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CMC System CE
EMS Equipment;
EKG Rhythms;
12 Lead EKG’s
Condell Medical Center
EMS System
July 2008
Site code #10-7200E1208
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module, the
EMS provider should be able to:


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maintain familiarity with equipment used in delivering
patient care
C-collar, KED, HARE, IO, Quicktrach, ETT, ETCO2,
and EDD
review a variety of EKG rhythms and treatment based on
Region X SOP’s
review and participate in discussion of case
presentations
successfully complete the quiz with a score of 80% or
better
Immobilization With Cervical Collars
Indication
 To be used when a spinal insult/injury has been
suspected based on mechanism of injury,
history, or signs and symptoms
Complaints of pain to the neck, numbness or tingling
of any of the extremities or parts of the extremities
no matter how small the area
Traumatic Injury above the level of the clavicles such
as soft tissue damage to the head, face, or neck
from trauma
Altered level of consciousness where injury or
complaint cannot be ruled out
Region X SOP
In-Field Spinal Clearance
A reliable patient without
signs/symptoms of
neck/spine injury and
negative mechanism of
injury does not require
full spinal immobilization
WHEN IN DOUBT,
FULLY
IMMOBILIZE THE
PATIENT
In-Field Spinal Clearance
Mechanism of injury







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
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High velocity MVC > 40mph
Unrestrained occupant in MVC
Passenger compartment intrusion > 12 inches
Ejection from vehicle
Rollover MVC
Motorcycle collision >20 mph
Death in same vehicle
Pedestrian struck by vehicle
Falls > 2 times patient height
Diving injury
In-Field Spinal Clearance
Signs and symptoms
 Pain in neck or spine
 Tenderness / deformity of neck or spine
upon palpation
 Paralysis or abnormal motor exam
 Paresthesia (tingling) in extremities
 Abnormal response to painful stimuli
In-Field Spinal Clearance
Patient reliability
 Signs of intoxication
 Abnormal mental status
 Communications difficulty
 Abnormal stress reaction
Includes persons upset at scene of
incident
IF YOU DO NOT HAVE THE
PROPER SIZED COLLAR,
IT IS BETER TO USE A
TOWEL ROLL AND TAPE
TO IMMOBILIZE THE
PATIENT
Before application of the cervical collar,
make sure the initial assessment has been
completed and life-threatening problems
have been addressed.
You may need to continue manual c-spine
control for the unruly, uncooperative
patient; document your additional efforts
Fit of the C-collar
The front height of the collar should fit
between the point of the chin and the
chest at the suprasternal notch (where the
clavicles and sternum meet)
The collar should rest on the clavicles and
support the lower jaw
The collar should not stretch the neck (too
high), not support the chin (too short), and
not constrict the neck (too tight)
Patient Positioning
Keep the patient’s head in the in-line
anatomical position during manual
stabilization and application of the collar
 A neutral position with the head facing
front, not tilted forward or back or turned
to either side
Measuring For The C-Collar
The provider to place their fingers
horizontal and measure from the top of the
patient’s shoulder (at the crease of the
neck) to a line visually drawn at the bottom
of the patient’s chin
Keep your fingers horizontal, not angling
downward with the patient’s neck
 The collar will be one size too short if
the fingers are slanted in measurement
Measuring for the C-Collar
Place your fingers along the plastic side of
the c-collar to the closest hole opening
Adjust the collar into place and snap the
locks into place
The collar is readjustable if the sizing is
not correct
Hint: directions are printed on the side of
the collar for quick reference
Measurement
markings
Neck opening
to grasp to
secure Velcro
strap
Applying the C-Collar
Preform the collar by rolling the collar
Position the chin into the collar bottom
The 2nd rescuer applying the collar should stand
at the side of the patient to wrap their fingers into
the neck opening and firmly grasp the Velcro
collar strap
Avoid any torque movement and secure the
strap into place with Velcro
Visually inspect the placement of the collar for
appropriateness of application
Secure the patient to the backboard before
stopping manual stabilization of the c-spine
A Perfect Fit
Consider the facts:
 In a room of 12-15 EMS providers, on
average, only 1 person would wear a
no-neck sized collar

If the majority of your patients are being
sized as a no-neck for the collar, then
you are not measuring them correctly
and you are not providing adequate care
for your patient
KED Device
Indications
 To allow immobilization of the patient
when moving them from a sitting
position to the long backboard and when
there is time to apply the device
Remember – it takes a lot of time to apply
the KED device
 Do you have the time to do it right or do
you need rapid extrication?
KED Device
KED Device
Manually secure the c-spine with the head in
the neutral, in-line position
Assess the patient’s distal pulse, motor
function, and sensation (PMS)
 To be assessed before and after
immobilization
Apply the appropriately sized cervical collar
and continue to maintain manual
immobilization
KED cont’d
Position device behind the patient
Secure the device to the patient’s torso
 The top of the device should fit snuggly
into the armpit
Pad behind the patient’s head as needed
and secure the patient’s head to the KED


One Velcro strap to secure the forehead
One strap under the chin and attached to the
KED – watch for pressure on the fleshy neck
KED cont’d
Evaluate and adjust all straps


Straps are to be tight enough to prevent
up/down or lateral movement but not so tight
to restrict breathing
Straps should not be pinching any flesh in the
groin
Secure patient’s wrists and ankles as
needed when moving the patient onto the
backboard
Reassess distal PMS in extremities before
and then again after moving patient
HARE Traction
Indications
 To immobilize an injured leg when there
is swelling, pain, and or deformity to the
mid-thigh suggesting fracture of the
femur in the absence of injury to the
lower leg or of joint injury
HARE Traction


With a fractured femur, the powerful
thigh muscles can go into spasm
causing extreme pain for the patient
The traction reduces the incidence of
thigh muscle spasms reducing the pain
level for the patient and preventing
further internal trauma from sharp,
ragged bone ends
Pain Management SOP
Orthopedic injuries can be very painful.
When indicated and the patient condition is
satisfied (ie: B/P remains > 100mmHg)
 Morphine 2 mg IVP slowly over 2 minutes
 May repeat 2 mg IVP every 2 minutes up
to a max of 10mg
Observe & document the patient’s response
to the intervention and monitor the blood
pressure and for respiratory depression
HARE Traction Application
Manually stabilize the injured leg
Assess PMS - distal pulses, motor function
(“can you wiggle your toes?”), and
sensation (“can you feel me touching your
toe? Which toe?”)
Apply and maintain manual traction
 Usual amount of traction is when the
patient reports relief of muscle spasms
HARE cont’d
Measure for the correct length of the splint
 Place the splint alongside the non-injured leg
 Make adjustments to the overall length
The ischial padded ring to fit from the ishial
tuberosity (from the bottom of the buttocks)
and extended past the foot with enough room
to apply traction with the ankle strap
 Set the device under the patient’s injured leg
 Apply the ischial strap (proximal strap)
 Apply the distal ankle hitch
 Apply mechanical traction and let go of manual
traction when the mechanical traction takes over
HARE cont’d
Position and secure the remaining straps

Avoid placing any straps over the injured area
and the knee
Reassess distal PMS
Secure the patient to the backboard
Verify that enough of the backboard
protrudes off the cot to be able to continue
to support the distal end of the HARE
traction
HARE Traction Secured In Place
FAQ’s - Intraosseous Needle
Does the IO replace the IV?

IO access is not a replacement for routine IV
therapy; IO is an appropriate option when IV
access is not possible and IV access is
necessary
Is there any limitation to fluids or
medications that can be infused via the IO?

Any fluid or medication that can be infused via
IVP may be infused via IO
FAQ’s - Intraosseous Needle
What are the advantages to IO access
over IV?


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IO vessels don’t collapse in shock
IO access is quicker than IV in shock or
trauma
IO requires minimal training and skill
IO access has a low complication rate (<1%)
Any medications that can be given IVP can be
given via IO
Blood work can be drawn from the IO needle
FAQ’s - Intraosseous Needle
How long does it take the hole in the bone to
heal after removal of the IO needle?
 Complete healing can take up to several
days. Sufficient healing where another IO
needle can be placed is usually considered 24
hours but at 24 hours there is still risk of
extravasation (leakage) of fluid from the 1st
site (FYI: Region X SOP requests no repeat
IO needle in the same site for 48 hours)
Is the bone weaker after being drilled?
 No; the catheter size is 15 G (adult and
pediatrics) and is considered a small hole in
comparison to the bony framework
FAQ’s - Intraosseous Needle
What flow rates can I expect via the IO
route?

The flow rates will vary patient to patient. Flow
rates to date have varied from 20 ml/hour (rarely)
to as high as 6000ml/hour. Flow rates depend on
anatomical site used, adequacy of initial flushing,
pressure used on infusion bag, and type of
medication or fluid being infused.
FAQ’s - Intraosseous Needle
What are the requirements for optimal flow
rates?



The IO space needs to be flushed under high
pressure with a syringe (connected to the primed
extension tubing). Thick marrow occupies medullary
space and can inhibit free flowing fluids.
You need to have a pressure bag at a minimum of
300 mmHg (or B/P cuff (hand pressure in the
absence of anything else but may not be enough
pressure alone)) on the infusion bag for continuous
flow.
Gravity alone will rarely generate adequate flow rates.
FAQ’s - Intraosseous Needle
Do I need to flush with saline after drugs
are given?

Yes, to make sure all of the medication has
entered the vascular space. There is
approximately 1 ml of dead space in the IO
site that needs to be flushed.
FAQ’s - Intraosseous Needle
When I push drugs via the IO, how fast
does it take for the drug to reach the
heart?

In cardiac arrest, drugs given via the tibial site
will reach the heart within 51 seconds. In a
normal circulating animal study, the drug
reached the heart in 4 seconds.
FAQ’s - Intraosseous Needle
Do I need to clean the site differently for
an IV versus an IO insertion?

No, the same skin preparation is sufficient for
both devices and the usual aseptic technique
is required for both.
FAQ’s - Intraosseous Needle
How much pain is there to place the IO
needle?


IO insertion is no more painful than a large
bore peripheral IV stick. Conscious patients
report significant pain after infusion of fluids or
medication have been started – this is from an
extensive network of nerve fibers in the
medullary cavity.
If the EMS patient is restless related to pain at
the site, contact Medical Control
FAQ’s - Intraosseous Needle
Can I use the adult IO needle in the
pediatric patient?


The adult EZ IO needle is to be used for all
patients weighing more than 39 kg (88
pounds per Region X SOP). At times there
may be a significant amount of tissue over the
site that the longer adult needle may be
required.
During insertion, when the tip of the needle is
just touching the outer surface of the bone,
you need to be able to observe the proximal
hash mark on the needle shaft. Then you will
know there is enough needle length to insert.
EZ IO Needle
FAQ’s - Intraosseous Needle
Can anyone insert an IO needle?

This device can only be used by the order of a
licensed physician. Our protocols allow for the
EMT-P to insert the device because they work
under the license of the medical director. Our
system requires the EMT-P to receive training
on the use of the device and to return
demonstrate insertion of the device before
being allowed to use the device in the field.
FAQ’s - Intraosseous Needle
What are my resources if I need further
information on the EZ IO device?


Contact your Medical Officer, a system EMS
coordinator, the company 24/7 at toll free
1-800-680-4911
The Vidacare company provides website
training (www.vidacare.com “Training and
Education”)
Quicktrach
Indications

To establish an airway when conventional
methods to ventilate the patient have failed
Contraindications



Tracheal transection (trachea cut in half)
Children less than 3 years of age (per
manufacturer)
When an alternative and less invasive
maneuver allows ventilation
Quicktrach
syringe
hub of
catheter
neck
strap
stopper
Quicktrach Packaging Box
Label the outside of your white packaging
box – they look the same for the 2 mm
size pediatric box and 4mm size adult box
The needles
look very
similar except
for length
Quicktrach Procedure
Adults >100 pounds use the 4.0 mm ID and
pediatrics <100 pounds use the 2.0 mm ID device
Place the patient supine with head slightly
extended if no cervical spine trauma is suspected
Locate the cricothyroid membrane
 Membrane is midline between the thyroid
cartilage (Adam’s apple) and cricoid cartilage
below the Adam’s apple
Cleanse the overlying skin
Quicktrach Procedure cont’d
Puncture the cricothyroid membrane at a 90
degree angle
Confirm entry of the needle in the trachea by
aspirating air thru the syringe
Change the angle of insertion to 60 degrees
Slide the catheter sheath forward to the level of
the stopper
Remove the stopper
 Note: the stopper is a very tight fit and may
need to be wiggled to be removed
Advance the plastic cannula as you
remove the needle and syringe
Insertion of
Quicktrach
Quicktrach Procedure cont’d
As soon as the needle and syringe are removed,
begin to ventilate the patient
Then secure the catheter in place using the
strap provided
 Helpful to secure one side of the strap in
place before beginning the procedure
 Once secured, the hub of the catheter should
be snug against the neck
Confirm placement
 Auscultation, bilateral chest rise and fall
Advanced Airway Devices
Endotracheal tube (ETT)
 Used when the airway needs to
be protected as in a patient with
an altered level of
consciousness (such as stroke,
overdose, trauma) or the patient
needs to be ventilated (such as
respiratory or cardiac arrest)
ETT in place
Sellick’s Maneuver – Cricoid
Pressure
Gentle pressure applied on the anterior cricoid
cartilage
 Closes the esophageal opening
 Helps prevent regurgitation and reduces
gastric distention
 Can help “drop” the larynx to facilitate
visualizing the vocal cord opening
Use the thumb and index finger and apply
pressure posteriorly (backward) to the anterior
and lateral aspects of cricoid cartilage
Sellick’s Maneuver – Cricoid
Pressure
Once pressure is
applied, pressure
cannot be
removed until an
ETT is placed
and the cuff is
inflated
Confirming Initial Placement ETT
Direct visualization
Watch the tube pass thru the vocal cords
5 point auscultation
Listen over the epigastric area
 You should not hear anything
Listen to the right and left chest wall
 Listen upper chest walls under the
clavicles
 Listen lateral chest walls midaxillary line
Observe for chest rise and fall
ETCO2 – yellow color after 6 breaths
EDD if used– no resistance to withdrawing air
ETCO2 Measurement
Measures for the presence of end tidal
(end of breath) CO2 exhaled from the
lungs
Helpful to assist in initial confirmation of
ETT placement
Helpful to assist in continual confirmation
of correct placement of ETT
Not a substitute for observation and
assessment of the patient
FENEM CO2 Indicator
Remove the indicator from the sealed
packaging inside the BVM bagging
The indicator should initially be indicating
a purple color
Place the indicator onto the exhalation port
of the BVM neck
Ventilate the patient with 6 breaths of
moderate tidal volume
The color indicator can change back and
forth allowing for >2 hours of reliability
Color Indicators For The ETCO2
Yellow – CO2 is being detected;
placement is good
Tan- minimal CO2 is being detected;
evaluate CPR technique, patient
perfusion, device placement
Purple – no CO2 is being detected;
evaluate placement by other means
and consider removal &
replacement of ETT
EDD
Esophageal detector device – EDD
 Helps determine if the ETT is in the
trachea or esophagus
Squeeze (collapse) the EDD and place on
the end of the ETT
 If the bulb refills easily, ETT is in the
trachea
 If bulb refills slowly or not at all, ETT is in
the esophagus
EDD
Using the EDD
Use is required only when the ETCO2
indicator is not conclusive
Drawback is that you have to stop
ventilating the patient to evaluate ETT
placement
Document whatever device was used
to confirm ETT placment
Ventilation Rates
Ventilation via BVM in non-intubated apneic patient
 One breath every 5 - 6 seconds (10 - 12 breaths
per minute)
 Supplement the patient’s own respirations if any
Ventilating during 1 and 2 man CPR via BVM prior
to intubation
 Two breaths after every 30 compressions
Patient who has been intubated
 One breath every 6 – 8 seconds (8 – 10 breaths
per minute)
 During CPR, ventilator bags once every 6-8
seconds during continuous CPR
Combitube
An advanced airway that is an alternative
to the use of an ETT
Inserted without visualization of the vocal
cords

The tube is most likely to enter the esophagus
2 balloon cuffs are inflated with air
If the tube is in the esophagus, ventilation
to the trachea is via side ports
If the tube is in the trachea, ventilation is
via an opening in the distal tip of the tube
Combitube
Approval of the Combitube
Use is department specific
 The EMS office will grant approval on a
department by department basis
 If your department wants to carry the
combitube, your department will do the
training
 See your department medical officer if
you have questions
Rhythm Analysis
Rate – Under 60? 60-100? Over 100?
Regularity – Regular or irregular R to R?
P waves – Present? Uniform? Followed by
a QRS?
PR interval – normal 0.12 – 0.20 seconds

>0.20 seconds the delay is at the AV node
QRS complex – normal <0.12 seconds

>0.12 seconds indicates a conduction delay in
the ventricles or an abnormal pathway is
being used in the ventricles
What are these rhythms?
Rhythm Interpretation
Rhythm A – complete heart block
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Regular R to R
Regular P to P
No consistent PR interval and no pattern to
the PR interval
Signs and symptoms dependent on overall
ventricular rate
Rhythm B – paced rhythm; 1:1 capture
Treatment for Symptomatic Type II
- Classical or 3rd Degree Heart
Block
Begin TCP

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Place anterior pad in apical area (over apex of
heart on left chest wall)
Place posterior pad in mid-upper back
between spine and scapula
For discomfort, Valium 2 mg IVP slowly over
2 minutes
May repeat Valium 2 mg slow IVP every 2
minutes to a max of 10 mg as needed for
chest wall discomfort
TCP
Rate: set at 80 per minute
Sensitivity: set on auto (demand mode)
 If rate picks up >80, the TCP will go into the
standby mode
Output: start at lowest setting and increase mA
until capture evident on EKG
Evaluate the patient’s hemodynamic state:
 Level of consciousness
 Radial pulse
 Blood pressure
 Skin parameters
What is this rhythm?
Rhythm Interpretation & Treatment
Sinus tachycardia

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Regular rhythm
Rate > 100 beats per minute (120)
PR interval 0.12 – 0.20 seconds (0.16)
QRS complex < 0.12 seconds (0.06)
Intervention

Determine the cause and address the cause
Anxiety, pain, fever, other forms of increased body
temperature (ie: heat disorders), shock,
dehydration, increased activity

Do not use drug therapy on sinus tachycardia
What is this rhythm?
Interpretation & Treatment
Atrial fibrillation with uniformed PVC’s


Underlying rhythm irregularly irregular
When heart rates are faster and sustained
over 100, the patient tends to develop more
symptoms & is less tolerant of the decreased
cardiac output
Tired and weak feeling
Skin cool and clammy
Dizziness when upright
Lowered blood pressure
PVC’s
Usually a sign of ventricular irritability
The patient may be aware of early or
skipped beats
May or may not produce a matching radial
pulse depending on cardiac output with
the beat
Often, oxygen diminishes the PVC activity
If the patient is symptomatic due to PVC’s
or the PVC’s are dangerous (multifocal,
frequent, R on T), contact Medical Control
for orders
Treatment Rapid Atrial Fib/Flutter
Stable with B/P >100 mmHg


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Verapamil 5 mg IVP slowly over 2 minutes
If no response in 15 minutes and B/P remains
> 100 mmHg, repeat Verapamil 5 mg IVP
slow
Watch for hypotension – treat with 200 ml fluid
challenge
Unstable B/P < 100 mmHg

Contact Medical Control for orders including
potential Verapamil order
Is There ST Elevation?
ST elevation in leads II, III, aVF
Is There ST Elevation?
ST elevation in V1 – V4
Is There ST Elevation?
ST elevation in V2 – V6
Is There ST Elevation?
Normal 12 Lead EKG - No ST
Case #1
You are on the scene of a 72 year-old male
in full arrest.
Your crew is encountering several problems
and you need to determine what to do.
#1 – the BVM does not perform a tight seal
and you cannot get adequate chest rise and
fall
#2 – you are unable to establish an IV
#3 – you can’t remember the drugs or
dosages for VF
Case #1 Discussion
Problem #1 – difficulty supporting ventilations via
BVM



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You may “secure” the airway in whatever manner
works at that time
If you are having difficulty using the bag-valve-mask
(BVM), then intubation becomes a high priority
Secure the airway via placement of an ETT
Confirm placement
Direct visualization
5 point auscultation
Bilateral rise & fall of the chest
ETCO2 detector (or EDD)
Case #1 Discussion
Problem #2 – no IV access




If there was failure of 2 peripheral attempts
and/or you are unable to find a peripheral site
in 90 seconds, insert the EZ IO
Any medication that was put through the
peripheral IV can be placed into the IO
Remember to place a pressure bag around
the IV bag to facilitate the flow rate
Place a florescent yellow wrist band on the
patient (preferably same side as the IO
insertion)
Case #1 Discussion
Problem #3 – Drugs and dosages for VF

Vasopressor – to support blood vessel tone
Epinephrine 1:10,000 1 mg IVP
Repeat every 3 – 5 minutes

Antidysrhythmic – to suppress ventricular
irritability, to increase the VF threshold
Choose one (mixing these can cause increased
cardiac irritability)
Amiodarone 300 mg rapid IVP/IO (diluted in 20 ml
syringe); repeat after 5 minutes at 150 mg IVP/IO
Lidocaine 1.5 mg/kg IVP/IO; repeat after 5 minutes
0.75 mg/kg IVP/IO; call medical control if further
doses (up to 3mg/kg) of Lidocaine are needed
Case #2
You are on the scene of a MVC
There is a family of 4 – mom, dad, 8 year old
and 1 year old
You have immobilized mom, dad, the 8 y/o
You do not have a cervical collar to fit the 1
y/o
#1 - What do you do?
#2 - How do you document immobilization?
#3 - How can you obtain vital signs on this
infant?
Case #2 Discussion
Problem #1 – no collar to fit the infant
Do not penalize the child for their size – if
the rest of the vehicle occupants needed
to be immobilized, so does this infant




Keep the child in their car seat if possible
Use towel rolls and tape
Use towels to pad along the infant’s sides and
into any gaps to improve immobilization
If the infant squirms too much, use manual
control also
Case #2 Discussion
Problem #2 – documentation of immobilization


Document any manual efforts
Document distal pulses, motor, and sensation
before and after immobilization (PMS)
On an infant this information may heavily rely on your
skills of observation


Document the use of rolled towels and where they
have been placed and taped
Document the use of the infant car seat
Case #2 Discussion
Problem #3 – obtaining difficult vital signs
Vital signs can often be a challenge
Think out of the box to obtain vital signs
Can’t get a blood pressure or don’t have ready
access to a B/P cuff?
 If you can feel a radial pulse the B/P is
minimally 80-90 systolic
 What is the patient’s level of consciousness?
The blood flow to the brain needs to be
adequate for a decent level of
consciousness
Case #2 Problem #3 cont’d
Can’t obtain a radial pulse?


On infants feel a brachial
On all persons you can get an apical pulse
Stethoscope held over the heart
 Can be difficult to accurately hear especially in
the very young
 Lub dub can blend and make it difficult to count
accurately
 Start practicing now to be able to hear the
difference and count accurately
Document the heart rate as “AP” to indicate
obtained via apical
Case #2 Problem #3 cont’d
On all persons whether they allow you to
physically assess them or not there are
certain assessments that can and should
be made and documented



Level of consciousness
Respiratory rate and effort– you can get from
across the room
Skin parameters – color & often moisture
References
Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care. Second
Edition. Brady. 2007.
Limmer, D., O’Keefe, M. Emergency Care
10th Edition. Brady. 2005.
Region X SOP March 2007. Amended
January 2008.
www.vidacare.com (EZ IO needle)