.e. accordion roll straps).
Remember to assess before you cover.
C. Specialized Uses.
1.
Pregnant patients:
The chest flaps may be folded forward inward, leaving the patient's
abdomen exposed. Use caution in placement and tightening of the straps.
Tab 500
Medical Procedures/Equipment K-2
KED, continued
2.
Pediatric Patients:
Adjustments may be made by placing blankets or towels on the patient's chest and
securing the KED.
3.
Fractured Hip:
Invert the KED allowing equal space above and below the hip. Use existing straps to
secure the KED to body and leg.
4.
Use with Cardiac Monitor:
Folding the chest flaps inward provides more chest exposure for use of EKG
electrodes or for chest compressions. Defibrillation may be performed by loosening
the two upper chest restraints.
Tab 500
Medical Procedures/Equipment K-3
L
TUBECHEK-B
Esophageal Intubation Detector
The TUBECHEK-B is a soft pliable disposable device used to assist verification of endotracheal
tube placement in the trachea. Its purpose is not to eliminate clinical judgment, however, it is
mandated by the Fulton County EMS Medical Director that it be used as an adjunct to assess
tracheal intubation. This device is to be used on all intubated patients in conjunction with
verifying breath sounds, with the following cautions.
1.
2.
3.
4.
5.
6.
Endotracheal tube obstruction, morbid obesity, pulmonary edema, main stem
bronchus intubation, severe bronchospastic or obstructive lung disease may lead to
equivocal results due to decreased air available for aspiration.
Pharyngeal intubations may yield erroneous results. Monitor tube depth. Also caution
should be used in scenarios where tube may kink, i.e. Nasotracheal intubations.
Inflating properties of bulb will be adversely affected in temperatures close to
freezing.
Contraindicated in patients less than 20kg (44 lbs).
Caution if aggressive ventilation has occurred prior to TUBECHEK placement. (i.e.
ventilation with a mask and airway adjunct). YOU MAY GET A FALSE POSITIVE.
Contraindicated in pregnancy.
A. Procedure
I.
ii
iii.
iv.
v.
vi.
Safe scene, standard precautions.
Assess the need for intubation and if applicable, intubate using proper technique.
Perform leak test; (Compress bulb, apply gloved thumb over adapter and release.
Discard if air leak is detected.)
Compress TubeChek, attach to endotracheal tube and release.
a.
If air returns and fills bulb rapidly, (less than 5 seconds), the tube is probably in
the trachea. Confirm clinically, ventilate and secure tube.
b.
If the air fills the bulb slowly (5 to 30 seconds), carefully assess tube
placement using direct laryngoscopic visualization, confirm clinically, ventilate
and secure the tube. It is mandatory that every time an intubated patient is
moved reconfirmation of tube placement occur.
c.
If the air does not fill the bulb or vomit returns, the endotracheal tube is likely in
the esophagus. Re-intubate patient or support ventilation by alternate means.
Assess lung sounds listening in four fields and the epigastrium.
Continue appropriate ventilatory support.
Tab 500
Medical Procedures/Equipment L-1
M
PULSE OXIMETER
The Pulse Oximeter is an instrument used to ascertain a patient's arterial oxyhemoglobin
saturation (% SpO²). This is done by measuring the absorption of red and infrared light passing
through the tissue.
A.
Advantages
1.
2.
3.
4.
5.
Early warning system (may alert EMS before cardiac monitors).
The Pulse Oximeter will enhance the EMS ability to identify, assess and treat
hypoxemia for any reason (i.e. drug overdose).
The Pulse Oximeter will assist in monitoring the effectiveness of other treatments (i.e.
bronchodilator therapy).
The Pulse Oximeter will assist in monitoring O² saturation during suctioning and
intubation.
The Pulse Oximeter will assist in the assessment of perfusion in patients with
orthopaedic injuries.
B. Ranges
1.
2.
3.
4.
C.
95% - 100%, ideal range
90% - 95%, mild to moderate hypoxemia. Check airway and increase O² support.
85% - 90%, severe hypoxemia. If the patient is symptomatic, aggressive, airway
intervention and hyperventilation is indicated. Remember to treat underlying causes
(i.e. pulmonary edema).
Below 85%, if the patient is symptomatic, intubate and ventilate.
Factors Affecting Reading
1.
2.
Excessive ambient light, especially sunlight.
Excessive motion.
Tab 500
Medical Procedures/Equipment M-1
Pulse Oximeter, continued
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
D.
Application
1.
2.
3.
4.
5.
E.
Nail polish - green, black or red
Moisture in sensor.
Improper sensor attachment.
Poor patient perfusion.
Venous pulsations.
Anemia or low hemoglobin.
Sensor not at heart level.
Pierced ears (when using ear lobe sensor).
Temperature
Low battery
Safe scene, standard precautions.
Explain procedure to patient.
Attach sensor.
Turn the unit to "on" by pressing #1. Unit will give a read out after (10) ten seconds or
(8) eight green flashes of the LED light.
Shut the unit off when the monitoring is complete by pressing #3.
Points to Remember
1.
2.
3.
4.
5.
6.
Treat your patient, not the monitor.
Clean unit after each use (especially sensors).
LED light flashes with each pulse beat. Green is good, yellow is marginal, red is
inadequate.
Do not use finger clip on thumb.
Use ear clip for peripheral shut down.
It may be helpful to use an alcohol prep on the index finger or ear lobe before
applying sensor.
Tab 500
Medical Procedures/Equipment M-2
N
BLOOD GLUCOSE METER
The Blood Glucose Meter is the device used for determining the patient's blood glucose level by
using colorimetric electrochemical technology and giving a plasma value in milligrams per deciliter.
Blood for testing may be either capillary or venous. Blood glucose readings will be significantly off
it the patient is dehydrated. It should also be noted that in cold temperatures (<40º), the unit may
malfunction. If the Blood Glucose Meter malfunctions for any reason, this should not hinder patient
care. If the patient is symptomatic and it is suspected to be from a low blood sugar, one (1) 50ml
ampule of 50% Dextrose should be administered IV. If alternative sample site (i.e., forearm) is
used, it should be noted that the blood sugar readings will be different than using the finger. Blood
sugar results from fingers are the most accurate due to physiologic differences in circulation
between fingers and other sites.
A.
Blood Glucose Testing
1.
2.
3.
4.
5.
6.
Safe scene, standard precautions.
Explain procedure to patient.
Prep area with providine iodine and let dry, if indicated.
Place test strip in meter. Obtain either capillary or venous sample, preferably capillary
and apply to one edge of test strip while in meter.
Glucose reading will take approximately 15 seconds.
Discard test strip and lancet appropriately.
Things to remember:
A.
B.
C.
D.
E.
F.
G.
H
I.
J.
Meter must be clean and dry.
Code on meter must match strips.
Strips must not be damaged.
Do not smear blood or apply second drop.
Operating temperature 41-104ºf.
Test meter every time new bottle of test strips are opened or the meter has been dropped.
Clean meter after each use with disinfection solution.
Control solution should be discarded 3 months after opening. Write date on bottle.
Testing time 5 seconds.
Result range 20 to 500 mg/dl.
Tab 500
Medical Procedures/Equipment N-1
O
TRACTION SPLINT
The traction splint is the equipment used to immobilize specific leg injuries. Guidelines set forth by
the manufacturer should be followed when applying this device. This equipment requires two
rescuers for application. Splint application should be practiced often to become proficient in rapid
application.
A.
Application
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Safe scene, standard precautions.
Explain procedure to patient.
Check P.M.S. (pulse, motor, sensory).
Place splint alongside of patient and adjust length and straps. Length should be from
belt line to several inches below heel.
One rescuer stabilizes the leg while another rescuer wraps the ankle hitch around the
ankle.
One rescuer continues to stabilize the leg while the other rescuer gently pulls
longitudinal traction supporting the heel with the other hand and maintains traction.
Check P.M.S. (pulse, motor, sensory).
The splint is now placed under the injured leg placing the rubber thigh pad against
the eschewal tuberosity.
Attach top groin strap and securely fasten.
Attach "S" hook of splint to ankle hitch.
Turn the traction knob applying mechanical traction until it equals the manual traction.
Manual traction may now be released and the heel stand adjusted.
Check PMS (pulse, motor, sensory).
Secure Velcro leg straps, two above the knee and two below.
Secure patient to long board.
Secure traction splint to long board.
Check P.M.S. (pulse, motor, sensory).
B. Points to Remember
1.
2.
3.
4.
5.
Splint should be checked before and after use.
Splint should be cleaned after use.
Check P.M.S. often
If the splint application is delayed, manual traction should be applied.
Do not release traction once applied, unless repositioning required due to loss of
circulation.
Tab 500
Medical Procedures/Equipment O-1
Traction Splint, continued
Basic Application of Sager Type Emergency Traction Splint
The traction splint is the equipment used to immobilize specific leg injuries. Guidelines set forth by
the manufacturer should be followed when applying this device. This equipment requires one
Rescuer for application.
A.
Application
1.
Safe scene, standard precautions.
2.
Explain procedure to patient.
3.
Check P.M.S. (pulse, motor, sensory).
4.
Position the splint - Place the splint between the patient’s legs and apply the thigh
strap snugly against the thigh of the injured limb, seating the cushion against the
patient’s perineum. Extend the inner shaft of the splint to place the pulley wheel or
cross bars adjacent to the patient’s heel. S-101/301 Sager Single - When positioning
the splint, face the pulley wheel on the same side and towards the injured limb.
5.
Set the splint - Apply the ankle harness firmly around the ankle above the medial and
lateral malleolus. Pull the control tabs on the ankle harness to shorten the ankle sling,
pulling it up against the sole of the foot. You are now ready to administer Quantifiable
Dynamic Traction. Extend the splint shaft to achieve the amount of traction desired,
while observing the amount registered on the traction scale. Check the thigh strap, re
-tighten to retain snug fit.
6.
Secure the splint - Slip the largest leg cravat under the hollow behind the knee and
seesaw it up to the upper thigh. Follow with the shortest cravat under the knee and
seesaw down under the lower leg. Place remaining cravat under the knee and then
secure all three cravats binding the leg and splint together. Wrap the figure 8 strap
snugly around the ankles and over the feet.
7.
Secure Velcro leg straps.
8.
Check PMS (pulse, motor, sensory).
Tab 500
Medical Procedures/Equipment 0-2
Traction Splint, continued
9.
Secure patient to long board.
B.
10.
Secure traction splint to long board.
11.
Check P.M.S. (Pulse, motor, sensory).
Points to Remember
1.
Splint should be checked before and after use.
2.
Splint should be cleaned after use.
3.
Check P.M.S. often
Tab 500
Medical Procedures/Equipment O-3
P
TRANSTHORACIC EXTERNAL CARDIAC PACING
The External Cardiac Pacer delivers an electrical stimulus to the heart, causing cardiac
depolarization and hopefully myocardial contraction.
A.
Advantages
1.
B.
Disadvantages
1.
2.
C.
Symptomatic Bradycardia
Witnessed Asystole
Symptomatic Type II Second Degree Heart Block
Symptomatic Third Degree Heart Block
Tab 800, F-1, F-2, F-3
Tab 800, C-1, C-2, C-3
Tab 800, G1-G3
Tab 800, G-3
Set Up
1.
2.
3.
E.
Temporary external pacing cannot be used as a permanent treatment for conduction
problems.
The pacer cannot be used in a wet or flammable environment.
Specific Indications
1.
2.
3.
4.
D.
Easy to perform and requires minimal training.
Cardiac monitor/pacer
Self adhesive combo patches
Advanced cardiac life support supplies
Patch Placement - Quick Combo Patch
1.
Anterior Lateral Placement - This is the preferred method since the combo patch can
be utilized for: monitoring (lead II), defibrillation, cardioversion and pacing in this
position.
a.
b.
Place the anterior electrode on the patient’s upper right torso, lateral to
the sternum and below the clavicle.
Place the lateral electrode (+) lateral to the patient’s left nipple in the
mid axillary line with the center of the electrode in the mid axillary line.
Tab 500
Medical Procedures/Equipment P-1
Pacing, continued
2.
Anterior Posterior Placement - This is not the preferred method since you are unable
to monitor lead II. It may, however, be used as an alternative if anterior/lateral
placement is not feasible.
a.
Place the anterior electrode (+) over the left pericardium. The upper edge of
b.
the electrode should be below the nipple. (Avoid placement over the nipple,
the diaphragm or the bony prominence of the sternum.)
Place the posterior (-) electrode behind the heart in the infra scapular area. Do
not place the electrode over the bony prominence of the spine or scapula.
Special Considerations:
1.
Pediatric considerations, using the quick combo patch, the placement of the pediatric
size patch remains the same as the adult. It should be noted that pediatric pacing is
not a pre-hospital procedure unless ordered by On-Line Medical Control.
However, the anterior/lateral patch placement allows for pre-hospital lead II
monitoring, defibrillation and cardioversion.
2.
Obese patients or patients with large breasts, apply patches to a flat area on the
chest, if possible. If skin folds prevent good adhesion, it could be necessary to spread
skin folds apart to create a flat surface.
3.
Thin patients follow the contour of the ribs and spaces when pressing the electrodes
onto the torso. This limits air spaces or gaps under the electrodes and promotes
good skin contact.
4.
Patients with implanted pacemakers place electrodes away from internal pacemaker.
5.
Patients with implanted defibrillators (AICD): apply electrodes in the anterior/lateral
position and treat the patient as any other patient requiring emergency care. If
defibrillation is unsuccessful, it may be necessary to try alternate electrode placement
due to the insulative properties of implanted defibrillator electrodes.
6.
If you need to remove a combo patch for any reason, do not re-use the same patch.
Apply a new patch.
7.
In the conscious patient that the level of consciousness has deteriorated to the point
that an analgesic is not required and IV access is unsuccessful, pacing should be
initiated and an IV attempted after improved cardiac output. This patient is not a
candidate for I.O.
Tab 500
Medical Procedures/Equipment P-2
Pacing, continued
8.
F.
Limb leads must be attached in order to pace as the combo-patch cannot monitor
lead II and pace at the same time.
Procedure
1.
2.
Safe scene, standard precautions.
Reassure patient/explain procedure.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
ABC (airway, breathing, circulation).
Oxygen as indicated.
Attach cardiac monitor (monitor lead II using standard limb leads).
Identify rhythm.
IV normal saline (reg. gtt. tubing)
Attach combo patches.
Pulse oximeter
Vitals
For conscious patients with a pulse, if indicated and patient weighs over 50kg. and
has a systolic BP >110 mm Hg administer Morphine Sulfate 3mg slow IV push, if
allergic to Morphine, administer Versed 5mg. If weight is less than 50kg. BP
<110mm Hg or a second analgesic dose is required, contact On-Line Medical
Control for choice and dose of sedation medication.
Attach cable to cardiac pacer.
Assure proper sensing of intrinsic QRS complexes. This is usually done by adjusting
the ECG gain or sensitivity control.
For patients with a pulse, set rate at 80 bpm. Set current at 20 milliamps and
increase 5 milliamp increments until capture. DO NOT mistake pacing electrical
interference for electrical capture for patients with a pulse. Interference can be
evidence by absence of a T-wave on the monitor and EKG recording. (Electrical
capture is noted by a wide QRS (negative or positive) and a tall broad T-wave in
the opposite polarity, mechanical or ventricular capture is evidence by signs of
improving cardiac output). Palpate for carotid or femoral pulse and check the color
and temperature of the skin. Check for improving blood pressure and level of
consciousness. Apply adhesive patches to clean dry skin in the anterior-lateral
position (see Q5). Place the anterior electrode (-) on the patient’s upper right torso,
lateral to the sternum and below the clavicle. The lateral electrode (+) is placed
lateral to the left nipple in the mid axillary line with the center of the electrode in the
mid-axillary line.
Tab 500
Medical Procedures/Equipment P-3
Pacing, continued
15.
16.
17.
18.
For “witnessed” asystole as defined in Tab 800, C-1: If you obtain electrical capture
with TCP, leave pacing on. If you have no capture, a pacing attempt for witnessed
asystole shall consist of 1 minute pacing with rate set at 80 and milliamps set at
highest level that can be tolerated by rescuer during CPR (usually 200 milliamps)
CPR will be maintained during this time. Then discontinue pacing to evaluate for a
rhythm change. (For patients with a pulse, skip 15 and start at 16)
Repeat Vitals.
Assess patient’s comfort level.
Acquire 12 lead.
19.
Anticipate further therapy as indicated.
Tab 500
Medical Procedures/Equipment P-4
Q
PHOTO KIT
Each Fulton County EMS squad is issued one (1) digital camera. The camera is to be utilized to
take photographs of vehicles showing mechanism of injury to patients. The hospitals have a cable
to attach to the camera to print or view pictures on a PC. Any other use of this camera is prohibited
without express consent of Fulton County Emergency Medical Services. (i.e. Internet, personal
usage).
Tab 500
Medical Procedures/Equipment Q-1
R
PATIENTS RESTRAINTS
Special Considerations:
A. At times, it is necessary to restrain individuals who are incompetent to refuse treatment or
transport. These patients may be combative, violent or otherwise out of control. The intent
of physical restraints is to protect the patient, emergency responders, and the public from
the potentially dangerous actions of the patient. Restraints are never to be used as a
punishment to the patient or as a convenience measure, but are to be used to assist in the
care of the patient. Keep in mind the approach to restrain must include provisions for the
safety of all involved. Because of the dynamic nature of incidents requiring restraints, it is
impossible to make this policy all-inclusive. The responder must use a common sense
approach. As a general principle, restraints must be used with the continuum of force
concepts. The level of restraint used must match the actual or potential level of threat that
the individual possesses. It should be noted that certain types of restraints have lethal
potential. Awareness of this potential and precautions to avert mortality must be ensured
during and after the application of restraints. Listed below are examples that due regard
must be exercised:
1.
2.
3.
4.
Determine whether or not restraints must be used.
How physical restraints will be employed
Monitoring after physical restraints are employed
Chest, neck, and prone restraints are potentially lethal and should not be used.
B. Generally, there is a reason that an individual is out of control and in need of physical
restraint. Consideration of the causes of the episode and attention to a possible need for
treatment is imperative. As soon as the patient is restrained, it is essential to address the
possible causes of the event. Some examples are listed below:
1. Acute rage / Acute agitated state
i. This type of patient may deteriorate into cardiac arrest after physical restraint.
This may be caused by the influence of drugs. (i.e. Cocaine, PCP). Early
recognition and intervention is imperative.
2. Psychosis
i. Acute
ii. Decompensated chronic
3. Medical Causes
i. Hypoxia
ii. Shock
Tab 500
Medical Procedures/Equipment R-1
Restraints cont.
C. When the use of restraints becomes necessary in the pre hospital setting, soft restraints
should be used by EMS. Examples of soft restraints are:
1.
2.
3.
4.
Kling
Commercial soft restraints
Cloth
Cravats
D. It may become necessary for the out of control patient to be place in hard restraints. Only
Law Enforcement may use hard restraints. Once hard restraints are used by Law
enforcement, an officer MUST accompany the transporting unit to the emergency room.
Examples of hard restraints:
1. Handcuffs
2.
3.
4.
5.
6.
Cable ties
Leg shackles
Wrist chains
Hobble restraints
Wrap device
Use of Restraints
A. Once it has become necessary to use restraints and a course of action has been decided
upon. The following steps should be followed:
1.
2.
3.
4.
5.
Offer the patient a final chance to cooperate
B.S.I. and Scene Safety
Approach patient swiftly from all sides at once
Only one person should communicate with the patient
Physically restrain as appropriate (use the minimum amount of force
necessary)
6. Maintain ABC’s
7. Follow appropriate protocol for patients condition
8. Contact On-Line MEDICAL CONTROL
Tab 500
Medical Procedures/Equipment R-2
S
CAPNOGRAPHY
The LifePak 12 has the capability to provide both graphic and quantitative measure of the CO²
content of exhaled air.
A.
Limitations
1.
2.
Cannot be used to assess when a tracheal tube has been placed in the right main
stem bronchus.
Cannot determine the location of a misplaced tracheal tube without further assessing
other physiological parameters.
B. Indications for CO² monitoring.
1.
2.
CO² monitoring is MANDATED for all advanced airways by the Medical Director
Patients with a chief complaint of shortness of breath or difficulty breathing.
C.
LifePak 12 set up
1.
Select the appropriate monitoring method
a.
b.
2.
FilterLine Set (adult/pediatric) for endotracheal tubes.
Smart Capnolines (intermediate/adult) for non-intubated patients.
Open the CO² tubing connector door and connect the selected CO² filter line tubing
by turning clockwise.
NOTE: Connect the tubing to the LifePak 12 first: then connect it to the patient.
3.
4.
5.
6.
7.
Press “ON”. Adjust contrast as necessary.
Verify that the Et CO² monitor display is on.
Connect the Microstream CO² FilterLine or Capnoline to the patient.
Display the CO² waveform in channel 2 or 3
Facts about the autoscale as follows:
a.
b.
c.
CO² monitoring is initiated as soon as the FilterLine or Capnoline is connected.
Auto zero function is automatic and is part of the initial self-test.
To clear the two following messages, remove the FilterLine and reconnect it to
the LifePak:
i.
ii.
“CO² FilterLine purging” or
“CO² FilterLine blockage”
Tab 500
Medical Procedures/Equipment S-1
Capnography continued,
8.
CO² alarms are preset
a.
b.
c.
Et CO² high alarm is set to 70 mmHg
Et CO² low alarm is set to 5 mmHg.
Apnea Alarm
On whenever EtCO² monitoring is in use and the device has detected a
valid breath.
ii.
The “Alarm Apnea” appears in the display along with the time since the
last detected breath when no valid breath has been detected for 30
seconds.
Waveform and numerical value should be present in their appropriate positions on
the LP12 screen
i.
9.
D.
Precautions
1.
Carefully route the patient tubing (FilterLine) to reduce the possibility of entanglement
2.
3.
4.
5.
6.
or strangulation.
The EtCO² monitor is intended only as an adjunct in patient assessment and is not to
be used as a diagnostic apnea monitor. An apnea message appears when if a valid
breath has not been detected for 30 seconds. It must be used with clinical signs and
symptoms.
Microstream accessories are single patient one-time usage.
Monitoring devices are able to be utilized on adult and pediatric patients.
Main stem intubation cannot be detected by the CO² monitoring system.
Capnography monitoring is not to be removed from the patient until that patient has
been moved for the last time by the paramedics.
Tab 500
Medical Procedures/Equipment S-2
Capnography cont.
E. Troubleshooting
F.
Endotracheal Tube Placement
1.
2.
This protocol does not relieve the EMS personnel from his/her duty to properly
assess and document the placement of an endotracheal tube.
The following MUST BE documented on the run form when an ET tube has been
placed.
a.
b.
c.
Procedural visualization of the vocal cords for oral endotracheal tube
confirmation.
Visual observation of the tube passing through the vocal cords for oral
endotracheal tubes.
Confirmation of bilateral, equal breath sounds where both lungs are present
and likely to be uninjured.
Tab 500
Medical Procedures/Equipment S-3
Capnography cont.
d.
e.
TubeCheck confirmation of placement.
Confirmation of a capnographic waveform and the capnometric value.
Tab 500
Medical Procedures/Equipment S-4
T
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)
Continuous Positive Airway Pressure has been shown to rapidly improve vital signs, gas
exchange, and the work of breathing, decrease the sense of dyspnea, and decrease the need for
endotracheal intubation in the patients who suffer from shortness of breath from asthma, COPD,
pulmonary edema, CHF, and pneumonia. In patients with CHF, CPAP improves hemodynamics
by reducing preload and afterload.
INDICATIONS:
Any patient who is in respiratory distress with signs and symptoms consistent with asthma,
COPD, pulmonary edema, CHF, or pneumonia and who is:
1. Awake and able to follow commands
2. Is over 12 years old and is able to fit the CPAP mask
3. Has the ability to maintain an open airway
4. And exhibits two or more of the following;
i. A respiratory rate greater than 25 breaths per minute
ii. SPO2 of less than 94% at any time
iii. Use of accessory muscles during inspiration
CONTRAINDICATIONS:
A. Patient is in respiratory arrest/apneic
B. Patient is suspected of having a pneumothorax or has suffered trauma to the chest
C. Patient has a tracheostomy
D. Patient is actively vomiting or has upper GI bleeding
PRECAUTIONS:
A. Use care if patient:
a. Has impaired mental status and is not able to cooperate with the procedure.
b. Had failed at past attempt at noninvasive ventilation.
c. Has active upper GI bleeding or history of recent gastric surgery
d. Complains of nausea or vomiting
e. Has inadequate respiratory effort
f. Has excessive secretions
g. Has facial deformity that prevents the use of CPAP
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Medical Procedures/Equipment T-1
CPAP (cont.)
PROCEDURE:
1.
2.
3.
4.
5.
6.
Make sure the patient does not have a PNEUMOTHORAX!
EXPLAIN THE PROCEDURE TO THE PATIENT.
Ensure adequate oxygen supply to ventilate device
Place the patient on continuous Pulse Oximetry
Place the delivery device over the mouth and nose
Secure the mask in place with the provided straps
7. Use 5 -10 cm H20 of PEEP (maximum setting)
a. Turning the dial clockwise increases PEEP
b. Likewise, counter clockwise decreases PEEP
8. Check for air leaks
9. Monitor and document patient’s respiratory response to the treatment
10. If necessary, consider the use of an in line aerosol (Albuterol) treatment.
11. Continue to coach the patient to keep mask in place and readjust if needed
12. If respiratory status deteriorates, remove device and consider bag valve mask
ventilation and/or an advanced airway.
REMOVAL PROCEDURE:
CPAP therapy needs to be continuous and should not be removed unless the patient cannot
tolerate the mask or experiences continued or worsening respiratory failure.
PEDIATRIC CONSIDERATIONS:
CPAP should not be used in children less than 12 years of age
SPECIAL NOTES:
1.
2.
3.
4.
Advise receiving hospital as soon as possible so they can be prepared for the patient
Do not remove CPAP until the hospital therapy is ready to be placed on patient
Watch patient for gastric distention
Reassessment of the patient’s status is critical and should be performed every 5-10
minutes.
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Medical Procedures/Equipment T-2
U
EZ-IO DRILL
INDICATIONS:
Adult and pediatric patients that need
1. Intravenous fluids or medications and a peripheral IV cannot be established in 2
attempts or 90 seconds AND in patients who exhibit 1 or more of the following:
i. An altered mental status (GCS < 8)
ii. Respiratory compromise (SaO2 80% after appropriate oxygen therapy,
respiratory rate <10 or >40 nub).
iii. Hemodynamic instability (Systolic <90).
CONTRAINDICATIONS
A. Fracture of the tibia or femur (consider alternate tibia)
B. Previous orthopedic procedures (IO within 24 hours, knee replacement)(consider
alternate tibia)
C. Pre-existing medical condition (tumor near site or peripheral vascular disease)
D. Infection at the insertion site (consider alternate site)
E. Inability to locate landmarks (significant edema)
F. Excessive tissue at insertion site.
EQUIPMENT
1.
2.
3.
4.
5.
6.
7.
8.
EZ-IO Driver
Appropriate sized EZ-IO needle
Alcohol or betadine swab
IV or extension set
10 mL Syringe
Tape or Gauze
Pressure Infuser Bag
2% Lidocaine (Xylocaine)
CONSIDERATIONS
Flow rates:
Due to the anatomy of the IO space, you will note flow rates to be slower than those
achieved with IV catheters.
- Ensure the administration of a 10 ml rapid bolus (flush) with a syringe.
- Use a pressure bag or pump for continuous infusion
Tab 500
Medical Procedure/Equipment U-1
EZ-IO (cont.)
Pain:
Insertion of the EZ-IO in conscious patients causes mild to moderate discomfort and is
usually no more painful than a large bore IV.
- You may consider using 2% Lidocaine Jelly topically at the insertion site.
PRECAUTIONS
The EZ-IO is not intended for prophylactic use.
PROCEDURE
1. Wear appropriate Body substance Isolation Equipment
2. Determine EZ-IO Indications
3. Rule out contraindications
4. Locate insertion site
5. Cleanse insertion site using aseptic technique
6. Consider application of topical anesthetic
7. Prepare the EZ-IO driver and needle set
8. Stabilize the leg and insert EZ-IO needle set
9. Remove EZ-IO driver from needle set while stabilizing catheter hub.
10. Remove stylet from needle set, secure stylet.
11. Confirm placement
12. Connect primed EZ-Connect
13. Flush or bolus the EZ-IO catheter rapidly with 10mL of normal saline using a 10mL
syringe
14. Place a pressure bag on the solution to be infused
15. Begin infusion
16. Dress site, secure tubing and apply wristband
17. Monitor EZ-IO site and patient conditions.
Tab 500
Medical Procedures/Equipment U-2
V
ResQpod
The ResQpod is an Impedance Threshold Device (ITD) that prevents unnecessary air from
entering the chest during the chest decompression phase of CPR creating a negative pressure
vacuum in the chest. This enhanced vacuum results in a greater venous blood return (preload) to
the heart resulting in improved cardiac output. Improved cardiac output leads to enhanced blood
flow to vital organs and increases the likelihood of spontaneous circulation in cardiac arrest.
Indications
The ResQpod should be used on all cardiac arrest patients 12 years of age or older and weighing
at least 80 pounds.
Contraindications
1.
2.
3.
4.
Pediatric under 12 years of age or less than 80 pounds.
Traumatic arrest with flail chest or uncontrolled hemorrhaging
Discontinue use of the ResQpod on return of a pulse.
Do not use on patients who are breathing or have a pulse.
Cautions
1. If the light malfunctions leave the ResQpod in place as the internal diaphragm
mechanism is independent of the lights. (Ventilate at 10 times a minute)
2. If the ResQpod fills with blood or fluids remove it from the Advanced Airway and shake
out fluids and reapply the device.
3. Since the ResQpod adds weight to the Advanced Airway it is recommended that the
Thomas ET Tube Holder is used when available and a CID be put on the patient.
Reconfirmation of Advanced Airway placement is still mandated each time the patient is
moved.
Operation
1. Use with a pocket mask, BVM and oral or nasal airway.
a. Attach ResQpod to mask.
b. Start CPR at a ratio of 30 Compressions to 2 Ventilations (do not use timing light)
c. A proper face to mask seal must be constantly maintained while using the
ResQpod
2. For an intubated patient
a. Attach ResQpod to Advanced Airway
b. Attach Capnography to POD
c. Turn timing lights on and ventilate with BVM
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Medical Procedures/Equipment V-1
W
Saline Locks
I. Overview The Saline Lock provides an alternative to conventional IV therapy using infusion of IV solution
through IV tubing for patients that require precautionary IV access.
The purpose of these procedures is to define the indications for use, insertion and maintenance
procedures.
The Saline Lock is a plastic male adapter with a needless hub at the end and a plastic tip that is
inserted directly into an IV catheter. The Saline Lock is primarily indicated for precautionary venous
access only, but may be used for infusion of IV solutions and medications administration.
The Saline Lock must be flushed with 10 cc’s of Normal Saline
for injection after initial
attachment. If used properly, the Saline Lock will not require additional flushing during the pre
hospital phase of care to maintain patency.
II. Indications:
A. Use of a Saline Lock is indicated when patient condition requires intravenous access on
a precautionary basis. (Example - hemodynamically stable patient presenting with CVA)
B. In some cases, a patient that initially only required precautionary IV access with a Saline
Lock may require an IV push medication administration. In this situation, a 10 ml saline
flush will be required following the medication administration. (Example – Medication
administration for Pain Management)
C. In some cases a patient may require an IV infusion after initiating a saline lock. In this
case leave the saline lock in place and attach the IV tubing to the saline lock.
.
III. Procedures:
A. Prepare equipment:
1. J-Loop must be flushed using a saline bolus. Pre-Filled 10 ML saline syringe
should be used.
2. IV Start Kit and angiocatheter.
Tab 500
Medical Procedures/Equipment W-1
Saline Locks, continued
B. After successful IV cannulation, the open end plastic tip of the Saline Lock (J-Loop) will
be inserted into the IV catheter hub using aseptic technique. The Saline Lock should be
placed securely into the IV catheter to prevent accidental removal and loss of blood.
C. Once inserted, draw back on the syringe plunger to observe venous blood return (verifies
patency), then slowly administer the remainder of Normal Saline syringe. Secure the JLoop using tape or other commercial device.
Tab 500
Medical Procedures/Equipment W-2
X
Intranasal (IN) Medication
Administration
Medication administration in a certain subgroup of patients can be a very difficult
endeavor. For example, an actively seizing or medically restrained patient may make
attempting to establish an IV almost impossible which can delay effective drug
administration. Moreover, the paramedic or other member of the response team may
be more likely to suffer a needle-stick injury while caring for these patients.
In order to improve pre hospital care and to reduce the risks of accidental needle-stick,
the Mucosal Atomizer Device (MAD) has been authorized for use in certain patients.
The MAD allows certain IV medications to be administered into the nose. The device
creates a medication mist which lands on the mucosal surfaces, and is absorbed directly
into the blood stream.
Not all medications may be administered via the intranasal (IN) route. Medications will
be limited to:
Versed (Midazolam)
Valium (water-based only)
Glucagon
Fentanyl
 Narcan (Naloxone)
Generally, medications administered via the IN route require a higher concentration of
drug in smaller volume of fluid than typically used with the IV route. Avoid giving more
than 1-2mL per nare. Split the dose between each nares.
Problems with nasal drug delivery:





Damage to the nasal mucosa: If the nasal mucosa is injured (by trauma) or destroyed
(by chronic cocaine use) then reduced mucosal surface area exists, and it is unlikely that
nasal drug will delivery will be effective.
IMPORTANT: If a patient fails to awaken following nasal naloxone, they may still
respond to intravenous naloxone. Therefore, if you suspect an opiate overdose and the
patient fails to awaken following an IN dose of naloxone, you should administer
naloxone as a shot.
Nasal trauma or septal abnormalities may inhibit mucosal absorption.
URI, secretions: Patients with active URI that have large amounts of mucous secretion,
as well as those who are suffering a bloody nose will not absorb the medications as well
because the medication will have difficulty contacting the nasal mucosa.
Perfusion: Severe hypotension, severe vasoconstriction, etc will reduce blood flow to the
nasal mucosa and may prevent adequate absorption.
Tab 500
Medical Procedures/Equipment X-1
Intranasal Administration, cont.
Certain conditions may make nasal administration of a medication
ineffective. Epistaxis, excessive mucous, nasal trauma, and septal abnormalities
may inhibit absorption. If these conditions are present, alternative routes may be
advisable.
A.
Procedure:
A. Load syringe with appropriate dose of medication (draw only the amount to be
administered).
B. Attach MAD nasal atomizer.
C. Place atomizer 1.5 cm into the nostril.
D. Briskly compress the syringe to administer ½ of the medication.
E. Remove and repeat into the other nostril until all of the medication has been
administered.
F. Monitor and document the patient’s response to the medication in the patient
care report (PCR).
Tab 500
Medical Procedures/Equipment X-1