§ 107 Procedures and Patient Care Reference 12-LEAD—MONITORING AND LEAD PLACEMENT ............................................................ 109 12-LEAD—LOCALIZING SITE OF INFARCT ............................................................................. 110 12-LEAD—STEMI RECOGNITION AND DESTINATION .......................................................111 12-LEAD—STEMI REPORT ........................................................................................................... 112 12-LEAD—TRANSMISSION OF MONITOR DATA ................................................................. 113 BLS AIRWAY MANAGEMENT............................................................................................114 –115 INTRAOSSEOUS INFUSION IN ADULTS.........................................................................116 –117 INTRAOSSEOUS INFUSION IN ADULTS—HUMERAL SITE ............................................... 118 INTRAOSSEOUS INFUSION—PROXIMAL AND DISTAL TIBIA ......................................... 119 INTRAOSSEOUS INFUSION IN CHILDREN ............................................................................. 120 KEY PROCEDURES ............................................................................................................... 121–126 NON-INVASIVE MONITORING OF END-TIDAL CO 2 ......................................................... 127 OXYGEN THERAPY ........................................................................................................................ 128 OXYGEN TITRATION AND PULSE OXIMETRY MONITORING .......................................... 129 PAIN ASSESSMENT AND MANAGEMENT ............................................................................. 130 PAIN ASSESSMENT TOOLS ......................................................................................................... 131 PEDIATRIC ASSESSMENT ............................................................................................................ 132 PEDIATRIC VITAL SIGNS/GLASGOW COMA SCALE............................................................ 133 PEDIATRIC MEDICATION ADMINISTRATION ....................................................................... 134 RULE OF NINES—BURN SURFACE AREA ............................................................................... 135 SEPSIS SCREENING ....................................................................................................................... 136 SPINAL INJURY ASSESSMENT.................................................................................................... 137 SPINAL MOTION RESTRICTION (SMR) ................................................................................... 138 VASCULAR ACCESS ....................................................................................................................... 139 VENTRICULAR ASSIST DEVICES (VAD) ................................................................................... 140 table of contents—procedures and patient care
Transcript
§ 107Procedures and Patient Care Reference
12-LEAD—MONITORING AND LEAD PLACEMENT ............................................................10912-LEAD—LOCALIZING SITE OF INFARCT ............................................................................. 11012-LEAD—STEMI RECOGNITION AND DESTINATION .......................................................11112-LEAD—STEMI REPORT ........................................................................................................... 11212-LEAD—TRANSMISSION OF MONITOR DATA ................................................................. 113 BLS AIRWAY MANAGEMENT ............................................................................................114–115INTRAOSSEOUS INFUSION IN ADULTS.........................................................................116–117INTRAOSSEOUS INFUSION IN ADULTS—HUMERAL SITE ............................................... 118INTRAOSSEOUS INFUSION—PROXIMAL AND DISTAL TIBIA ......................................... 119INTRAOSSEOUS INFUSION IN CHILDREN .............................................................................120KEY PROCEDURES ............................................................................................................... 121–126NON-INVASIVE MONITORING OF END-TIDAL CO2 .........................................................127OXYGEN THERAPY ........................................................................................................................128OXYGEN TITRATION AND PULSE OXIMETRY MONITORING ..........................................129PAIN ASSESSMENT AND MANAGEMENT .............................................................................130PAIN ASSESSMENT TOOLS ......................................................................................................... 131PEDIATRIC ASSESSMENT ............................................................................................................ 132PEDIATRIC VITAL SIGNS/GLASGOW COMA SCALE............................................................133PEDIATRIC MEDICATION ADMINISTRATION .......................................................................134RULE OF NINES—BURN SURFACE AREA ...............................................................................135SEPSIS SCREENING .......................................................................................................................136SPINAL INJURY ASSESSMENT.................................................................................................... 137SPINAL MOTION RESTRICTION (SMR) ...................................................................................138VASCULAR ACCESS .......................................................................................................................139VENTRICULAR ASSIST DEVICES (VAD) ...................................................................................140
table of contents—procedures and patient care
108 §Procedures and Patient Care Reference
§ 109Procedures and Patient Care Reference
12-LEAD MONITORING AND LEAD PLACEMENTLimb Lead Placement: • Place limb leads on distal extremities if
possible• Confirm correct lead placement for each
limb • May be moved to proximal if needed (if
motion artifact)
Chest Lead Placement: To begin placement of chest leads, locate sternal angle (2nd ribs are adjacent) then count down to 4th interspace (below 4th rib)
V1—4th intercostal space at the right sternal borderV2—4th intercostal space at the left sternal borderV4—5th intercostal space at left midclavicular lineNote: Place V4 lead first to aid in correct placement of V3V3—Directly between V2 and V4V5—Level of V4 at left anterior axillary lineV6—Level of V4 at left mid-axillary lineIMPORTANT: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG12-lead monitoring should continue throughout call to assess for potential changes.
sternal angle
110 §
LOCALIZING SITE OF INFARCT• Localization of an infarct pattern adds to the accuracy of ECG
interpretation • A STEMI will have 1 mm or more ST-segment elevation in 2 or more
contiguous leads (which means findings noted in the same anatomical location of the infarct) • Contiguous leads for inferior infarction include II, III, and aVF • Contiguous leads for anterior infarction include V1–V4 (V1–V2
elevation also called septal infarction) • Contiguous leads for lateral myocardial infarction include Leads I, aVL,
V5, and V6 • Lateral MI findings may be in addition to anterior or inferior MI
patterns (anterolateral or inferolateral)
I–LATERAL aVR V1–SEPTAL or ANTERIOR
V4–ANTERIOR (V4R–RVMI)
II–INFERIOR aVL–LATERAL V2–SEPTAL or ANTERIOR V5–LATERAL
III– INFERIOR aVF–INFERIOR V3–ANTERIOR V6–LATERAL
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LOCALIZING SITE OF INFARCT• Localization of an infarct pattern adds to the accuracy of ECG
interpretation • A STEMI will have 1 mm or more ST-segment elevation in 2 or more
contiguous leads (which means findings noted in the same anatomical location of the infarct) • Contiguous leads for inferior infarction include II, III, and aVF • Contiguous leads for anterior infarction include V1–V4 (V1–V2
elevation also called septal infarction) • Contiguous leads for lateral myocardial infarction include Leads I, aVL,
V5, and V6 • Lateral MI findings may be in addition to anterior or inferior MI
patterns (anterolateral or inferolateral)
STEMI RECOGNITION AND DESTINATIONSTEMI RECOGNITION
• Patients who have ECGs of acceptable quality with the following messages are candidates for transport to STEMI Receiving Centers:• ***Acute MI Suspected*** (LIFEPAK 12) • ***Meets ST-Elevation MI Criteria*** (LIFEPAK15)
• The 12-lead ECG should be inspected prior to initiation of a STEMI Alert—a steady baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation
• Causes of artifact include patient motion or tremor, poor lead contact, or electrical interference
• Good skin preparation is essential for optimal lead contact and clear 12-lead tracings
• If artifact is noted the ECG should be repeated• Paced rhythms may cause false readings—the
pacemaker spike is not always detected by the computer algorithm. Inform facility if patient has a pacemaker during report.
STEMI REPORT If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon as possible following completion of the ECG
DESTINATION POLICY
Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC)• Patients shall be transported to the closest SRC
unless they request another facility • A SRC that is not the closest facility is an acceptable
destination if estimated additional transport time does not exceed 15 minutes
• Patients with cardiac arrest and return of spontaneous circulation shall be transported to the closest SRC regardless of 12-lead results.
• Patients with unmanageable airway en route shall be transported to the closest available emergency department
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STEMI REPORT• A patient with a computer interpretation of ***Acute MI Suspected***
(LP-12) or ***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center
• Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have significant baseline artifact or other deficit before initiating a STEMI Alert
SITUATION • Identify the call as a “STEMI Alert” • Estimated time of arrival (ETA) in minutes • Patient age and gender • Report ECG computer interpretation has a STEMI
message (as listed above) • Report if subsequent ECG findings are variable
or if ECG quality not optimal (e.g., if no ***Acute MI*** findings noted in tracings without significant artifact)
• Verify that 12-lead ECG Transmission has been completed and received
BACKGROUND • Presenting chief complaint and symptoms • Pertinent past cardiac history • History of pacemaker (important—paced rhythms
may give false ECG interpretations)ASSESSMENT • General assessment
• Pertinent vitals (especially heart rate and BP) and physical exam
• Cardiac rhythm • Pain level
RX – RECAP • Prehospital treatments given • Patient response to prehospital treatments
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STEMI REPORT• A patient with a computer interpretation of ***Acute MI Suspected***
(LP-12) or ***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center
• Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have significant baseline artifact or other deficit before initiating a STEMI Alert
SITUATION • Identify the call as a “STEMI Alert” • Estimated time of arrival (ETA) in minutes • Patient age and gender • Report ECG computer interpretation has a STEMI
message (as listed above) • Report if subsequent ECG findings are variable
or if ECG quality not optimal (e.g., if no ***Acute MI*** findings noted in tracings without significant artifact)
• Verify that 12-lead ECG Transmission has been completed and received
BACKGROUND • Presenting chief complaint and symptoms • Pertinent past cardiac history • History of pacemaker (important—paced rhythms
may give false ECG interpretations)ASSESSMENT • General assessment
• Pertinent vitals (especially heart rate and BP) and physical exam
• Cardiac rhythm • Pain level
RX – RECAP • Prehospital treatments given • Patient response to prehospital treatments
TRANSMISSION OF MONITOR DATA• 12-Lead ECG transmission is an enhancement to the STEMI system that allows facilities
to interpret 12-lead data prior to patient arrival, appropriately prepare, and appropriately activate resources when indicated
• Transmission of cardiac arrest monitor data and data related to treatment of dysrhythmias and patient intubations allows appropriate documentation and review of care provided in those situations
12-Lead ECG Transmission
12-LEAD TRANSMISSION
• Any 12-Lead ECG that indicates that a patient is having a STEMI should be transmitted to the STEMI receiving center where the patient is being transported
• For other patients who have 12-Lead ECGs done, at least one should be transmitted to the destination hospital or other monitor site identified by your provider agency
IDENTIFIERS At a minimum, 12-Lead ECG labeling should include initials of the first and last name of the patient. Provider agencies may require additional labeling
HOSPITAL NOTIFICATION
Once a STEMI 12-Lead has been transmitted to a STEMI receiving facility, that facility should be notified as soon as possible following the transmission of the ECG to verify receipt and to complete STEMI alert
REVIEW Not all hospitals have ability to review transmitted ECGs and some may filter out normal or non-acute appearing ECGs. Hard copies of ECGs also must be left at all receiving facilities.
Transmission of Cardiac Arrest and Other Monitor DataINDICATIONS FOR TRANSMISSION
• Cardiac arrests • Any calls that involve the treatment of a cardiac dysrhythmia
(medication, cardioversion or pacing) • Any call involving monitoring of intubated patients• Any other call in which the paramedic believes data review may
add to PCR documentation of events
TRANSMISSION • Transmit "ALL" data to the monitor site identified by your provider agency
REVIEW • This data is transmitted to the provider agency and to EMS for review but does not go to hospitals for immediate access. Code summaries should be printed and left at receiving facilities.
Note: Optimally, a single monitor should be used to gather data, particularly with regard to cardiac arrest or continuous monitoring of intubated patients
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BLS AIRWAY MANAGEMENTGOALS The goal of airway management is to ensure
adequate ventilation and oxygenation. Initial airway management should always begin with BLS Maneuvers
VENTILATION RATES AND DELIVERY
Avoid excessive ventilation. In non-arrest patients, ventilation rates:
Deliver ventilations over one second to produce visible chest rise and to avoid distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary based on patient size.
PREFERRED MANEUVERS
Two-person technique is the preferred method to ventilate patients using bag-valve mask deviceManeuvers—Use “JAWS”J—Jaw thrust maneuvers to open airwayA—Airway—Use oral or nasal airwayW—Work together—Ventilation using a bag-valve mask should include two rescuers—one to hold mask and other to deliver ventilationsS—Slow and small ventilations to produce visible chest rise
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BLS AIRWAY MANAGEMENTGOALS The goal of airway management is to ensure
adequate ventilation and oxygenation. Initial airway management should always begin with BLS Maneuvers
VENTILATION RATES AND DELIVERY
Avoid excessive ventilation. In non-arrest patients, ventilation rates:
Deliver ventilations over one second to produce visible chest rise and to avoid distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary based on patient size.
PREFERRED MANEUVERS
Two-person technique is the preferred method to ventilate patients using bag-valve mask deviceManeuvers—Use “JAWS”J—Jaw thrust maneuvers to open airwayA—Airway—Use oral or nasal airwayW—Work together—Ventilation using a bag-valve mask should include two rescuers—one to hold mask and other to deliver ventilationsS—Slow and small ventilations to produce visible chest rise
BLS AIRWAY MANAGEMENTAIRWAY POSITIONING
Position the patient to optimize airway opening and facilitate ventilations (see below)• Use the sniffing position with head extended (A)
and neck flexed forward (B) unless suspected spinal injury
• Position with head/shoulders elevated—anterior ear should be at the same horizontal level as the sternal notch (C). This is especially advantageous in larger or morbidly obese patients.
C
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INTRAOSSEOUS INFUSION IN ADULTSINDICATIONS • Cardiac arrest
• When IV access unsuccessful or after evaluation of potential sites it is determined that an IV attempt would not be successful in the setting of:• Shock or evolving shock, regardless of cause • Impending arrest or unstable dysrhythmia
CONTRAINDICATIONS • Fracture of the targeted bone• IO within the past 48 hours in the targeted bone • Infection at the insertion site • Burns that disrupt actual bone integrity at insertion site • Inability to locate landmarks or excessive tissue over the
insertion site • Previous orthopedic procedure near insertion site (prosthetic
limb or joint)
INSERTION SITE • Proximal humerus (preferred in patients with perfusing rhythm) • Proximal tibia • Distal tibia (if proximal humerus or tibia unavailable)
PROCEDURE 1. Locate insertion site: • The proximal humerus site is the greater tubercle,
identifiable as a prominence on the humerus when the arm is rotated inward and the patient’s hand is on the abdomen
• The proximal tibia site is on the flat medial aspect of the tibia 2 finger-breadths below the lower edge of the patella and medial to the tibial tuberosity
• The distal tibia site is 2 finger-breadths above the most prominent aspect of the medial malleolus (inside aspect of ankle) in the midline of the shaft of the tibia
2. Prep the insertion site with chlorhexidine and let air dry 3. Select and load the appropriately sized needle on the driver
• For humeral access the 45 mm (yellow) needle is used except in adult patients less than 40 kg
• For proximal and distal tibial access the amount of soft tissue should be gauged to determine if a 25mm (blue) or 45 mm (yellow) needle is appropriate
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INTRAOSSEOUS INFUSION IN ADULTSPROCEDURE 4. Introduce the intraosseous needle through the skin as follows without pulling
trigger of the power driver:• For humeral site, the direction of the needle should be placed
perpendicular to the skin, directed at a downward angle of 45 degrees from the frontal plane, heading slightly downward toward the feet (see images);
• For tibial sites, the direction of the needle should be at a 90 degree angle to the flat surfaces of the tibia (see images).
5. Once the needle has touched the bone surface, assess to see if the black line on the needle is visible. If it is not visible, either a larger needle is needed or (in the case of use of 45 mm needle) the soft tissue is too thick to allow use of the IO.
6. With firm pressure, insert needle using power driver. In most cases, the hub should be flush or touching the skin. Verify that needle is firmly seated in the bone (should not wobble).
7. Remove stylet and instill lidocaine if patient not in arrest:• For adult patients not in arrest, 40 mg (2 ml) of lidocaine
2% should be infused slowly over 1–2 minutes and allow one additional minute before starting flush.
• For patients in arrest, no lidocaine is necessary initially but may be needed if patient regains consciousness.
8. Flush with 10 ml saline. In conscious patients, flush with 5 ml saline initially and repeat if necessary (may cause less patient discomfort).
9. Attach stabilizer to skin.10. Attach IV tubing to intraosseous hub, and begin infusion using pressure
bag on IV bag.11. If painful, an additional 20 mg (1 ml) of lidocaine 2% can be infused over
30 seconds, and after another minute, infusion should be restarted.12. Monitor site for swelling or signs of infiltration and monitor pulses distal to
area of placement.13. Place wristband included with IO set on patient.
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INTRAOSSEOUS INFUSION IN ADULTS—HUMERAL SITE
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INTRAOSSEOUS INFUSION—PROXIMAL AND DISTAL TIBIA
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INTRAOSSEOUS INFUSION IN CHILDRENIndications and contraindications same as adult procedure. Use only proximal tibial site in children.PROCEDURE 1. Locate the insertion site—for pediatric patients the location of proximal tibial
site is on the flat medial aspect of the tibia 2 finger-breadths below the lower edge of the patella and medial to the tibial tuberosity.
2. Prep the insertion site with chlorhexidine and let air dry.3. Select and load the appropriately sized needle onto the driver:
• The 15 mm (pink hub) needle is appropriate in infants or in small children with thin amounts of soft tissue in the proximal tibial site;
4. Introduce the intraosseous needle at a 90 degree angle to the flat surface of the tibia without pulling the trigger of the power driver.
5. Once the needle has touched the bone surface, assess to see if the black line on the needle is visible. If it is not visible, remove needle, switch to a longer needle set and reinsert (again without pulling the trigger of the power driver).
6. With mild to firm pressure, insert needle using power driver. For small children, once a “give” is sensed as the outer bony cortex is penetrated, remove finger from power driver trigger to stop insertion (do not withdraw driver when stopping). The IO hub may not be against the skin.
7. Remove stylet and instill lidocaine if patient not in arrest:• For pediatric patients not in arrest, 0.5 mg/kg of lidocaine
2% should be infused slowly over 1–2 minutes and allow one additional minute before starting flush. See pediatric drug chart for weight-based dose.
• For patients in arrest, no lidocaine is necessary initially but may be needed if patient regains consciousness.
8. Flush with 5 ml saline9. Attach stabilizer to skin10. Attach IV tubing to intraosseous hub:
• Utilize stopcock and syringe to administer appropriate fluid dose in smaller children
• Pressure bag may be used in larger children (>50 kg).11. Monitor site for swelling or signs of infiltration and monitor pulses distal to
area of placement12. Place wristband included with IO set on patient.
12-Lead ECG INDICATIONS:• Chest pain or suspected Acute Coronary Syndrome (ACS) • Atypical ACS or anginal equivalents:
• Symptoms include shortness of breath, diaphoresis, syncope, dizziness, weakness, and altered level of consciousness
• Elderly patients, females and diabetics are more likely to present atypically
• Dysrhythmias (both pre- and post-conversion) • Suspected cardiogenic shock • Cardiac arrest after return of spontaneous circulationCONTRAINDICATIONS:• Uncooperative patient • Any condition in which delay to obtain ECG would compromise
immediately needed care (e.g. arrhythmia requiring immediate shock)
AUTOPULSE (SRVFPD)
INDICATIONS:• Cardiac Arrest in AdultsCONTRAINDICATIONS:• Pediatric patients• Trauma patients• Patients too small or large for the compression band
BLOOD GLUCOSE TESTING
INDICATIONS:• Altered level of consciousness • Patients with signs and symptoms of hypoglycemia (may
include diaphoresis, weakness, hunger, shakiness, anxiety)CONTRAINDICATIONS:• Patients not meeting any indication
CO-OXIMETRY (CARBON MONOXIDE)
INDICATIONS:• Suspected carbon monoxide poisoningCONTRAINDICATIONS:• NoneCOMMENT:• May be unreliable with poor perfusion, excessive patient
INDICATIONS:The patient is awake, able to maintain airway and follow commands and has 2 or more findings:• RR >25• Pulse ox <94%• Use of accessory musclesCONTRAINDICATIONS:• Unconscious or unable to follow commands• Respiratory arrest / apnea• Pneumothorax• Vomiting• Major head, facial or chest trauma
ENDOTRACHEAL INTUBATION
INDICATIONS:• Patient with decreased sensorium (GCS less than or equal to 8)
and apneic (adults)• Patient with decreased sensorium (GCS less than or equal to 8)
and ventilation unable to be maintained with BLS airwayCONTRAINDICATIONS:• Pediatric patients under 40 kg• Suspected hypoglycemia or narcotic overdose• Maxillo-facial trauma with unrecognizable facial landmarks• Seizures• Patients with an active gag reflexCOMMENT:• In non-arrest patients, allow no more than 2 interruptions of
ventilation lasting up to 30 seconds during laryngoscopy or intubation attempts
INDICATIONS:Symptomatic bradycardiaCONTRAINDICATIONS:• Cardiac arrest• Hypothermia• Pediatric PatientsCOMMENT:Use careful titration with midazolam or fentanyl if required for relief of discomfort
HELMET REMOVAL INDICATIONS:Helmet should be removed if:• Interferes with airway management or spinal motion restriction• Improper fit, allowing head to move within helmet• Patient in cardiac arrestCONTRAINDICATIONS:• Patient airway and spinal motion restriction can be addressed
without helmet removalCOMMENT:Face mask of sports helmets can be removed to facilitate easy airway access. If helmet removed, shoulder pads (if worn) must also be removed to maintain neutral spinal alignment
IMPEDANCE THRESHOLD DEVICE(ITD)—ResQPOD (SRVFPD)
INDICATIONS:Patients 9 years of age in cardiac arrestCONTRAINDICATIONS:• Age below 9 years• Perfusing pulse or spontaneously breathing• History of traumatic cardiac arrest due to blunt chest trauma• Flail chestCOMMENT:
• If secretions encountered, clear device by removing and shaking
• Remove if patient resumes spontaneous breathing or regains perfusing pulse
INDICATIONS:• Patient with altered mental status, respiratory rate less
than 12 and suspected opiate overdoseCONTRAINDICATIONS:• Shock• Copious nasal secretions or bleeding• Patients with established vascular accessCOMMENT:May be less effective in patients with prior nasal mucosal damage
KING AIRWAY INDICATIONS:• Cardiac arrest • Inability to ventilate non-arrest patient (with BLS airway
maneuvers) in a setting in which endotracheal intubation is not successful or unable to be done
CONTRAINDICATIONS:• Presence of gag reflex• Caustic ingestion• Known esophageal disease (e.g. cancer, varices, stricture)• Laryngectomy with stoma (place ET tube in stoma)• Height less than 4 feet
LUCAS CHEST COMPRESSION SYSTEM
INDICATIONS:Patients with medical cardiac arrest who properly fit device.CONTRAINDICATIONS:• Traumatic arrest• Pregnant Patients• Improper fit of device
• Too small—suction cup pad does not touch chest when lowered as far as possible
• Too large—support legs of LUCAS cannot be locked to back plate without compressing patient
INDICATIONS:Signs and symptoms of tension pneumothorax:• Altered level of consciousness• Decreased BP• Increased pulse and respirations• Absent breath sounds, hyperresonance to percussion on
affected side• Jugular venous distention• Difficulty ventilating• Tracheal shiftCONTRAINDICATIONS:• Any condition without signs and symptoms of tension
pneumothorax
ORAL GLUCOSE INDICATIONS:• Altered level of consciousness with known history of
diabetes. Patient is conscious and should be able to sit in an upright position.
CONTRAINDICATIONS:• Unconscious patient or unable to sit uprightCOMMENT:• Administer up to 30 grams in the patient’s mouth.
Optimally the patient will self-administer.• If patient has difficulty swallowing, discontinue
procedure and assure open airway
STOMAL INTUBATION
INDICATIONS:Patients requiring intubation who have mature stoma and do not have a replacement tracheostomy tube availableCONTRAINDICATIONS:Patients without mature stomaCOMMENT:Pass tube until cuff is just past stoma. If inserted further, mainstem bronchus intubation may occur as carina is only around 10 cm from stoma.
INDICATIONS:• External hemorrhage from extremity that cannot be
controlled with application of dressings with direct pressure
• May be appropriate for use for hemorrhage control in multi-casualty settings
CONTRAINDICATIONS:• Hemorrhage that can be controlled with pressure or
dressings
TRACHEOSTOMY TUBE REPLACEMENT
INDICATIONS:• Dislodged tracheostomy tube (decannulation)• Tracheostomy tube obstruction not resolved by suctionCONTRAINDICATIONS:• Recent tracheostomy surgery (less than 1 month)• Inadequately sized tract or stoma for insertion of new
tube (use endotracheal tube instead)
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NON-INVASIVE MONITORING OF END-TIDAL CO2NON-INVASIVE ETCO2 MONITORING
• In patients without shock (normal perfusion), use of non-invasive end-tidal carbon dioxide measurement (ETCO2) can be valuable in monitoring respiratory rate and ventilation
• ETCO2 measurements are an earlier indicator of respiratory depression than pulse oximetry
INDICATIONS FOR ETCO2 MONITORING
• Patients at risk for inadequate ventilation may include: • Patients with borderline respiratory rates
(8–12) from overdose or other cause (may help determine if naloxone appropriate)
• Patients who have received medications such as fentanyl or midazolam that may depress respiratory rate.
• Patients with chronic lung disease and chronic hypoxia—many patients have elevated ETCO2 levels to begin with and rapidly increasing levels may indicate that a patient has decreased respirations due to oxygen therapy (loss of hypoxic drive)
ETCO2 FINDINGS • ETCO2 readings may be unreliable if there is shock or poor perfusion
• Normal ETCO2 levels range from 32–36, but this may vary based on the patient’s underlying respiratory and metabolic status
• ETCO2 levels that rise from a normal baseline to above 40 generally indicate hypoventilation is occurring
• Patient stimulation, use of BVM, or use of naloxone may be appropriate based on the situation
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OXYGEN THERAPYOXYGEN SAFETY • Oxygen has the potential to be harmful to patients
—the general goal is to have normal oxygen levels (normoxemia)—high levels are not better than normal levels. When pulse oximetry can be used, an SpO2 of 94% is considered adequate.
• Conditions in which high levels may be dangerous include stroke, patients who have return of circulation following cardiac arrest, and patients with severe chronic lung disease
INITIAL INDICATIONS FOR OXYGEN
Supplemental oxygen is indicated in the following conditions: • Altered Level of Consciousness (e.g. overdose,
seizure, stroke)• Cardiac Arrest• Chest Pain or other suspected cardiac problem
(rapid or irregular pulse)• Respiratory Distress/Respiratory Depression or Apnea• Shock• Smoke or other chemical Inhalation• Suspected carbon monoxide exposure• Trauma (major)Follow specific treatment guidelines where applicable
BLS OXYGEN ADMINISTRATION
In general, patients in distress should receive high-flow oxygen initially• Chest pain and stroke patients without respiratory
distress or shock should receive low-flow oxygenOXYGEN DELIVERY Low flow—Use nasal cannula with 4 L/min initial flow
High-flow—Non-rebreather mask with 15 L/min flow Supplement with BVM if patient is apneic or has shallow respirations
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OXYGEN TITRATION AND PULSE OXIMETRY MONITORING
PULSE OXIMETRY • Utilize pulse oximetry in all patients with oxygen therapy or suspected hypoxia
• Pulse oximetry is a tool to measure oxygenation, but must be combined with other assessments and skills to determine best patient care
PULSE OXIMETRY PITFALLS
• Pulse oximetry readings can be misleading with poor perfusion (shock) or cold extremities, hypothermia, anemia or in carbon monoxide poisoning.
• Readings may be difficult to obtain or unreliable during with excessive patient movement (e.g.seizures) or if nail polish is present.
ALS OXYGEN TITRATION
• High flow oxygen should be maintained in patients with shock and in those with severe respiratory distress or profound hypoxia
• In most conditions, titration of oxygen should occur to assure an SpO2 of at least 94%
• Titration may involve decreasing the oxygen flow for either nasal cannula or non-rebreather masks, or switching from high to low flow devices
• Stable patients without distress who have SpO2 readings of 94% or greater without therapy do not need supplemental oxygen
• Some patients with chronic lung problems will not be able to attain an SpO2 of 94% and in fact may be at baseline with readings of 90% or less• The patient’s level of distress is an important
finding in these cases—patients may be without distress at lower baseline levels and do not require high-flow oxygen
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PAIN ASSESSMENT AND MANAGEMENTRelief of pain and suffering is an important component of quality EMS field care. Pain assessment is the 5th vital sign and should be performed on each patient using an age appropriate pain scale. Pain is a subjective experience for the patient and should be treated following the appropriate pain treatment guideline.
Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts should be made to alleviate pain using both pharmacologic (e.g, Fentanyl, Nitroglycerin for cardiac cases) and non-pharmacologic (e.g., splinting, spinal motion restriction) measures.
• Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5 minutes after every medication administration
• Assess pain using the same pain scale before and after pain administration and document
• Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved. Administer medication cautiously and monitor patient.
• Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional narcotic administration.
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PAIN ASSESSMENT TOOLSFACES PAIN RATING SCALE (AGES 3 TO ADULT)
See pain scale and English/Spanish chart on back cover of field manual• Point to each face using the words to describe the
pain intensity • Ask the patient to choose the face that best
describes how they are feeling. A person does not have to be crying to have the worst pain.
0–10 NUMERIC PAIN RATING SCALE (AGES > 9 YO)
Explain scale (0 means no pain and 10 is the most severe pain they have ever had). Ask patients what number on a scale of 0–10 they would give as the level of pain currently.
PAIN ASSESSMENT IN THE VERY YOUNG, NON-VERBAL INFANT AND CHILD
Pain assessment in infants, non-verbal young children or developmentally delayed children is more complex and presents special challenges. Despite this, pain medication should be considered in cases where the infant or child is in severe pain. This includes evidence of painful mechanisms such as burns, limb fractures or other events. Using pain medication in these children requires judgment and caution. Signs and symptoms of pain in non-verbal young or developmentally delayed children include:• Inconsolable crying, screaming that cannot be
distracted from by a caregiver• High pitched crying• Any pain face expression that is continual, such as
grimace or quivering chin• Constant tense/stiff body tone and/or guarding
“ Whatever is painful to adults, is painful to children until proven otherwise ”
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PEDIATRIC ASSESSMENTBegin interventions immediately and transport promptly if life-threatening conditions are identified in general visual assessment or primary assessmentPEDIATRIC ASSESSMENT TRIANGLE—GENERAL VISUAL ASSESSMENT
Assess effort Increased or decreased effort or abnormal sounds
CIRCULATION Assess for skin color Abnormal skin color or external bleeding
PREHOSPITAL PRIMARY ASSESSMENT ASSESSMENT SIGNS OF LIFE-
THREATENING CONDITIONAIRWAY Assess patency Complete or severe airway obstruction
BREATHING Assess respiratory rate and effort, air movement, airway and breath sounds, pulse oximetry
Apnea, slow respiratory rate, very fast respiratory rate or significant work of breathing
CIRCULATION Assess heart rate, pulses, capillary refill, skin color and temperature, blood pressure
Tachycardia, bradycardia, absence of detectable pulses, poor blood flow (increased capillary refill, pallor, mottling, or cyanosis), hypotension
DISABILITY Assess AVPU response, pupil size and reaction to light, blood glucose
Decreased response or abnormal motor response (posturing) to pain, unresponsiveness
EXPOSURE Assess skin for rash or trauma Hypothermia, rash (petichiae/purpura) consistent with septic shock, significant bleeding, abdominal distention
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PEDIATRIC ASSESSMENTBegin interventions immediately and transport promptly if life-threatening conditions are identified in general visual assessment or primary assessmentPEDIATRIC ASSESSMENT TRIANGLE—GENERAL VISUAL ASSESSMENT
EYE RESPONSE Opens spontaneouslyOpens to speechOpens to painNo response
4321
Opens spontaneouslyOpens to speechOpens to painNo response
4321
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PEDIATRIC MEDICATION ADMINISTRATIONPatient safety in medication administration is paramount. Accurate administration of pediatric medications requires multiple steps. Follow each of these steps in every case.ASSESS PATIENT Remember the 6 Rights—Right patient, right drug (and
indication), right dose, right route of administration, right timing and frequency, right documentation
OBTAIN WEIGHT ESTIMATE IN KG
• Use Broselow tape in every child of appropriate height to determine color range of weight• Broselow applies to patients less than 147 cm
tall (4 feet 10 inches) • If taller than Broselow tape, estimate weight by
patient/parent history or paramedic estimate and ALWAYS convert to kg using conversion table
DETERMINE VOLUME ON DRUG CHART
• Consult drug chart based on medication name to determine volume in ml
• If 50 kg or greater, utilize adult dosagesDRAW UP MEDICATION
• Verify drug being administered • Utilize smallest syringe for volume (e.g. 1 ml or less,
use tuberculin syringe) • When giving IM or intranasal medication, load
syringe only with amount to be administeredDOUBLE CHECK TO CONFIRM VOLUME
• Double-check volume and dose with drug chart in hand—verbalize name of medication, volume, dosage and route to another paramedic or EMT on scene
ADMINISTER MEDICATION
• Administer by appropriate route • Observe patient for any signs of adverse reaction
DOCUMENTATION • Always document drug dosages in chart by mg (most drugs), grams (Dextrose), or mcg (Fentanyl)
• Document response to medication and any observed adverse reaction
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PEDIATRIC MEDICATION ADMINISTRATIONPatient safety in medication administration is paramount. Accurate administration of pediatric medications requires multiple steps. Follow each of these steps in every case.ASSESS PATIENT Remember the 6 Rights—Right patient, right drug (and
indication), right dose, right route of administration, right timing and frequency, right documentation
OBTAIN WEIGHT ESTIMATE IN KG
• Use Broselow tape in every child of appropriate height to determine color range of weight• Broselow applies to patients less than 147 cm
tall (4 feet 10 inches) • If taller than Broselow tape, estimate weight by
patient/parent history or paramedic estimate and ALWAYS convert to kg using conversion table
DETERMINE VOLUME ON DRUG CHART
• Consult drug chart based on medication name to determine volume in ml
• If 50 kg or greater, utilize adult dosagesDRAW UP MEDICATION
• Verify drug being administered • Utilize smallest syringe for volume (e.g. 1 ml or less,
use tuberculin syringe) • When giving IM or intranasal medication, load
syringe only with amount to be administeredDOUBLE CHECK TO CONFIRM VOLUME
• Double-check volume and dose with drug chart in hand—verbalize name of medication, volume, dosage and route to another paramedic or EMT on scene
ADMINISTER MEDICATION
• Administer by appropriate route • Observe patient for any signs of adverse reaction
DOCUMENTATION • Always document drug dosages in chart by mg (most drugs), grams (Dextrose), or mcg (Fentanyl)
• Document response to medication and any observed adverse reaction
RULE OF NINES—BURN SURFACE AREA
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SEPSIS SCREENING• Sepsis is a life-threatening condition that can occur when a systemic reaction
known as Systemic Inflammatory Response Syndrome (SIRS) develops and is related to an infection
• The inflammatory response may be the result of exposure to infectious agents in the blood, urine, lungs, skin, or other organs
RISK FACTORS Common risk factors for sepsis include elderly age, diabetes, and immunocompromised states. Other risk factors include cancer, renal disease, alcoholism, injection drug use, malnutrition, hypothermia, or recent surgery or invasive procedure.
INDICATIONS FOR SCREENING
Sepsis screening should be done in adults in the setting of suspected infection. Examples:• Fever; • Respiratory symptoms such as tachypnea, shortness of
breath, cough, sputum production; • Abdominal symptoms such as vomiting, diarrhea, or
abdominal pain; • Urinary symptoms such as flank pain or painful/frequent
urination; • Skin infections (cellulitis or abscess); • General weakness, altered level of consciousness or lethargy,
especially in the elderly
ASSESSMENT Sepsis screening includes assessment of pulse rate, respiratory rate and temperature. It is important to note that an elevated temperature may not be seen in sepsis, particularly in elderly patients or advanced stages.
CRITERIA FOR POSITIVE SCREEN
A positive sepsis screen in adults occurs in the setting of suspected infection when two of the three following conditions are met:• Heart rate/pulse greater than 90; • Respiratory rate greater than 20; • Temperature above 100.4 or below 96.
HOSPITAL REPORTING
If a positive sepsis screen is encountered, the receiving facility should be notified as part of the report from the field. Report the finding as a “positive sepsis screen.” Not all patients with a positive screen will have sepsis but alerting the facility may assist in calling attention to time-sensitive steps in evaluation and care that are needed to be taken upon hospital arrival.
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SPINAL INJURY ASSESSMENTASSESSMENT PRINCIPLES
• Careful motor/sensory and spine exams • Consider reliability of patient • Consider factors that elevate risk
PATIENT RELIABILITY Unreliable assessments if:• Coma or altered level of consciousness (including
significant impairment by drugs or alcohol) • Communication barrier • Significant distracting injury
EXAMINATION AND KEY FINDINGS
Examination should include:• Wrist or finger extension of both hands • Plantarflexion and dorsiflexion of both feet • Gross sensation in all extremities• Check for abnormal sensations to extremities
Key findings on examination include:• Midline spinal tenderness on palpation • Obvious deformity of spine • Neurologic deficit of extremities
• Weakness, paralysis, sensory findings or subjective sensory complaints (numbness or tingling)
• Presence of priapism or spinal shock
RISK ASSESSMENT • History of high-velocity blunt injury increases risk • Axial load injury to the head (e.g. diving) increases risk • Low-velocity injuries such as falls from standing
or lower-velocity motor vehicle accidents have increased risk in older patients (65 and older)
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SPINAL MOTION RESTRICTION (SMR)• The purpose of full spinal motion restriction is to protect patients from
potential further injury when an unstable spinal fracture exists. • Full spinal motion restriction may cause airway or respiratory compromise,
lead to skin breakdown (decubiti) and may cause significant pain. • Routine use of full spinal motion restriction should be avoided and should
be reserved for patients with confirmatory physical findings or high suspicion of spinal fracture.
SPINAL MOTION RESTRICTION IN BLUNT TRAUMAFULL SPINAL MOTION RESTRICTION METHODS
• Cervical collar, head bed, concave or padded board, straps• Cervical collar with full-length vacuum splint
INDICATIONS FOR FULL SPINAL MOTION RESTRICTION (BLUNT TRAUMA):
• Major blunt trauma meeting criteria for trauma center activation • Presence of neurologic deficit (paralysis, weakness, numbness or
tingling), priapism or suspected spinal shock • Obvious anatomic deformity of spine• Significant tenderness on palpation of vertebral column • Significant blunt trauma mechanism when patient evaluation is
unreliable
MODIFIED SPINAL MOTION RESTRICTION METHODS
• Cervical collar only• Cervical collar with padding to limit movement • Cervical collar with KED or half-length vacuum splint
INDICATIONS FOR MODIFIED SPINAL MOTION RESTRICTION (BLUNT TRAUMA)
• Blunt trauma not meeting above criteria but with pain complaints or concerns based on mechanism or patient risk
• Examples of patients may include those ambulatory after self-extrication, low-velocity mechanisms, and those with no neurologic findings.
SPINAL MOTION RESTRICTION IN PENETRATING TRAUMAINDICATIONS FOR FULL SPINAL MOTION RESTRICTION
• Spinal motion restriction should only be employed in penetrating trauma if there is a neurologic deficit or an obvious deformity of the spine
• Patients who have both penetrating injury and a significant blunt injury should be evaluated using blunt trauma criteria
• Altered level of consciousness or presence of an entry/exit wound in proximity of the spine are no longer indications for SMR
SALINE LOCK When medication alone is being given or a potential for medication is anticipated
No anticipated need for prehospital medication or fluid
ARM IV When fluids or medications needed and patient not in shock or arrest. Antecubital site not ideal unless no other vein available.
No anticipated need for prehospital medication or fluid
ANTECUBITAL IV
• Shock• Adenosine (rapid IV bolus) • Cardiac arrest if easily
accessible • Other peripheral sites not
available and medications or fluids indicated
No anticipated need for prehospital medication or fluid
INTRAOSSEOUS ACCESS (IO)
• Cardiac arrest • Profound shock or unstable
dysrhythmia when rapid IV access or suitable vein cannot be rapidly located • Use lidocaine for pain
control in non-arrest patients PRIOR to IO flush, fluid or medication (Infusion is painful!)
• If no medication or fluid is being administered (do not use for prophylactic vascular access)
• If patient stable • When other routes for
medications available (IM, IN)
EXTERNAL JUGULAR IV
Unstable patient needs emergent IV medication or fluids AND no peripheral site is available AND IO not appropriate (e.g. very alert patient)
• Contraindicated in cardiac arrest unless IO and antecubital IV cannot be started (interrupts CPR)
• When other routes for medications available (IM, IN)—e.g. naloxone or use of glucagon instead of dextrose
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VENTRICULAR ASSIST DEVICES (VAD)BACKGROUND INFORMATION• A Ventricular Assist Device (VAD) is an implanted device used to partially or completely
replace the pumping function of a failing heart. VADs are used both as a bridge device while patients are awaiting heart transplant, and now increasingly are used permanently in patients who are not transplant candidates (referred to as destination therapy).
• VAD patients and their families/caretakers have been given training for their devices and they should be capable of basic troubleshooting of the device. Hospitals that implant VADs have 24-hour on-call coverage (VAD Coordinators) for families or responders to contact in case of any issues. The contact phone number should be present on the patient’s equipment and this person may be able to help the family or responding personnel in assessing the device.
ASSESSMENT• Depending on the type of VAD, a patient may or may not present with a palpable pulse,
and blood pressure may not be detected, particularly with automatic measurements. Most newer VADs work without generating a pulse. The pulse, if present, may not correspond to the patient’s heart rate on the monitor.
• In the absence the ability to detect pulse and blood pressure, patient evaluation of skin signs, level of consciousness, oxygen saturation, non-invasive end-tidal carbon-dioxide, and general appearance may give the best clues as to the patient’s clinical status.
TREATMENT• Patients may be cardioverted or defibrillated if symptomatic, but asymptomatic
dysrhythmias do not require treatment • VAD devices may become dislodged with chest compressions and this may lead to
massive hemorrhage. Do not perform chest compressions on patients with VADs, even if the patient is unconscious.
• Treatment should otherwise follow appropriate treatment guidelines. Medical direction is provided by the base hospital (VAD coordinators cannot provide medical direction).
DESTINATION and DISPOSITION• In most circumstances, when transport is indicated the appropriate destination for the
patient is the hospital where the VAD was implanted and the patient is managed. • For very minor conditions (e.g. small laceration repair) local transport may be appropriate. • Contact the base hospital if there are questions concerning destination. • If possible, the patient’s family member or caregiver should accompany the patient
in the ambulance, and all related VAD equipment (e.g. spare batteries) should also be transported with the patient.
• In arrest situations, determine if DNR/POLST or advance directives are available. Many VAD patients have made end-of-life care decisions.
