Table of Contents. Autopulse Resuscitation System...1. Autovent...3. Blood Alcohol Draw on Scene...5. Blood Draw using Vacutainer Tubes...

Transcription

1 Table of Contents Autopulse Resuscitation System...1 Autovent...3 Blood Alcohol Draw on Scene...5 Blood Draw using Vacutainer Tubes...6 Blood Glucose Test...8 Buretrol Usage...9 Cardiac Monitor...10 Cardioversion...14 Continuous Positive Airway Pressure Device...15 Cricothyrotomy Needle...18 Cricothyrotomy Surgical...20 Defibrillation...22 Defibrillation Pediatric...23 End Tidal CO2 Monitoring and Capnography...24 Intraosseous Infusion - Femoral...26 Intraosseous Infusion - Humeral Head...28 Intubation Endotracheal...32 Intubation Nasotracheal...34 IVAC Medsystem III MultiChannel Infusion Pump...36 King Tube...40 Medication Administration Intramuscular...43 Medication Administration Nasal Atomizer...45 Medication Administration Nebulizer...46 Medication Administration Subcutaneous...47 Nasogastric or Orogastric Tube...48 Oxygen Administration...49 Peripheral IV Administration...50 i

2 Table of Contents Pleural Decompression...52 Removal of Taser Probes...53 Reconstitution of Medications...54 ResQPOD Impedance Threshold Device...55 I-gel Supraglottic Airway...57 Transcutaneous Pacing Procedure...60 ResQGuard Impedance Threshold Device...61 Emergency Escharotomy...63 Venous Lactate Monitoring Procedure...65 Central Venous Access Devices...67 Medication Administration Cross Check...69 Combat Application Tourniquet...71 ITClamp Hemorrhage Control System...73 ii

3 Autopulse Resuscitation System Procedure Guidelines 9.00 AUTOPULSE RESUSCITATION SYSTEM INDICATIONS: The AutoPulse Resuscitation System Model 100 is used by trained personnel as an adjunct to manual CPR on adult patients in cases of clinical death, as defined by a lack of spontaneous breathing and pulse. CONTRAINDICATIONS: Obese Patient weighs >300 lbs. Pediatrics RELATIVE CONTRAINDICATION: Traumatic cardiac arrest patients (wounds resulting from sudden physical injury or violence) SYSTEM COMPONENTS: AutoPulse platform LifeBand AutoPulse Battery AutoPulse Battery Charger PROCEDURE: Initiate manual chest compressions at 30:2 or, 100/min for two minutes when an advanced airway has been inserted. Ventilate the patient per the current AHA CPR guidelines During the first two minutes of manual chest compression: Apply defibrillation pads to the patient?s bare chest Prepare the AutoPulse for use: Power up the device using the ON/OFF button located on the top edge of the device Make sure that no user advisory, fault, or system error messages display Open the Velcro LifeBand Chest Compression Assembly (CCA) After the initial 200 manual compressions (2 minutes) sit patient up by pulling the patient?s arms forward (use proper method when c-spine injury suspected) Make a single cut down the back of the patient?s clothing to remove Slide the AutoPulse device behind the patient and lower the patient down onto the device centering the supine patient laterally with the patient?s armpits just above 1

4 the YELLOW line Close the LifeBand chest band around the patient?s chest Place the patient with the yellow alignment tab on top of patient?s chest Locate mating slot of other band and place on top of band already on chest. Press the bands together to engage and secure the Velcro fastener. Make sure the bands are not twisted. If bands cannot be closed, use manual chest compressions Press and release the Start/Continue button once. The AutoPulse automatically adjusts the bands to the patient?s chest and determines the appropriate compression. Do not touch the patient or the LifeBand CCA while the AutoPulse is analyzing the patient?s size. Verify the patient is properly aligned and that the LifeBand CCA has taken up any slack in the bands. Press the Start/Continue button a second time to start compression cycles and the AutoPulse will begin chest compression cycles. Set the mode to either the pre-set compression-to-ventilations or continuous compressions option. Continue to monitor the placement of the patient on the AutoPulse after moving the patient or transporting to ensure proper alignment. Using Zoll approved restraints to secure the patient to the platform is recommended. NOTE: Do not stop the device for more than 10 seconds after at least 2 minutes of compressions per the 2005 American Heart Association?s (AHA) CPR guidelines. Intravenous cannulation, endotracheal intubation, or any other procedure should either be attempted during chest compressions or during the 10 second pause. Approved alternatives to those procedures, such as intraosseous infusion and a BLS airway (example: King Tube) should be considered. Cardiac defibrillation should be attempted during a 10 second pause. 2

5 Procedure Guidelines 9.01 AUTOVENT Autovent INDICATIONS: To provide ventilatory support in the intubated adult patient during interfacility transfers. To assist ventilations in the intubated medical patient. CONTRAINDICATIONS: Trauma patients. Pediatric patients (under 8 years of age and 70 lbs. Or less). EQUIPMENT: Oxygen supply with greater than 500 psi. Stethoscope. Bag Valve Mask for ventilatory backup. Suction on stand-by. PROCEDURE: Connect the oxygen high-pressure line to the quick-connect Oxygen adapter. Connect (Hand tighten) the other end to the gas inlet of the control module. Connect (Hand tighten) the Patient Valve Supply tubing to the Patient Valve outlets of the control module. After initial control module settings have been made, connect the patient Valve Assembly directly to the endotracheal tube adapter. During interfacility transfers, maintain the BPM and Tidal Volume settings per physician orders. MONITOR: Assess the following parameters immediately after connecting the patient to the ventilator: 3

6 Breaths Per Minute (BPM), adjust the BPM control knob to maintain an adequate ventilator rate. Average adult settings are greater than or equal to 12 BPM. Tidal Volume, adjust for adequate bilateral chest rise and fall to maintain an adequate ventilatory depth. Average adult settings are between 400 to 1,000 ml. Auscultate for the presence of bilateral breath sounds and the absence of abdominal sounds. Reassess and document breath sounds every 10 minutes or when change in the patient?s chief complaint, level of consciousness, airway, breathing, circulation, and vital signs to ensure that endotracheal tube is still in proper position. 4

7 Procedure Guidelines Blood Alcohol Draw on Scene 9.02 BLOOD ALCOHOL DRAW ON SCENE PATIENT (person that will be treated and transported) Initial Medical Care. Obtain Blood draw kit from Law Enforcement. Solicit aid from Law Enforcement to ensure proper chain of custody. Treat the patient per the appropriate PRACTICE PARAMETER. Determine if you can safely (without jeopardizing patient care) draw the blood and convey to officer requesting draw. Draw blood as per BLOOD DRAW USING VACUTAINER PROTOCOL Record date on kit, officer?s name, and how you drew blood in your report. Complete a FDLE / ICP Form II and send with paperwork (Place CAD # in upper right corner). REFUSAL OF MEDICAL CARE (person that will be treated and released) Assess the patients mental ability to refuse If mentally incompetent, enlist law enforcement to aid transport. If mentally competent, completely advise patient of possible complications (with witness present) and advise patient they will have to sign refusal. Draw blood as per procedure (see next page) Record date on kit, officer?s name, and how you drew blood in your report. Have patient sign refusal, have same officer witness refusal. Complete a FDLE / ICP Form II and send with paperwork (place CAD # in upper right corner). Note: A patient history and assessment that includes vital signs and blood glucose level should be obtained, if possible, on all patients that are being drawn for blood alcohol levels. 5

8 Blood Draw using Vacutainer Tubes Procedure Guidelines 9.03 BLOOD DRAW USING VACUTAINER TUBE PROCEDURE: Open needle cartridge. Twist to break the tamper-evident seal. Remove cap, exposing the back portion of the needle and threaded hub. Do not remove front needle cover. Assemble needle to holder. Thread needle into holder until firmly seated. Insert VACUTAINER tube into holder. Push straight onto needle, no further than the guideline on the holder. Apply tourniquet, prepare venipuncture site using only the non-alcoholic antiseptic pad provided in this kit. Position the arm in a downward or lowered altitude. Remove needle cover, perform venipuncture in the usual manner, keeping the tube in an upward position with the stopper upper-most. Push VACUTAINER tube forward to end of holder, piercing the rubber stopper. When blood flows into tube, REMOVE TOURNIQUET AS SOON AS BLOOD BEGINS TO FILL TUBE. DURING THIS PROCEDURE, DO NOT ALLOW CONTENTS OF VACUTAINER TUBE TO CONTACT STOPPER. SPECIAL ATTENTION SHOULD BE GIVEN TO ARM POSITION, TUBE POSITION IN ORDER TO PREVENT POSSIBLE BACKFLOW FROM THE TUBE AND ITS ATTENDANT POSSIBILITY OF ADVERSE REACTION TO THE PATIENT. 6

9 When the tube fill is complete and blood ceases to flow, remove the tube from the holder. Insert the second VACUTAINER tube straight into the holder until blood flows When sampling is completed immediately remove the needle/holder assembly with the last VACUTAINER tube, then remove the tube from the assembly: Apply and hold a dry sterile compress to the venipuncture site. Elevate the arm. To assure proper mixing with anticoagulant powder, Slowly invert the tubes at least five times immediately after blood collection. DO NOT SHAKE VIGOROUSLY! Vacutainer (and/or Microtainer ) is a registered trademark of Becton, Dickinson and Company 7

10 Procedure Guidelines 9.04 BLOOD GLUCOSE TEST Blood Glucose Test INDICATIONS: Altered sensorium or suspected blood sugar abnormality based on history. EQUIPMENT: Blood Glucose Meter. Test Strip and Code Strip. Lancing Device / Lancet OR Syringe for blood draw. PROCEDURE: Prepare the Lancing Device for a finger stick OR draw blood with syringe through IV catheter. Place the test strip on to the receptacle in the meter. Allow the meter to perform a selftest. Stick the fingertip with the lancet device and press the finger to form a small drop of blood, or obtain blood via syringe. Blood will be drawn into the Test Strip. The timer will begin counting down from 5 to 15 seconds depending on the meter. After the necessary time, the blood glucose result will appear in the Display Window. (If "Lo" appears in the display, the glucose value may be below 40 mg / dl. If "Hi" appears, your result may be above 500 mg / dl.) Dispose of used Test Strip and Lancet in sharps container. Refer to Practice Parameters for treatment guidelines based on test results. 8

11 Procedure Guidelines 9.05 BURETROL USAGE Buretrol Usage SET-UP: A Buretrol may be used in lieu of the "Select-a-flow" administration device. It is not intended for use on trauma or fluid replacement/challenge. The Buretrol is to be considered as a fluid volume limiter. Attach the Buretrol to an IV bag. Slide the lower flow rate adjuster to just under the drip chamber and roll to the zero flow position. (closed) Open the top rate adjuster, the one closest to the IV bag and fill the Buretrol chamber with the desired amount of fluid. After the desired amount of fluid is in the chamber, close the rate adjuster closest to the IV bag and hang on IV pole upside down. (This will prevent any accidental addition of fluid to the chamber.) Squeeze and fill half the drip chamber below the Buretrol chamber, then fill IV tubing. Use by adjusting the rate with lower adjustment wheel. SUGGESTED USES: Fluid administration to pediatrics, (over hydration of pediatrics is a real concern.) Administration of Magnesium Sulfate, i.e. eclampsia 5grams over 30 min. Take 10ml of Magnesium Sulfate, place in 20cc's of fluid in Buretrol chamber, the total fluid in chamber is 30cc's this includes the drug. Run at a drop a second and in thirty minutes you will have delivered your drug. Acute Asthma 2 grams over minutes. Place 4ml of Magnesium Sulfate and place in 8-11 cc's of saline and run at a drop a second. This will give the desired dose over the prescribed time frame. Allergic Reaction Tagamet/Cimetidine: Place 2ml of Tagamet in 8cc's of saline and run at a drop a second. This will give the desired dose of 300mg over 10 minutes It should be noted that this device is a great tool for CHF. It is a pure volume limiter, too much fluid can place these patients in failure. Remember: in a mini drip chamber gtt/min.= ml/hr. (60gtt/min=60ml/hr) in a Buretrol, a drop a second =1ml/hr. Therefore this makes the doses stated herein correct provided time and fluid are the same number. The benefit to this method is that once the drug is finished you have a normal saline drip which is limited by the amount of fluid in the chamber. 9

12 Procedure Guidelines 9.06 CARDIAC MONITOR FAST PATCH METHOD INDICATIONS: Cardiac Monitor Determination and monitoring of cardiac rhythms with anticipation of defibrillation. PROCEDURE: Remove clothing from patient's chest. Apply Fast Patch pads: Apply PAD and STERNUM wire to upper sternum slightly toward right shoulder. Apply PAD and APEX wire to the anterior (mid-axillary) line below the nipple. Ensure the paddles are in FAST PATCH adapter with the paddles in the proper side. Ensure the monitor is in the PADDLES mode in the lead selection. THREE LEAD METHOD INDICATIONS: Determination and monitoring of cardiac rhythms. PROCEDURE: Remove clothing from area electrodes will be placed. Apply wires to electrodes. Place on patient as illustrated for selection lead. 10

13 INDICATIONS: Any patient greater than 35 years of age with any of the following signs or symptoms: Chest pain Dyspnea Palpitations Weakness Diaphoresis Pre-syncope, syncope Nausea, vomiting Stroke Dysrythmias Post-resuscitation Pre and post-cardioversion During PEA to help identify the cause For Confirmation of Asystole Upper torso pain (above the umbilicus), ex. extremities Trauma to the Upper Torso Suspected Electrolyte Disturbances (e.g. DKA, dehydration, renal failure/dialysis, toxic ingestions, etc...) PROCEDURE: Insert the limb lead and the precordial lead attachment into the main cable as shown below: 11

14 Limb Lead Electrode Sites When acquiring a 12-Lead ECG, the limb lead electrodes are typically placed on the wrists and the ankles as illustrated below. In fact the limb lead electrodes can be placed anywhere along the limbs. However, do not place the leads on the torso when acquiring a 12-Lead ECG or you will record a non-standard report. AHA Labels IEC Labels RA Right Arm R Right LA Left Arm L Left RL Right Leg N Negative LL Left Leg F Foot Precordial Lead Electrode Sites The six precordial (chest) leads are placed on specific locations on the chest. Proper placement is important for accurate diagnosis and should be identified as shown below: 12

15 Lead Location V1 Fourth intercostal space to the right of the sternum V2 Fourth intercostal space to the left of the sternum V3 Directly between leads V2 and V4 V4 Fifth intercostal space at midclavicular line V5 Level with V4 at left anterior axillary line V6 Level with V5 at left midaxillary line. (Midpoint of armpit) Locating the V1 position (fourth intercostal space) is critically important because it is the reference point for locating the placement of the remaining V leads. To locate the V1 position: Place your finger at the notch in the top of the sternum. Move your finger slowly downward about 1.5 inches until you feel a slight horizontal ridge or elevation. This is the?angle of Louis? where the manubrium joins the body of the sternum. Locate the second intercostal space on the right side, lateral to and just below the angle of Louis. Move your finger down two more intercostal spaces to the fourth intercostal space, which is the V1 position. Other important considerations: When placing electrodes on female patients, always place leads V3 - V6 under the breast rather than on the breast. Never use the nipples as reference points for locating the electrodes for men or women patients because nipple locations may vary widely. The monitor acquires 10 seconds of ECG data for each 12-Lead ECG requested. If the monitor detects signal noise while acquiring data (such as patient movement or disconnected electrode), the monitor displays the message WAITING FOR GOOD DATA. 13

16 Cardioversion Section 9 Procedure Guidelines 9.07 CARDIOVERSION INDICATIONS: Supraventricular Tachycardia Practice Parameter 4.07 Ventricular Tachycardia With A Palpable Pulse Practice Parameter 4.09 Wide Complex Tachycardia - Uncertain Origin Practice Parameter 4.10 If the patient presents with one or more unstable criteria, (significant discomfort of suspected cardiac origin, severe dyspnea, altered mental status, or hypotension with signs of decreased tissue perfusion), DEFIBRILLATION may be administered at the same joule setting listed in the Practice Parameters to avoid delays associated with synchronization. Symptomatic Atrial Fibrillation / Atrial Flutter with RVR. Check the equipment - Turn on the monitor / defibrillator. Apply monitor per Procedure Guideline. Verify function of synchronizer button. QRS complex must be upright on monitor - inverted or low amplitude complexes may not trigger synchronizing circuit. Turn up machine gain until a small dot appears on the QRS complex. This indicates that the synchronizer circuit has been activated. Confirm the rhythm. CARDIOVERSION PROCEDURE: Confirm the rhythm. Select synchronization and look for flagging of the QRS. Check paddle or fast patch pads position and conduction. Select appropriate energy level per Standing Order. Check to ensure all people, including yourself; are clear of the patient. Ensure EMS personnel are in a safe operating location. Apply pounds of pressure to paddles, (If applicable). Discharge energy by pressing discharge buttons simultaneously and hold until energy is delivered. Machine will not deliver energy until the proper time. Observe for rhythm change and check the patient for a pulse, (If applicable). Repeat per Practice Parameters. 14

17 Continuous Positive Airway Pressure Device Procedure Guidelines 9.08 CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE Continuous Positive Airway Pressure (CPAP) has been shown to rapidly improve vital signs, gas exchange, the work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in the patients who suffer from COPD, pulmonary edema, CHF, and pneumonia. In patients with CHF, CPAP improves hemodynamics by reducing preload and afterload. CPAP maintains positive airway pressure above atmospheric pressure throughout inspiration and exhalation in order to increase the transpulmonary pressure gradient allowing gas to passively flow down into the smaller airways and alveoli, as well as preventing the bronchioles from collapsing. NOTE: IN ORDER FOR CPAP TO BE USED, THE PATIENT MUST BE BREATHING. INDICATIONS: Hypoxemia secondary to Congestive Heart Failure and Acute Cardiogenic Pulmonary Edema PRACTICE PARAMETER 4.11 For relief of Hypoxemia and Shortness of Breath (SOB)/Dyspnea secondary to Pneumonia, Acute Asthma / COPD with wheezing? PRACTICE PARAMETER 3.01 Carbon Monoxide Poisoning ( 5 cmh2o)? PRACTICE PARAMETER 3.02 Near-drowning (10 cmh2o)? PRACTICE PARAMETER 6.08 CONTRAINDICATIONS: Penetrating chest trauma Severe hypotension Persistent nausea and or vomiting Unconscious or obtundation Respiratory / Cardiac arrest Patient unable to protect their own airway Agonal respirations SIGNS AND SYMPTOMS: Dyspnea and tachypnea. Chest Pain, hypertension, tachycardia. Anxiety, restlessness, altered L.O.C. Rales, wheezes, frothy sputum (severe cases) 15

18 ASSEMBLE THE EQUIPMENT Do not bypass, delay or withhold conventional treatment while assembling or using the CPAP device. Connect the locking bayonet outlet adapter with the clear prongs perpendicular to the black prongs on the face of the CPAP machine. Push the circuit down to the rim of the black ports. Turn the circuit clockwise to lock it in place. Connect the oxygen tube to the 50psi inlet on the CPAP machine.(be sure the control knob is still in the OFF position) Connect the other end of the oxygen tube to oxygen cylinder(minimum of 1000psi) PROCEDURE: Assess Vital Signs Attach heart monitor and pulse oximeter Assemble the equipment as per Figure 1 Patient requires?verbal sedation? to be used effectively. Setting the desired CPAP level Open the cylinder. DO NOT turn on the FLOW. (Start CPAPos at ambient pressure?0? cmh2o) To set the flow occlude the inlet and turn the black knob clockwise (at least one complete revolution) until the desired CPAP level is achieved. Instruct patient to hold mask, breath in through their nose slowly and exhale through their mouth as long as possible (count slowly and aloud to four then instruct to inhale slowly). CAUTION: In some cases patient will have to be persuaded to place mask on to face. Offer reassurance. Example: Patient:?I can?t get air in!? Paramedic:?This will help you get air in.??this will help you breath easier as the pressure on the machine is increased?. Explain to the patient that you will begin to slowly increase the pressure and to continue exhaling out against the pressure as long as possible before inhaling. Slowly titrate the pressure to the appropriate level: CHF/APE/NEAR DROWNING -10cmH2O COPD/CO POISONING - 5 cmh2o Once the desired CPAP level is achieved, connect the mask to the circuit. Placing the mask on the patient: Before placing the mask onto the patient?s face, place the Nasal EtCO2 on the patient, then assist the patient with sealing the mask to their face. (Be sure to cover the patient?s 16

19 nose and mouth-tight seal-no leaks) Next use the black head gear to physically strap the mask to patient?s face. COMPLICATIONS: WARNING: Potential side effects of CPAP may include fluid retention, pneumothorax, decreased cardiac output and gastric distention. Stop treatment. Provide supportive BLS/ALS interventions as needed. Paramedic should immediately notify Medical Control and ED staff upon arrival. HOSPITAL NOTIFICATION: Notify hospital via radio that patient is on CPAP and request that Respiratory be notified. MONITORING THE PATIENT: During operation, monitor the following periodically: Monitor to assure that there are no leaks at the patient connection. Monitor the Airway Pressure Gauge. Monitor SpO2 Monitor B/P and EKG Monitor the patient?s breathing with chest auscultation Monitor the patient for signs of dehydration and discomfort in the upper airways Monitor the patient?s condition for improvement, including the respiratory rate, mental status and SpO2 percentage. If the patient?s condition is improving, continue to monitor the patient. If the patient?s condition is not improving, increase the oxygen adjustment valve. Titrate in increments of ½ turns q 2 minutes to SpO2 of 100%. If the patient?s condition is deteriorating despite increasing the oxygen adjustment valve, discontinue the CPAP device and prepare for orotracheal intubation. To turn the CPAPos unit off, disconnect the O2 supply hose from the source or turn off at the O2 cylinder. DOCUMENTATION: The Paramedic attending a patient with CPAP will do the following; Document indications for CPAP. Document CPAP settings. Document Effects/Adverse reactions Document vital signs every five minutes, include EtCO2 and SpO2. Complete CPAP QI Form 17

20 Procedure Guidelines Cricothyrotomy Needle 9.09 CRICOTHYROTOMY (NEEDLE) INDICATIONS: If unable to ventilate and airway not patent, perform Needle Cricothyrotomy, as listed on line 6, page 2-8 in the Practice Parameters. Preferred over surgical cricothyrotomy in children under 12 years old. Preferred over surgical cricothyrotomy in patients with known clotting disorders and/or anticoagulant therapy. EQUIPMENT: 14 gauge over the needle catheter. 3.0 mm endotracheal tube adapter 12 ml syringe. Antiseptic swabs. 12 cc syringe. Tape. Occlusive dressing. BVM. PROCEDURE: Place the patient in a supine position with the neck in a neutral position. Gather and prepare equipment. Prepare site with Antiseptic swabs. Palpate the cricothyroid membrane, anteriorly, between the thyroid cartilage and cricoid cartilage. Stabilize the trachea with the thumb and forefinger of one hand. Stretch skin taut. Puncture the skin midline with the needle attached to the syringe, directly over the cricothyroid membrane. Direct the needle at a 45 degree angle caudally, while applying negative pressure to the syringe. Carefully insert the needle through the lower half of the cricothyroid membrane, aspirating as the needle is advanced. Aspiration of air signifies entry into the tracheal lumen. Remove the syringe and withdraw the needle while gently advancing the catheter downward into position, being careful not to perforate the posterior wall of the trachea. Attach 3.0 mm ET adapter to hub of catheter, connect BVM and ventilate while manually stabilizing catheter. Observe breath sounds and auscultate the chest for adequate ventilation. Secure the catheter to the patient's neck with tape (chevron) after area prepped with benzoin. Continue to ventilate and observe chest rise. ILLUSTRATION: 18

21 Palpate the cricothyroid membrane, anteriorly, between the thyroid cartilage and cricoid cartilage. Puncture the skin directing the needle at a 45-degree angle caudally. Remove needle from catheter. Gently advance catheter downward into position. 19

22 Procedure Guidelines 9.10 CRICOTHYROTOMY (SURGICAL) Cricothyrotomy Surgical INDICATIONS: If unable to ventilate and airway not patent, perform Cricothyrotomy, as listed on line 5, page 2-7 in the Practice Parameters. When an airway is needed and intubation is unsuccessful. CONTRAINDICATIONS: Children under 12 years old. Known bleeding disorder and/or anticoagulant therapy. Unable to locate landmarks. EQUIPMENT: #11 scalpel blade with handle. Needle nose hemostats. 5.0 to 7.0 mm endotracheal tube, cut above pilot balloon. Antiseptic swabs. Tape. BVM. PROCEDURE: (refer to illustrations): Place the patient in a supine position with the neck in a neutral position. Palpate the thyroid notch, cricothyroid membrane, and the sternal notch for orientation. Gather equipment. Prepare site with Antiseptic swabs. Stabilize the thyroid cartilage with thumb and 3rd finger of hand. Stretch skin taut. Make a superficial transverse skin incision over the cricothyroid membrane. Carefully puncture through the membrane and maintain site with tip of gloved index finger. 20

23 Insert the scalpel handle into the incision and rotate 90 degrees to open airway OR insert hemostats to enlarge opening for passage of tube. Insert cuffed endotracheal tube into the cricothyroid membrane incision directing the tube distally into the trachea. Inflate the cuff and ventilate the patient with BVM. Observe breath sounds and auscultate the chest for adequate ventilation. Secure the endotracheal tube. Continue to ventilate and observe chest rise. 21

24 Defibrillation Section 10 Procedure Guidelines 9.11 DEFIBRILLATION INDICATIONS: Ventricular Fibrillation. Pulseless Ventricular Tachycardia. Check the equipment - Turn on the monitor / defibrillator. Apply monitor per Procedure Guideline. Confirm the rhythm. DEFIBRILLATION: Confirm the patient is unresponsive and pulseless. Ensure synchronizer is turned off. Check paddles or fast patch pads position and conduction. Select appropriate energy level per Standing Order. Stop CPR and call ALL CLEAR. Check to ensure all people including yourself are clear of the patient. Ensure EMS personnel are in a safe operating location. Apply pounds of pressure to paddles, (If applicable). Discharge energy by pressing discharge buttons simultaneously. Observe for rhythm change and check the patient for a pulse, (If applicable). Repeat per Practice Parameters. 22

25 Procedure Guidelines 9.12 DEFIBRILLATION PEDIATRIC INDICATIONS: Ventricular Fibrillation Pulseless Ventricular Tachycardia: Defibrillation Pediatric First Defibrillation Second Defibrillation Third and Continuous Defibrillation 2 J per kilogram 4 J per kilogram 4 J per kilogram CHECK THE EQUIPMENT: Turn on the monitor / defibrillator. Apply appropriate size paddles. Use the largest paddle surface, which makes complete contact with the patient. Entire paddle should make complete contact with patient. DEFIBRILLATION: Confirm the patient is unresponsive and pulseless. Ensure synchronizer is turned off. Apply conductive medium. Position paddles. Stop CPR and call ALL CLEAR. check to ensure all people, including yourself, are clear of the patient. Ensure EMS personnel are in a safe operating location. Apply firm pressure to paddles. Discharge energy by pressing discharge buttons simultaneously. Observe for rhythm change and check the patient for a pulse, (if applicable). Repeat per Practice Parameters. 23

26 End Tidal CO2 Monitoring and Capnography Procedure Guidelines 9.13 END TIDAL CO2 MONITORING CAPNOGRAPHY INDICATIONS: Intubated Applications (Mainstream) Verification of ETT or King Tube placement ETT or King Tube surveillance during transport CPR: compression efficacy, early sign of ROSC, survival predictor* Optimize ventilation of patients Objective data to terminate resuscitation Non-Intubated Applications (Sidestream) Bronchospasm: asthma, COPD and anaphylaxis Hypoventilation: drug overdose, stroke, seizure, CHF, shock & circulatory compromise Hyperventilation: DKA, metabolic acidosis, sepsis, CNS Hyperventilation PROCEDURE: Select EtCO2 setting on monitor if not set to default Assure nasal cannula or sensor to E.T. tube or King Tube is correctly placed Check for wave forms Record wave form Capnography device should remain in place for continuous monitoring, with frequent checks to ascertain that the tube does not migrate. At hospital, record waveform again DOCUMENTATION: Upon confirmation of successful endotracheal intubation or King Tube placement (positive wave form), print a strip and document the initial reading on the abbreviated report. Document any airway or pharmacologic interventions based on capnography readings. Upon arrival to the emergency department and after transferring the patient to the hospital?s bed/gurney; obtain a second strip demonstrating a continued positive wave form. Attach both strips to the completed run report. A code summary should accompany all cardiac arrest reports. CAPNOGRAPHY WAVEFORM ANALYSIS: NORMAL? mm Hg MANAGEMENT: Monitor 24

27 DISLODGED ETT: Loss of waveform, Loss of EtCO2 MANAGEMENT: Replace ETT ESOPHAGEAL INTUBATION: Absence of waveform MANAGEMENT: Re-intubate HYPOVENTILATION:? RR, EtCO2 > 45 mm Hg MANAGEMENT: Assist ventilations/intubate HYPERVENTILATION:?RR, EtCO2 < 35 mm Hg MANAGEMENT:?ventilations BRONCHOSPASM:?Sharkfin? MANAGEMENT: Bronchodilators 25

28 Intraosseous Infusion - Femoral Procedure Guidelines INTRAOSSEOUS INFUSION - FEMORAL The SCEMS Medical Director has approved the EZ IO device for Intraosseous (IO) access: INDICATIONS: Immediate vascular access in emergencies. Intravenous fluids or medications are urgently needed and a peripheral IV cannot be established in 2 attempts or 90 seconds AND the patient exhibits one or more of the following: An altered mental status (GCS of 8 or less) Respiratory compromise (SaO2 90% after appropriate oxygen therapy, respiratory rate < 10 or > 40 min) Hemodynamic instability (Systolic BP of < 90). Cardiac arrest (medical or traumatic) Profound hypovolemia with alteration of mental status Burns blocking peripheral IV sites CONTRAINDICATIONS: (If a contraindication is present evaluate the opposite leg for placement.) Fracture to the tibia or femur. Previous orthopedic procedures. (Example? knee replacement) An extremity that is compromised by a pre-existing medical condition. (Example? tumor or peripheral vascular disease) Any infection or burn* over the insertion site. Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site) Relative contraindication. If patient has extensive burns, the site can be used if unable to obtain an IV. PROCEDURE: EZ IO Locate appropriate insertion site (Multiple sites are FDA cleared including - Proximal / Distal Tibia and Proximal Humerus) 26

29 Prepare insertion site using aseptic technique. Prepare the EZ-IO driver and appropriate needle set Stabilize site and insert appropriate needle set. Remove EZ-IO driver from needle set while stabilizing catheter hub Remove stylet from catheter, place stylet in shuttle or approved sharps container. Confirm placement. Connect primed EZ-Connect. Slowly administer appropriate dose of Lidocaine 2% (Preservative Free) IO to conscious patients. Syringe bolus (flush) the EZ-IO catheter with the appropriate amount of normal saline mg for adult patients > 0.5mg / kg for pediatric patients Utilize pressure (syringe bolus, pressure bag or infusion pump) for continuous infusions where applicable. Begin infusion. Dress site, secure tubing and apply wristband as directed. Monitor EZ-IO site and patient condition? Remove catheter within 24 hours. 27

30 Intraosseous Infusion - Humeral Head Procedure Guidelines INTRAOSSEOUS INFUSION - HUMERAL HEAD The Medical Director has approved the EZ IO device for Intraosseous (IO) access: INDICATIONS: Immediate vascular access in emergencies. Intravenous fluids or medications are urgently needed and a peripheral IV cannot be established in 2 attempts or 90 seconds AND the patient exhibits one or more of the following: An altered mental status (GCS of 8 or less) Respiratory compromise (SaO2 90% after appropriate oxygen therapy, respiratory rate < 10 or > 40 min) Hemodynamic instability (Systolic BP of < 90). Cardiac arrest (medical or traumatic) Profound hypovolemia with alteration of mental status Burns blocking peripheral IV sites CONTRAINDICATIONS: (If a contraindication is present evaluate the opposite arm for placement.) Fracture to the humerus. An extremity that is compromised by a pre-existing medical condition. (Example? tumor or peripheral vascular disease) Any infection or burn* over the insertion site. Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site) Relative contraindication. If patient has extensive burns, the site can be used if unable to obtain an IV. PROCEDURE: EZ IO Identify the proximal humerus: Place the patient?s hand over the abdomen (elbow adducted and humerus internally rotated) Place your palm on the patient?s shoulder anteriorly The area that feels like a?ball? under your palm is the general target area You should be able to feel this ball, even on obese patients, by pushing deeply 28

31 Place the ulnar aspect of one hand vertically over the axilla Place the ulnar aspect of the opposite hand along the midline of the upper arm laterally. Place your thumbs together over the arm. This identifies the vertical line of insertion on the proximal humerus Palpate deeply as you climb up the humerus to the surgical neck. It will feel like a golf ball on a tee? the spot where the?ball? meets the?tee? is the surgical neck 29

32 The insertion site is on the most prominent aspect of the greater tubercle, 1 to 2 cm above the surgical neck Insertion: Prepare the site by using antiseptic solution of your choice Use a clean,?no touch? technique Remove the needle cap Point the needle set tip at a 45-degree angle to the anterior plane and posteromedial Push the needle tip through the skin until the tip rests against the bone The 5mm mark must be visible above the skin for confirmation of adequate needle length Gently drill into the humerus 2cm or until the hub reaches the skin in an adult. The hub of the needle set should be perpendicular to the skin Hold the hub in place and pull the driver straight off Continue to hold the hub while twisting the stylet off the hub with counter clockwise rotations 30

33 The needle should feel firmly seated in the bone (1st confirmation of placement) Place the stylet in a sharps container Place the EZ-StabilizerTM dressing over the hub Connect primed EZ-Connect. Slowly administer appropriate dose of Lidocaine 2% (Preservative Free) IO to conscious patients. Syringe bolus (flush) the EZ-IO catheter with the appropriate amount of normal saline mg for adult patients > 0.5mg / kg for pediatric patients Utilize pressure (syringe bolus, pressure bag or infusion pump) for continuous infusions where applicable. Begin infusion. Dress site, secure tubing and apply wristband as directed. Monitor EZ-IO site and patient condition? Remove catheter within 24 hours. Pull the tabs off the EZ-Stabilizer dressing to expose the adhesive, apply to the skin Aspirate for blood/bone marrow (2nd confirmation of placement) Secure the arm in place across the abdomen VIDEOS Arrow EZ-IO Insertion Site Identification - Proximal Humerus Arrow EZ-IO Proximal Humerus Insertion 31

34 Procedure Guidelines Intubation Endotracheal 9.15 INTUBATION (ENDOTRACHEAL) INDICATIONS: Respiratory or cardiac arrest. Glasgow Coma Scale of 8 or less. Decreased minute volume. Possible airway obstruction. EQUIPMENT: Laryngoscope handle with appropriate size blade. Proper size endotracheal tube. Water soluble lubrication gel, (lubricate distal end of tube at cuff). 10 cc syringe, (check cuff for patency). Stylet, (insert into ET tube). Tape or endotracheal securing device. Proper size oral pharyngeal airway. BVM. Suction. Stethoscope. PROCEDURE: If C-spine injury suspected, maintain cervical alignment and apply C-collar. Pre-oxygenate the patient before intubation procedure. Attach proper blade to laryngoscope handle and check light. Grasp laryngoscope handle in left hand. Grasp ET tube in right hand. Do not interrupt compressions to place an advanced airway. Remove all foreign objects, such as dentures, oral pharyngeal airways, etc. and suction the patient's airway if needed. Insert the blade into the right side of the patient's mouth sweeping the tongue to the left side. Visualize the vocal cords without pressure on the teeth. Insert the endotracheal tube until the cuff passes the vocal cords. (Insert far enough so that balloon port tubing is even with lips.) Remove the laryngoscope blade. Inflate the endotracheal cuff with the syringe with 5-10 cc of air and remove the syringe from inflation valve. Attach EtCO2 sensor to obtain wave-form Capnography. Ventilate the patient with a BVM and watch for chest rise. Listen to abdomen to ensure that an esophageal intubation has not been done. Listen for bilateral breath sounds. If abdominal sounds are heard, deflate the endotracheal cuff and remove the endotracheal tube immediately. Ventilate the patient and attempt intubation again. If lung sounds are unequal, deflate the endotracheal cuff and reposition the endotracheal tube. Inflate endotracheal cuff and reassess lung sounds. If lung sounds are still unequal, assess the patient for Pneumothorax, (simple or tension). 32

35 Ventilate patient per current guidelines. Resume CPR, (if applicable). SECURE: Use endotracheal securing device and secure endotracheal tube in place noting depth of tube. Measure and place a c-collar, to limit head movement. Secure head with head bed or restrain to spine board. Upon confirmation of successful endotracheal intubation (positive wave form), print a strip and document the initial reading on the abbreviated report. Continue ventilations. DOCUMENTATION: Upon confirmation of successful endotracheal intubation (positive wave form), print a strip and document the initial reading on the abbreviated report. Document any airway or pharmacologic interventions based on capnography readings. Upon arrival to the emergency department and after transferring the patient to the hospital?s bed/gurney; obtain a second strip demonstrating a continued positive wave form. Attach both strips to the completed run report. A code summary should accompany all cardiac arrest reports. 33

36 Procedure Guidelines Intubation Nasotracheal 9.16 INTUBATION (NASOTRACHEAL) INDICATIONS: Decreased minute volume in-patients who are not in arrest. Patients with possible spinal injuries. Patients who cannot be ventilated adequately by another means. CONTRAINDICATIONS: Facial trauma. Apnea. EQUIPMENT: Proper size nasotracheal tube, (1-2 sizes smaller than ET). Water-soluble lubrication gel, (lubricate distal end of tube at cuff). 10 cc syringe, (check cuff for patency). Tape or endotracheal securing device. BVM. Suction. Stethoscope. PROCEDURE: Ensure spontaneous respirations are in progress and being assisted with appropriate oxygen device. If C-spine injury suspected, maintain manual cervical alignment and apply the C-collar. Hyperventilate patient before intubation procedure. Select the most patent nasal passage. With the bevel of the tube facing the nasal septum, insert the tube into the naris parallel to the hard palate. Insert the tube beyond the "give" of the nasopharyngeal angle. Advance the tube during inhalation until coughing occurs or maximal breath sounds are heard. Advance the tube into the trachea simultaneously with the inspiration phase of respirations. Inflate the cuff with 5-10 cc of air and remove the syringe. Ventilate the patient with a bag valve attached and watch for chest rise. Listen to abdomen to ensure that an esophageal intubation has not been done. Listen for bilateral equal breath sounds. If abdominal sounds are heard, deflate the endotracheal cuff and remove the nasotracheal tube immediately and attempt intubation again. If lung sounds are unequal, deflate the nasotracheal cuff and reposition the nasotracheal tube. Inflate nasotracheal cuff and reassess lung sounds. If lung sounds are still unequal, assess the patient for Pneumothorax, (simple or tension). Ventilate patient. 34

37 SECURE: Tape or use endotracheal securing device and secure nasotracheal tube in place noting depth of tube. Reassess lung sounds to ensure endotracheal tube is still in proper position. Continue ventilations. 35

38 IVAC Medsystem III MultiChannel Infusion Pump Procedure Guidelines 9.17 IVAC MEDSYSTEM III MULTI CHANNEL INFUSION PUMP OPERATIONS GUIDELINES TO TURN PUMP ON: Press ON/OFF. TO LOAD CASSETTE: Pull cassette slide clamp out to completely occlude tubing. With tubing down, use a 45, upward motion to insert cassette into channel A, B, or C. Push until cassette snaps into holder. Ensure slide clamp is flush with entire cassette. Pull down gently on tubing collar, then press with thumb to seat tubing collar into recess beneath cassette. NOTE: Three beeps sound when cassette and tubing collar are inserted properly. Open regulating clamp. TO SET UP AN INFUSION: Press A, B, or C. Set Rate. Set Volume Remaining (VR). Clear Volume Infused (VI). Start infusion. NOTE: To display infusion information for all channels, press STANDARD DISPLAY. TO SET RATE: Press A, B, or C.- Rate is highlighted. Press? or? to set a rate. Verify rate and press Accept to confirm. TO CHANGE RATEWHILE INFUSING: Press A, B, or C. Rate is highlighted. Press? or? to set a new rate. Verify rate and press Accept to confirm. The new rate begins infusing immediately. TO SET VOLUME REMAINING: Press A, B, or C. Press Select to highlight VR. Press? or? to set volume remaining. 36

39 Press Accept to confirm TO CLEAR VOLUME INFUSED: Press A, B, or C. Press Select to highlight VI. Press Clear to reset to zero. Press Accept to confirm. TO START OR STOP AN INFUSION: Press A, B, or C. Press START/STOP. NOTE: When a channel is stopped for two minutes with a cassette in place, a Pump Not In Use advisory sounds. TO PLACE CHANNEL ON STANDBY: When channel is infusing: Press A, B, or C. Press START/STOP to stop infusion. Press STANDARD DISPLAY. Press STNDBY. When channel is stopped: Press STNDBY. NOTE: When a channel is placed on Standby, a Pump Not In Use does not sound. TO PLACE CHANNEL IN DUAL RATE MODE: Press A, B, or C. Press MORE OPTIONS. Press Mode. Press Select to highlight Dual Rate (IVPB). Press Accept to confirm. TROUBLESHOOTING TO RESPOND TO AN ADVISORY, ALARM OR FAULT MESSAGE: Press QUIET. Press the affected channel key: A, B, or C. Follow instructions on channel?s Alarm Information page. Press START/STOP to resume infusion. ADVISORIES: Check Air Sensor: Air is detected in tubing, tubing collar is not properly seated, or air sensor is dirty. Corrective Action: Verify tubing collar is fully seated in air sensor recess. Verify tubing in air sensor recess is not damaged, twisted or dirty. 37

40 Press ClrAir on channel?s Alarm Information page. Three beeps indicate air bubble has moved past air sensor. If no air is present, clean air sensor recess with isopropyl alcohol and let dry. Pump Not In Use: Two minutes have elapsed without infusion being started after installing cassette or stopping infusion. Corrective Action: Press START/STOP to begin infusion or press STNDBY. Infusion Complete VR=0: VR has counted down to zero. Pump is infusing at KVO rate. Corrective Action: Select a new VR, or if same volume is desired, press REPEAT. ALARMS: Four sharp beeps; flashing red light; infusion stopped. Air In Line: While channel is infusing, air is detected in tubing, or air sensor is dirty. Corrective Action: Refer to Check Air Sensor Corrective Action. Maintain pump at or slightly below IV site to minimize formation of micro bubbles. Air In Lower Tubing: While channel is infusing, air bubbles are detected in tubing. Possible causes are out gassing and leaks in administration set. SEMINOLE COUNTY EMERGENCY MEDICAL SERVICES PRACTICE PARAMETERS 2009 Page 4 of 6 Procedure Guidelines 9.17 IVAC MEDSYSTEM III MULTI CHANNEL INFUSION PUMP Corrective Action:? Check administration set for any leaks.? Check lower tubing for multiple small air bubbles.? If air present, clear air.? If no significant air is present, press START/STOP to resume infusion.? Maintain pump at or slightly below IV site to minimize formation of micro bubbles. Cassette Jammed: Piston difficult to move, or loose piston sleeve. Corrective Action:? Remove cassette, check placement of soft, plastic piston sleeve and reposition, if necessary.? Verify piston moves freely. If tight, replace administration set.? If condition continues, try cassette in a different channel.? If alarm recurs, replace administration set. Cassette Not Latched: Cassette is partially disengaged or latching mechanism is dirty. Corrective Action:? Push cassette completely in. Ensure slide clamp is flush with entire cassette. Press START/STOP to resume infusion.? If condition continues, try cassette in a different channel.? If alarm recurs, replace administration set. Cassette Removed: Cassette is removed from holder while channel is infusing. Corrective Action:? Reinstall cassette, then press START/STOP to resume infusion. Check Fluid Side: Possible upstream restrictions to flow. SEMINOLE COUNTY EMERGENCY MEDICAL SERVICES PRACTICE PARAMETERS 2009 Page 5 of 6 Procedure Guidelines 9.17 IVAC MEDSYSTEM III MULTI CHANNEL INFUSION PUMP Corrective Action:? Check upstream tubing for a closed regulating clamp, closed vent with unvented container, kinked tubing, empty syringe, or any restriction to flow.? If NO occlusion is present, press CONFIRM, and press START/STOP to resume infusion.? Verify fluid flow in drip chamber. Faulty Cassette: Cassette is dirty or inoperative. Possible dysfunction of cassette sensor located in holder. Corrective Action:? Reinsert cassette, or 38

41 replace administration set.? If alarm recurs with several cassettes, disable channel for use. Fluid-Side Occluded: Upstream restriction to flow. Corrective Action:? Check upstream tubing for a closed regulating clamp, closed vent with unvented container, kinked tubing, empty syringe, or any restriction to flow.? Clear occlusion and press START/STOP to resume infusion. Patient-Side Occluded: Downstream restriction to flow. Corrective Action:? Check downstream line for kinks, closed clamps, closed stopcocks, clogged filters, site problems, etc.? Clear occlusion and press START/STOP to resume infusion. Pump Latch Closed: Small jaws located to right of air sensor are closed. Corrective Action:? Using finger, press down the closed pumping latch jaw until it snaps open.? NOTE: DO NOT PRESS THE SERVICE SOFTKEY. The Service Softkey should only be utilized when the pumping latch jaw is visibly broken. If the Service Softkey is activated, the pump will lock into SERVICE MODE, which can only be cleared by a factory professional. SEMINOLE COUNTY EMERGENCY MEDICAL SERVICES PRACTICE PARAMETERS 2009 Page 6 of 6 Procedure Guidelines 9.17 IVAC MEDSYSTEM III MULTI CHANNEL INFUSION PUMP FAULTS: Siren sound; flashing red light; infusion stopped.? Press A, B, or C.? Follow instructions on channel?s Alarm Information page.? Press RETRY to clear Fault.? If Fault alarm recurs, CONTACT SUPPORT SERVICES. WATCHDOGS: Continuous tone with blank screen; red and green lights are lit; infusion stopped. Safety checks built into software have detected an instrument fault condition. Attempt to reset pump:? Turn pump off, then on again. Resume infusion.? If Watchdog alarm recurs or pump cannot be turned on, submit pump for servicing. TROUBLESHOOTING RESPONSE KEYS: QUIET silences Advisories, Alarms, and Faults. This key is accessible on Standard Display page and Alarm Information page. CANCEL clears Advisories and Alarms. ClrAir pushes air bubbles past air sensor. Each push clears 0.2 ml of air. ClrAir may be pressed 5 times. NOTE: Three beeps indicate air bubble has moved past air sensor. CONFIRM allows infusion to continue if no occlusion is present and fluid is flowing in drip chamber. NOTE: A? icon appears on Standard Display page to indicate CONFIRM has been pressed. RETRY clears a fault. Use when attempting to re-establish normal operation of a channel. SERVICE or BIOMED disables use of selected channel,?service? appears on status line. NOTE: Servicing of instrument is required before channel will function. 39

42 Procedure Guidelines 9.18 KING TUBE King Tube KING LTS-D LARYNGEAL TUBE AIRWAY: The King LTS-D is a double-lumen supralaryngeal device with oropharyngeal and esophageal low-pressure cuffs, a ventilation outlet between the two cuffs, and a blind distal tip. The King Tube is designed for positive pressure ventilation over 30 cm H2O and spontaneously breathing patients, yet offers the unique ability to easily pass a gastric tube through a second channel of the airway and into the esophagus and stomach. The anatomically shaped distal tip and cuff assist in the airway?s passage behind the larynx and into the normally collapsed esophagus. The second lumen of the KING LTS-D, which is open at the distal tip of the tube, provides three key additional benefits: Passage of gastric tube up to 18 French Channel for regurgitation, which significantly reduces potential for regurgitation to get past the cuff and therefore aids in reducing the chance for aspiration Provides?vent? for gastric pressure and stomach decompression. INDICATIONS: Primary airway management in cardiac arrest Failed intubation Difficult airway cases Upper gastrointestinal or airway hemorrhage that threatens airway patency. CONTRAINDICATIONS: Responsive patient with intact airway?protective reflexes Patients with known esophageal disease Caustic ingestions Upper-airway obstructions due to foreign bodies or pathology Children/adults less than 4-feet tall. 40

43 EQUIPMENT: BVM Lubricant cc syringe ET Tube holder EtCO2 sensor Gastric tube up to 18F PROCEDURE: Select the appropriate size tube, based on the patient's height: Size 3: 4 to 5 ft ( cm) Size 4: 5 to 6 ft ( cm) Size 5: > than 6 ft (180 cm) Apply lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near the ventilatory openings. Pre-oxygenate via BVM. Position the head. The ideal head position for insertion of the KING LTS-D is the?sniffing position?. However, the angle and shortness of the tube also allows it to be inserted with the head in a neutral position. For obese patients, elevation of the shoulders and upper back should be considered. Hold the KING LTS-D at the connector with dominant hand.with non-dominant hand, perform a tongue-jaw lift and insert tube into corner of mouth. With the KING LTS-D rotated laterally degrees, such that the blue orientation line is touching the corner of the mouth. Introduce tip into mouth and advance behind base of tongue. As tube tip passes under tongue, rotate tube back to midline (blue orientation line faces chin). Without exerting force, advance tube until base of connector is aligned with teeth or gums. Advance the device until the lips are rest between the black bands on the device. Using the syringe provided, inflate the cuffs of the KING LTS-D with the appropriate volume: Size 3-50 ml Size 4-70 ml Size 5-80 ml Attach BVM to the 15 mm connector of the KING LTS-D. While gently bagging the patient to assess ventilation, simultaneously withdraw the KING LTS-D until ventilation is easy and free flowing (large tidal volume with minimal airway pressure). Depth markings are provided at the proximal end of the KING LTS-D which refer to the distance from the distal ventilatory opening. When properly placed, with the distal tip and cuff in the upper esophagus, and the ventilatory openings aligned with the opening to the larynx. The depth markings give an indication of the distance, in centimeters, from the vocal cords to the teeth. Confirm proper position by auscultation, chest movement and EtCO2 wave form verification. 41

44 For gastric distention, up to an 18 Fr gastric tube can be used through the gastric access lumen of the KLTSD. Note: Lubricating the gastric tube greatly facilitates its passage. 42

45 Medication Administration Intramuscular Procedure Guidelines 9.19 MEDICATION ADMINISTRATION INTRAMUSCULAR INDICATIONS: Intramuscular injection is used for the delivery of certain drugs not recommended for other routes of administration. The intramuscular route offers a faster rate of absorption than the subcutaneous route, and muscle tissue can often hold a larger volume of fluid without discomfort. In contrast, medication injected into muscle tissues is absorbed less rapidly and takes effect more slowly that medication that is injected intravenously. This is favorable for some medications. CONTRAINDICATIONS: Careful consideration in deciding which injectable route is to be used for the prescribed medication is essential. The intramuscular route should not be used in cases where muscle size and condition is not adequate to support sufficient uptake of the drug. Intramuscular injections should not be given at a site where there is any indication of pain. DESCRIPTION: Intramuscular (IM) injections are given directly into the central area of selected muscles. There are a number of sites on the human body that are suitable for IM injections; however, there are three sites that are most commonly used in this procedure. Deltoid muscle The deltoid muscle located laterally on the upper arm can be used for intramuscular injections. Originating from the Acromion process of the scapula and inserting approximately one-third of the way down the humerus, the deltoid muscle can be used readily for IM injections if there is sufficient muscle mass to justify use of this site. The deltoid's close proximity to the radial nerve and radial artery means that careful consideration and palpation of the muscle is required to find a safe site for penetration of the needle. There are various methods for defining the boundaries of this muscle. Vastus lateralis muscle The vastus lateralis muscle forms part of the quadriceps muscle group of the upper leg and can be found on the anteriolateral aspect of the thigh. This muscle is more commonly used as the site for IM injections as it is generally thick and well formed in individuals of all ages and is not located close to any major arteries or nerves. It is also readily accessed. The middle third of the muscle is used to define the injection site. This third can be determined by visually dividing the length of the muscle that originates on the greater trochanter of the femur and inserts on the upper border of the patella and tibial tuberosity through the patella ligament into thirds. Palpation of the muscle is required to determine if sufficient body and mass is present to undertake the procedure. Gluteus medius muscle The gluteus medius muscle, which is also known as the ventrogluteal site, is the third commonly used site for IM injections. 43

46 The correct area for injection can be determined in the following manner. Place the heel of the hand of the greater trochanter of the femur with fingers pointing towards the patient's head. The left hand is used for the right hip and vice versa. While keeping the palm of the hand over the greater trochanter and placing the index finger on the anterior superior iliac spine, stretch the middle finger dorsally palpating for the iliac crest and then press lightly below this point. The triangle formed by the iliac crest, the third finger and index finger forms the area suitable for intramuscular injection. PREPARATION: Before administering medication, verify the intended medication for accuracy and prepare the medication from the vial or ampule. Locate the correct area for injection using the above guidelines or those taught during training. Clean the site with an alcohol swab or other cleansing agent. Prepare the syringe by removing the needle cover, inverting the syringe, and expelling any excess air. Approximately 0.1?0.2 ml of air should be left in the syringe so that the air in the top of the syringe chamber, when the syringe and needle are pointing down, forces the entire amount of medication to be delivered. This also prevents medication residue from being left in the needle, where it can leak into the subcutaneous and dermal layers when the syringe and needle are removed from the muscle. When ready to inject, spread the skin using the fingers of the non-dominant hand. Holding the syringe with the thumb and forefinger of the dominant hand, pierce the skin and enter the muscle. This process should be done quickly with sufficient control so as to lessen the discomfort of the patient. If there is little muscle mass, particularly in infants or the elderly, then you may need to pinch the muscle to provide more volume of tissue in which to inject. Aspirate at the injection site (while syringe and needle are within the muscle) by holding the barrel of the syringe with the non-dominant hand and pulling back on the syringe plunger with the dominant hand. If blood appears in the syringe, it is an indication that a blood vessel may have been punctured. The needle and syringe should be immediately withdrawn and a new injection prepared. If no blood is aspirated, continue by slowly injecting the medication at a constant rate until all medication has been delivered. Withdraw the needle and syringe quickly to minimize discomfort. The site may be briefly massaged, depending on the medication given. Some medication manufacturers advise against massaging the site after injection, as it reduces the effect and intention of the medication by dispersing it too readily or over too large an area. Manufacturers' recommendations should be checked. Discard the used syringe and needle intact as soon as possible in an appropriate disposal receptacle. Check the site at least once more a short time after the injection to ensure that no bleeding, swelling or any other signs of reaction to the medication are present. Monitor the patient for other signs of side effects, especially if it is the first time the patient is receiving the medication. Krapp, K. & Cengage, G., Ed. (2002). Intramuscular Injection. Encyclopedia of Nursing and Allied Health. Retrieved April 14, 2009, from 44

47 Medication Administration Nasal Atomizer Procedure Guidelines 9.20 MEDICATION ADMINISTRATION NASAL ATOMIZER INDICATIONS: For atomizing for the following medications across the nasopharyngeal mucous membranes: Versed Morphine Narcan Glucagon Romazicon Lidocaine CONTRAINDICATIONS: Oil-based medications (i.e. Valium) PROCEDURE: Disconnect MAD from included syringe. Fill syringe with desired volume of medication and eliminate remaining air. Connect the MAD to the syringe. Place the MAD tip in the nostril. Compress the syringe plunger to spray atomized solution into the nasopharyngeal cavity. Re-use the MAD on the same patient as needed, and then discard. 45

48 Medication Administration Nebulizer Procedure Guidelines 9.21 MEDICATION ADMINISTRATION - NEBULIZER INDICATIONS: Acute asthma / COPD With Wheezing? PRACTICE PARAMETER 3.01 Croup / Epliglottitis? PRACTICE PARAMETER 3.04 Acute Pulmonary Edema - PRACTICE PARAMETER 4.11 EQUIPMENT: 1 oxygen supply tubing. 1 nebulizing chamber. 1 T piece. 1 mouth piece or aerosol mask. Non-humidified oxygen with a flow meter. Medication to be given. Aerosol mask doesn?t require patient?s help and may deliver a higher O2 percentage. PROCEDURE: Assemble oxygen supply tubing to the nebulizer. Add the medication to the nebulizing chamber. Connect the top of the nebulizing chamber. Connect the T piece to the top of the nebulizing chamber. Connect the mouth piece to the T piece. Connect the oxygen supply tubing to the oxygen flow meter. Set the flow meter to 6-8 liters / minute and watch for the medication to mist. Give the nebulizer to the patient and have them breathe the medication. If the patient is unable to hold the nebulizer, remove the mouth piece from the T piece and apply T piece to an aerosol mask. Auscultate breath sounds. MONITOR: Blood pressure Heart rate Respiratory status 46

49 Medication Administration Subcutaneous Procedure Guidelines 9.22 MEDICATION ADMINISTRATION SUBCUTANEOUS INDICATIONS: Subcutaneous injection is the method used to administer drugs when a small amount of fluid is to be injected, the patient is unable to take the drug orally, or the drug is destroyed by intestinal secretions. CONTRAINDICATIONS: If the drug to be administered is harmful to superficial tissues, it should be administered intramuscularly or intravenously. DECRIPTION: With the subcutaneous route, a small thin needle is inserted beneath the skin and the drug injected slowly. The drug moves from the small blood vessels into the bloodstream. Subcutaneous injections are usually given in the abdomen, upper arm, or the upper leg. ADMINISTRATION: Prepare the syringe and needle. If a sterile, multiple-dose vial is used, the rubbercapped bottle should be rubbed with an antiseptic swab. The needle is then inserted through the center of the cap and some air from the syringe inserted to equalize the pressure in the container. Slightly more of the required amount of drug is then removed. Holding the syringe vertically at eye level, the syringe piston is pushed carefully to the exact measurement line. If a small individual vial containing the correct amount of drug is used, the outside should be wiped with an antiseptic swab and held in the swab while the top is removed. The needle is then inserted into the vial, taking care that the tip of the needle does not scratch against the sides of the vial, thereby becoming blunt. The injection site is then rubbed with a swab and disinfectant to cleanse the area and increase the blood supply. A small piece of skin and subcutaneous tissue is pinched between the thumb and forefinger, and the needle inserted quickly at a 45-degree angle. It is important to ensure that the needle is not in a vein. Therefore the syringe should be aspirated a little by pulling back on the piston. The skin is then released and the syringe piston pushed down steadily and slowly. A sterile cotton swab should be pressed over the injection site as the needle is quickly withdrawn, and the swab is taped to the skin for a few minutes, if required. Krapp, G. & Cengage, G. Ed. (2002). Subcutaneous Injection. Encyclopedia of Nursing and Health. Retrieved April 14, 2009, from 47

50 Nasogastric or Orogastric Tube Procedure Guidelines 9.23 NASOGASTRIC/OROGASTRIC TUBE Contact Medical Control for Physician's Orders INDICATIONS: Gastric decompression CONTRAINDICATIONS: Absolute? Known or suspected esophageal varices Relative? Ingestion of caustic poison EQUIPMENT: 14, 16 or 18 Fr. Levin tube, (for adults). 35 cc syringe. Water soluble lubrication gel. Tape. H2O. Saline. PRECAUTIONS: It will be difficult and painful to pass tube on a patient with a deviated septum or nasal obstructions. In conscious patients, gag reflex will be elicited. If patient gags, pause insertion allowing patient to take breaths or drink a few sips of water. Epistaxis is a common complication. If tube curls up inside pharynx, withdraw it and re-insert. It is possible to inadvertently intubate trachea with NGT. PROCEDURE: CONTACT MEDICAL CONTROL FOR PHYSICIAN'S ORDERS. Mark distance tube should be inserted by measuring from nose to ear lobe to below xyphoid process. Lubricate distal 6-8" of NGT. Examine nose for septal deviation. Use right nares if both nostrils are the same size. Place patient in semi-fowler's position, if condition permits and slightly flex head. Insert tube in nostril and gently pass tube into nose or thru King Tube. Encourage patient to swallow as tube is advanced to pre-determined depth. Confirm tube placement by aspirating gastric contents and by auscultating epigastrium while injecting cc air through tube. Aspirate stomach contents and irrigate concomitantly, as ordered. Tape tube in place and maintain suction if ordered. 48

51 Oxygen Administration Section 9 - Procedure Guidelines 9.24 OXYGEN ADMINISTRATION INDICATIONS: Nasal Cannula: for the spontaneously adequately breathing patient with no significant compromise or potential compromise in condition. Choice is determined by severity of condition, practice parameters and patient tolerance. NC should also be considered when the patient is unable to tolerate a mask. Non-Rebreather Mask: for any patient whose condition or complaint suggests that severe hypoxia or breathing may be a problem. Use on all multi-trauma patients and all patients who present with sign and symptoms of shock. Bag Valve Mask (BVM): Assist ventilations in the conscious or unconscious hypoxemic patient who is not moving air adequately. Ventilate the apneic patient. EQUIPMENT: Nasal Cannula: 4-6 liters/minute delivers % of oxygen. Non-Rebreather Mask (NRB): 15 liters/minute delivers > 90 % of oxygen. Bag Valve Mask, (BVM), with supplemental oxygen at 15 liters/minute and reservoir attached delivers nearly 100% oxygen. 49

52 Peripheral IV Administration Section 9 - Procedure Guidelines 9.25 PERIPHERAL IV ADMINISTRATION Preparing the IV: The E.M.S. personnel correctly assemble the components: IV solution. Micro drip, macro drip, blood set tubing, buretrol or dial-a-flow # 14 - #24 catheter over the needle, or butterfly needle. Venous tourniquet. Antiseptic swab. Gauze pad or adhesive bandage. Antibiotic ointment. Veniguard. Preparation: Open IV bag for clarity, expiration date, etc. Examine the IV bag envelope at the edge where it is notched. Read the name of the solution. Open IV tubing. Close control valve below the drip chamber. Insert IV tubing in the IV solution bag port. Squeeze the drip chamber until the drip chamber is half full of solution. Uncap distal end of tubing and hold the cap so it does not become contaminated. Open the IV tubing valve to allow the solution to flow through until all bubbles are out of the tubing. Close the tubing valve and recap the distal end of the tube. Insertion: Explain to the patient that an IV is going to be started. Place the tourniquet around the patient's arm proximal to the IV site. Palpate veins for resilience. Clean the skin with the antiseptic swab in an increasing sized concentric circle and follow it with an alcohol swab. Stabilize the vein distally with the paramedic's thumb/fingers. Enter the skin with the bevel of the needle facing upward. Enter the vein, obtain a flashback, and advance the catheter off of the catheter over the needle and remove the needle while compressing the proximal tip of the catheter to minimize blood loss. Remove the tourniquet. Connect IV tubing to the catheter. Open the IV clamp to assure free flow. Set IV infusion rate. 50

53 Secure: Tape gauze or adhesive bandage with antibiotic ointment over the insertion site of the skin. Secure the IV catheter and tubing with prepared tape. Recheck IV drip rate to make sure it is flowing at appropriate rate. Troubleshooting the IV, (if the IV is not working well): Make sure the tourniquet is off. Check the IV insertion site for swelling. Check the IV tubing clamp to make sure it is open. Check the drip chamber to make sure it is half full. Lower the IV bag below IV site and watch for blood to return into the tubing. 51

54 Pleural Decompression Section 9 - Procedure Guidelines 9.26 PLEURAL DECOMPRESSION INDICATIONS: Chest decompression for relief of tension pneumothorax. EQUIPMENT: 14 gauge inch catheter over the needle. Sterile glove finger. Thread the #14 gauge catheter through the end of the glove finger from the inside. Tape. Sterile gauze pads. Antiseptic swabs. Occlusive dressing. PROCEDURE: Locate decompression site. Identify the 2nd intercostal space in the mid-clavicular line on the same side as the pneumothorax. OR Identify the 5th intercostal space in the mid-axillary line on the same side as the pneumothorax. Prepare the site with an antiseptic swab: Firmly introduce catheter immediately above the distal rib of the site selected with a glove finger placed over the needle and catheter to serve as a flutter valve. Insert the catheter through the parietal pleura until air exits. It should exit under pressure. Advance catheter and remove needle. Secure the catheter taking care not to allow it to kink. Reassess lung sounds and patient condition. Dress area with Occlusive dressing then cover with sterile gauze pad. Flutter valve must be outside dressing and unobstructed. Assess breath sounds and respiratory status. 52

55 Procedure Guidelines Removal of Taser Probes 9.27 REMOVAL OF TASER PROBES Scene Safety Consideration: Before touching any patient who has been subdued using a Taser, determine if the patient is cooperative and restrained by Law Enforcement. BSI precautions: Wear gloves and eye protection. Taser and Probes: Assessment of a Patient that has been Tasered: Identify the location of the probes on the patient?s body. If any of the probes are embedded in the following areas do not remove them and transport the patient to an Emergency Department: Face Neck Groin Spinal Column Removal of Probe: If the probes are located in an area that is not specified above it can be removed by an EMT or paramedic. To remove the probe: Place gloved hand on the patient in the area where the probe is embedded and stabilize the skin surrounding the puncture site. Place your other gloved hand firmly around the probe. In one fluid motion pull the probe straight out from the puncture site. Repeat procedure with second probe. Removed probes should be handled and disposed of like contaminated sharps in a designated sharps container. Check with your local law enforcement agency, they may require that the probes be kept as evidence. 53

56 Procedure Guidelines Reconstitution of Medications 9.28 RECONSTITUTION OF MEDICATIONS INDICATIONS: Preparation of Glucagon or Solu-Medrol EQUIPMENT: Diluting Solution. Glucagon Powder. Sterile 1 ml syringe. Alcohol swab. PROCEDURE: Remove the flip-off seals on bottles Nos. 1 and 2 (Glucagon). Wipe rubber stoppers on both bottles with the alcohol swab. Pull up 1/2 ml of air. Inject the air into the diluting solution bottle (No. 1). Keep the tip of the needle in the solution and withdraw the entire contents of the solution. Remove syringe from bottle No. 1 and insert into bottle No. 2 (Glucagon powder). Inject all of the diluting solution into bottle No. 2. Remove syringe and dispose of properly. Shake bottle No. 2 gently until the Glucagon powder dissolves and the solution becomes clear. Administer the Glucagon or Solu-Medrol immediately after reconstituting. 54

57 ResQPOD Impedance Threshold Device Procedure Guidelines 9.29 ResQPOD IMPEDANCE THRESHOLD DEVICE The ResQPOD Circulatory Enhancer is an impedance threshold device (ITD) that utilizes a valve to limit air entry into the lungs during chest recoil between chest compressions. It is designed to reduce intrathoracic pressure and enhance venous return to the heart. The use of ITDs have received a Class IIa recommendation from the American Heart Association for use in CPR. INDICATIONS: Witnessed cardiac arrest CONTRAINDICATIONS: Patients where CPR is not indicated. EQUIPMENT: To be used in conjunction with: BVM King Tube E.T. TUBE EtCO2 Sensor PROCEDURE: Attach ResQPOD patient port to EtCO2 sensor. Attach ResQPOD ventilation port to Bag/valve Slide the Ventilation Timing Assist Light switch to on when using the ResQPOD in conjunction with an advanced airway. DO NOT hyperventilate. 55

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59 Procedure Guidelines 9.39 I-gel Supraglottic Airway I-gel Supraglottic Airway I-gel is a second generation supraglottic airway, made of a medical grade thermoplastic elastomer, designed to create a non-inflatable anatomical seal of the pharyngeal, laryngeal and perilaryngeal structures. I-gel comes in four pediatric and three adult sizes available. Key components and their functions: Soft non-inflatable cuff Gastric channel for regurgitation, which significantly reduces potential for regurgitation to get past the cuff and therefore aids in reducing the chance for aspiration. Please note size one i-gel does not have a gastric channel. Provides?vent? for gastric pressure and stomach decompression. Epiglottic rest keeps the device from moving upwards out of position and prevents the epiglottis from down folding or obstructing the distal opening Buccal cavity stabilizer a built in natural curvature and propensity to adapt its shape from the patient?s anatomy, the widened design also provides vertical strength and prevents rotation. I-Gel INDICATIONS: Airway management in pediatric cardiac arrest Inability to intubation when rapid control of airway is essential Difficult airway cases Passive oxygenation during cardiac arrest CONTRAINDICATIONS: Responsive patient with intact airway?protective reflexes Patients with known esophageal disease Caustic ingestions Upper-airway obstructions due to foreign bodies or pathology Trismus, limited mouth opening, airway abscess, trauma or mass Warnings: I-gel must be lubricated according to the instructions for use Patient should be in?sniffing? position, unless head/neck movement are contraindicated Leading edge of i-gel tip must follow the curvature of the patient?s hard palate upon insertion 57

60 Excessive air leak during manual ventilations is a result of sub-optimal depth of the i-gel EQUIPMENT: BVM Lubricant EtCO2 sensor Gastric tube PROCEDURE: Size Selection: Select the appropriate size i-gel by assessing the patient?s anatomy. Although size selection on weight basis should be applicable to the majority of patients, individual anatomical variations mean the weight guidance provided should always be considered in conjunction with clinical assessment of the patient: Size 1: Neonate (wt. 2-5 kg) Size 1.5: Infant (wt kg) Size 2: Small Pediatric (wt kg) Size: 2.5: Large Pediatric (wt kg) Apply small bolus of a water based lubricant to the distal tip and posterior aspect of the i-gel, taking care to avoid introduction of lubricant in or near the ventilatory openings. Pre-oxygenate via BVM. Suction upper airway if necessary Position the head. The ideal head position for insertion of the i-gel is the?sniffing position?. However, if there is failure to achieve complete insertion utilizing the standard insertion technique attempt insertion while performing a jaw thrust. Hold the i-gel with dominant hand, position device so that the i-gel cuff outlet is facing toward the chin of the patient. Non-dominant hand should gently press down on patients chin. Introduce the leading soft tip into the patient?s mouth of the patient in the direction of the hard palate. Glide the device downward and backward along the hard palate with a continuous but gentle push until definitive resistance is felt Warning: Do not apply excessive force on the device during insertion. It is not necessary to insert fingers or thumbs into the patient?s mouth during the process of inserting the device. If there is early resistance perform?jaw thrust? to aid in insertion. I-Gel Inserted 58

61 Once resistance is met and the teeth are located on the integral bite block, do not repeatedly push the i-gel down or apply excessive force during insertion. NO more than three attempts in one patient should be attempted Attach BVM and Capnography to the 15 mm connector of the i-gel Secure i-gel, ensure that there is sufficient tension to hold the i-gel securely in place, but not excessive tension as to cause trauma to patients neck and or face or that may cause unwanted downward pressure on the i-gel causing displacement Ventilate patient at appropriate rate Confirm placement by auscultation and chest rise, monitor end title Co2 For gastric distention, see chart below of appropriate nasogastric (NG) tube. I-gel Size Maximum size of Nasogastric Tube 1 N/A

62 Transcutaneous Pacing Procedure Procedure Guidelines 9.30 TRANSCUTANEOUS PACING PROCEDURE INDICATIONS: Asystole Practice Parameter 4.02 Supraventricular Bradycardia and A.V. Blocks Practice Parameter 4.09 PEA with Absolute Bradycardia Parameter 4.04 PROCEDURE: Apply monitor and determine rhythm. Stop CPR, (if applicable). Place electrodes in proper position. Place the negative pad and negative pacer wire on left anterior chest, halfway between the xiphoid process and the left nipple, with the upper edge of the electrode below the nipple line. Place the positive pad and positive pacer wire on left posterior chest beneath the scapula and lateral to the spine. Turn the pacer on: Precautions: Pacemaker output may cause excessive pain/distress in the conscious patient. Consider administration of Diazepam 2-10 mg slow IVP. Set the rate at 60 beats per minute. Slowly increase milliamps until electrical and mechanical capture is achieved or maximum output is reached. Keep checking for a carotid or femoral pulse to determine the response to the pacing, (mechanical capture). If no response to maximum pacing output, interrupt pacing and proceed with appropriate protocol. Continue CPR, (if applicable). Leave pacing electrodes in place during drug therapy and check every 5-10 minutes for capture in maximum output setting if not successful initially. If capture present and patient remains hypotensive, increase rate of pacing, (do not exceed 80 BPM). STANDBY PACING: Turn the pacer on. Precautions: Pacemaker output may cause excessive pain/distress in the conscious patient. Consider administration of MIDAZOLAM 1-5 mg slow IVP to desired effect. Set rate at 60 BPM. Set milliamps at 0. If patient becomes unstable, slowly increase milliamps until electrical and mechanical capture is achieved or maximum output is reached. 60

63 ResQGuard Impedance Threshold Device Procedure Guidelines 9.31 ResQGUARD Impedance Threshold Device DEFINITION: The ResQGARD is an impedance threshold device (ITD) that provides therapeutic resistance to inspiration in spontaneously breathing patients. During inspiration, a negative pressure (created from expansion of the thorax) draws air into the lungs. When inspiratory impedance is added to the ventilation circuit, it enhances the negative pressure (vacuum) in the chest, which pulls more blood back to the heart, resulting in increased preload and thus, enhanced cardiac output on the subsequent cardiac contraction. INDICATIONS: Patients over 12 years old or over 50 Kg. Patients experiencing symptoms of low blood circulation or hypotension (Systolic Blood pressure of less than 100 mmhg), which can be secondary to a variety of causes such as dialysis, hypovolemia, dehydration, sepsis and orthostatic intolerance. CONTRAINDICATIONS: Known dilated cardiomyopathy Left-sided congestive heart failure Pulmonary hypertension and/or aortic stenosis Flail chest Chest pain and/or shortness of breath On-going, uncontrolled blood loss with penetrating thoracic (chest) injury PRECAUTIONS: The ResQGARD may benefit patients who suffer from non-thoracic penetrating injury and ongoing blood loss once a clinical decision has been made to treat the patient with fluid resuscitation, but the safety and effectiveness of the ResQGARD in this clinical setting has not been established. The safety and effectiveness in persons suffering from arterial stenosis or asthma has not been established. Prolonged use for more than 30 minutes has not been clinically evaluated. If respiratory distress develops during use of the ResQGARD, immediately discontinue use. PROCEDURE: Using the ResQGARD on a facemask: Connect the ResQGARD to the vented facemask provided; be sure pieces fit together snugly. Explain to the patient that the device will make it slightly more difficult to take a breath but that the resistance is what may make them feel better. Gently (but firmly) hold the ResQGARD over the nose and mouth (or have the patient hold), establishing and maintaining a tight face seal with facemask. A head strap (e.g. ResQStrap) may be used if the patient does not want to hold the ResQGARD in place. Breathe in slowly (over 2? 3 secs) and deeply; exhale normally. Breathe at a rate of 10? 16/minute. 61

64 If supplemental oxygen is used, attach the tubing to the oxygen port on the ResQGARD and deliver up to fifteen (15) lpm but do not exceed 15 lpm. Using the ResQGARD with a mouthpiece: Connect the ResQGARD to the mouthpiece provided; be sure pieces fit together snugly. Explain to the patient that the device will make it slightly more difficult to take a breath but that the resistance is what may make them feel better. Place the mouthpiece into the patient?s mouth and establish and maintain a tight seal with the lips. Breathe in slowly (over 2? 3 secs) and deeply through the mouth only; exhale normally. Breathe at a rate of 10? 16/minute. A nose clip may be helpful if the patient has trouble inspiring only through their mouth. If supplemental oxygen is used, attach the tubing to the oxygen port on the ResQGARD and deliver up to fifteen (15) lpm but do not exceed 15 lpm. Use the application device (mask or mouthpiece) that is best suited for the patient?s condition, compliance tolerance. 62

65 Procedure Guidelines Emergency Escharotomy 9.32 Emergency Chest Wall Escharotomy DEFINITION: The Emergency Chest Wall Escharotomy is indicated when full-thickness circumferential and near-circumferential skin burns over the torso result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced significant compromise of chest wall excursions and can hinder ventilation. Similarly, airway patency and venous return may be compromised by circumferential burns involving the neck. Emergency Chest Wall Escharotomy is the surgical division of the nonviable eschar, which allows the cutaneous envelope to become more compliant. Hence, the underlying tissues have an increased available volume to expand into, preventing further tissue injury or functional compromise (see image below). INDICATIONS: Patients presenting with circumferential or near-circumferential 2nd degree or higher burns to the torso with an impending or established respiratory compromise as a result of the burns. CONTRAINDICATIONS: On patients with an impending or established respiratory/ventilator compromise as a result of circumferential or near-circumferential 2nd degree or higher burns to the torso there are no contraindications for this procedure. COMPLICATIONS: May include continued respiratory compromise due to inadequate ventilation as a result of a partial or incomplete release of eschar. Excessive bleeding Incision or injury to underlying healthy tissue including neurovascular structures Infection PROCEDURE: The patient is placed in a supine position while maintaining ventilatory support efforts. Time permitting? cleanse the area of any excess debri or loose clothing. 63

66 Utilizing a surgical scalpel carry the incision of the eschar down through the level of the subcutaneous fat. An immediate release in tissue pressure is experienced often as a discernible popping sensation. Carry the incisions approximately 1 cm proximal, lateral and distal to the extent of the burn. Once the escharotomy is performed, monitor for improvement in ventilation as evidenced by improved compliance of ventilations using a bag/valve device, visible chest rise and improvements in oxygen saturation. If improved compliance is not seen after the initial incision, revise the escharotomy in an attempt to improved ventilatory support. Once completed, cover the torso / chest wall area with a sterile burn sheet. Maintain continuous monitoring of the patient?s respiratory compliance and oxygenation. 64

67 Venous Lactate Monitoring Procedure Procedure Guidelines 9.33 Venous Lactate Monitoring Procedure DEFINITION: The Venous Lactate Monitoring Procedure is indicated when a patient is suspected of sepsis or other medical condition that causes hypoperfusion of vital organs or there is a concern the patient is suffering from metabolic distress in shock or end-organ failure. It helps confirm cryptic shock. INDICATIONS: Patients presenting with signs and symptoms consistent of sepsis, have had a sepsis screening checklist completed with two or more positive major criteria and two or more positive minor criteria identified. CONTRAINDICATIONS: On patients with impending shock, suspected sepsis or end-organ failure, there are no contraindications for this procedure. COMPLICATIONS: Prolonged bleeding from the blood draw site. Pain from the lancing procedure. Infection. PROCEDURE: Please refer to the device?s USER MANUAL for more detailed procedures specific to the monitor being used by your agency. The procedure below is generic for the Lactate Pro monitors. Do not use alcohol to clean the site unless it is extremely dirty. If alcohol is used allow it to completely dry prior to testing, failure to do so will cause incorrect readings. If the patient's hands are sweaty, dry with gauze before testing, sweat will cause incorrect readings. Do not use blood from an IV site or if an IV tourniquet is on the patients arm. This will cause a high reading. Place a new test strip (green in color) into the Lactate Pro monitor by opening the foil and inserting the strip into the device. Be careful not to touch the strip. Use the test strip immediately after opening it. If left open to air for a long period of time (greater than 5 minutes) discard and use a new test strip. The monitor will display the calibration number (usually an F-0 through F-12 number) before it is ready to accept a sample. This number must match the one of the strip being used. If the strip is inserted and a sample not placed into the strip within three (3) minutes, the monitor will turn off automatically. Lance the finger using a safety type lancing device. Press to obtain the first drop of blood from the site. DISCARD the first drop. Use the second drop obtained to complete the test. Put the tip or end of the strip against the drop of blood. The strip using a wicking effect will draw the blood sample into the strip. When enough blood is drawn, the monitor will make a beep sound. 65

68 It takes 60 seconds to obtain a reading. The monitor will show a time countdown until the test is completed. If not enough blood is placed in the strip, the machine will not beep and/or run the test. Remove the strip, place a new one and repeat the test making sure enough blood is used and drawn until the beep sound is heard. The monitor will display?lo? if the venous lactate level is below 0.8 mmol/l and?hi? if the level is above 23.3 mmol/l. If this is the case, please repeat the test. Note in the incident record the results for both procedures. Levels equal to or greater than 4 mmol/l are considered positive findings for metabolic distress and hypoperfusion. The monitor must be checked with the?check strip? at least monthly or anytime there is a concern regarding the proper operation of the unit. It is suggested the check strip procedure to be completed the first Sunday of each month. 66

69 Central Venous Access Devices Section 9 - Procedure Guidelines 9.34 CENTRAL VENOUS ACCESS DEVICES Central Venous Access Devices (CVAD) or central venous catheters are used as the mainstay of treatment for patients requiring long term administration of medications or providing medical treatments such as antibiotics, chemotherapy or dialysis. These devices may be maintained with normal saline or heparin to prevent clotting or occluding the catheter. When to use: Seminole County Paramedics are authorized to access only Peripherally Inserted Central Catheters (PICC) and central venous catheters under the following conditions: After two peripheral IV attempts have been unsuccessful. Life-threatening event requiring immediate medication or fluid administration. Major trauma. Cardiac arrest. SCEMS Paramedics are not authorized to access dialysis shunts or implanted ports. How to identify: Central venous access devices come in a variety of styles. Always inquire, if possible, from the patient or family what type of access device is implanted on the patient ṖICC lines are usually single or double lumen (port) with a smaller size tubing inserted into the forearm or upper arm of the patient. Central venous catheters may have from one to three lumens (ports) and are usually inserted near the neck and into the subclavian vein. Implanted ports are located in the chest wall and they resemble a triangular or round device under the skin of the patient. These have no exposed ports or lines and must be accessed with a special needle. Dialysis catheters are usually large caliber lines with one venous (blue) and one arterial port (red). Procedure: Identify the location of the central venous access device. Cleanse the access port with alcohol or betadine. Central lines have clamps on each access port. Keep all clamps secured except the one being used for infusion. Any time the central line port is accessed and line or CLAVE type port being connected, the clamp must be secured to prevent air from entering the line. An open line can aspirate air into it causing an air embolus. Use a large syringe (12-20 ml) with a luer adapter to connect to the central line port. ASPIRATE the line gently and withdraw ml of fluid and blood until you have only blood on the line. This is done to aspirate the saline or heparin that was previously infused to maintain the line. DO NOT PUSH/FLUSH the contents of the catheter into the bloodstream! If the catheter is heparinized it will cause coagulation changes and may be detrimental to the patient. Discard the syringe used to aspirate the contents of the catheter. Cleanse the access port again before inserting a new saline filled syringe. 67

70 Using a new ml syringe filled with normal saline, gently flush the line in and assess for patency. The line should flow smoothly without resistance. If the line is difficult to flush or you are unable to flush? DO NOT USE! In the event the line cannot be flushed look for another IV site or gain access using an IO device. Once the line is accessed, connect IV tubing and infuse normal saline at the appropriate rate. Central lines and PICCs, once accessed must have continuous fluid infusion at a minimum of a KVO rate. SCEMS Paramedics are not authorized to discontinue the infusion once it is started and the line is flowing patent. Hospital staff must evaluate infusion before disconnecting or removing access based on their policies. Contraindications: Central Venous Access Devices must not be used: If a peripheral IV access can be easily attained As a preventative measure? prophylactic IV line The device is known to be occluded It is suspected to be infected or be the source of infection If other medications are already infusing through the line (compatibility problem) WARNING Central Venous Access Devices should be utilized ONLY if no other IV access can be obtained rapidly and before intraosseous access is performed during a LIFE-THREATENING emergency. SCEMS Paramedics must consider the RISK vs. BENEFIT of accessing these types of devices and use only when it is in the best interest of the patient. 68

71 Medication Administration Cross Check Section 9 - Procedure Guidelines 9.35 MEDICATION ADMINISTRATION CROSS CHECK With the reliance of medications as one of the primary treatment interventions during patient care it is important to recognize these products have potential harm as well as benefits. Patients could be harmed if the wrong medication, dose, concentration, or route of administration is used. To complicate matters, medications often come in similar packaging; have similar look-alike/sound-alike names which can further enhance the error potential. It is incumbent upon the entire EMS crew to be vigilant and observe careful medication administration protocol to reduce and prevent medical errors. The provider administering any medication will follow the Medication Administration Cross Check (MACC) procedure each time any medication is used. Medication Administration Cross Check Procedure: All SCEMS providers shall check the following prior to medication administration: Five patient rights Right Patient Right DRUG Right DOSE Right ROUTE Right Time Confirm any MEDICATION ALLERGIES that the patient may have and determine if there are any contraindications to administering the selected medicine. Confirm that the medication is NOT EXPIRED. The medication should be confirmed at each of the following steps: When the medication is retrieved from the drug box: Check for correct medication Check expiration date Do not use if medication is expired When the medication is drawn or IV bag is primed just prior to administration: Confirm it is the correct medication Confirm it is the correct dose Confirm the medication is not expired If one provider selects or draws the medication but is given by another provider the two providers must have verbal confirmation of these checks: Provider 1 (drawing the medication) shall verbalize to the administering provider the following: Name of medication Dose of medication and any dilution used Medication is not expired Provider 2 (administering the medication) shall confirm the information is accurate prior to administration. Documentation: It is incumbent upon all providers to properly document on the incident run report all medications administered including name, dose, concentration (if applicable), route of administration and response to the medication. The provider must also describe the process in which the medication was identified and cross check completed in the patient report. WARNING: 69

72 Medication Administration Cross Check is a required part of the administration procedure. All personnel must follow this procedure to prevent medication errors. SCEMS Paramedics must consider the RISK vs. BENEFIT of any medication given as medications may have adverse or lethal effects for the patient. 70

73 Combat Application Tourniquet Procedure Guidelines 9.36 COMBAT APPLICATION TOURNIQUET Severe traumatic extremity injuries with uncontrolled bleeding may sometimes require the application of a tourniquet. The Combat Application Tourniquet (C.A.T.) is designed to provide effective pressure on the injured extremity to occlude arterial bleeding. The C.A.T. is approved for use by SCEMS personnel where tourniquet application is indicated. See PP 6.06?Extremity Injuries? for indications. FEATURES: The C.A.T. uses a self-adhering band and friction adaptor buckle to fit a wide range of extremity sizes combined with a one-handed windlass system. The windlass system uses a free moving internal band to provide even circumferential pressure to the extremity. APPLICATION PROCEDURE: C.A.T. application Step 1 Apply tourniquet proximal to the bleeding site. Route the band around the limb and pass the tip through the inside slit of the buckle. Pull the band tight. Step 2 Pass the tip through the outside slit of the buckle. The friction buckle will lock the band in place. Step 3 Pull the band very tight and securely fasten the band back on itself. Step 4 Twist the rod until bright red bleeding has stopped and the distal pulse is eliminated. Step 5 Place the rod inside the clip; locking it in place. Check for bleeding and distal pulse. If bleeding is not controlled, consider additional tightening or applying a second tourniquet proximal side by side to the first and reassess. Step 6 Secure the rod inside the clip with the strap. Prepare the patient for transport and reassess. Record the time of application. 71

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75 ITClamp Hemorrhage Control System Procedure Guidelines 9.38 itclamp Hemorrhage Control System TRAINING itclamp? hemorrhage control system requires specific training prior to use. INDICATIONS The ITClamp?50 device is a trauma clamp device for the temporary control of severe bleeding in the extremities, axilla and inguinal areas. itclamp device CONTRAINDICATIONS The ITClamp50 is contraindicated where skin approximation cannot be obtained (for example, large skin defects under high tension). WARNINGS This device is intended for temporary?use only; FDA Approval is for 24 hours Patients must be seen promptly by medical personnel for device removal and surgical wound repair Only use device as directed to avoid needle stick injury Do not use where delicate structures are near the skin surface, within 10 mm, such as the orbits of the eye Will not control hemorrhage in non-compressible sites, such as the abdominal and chest cavities Ensure personal protective equipment is utilized to protect against potential splashing of blood during application PRECAUTIONS Single-use, disposable device; not for reuse. Re-use of contents may cause cross contamination, leading to patient risk and complication(s). Can be repositioned. itclamp50 is provided sterile (sterilized by EtO). Do not use if sterility seal has been tampered with or packaging is damaged. Not compatible with Magnetic Resonance Imaging (MRI) procedures. 73