Airway/Circulation

Question 1

APNEIC OXYGENATION

Procedure

Answer 1

♦ Position the patient in a semi-recumbent position (head-up greater than 20⁰).

♦ Place pt. on O2 via NC at 8-10lpm → Place a NRB at 12-15lpm over the nasal cannula.

♦ SPO2

♦ Follow the RSI procedure and leave the nasal cannula in place for passive Oxygenation

♦ Prior to RSI attempt have equipment present for failed airway attempt

♦ Continuous waveform capnography and pulse oximetry is required

Question 2

ENDOTRACHEAL TUBE INTRODUCER (BOUGIE)

Procedure

Answer 2

Contraindications: 3 attempts at oral intubation.

1. Prepare, Position, Pre-oxygenate with 100% O2

2. Follow Apneic Oxygenation protocol

3. Select proper ETT without stylet, test cuff, and prepare suction.

4. Select proper size Bougie®

5. Lubricate the distal end and cuff of the ETT and the distal 1/2 of the Bougie®

6. Using laryngoscopic techniques, visualize the vocal cords if possible using Sellick Maneuver/BURP as needed.

7. Introduce the Bougie® with curved tip anteriorly and visualize the tip passing the vocal cords or above the arytenoids if the cords cannot be visualized.

8. Once inserted, gently advance the Bougie® until you meet resistance.

9. Withdraw the Bougie® only to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie®.

10. Gently advance the Bougie® and loaded ETT until you meet resistance again, thereby assuring tracheal placement and minimizing the risk of accidental displacement of the Bougie®.

11. While maintaining a firm grasp on the proximal Bougie®, introduce the ETT over the Bougie® passing the tube to its appropriate depth.

12. Once the ETT is correctly placed, hold the ETT securely and remove the Bougie®.

13. Inflate the cuff with 3-to10 mL of air.

14. Confirm placement → bilateral breath sounds, chest rise and fall, absence of gastric sounds, end tidal CO2 measurement, waveform capnography, and continuous SPO2 readings.

15. Secure the tube and ensure cervical immobilization during transport.

16. Continuously waveform capnography and pulse oximetry required

Question 3

AIRWAY: CPAP

(clinical indications)

Answer 3

♦ Reactive airway disease patients with suspected inadequate ventilation, adequate mental status and enough respiratory drive to allow CPAP to function.

♦ Respiratory distress associated with congestive heart failure, pulmonary edema, etc.

♦ Patient is awake, oriented, and able to follow commands.

♦ Ability to maintain an open airway → RR > 25 bpm and pulse oximetry reading less than 95%

Question 4

AIRWAY: CPAP

(contraindications)

Answer 4

♦ Systolic blood pressure less than 90mmHg
♦ Respiratory arrest or agonal respirations
♦ Patient is unresponsive
♦ Shock with cardiac insufficiency
♦ Penetrating chest trauma
♦ Persistent nausea/vomiting
♦ Active upper GI bleeding or recent history of gastric surgery
♦ Facial abnormalities which will not allow a proper mask seal
♦ Must contact OLMD for patients < 12 y/o

Question 5

AIRWAY: CPAP

(procedure)

Answer 5

1. Ensure adequate O2 supply to ventilation device.

2. Explain the procedure to the patient.

3. Consider placement of a nasopharyngeal airway.

4. Place the delivery mask over the mouth and nose. Oxygen should be flowing through the device at this point.

5. Secure the mask with provided straps starting with the lower straps until minimal air leak occurs.

6. For reactive airway disease (i.e., COPD) set PEEP at 3-5 cm H2O. Use the lowest possible setting to avoid barotrauma.

7. For pulmonary edema, near drowning, aspiration and pneumonia set PEEP at 5-10 cm H20. Use the lowest possible setting to avoid barotrauma.

8. Evaluate pt response → assessing breath sounds, oxygen saturation, general appearance.

9. Oxygen levels should be titrated to the patient’s response.

10. Encourage the patient to allow forced ventilation to occur. Observe closely for signs of complications. The patient must be breathing for use of the CPAP device

Question 6

AIRWAY: RAPID SEQUENCE INTUBATION

(indications/contraindications)

Answer 6

Clinical Indications: A patient with the inability to maintain a patent airway. (adequately ventilate)

Contraindications: Ketamine should not be used as an induction agent for infants < 3 months old, patients with a known history of schizophrenia, or in patients with severe uncontrolled hypertension.

Etomidate should not be used in patients with known sepsis.

Question 7

AIRWAY: RAPID SEQUENCE INTUBATION

(procedure adult)

(steps 1-7)

Answer 7

Procedure (Adults):

1. Pre-oxygenate. → provide passive Oxygenation throughout the procedure.

2. Consider pain management with Fentanyl (Sublimaze) per Pain Management Protocol.

3. → Ketamine 2 mg/kg SLOW IO/IV (Maximum dose of 200mg). May repeat bolus of 1 mg/kg IV/IO post intubation q 10 minutes PRN

4. Consider push dose pressor, if hypotensive.

5. Alternatively, Etomidate (Amidate) 0.3 mg/kg slow IO/IV (max dose of 40 mg).

6. Administer Succinylcholine (Anectine) 2 mg/kg IO/IV. If contraindicated, consider Rocuronium (Zemuron) 1mg/kg IV/IO.

7. Once appropriate medications have been administered, intubation should be initiated. In some cases, a paralytic may not be necessary. Discontinue intubation attempt and ventilate with 100% oxygen if: thirty seconds has passed OR SPO2 falls below 91% OR HR falls < 60 bpm_._

Question 8

AIRWAY: RAPID SEQUENCE INTUBATION

(procedure adult)

(steps 8-14)

Answer 8

8. Confirm ETT placement by: bilateral breath sounds, chest rise and fall, absence of gastric sounds, esophageal bulb device, end tidal CO2 measurement, waveform capnography, and continuous SPO2 readings.

9. Secure the tube and ensure cervical immobilization during transport.

10. Unless contraindicated, insert a nasogastric or orogastric tube for flights when deemed necessary.

11. Post intubation, administer:

a. Midazolm (Versed) 0.1 mg/kg IO/IV/IN up to 10mg AND

b. Fentanyl (Sublimaze) 1 mcg/kg IO/IV/IN (max dose 100 mcg), repeat at 1 mcg/kg as needed

c. May also consider Lorazepam (Ativan) 1 – 2 mg IO/IV/IN, may repeat to a total dose of 4 mg.

d. Ketamine 1 mg/kg q 10 minutes as needed.

e. For long transports (if needed) administer Vecuronium (Norcuron) 0.1 mg/kg IO/IV (max of 10 mg) or Rocuronium (Zemuron) 1mg/kg IO/IV (max of 100 mg). A long acting paralytic should only be utilized if appropriate analgesia and sedation are not effective.

12. Have receiving physician verify tube placement and chart findings.

13. It is required that the airway be monitored continuously through waveform capnography and pulse oximetry. Reassess airway frequently and with every patient move.

14. If unable to intubate patient using conventional intubation technique or video laryngoscope assisted.

Question 9

AIRWAY: NEEDLE CRICOTHYROTOMY

(clinical indications/precautions)

Answer 9

Clinical Indications:

♦Management of an airway when standard airway procedures cannot be performed or have failed.

Precautions: Caution should be used in patients with:

♦Laryngeal injury.

♦Tracheal rupture.

♦Anterior neck swelling that obscures anatomical landmarks.

♦Anatomic anomalies or distortion of the larynx and trachea.

♦Bleeding disorder.

Question 10

AIRWAY: NEEDLE CRICOTHYROTOMY

(procedure 1-6)

Answer 10

1. Have suction and supplies available and ready.

2. Locate the cricothyroid membrane utilizing anatomical landmarks.

3. Use the non-dominate hand to secure the membrane

4. Prep the skin with an antiseptic solution.

5. Draw up 2 ½ cc of Normal Saline with a 5 cc syringe and attach the needle supplied in the needle cricothyrotomy kit. (usually a 5-cc syringe attached to a 14 gauge catheter-over-needle device), insert the needle through the cricothyroid membrane at a 45 to 60 degree caudal angle (toward the feet).

6. Aspirate for air with the syringe throughout the procedure.

Question 11

AIRWAY: NEEDLE CRICOTHYROTOMY

(procedure 7-12)

Answer 11

7. Once air bubbles return easily, stop advancing the device.

8. Secure the tube and ensure cervical immobilization during transport.

9. Remove the needle and leave the catheter in place..

10. Attach a 15 mm adapter (from a 3.0 tube) to the catheter hub. Ventilate with highest oxygen concentration using BVM.

11. Make certain ample time is used not only for inspiration but also for expiration. Assess for adequate oxygenation and ventilation by monitoring pulse oximetry and continuous waveform capnography.

12. Document time/procedure/confirmation/change in patient condition/time on the patient care record.

Question 12

BREATHING: PLEURAL DECOMPRESSION

(clinical indications)

Answer 12

Clinical Indications:

 Primary-Absolute Requirements

o Absent breath sounds on one side.

o Profound shock with a systolic blood pressure less than 80mmHg in adults. Profound shock in pediatrics must be determined by online medical direction.

o A patient with a flail chest severe enough to require endotracheal intubation for persistent hypoxia should have a precautionary needle decompression on the side of the injury.

 Secondary-Suggestive but not sufficient without the above

o Distended neck veins.

o Tracheal shift away from the affected side. o Altered mental status.

o Increased airway resistance, especially in intubated patients.

o Tympany to percussion on the affected side.

o Subcutaneous air in the intubated patient.

Question 13

BREATHING: PLEURAL DECOMPRESSION

(contraindications)

Answer 13

Contraindications:

♦ Patient has a simple pneumothorax

♦ Patient with a symptomatic tension pneumothorax that can be relieved by the removal of an occlusive dressing from an open chest wound.

Question 14

BREATHING: PLEURAL DECOMPRESSION

(procedure)

Answer 14

Procedure:

1. Elevate head of stretcher to 20-30 degrees (if not contraindicated).

2. Obtain age appropriate needle.

a. Adult: 14G over the needle angiocatheter.

b. Pediatric: 18G over the needle angiocatheter.

3. Clean the chest cavity vigorously with alcohol or betadine.

4. On the affected side, locate the mid-clavicular line and insert the IV catheter over the superior margin of the third rib (2nd intercostal space) or along the anterior axillary line at the 4th intercostal space.

5. Once the needle makes contact with the rib, slide over the top of it.

6. Advance the catheter and then remove the needle.

7. Auscultate breath sounds.

8. Attach a one way valve if possible.

9. Reassess frequently and repeat the procedure as needed.

10. Leave the catheter in place until it is replaced by a chest tube at the hospital.

Question 15

BREATHING: USE OF MECHANICAL VENTILATOR

(clinical indications)

Answer 15

Clinical Indications:

 The mechanical ventilator shall be used on all intubated patients unless they weigh 5kg or less, there is a direct physician order not to use the ventilator, or other lifesaving treatment priorities exist. In those rare cases, every effort should be made to place the patient on the ventilator as soon as the immediate life threats are addressed.

Question 16

BREATHING: USE OF MECHANICAL VENTILATOR

(procedure steps 1-4)

Answer 16

Procedure:

1. Obtain ventilator setting from the respiratory therapist or by observing the settings on the current ventilator. Ensure settings are appropriate for the patient. Chart these settings in the PTA vital signs column.

2. If the patient was just intubated or was not on a ventilator previously, then set the ventilator as follows:

a. PRVC/SIMV mode

b. Tidal Volume = 5 – 8 ml/kg (using patient’s ideal weight)

c. FiO2 of 90%, titrate to keep SPO2 between 94 – 99%

d. Peep = 5 ml

e. Based on patient’s condition and for pediatrics, pressure mode may be utilized

3. After determining settings, begin ventilation of the patient with the transport ventilator.

4. The settings may be adjusted at the determination of the clinician to maintain the comfort of the patient with an SPO2 consistent with the baseline of the patient and an ETCO2 between 35 – 45. Ventilator settings should not be adjusted more often than every 5 minutes.

Question 17

BREATHING: USE OF MECHANICAL VENTILATOR

(procedure steps 5-7)

Answer 17

5. Unless contraindicated, insert a nasogastric or orogastric tube for flights > 15 minutes or when deemed necessary.

6. It is required the airway be monitored continuously through waveform capnography and pulse oximetry.

7. If the patient is not sedated by a continuous IV drip, then sedation and analgesia shall be maintained with:

a. Midazolm (Versed) i. Adults: 0.1 mg/kg IO/IV/IN (may be repeated in 2.5 mg doses as needed) ii. Pediatrics: 0.1 mg/kg IO/IV/IN (may be repeated in 0.05 mg/kg doses as needed) Max dose 5mg.

b. Fentanyl (Sublimaze) 1 mcg/kg IO/IV/IN (maximum dose of 100 mcg), repeated in 1 mcg/kg doses as needed.

c. If patient needs further sedation, above doses of Midazolm (Versed) and Fentanyl (Sublimaze).

d. Ketamine 1mg/kg, repeated every 10 minutes as needed.

e. For long transports (if needed) administer Vecuronium (Norcuron) 0.1 mg/kg IO/IV (max of 10 mg) or Rocuronium (Zemuron) 1mg/kg IO/IV (max of 100 mg). A long acting paralytic should only be utilized if appropriate analgesia and sedation are not effective.

Question 18

CIRCULATION: ALTERNATIVE IV SITES

(indications/contraindications)

Answer 18

Clinical Indications:

 Alternative IV sites may be used in any life or limb-threatening situation where upper extremity veins are inaccessible.

Contraindications:

 For Intraosseous Site:

o Fracture in bone or joint replacement of intraosseous (IO) site.

o Current or prior infection at proposed IO site.

o Previous IO insertion at proposed site within 48 hours.

o Inability to find landmarks

Question 19

CIRCULATION: ALTERNATIVE IV SITES

(procedure for external neck vein)

Answer 19

Procedure: Alternative IV sites include: lower extremities, external neck veins, and intraosseous.

1. Lower Extremities: (Adult and Pediatric).

a. Lower extremities are discouraged in patients with vascular disease or diabetes

2. External Neck Vein: a. Place the patient in a supine head down position. This helps distend the vein and prevents air embolism.

b. Turn the patient’s head toward the opposite side if not contraindicated.

c. Prep the skin with the vein and aim toward the same shoulder.

d. Compress the vein lightly with one finger above the clavicle and cannulate the vein in the usual method.

e. Attach the IV and secure the catheter avoiding circumferential dressing or taping

Question 20

CIRCULATION: ALTERNATIVE IV SITES

(procedure for IO)

Answer 20

3. Intraosseous: (Adult & Pediatric)

a. Do not insert IO into a known fractured bone or joint replacement.

b. Locate appropriate landmarks.

i. Proximal Humeral Head Site

1. Place the patient’s palm on the umbilicus and elbow on the ground or stretcher or place the patient’s arm flat on the ground or stretcher with the palm facing downward.

2. Use your thumb to identify humeral shaft, slide thumb towards humeral head with firm pressure. Locate the tubercle by prominent bulge.

3. With your finger on the insertion site, keeping the arm adducted, externally rotate the humerus 90 degrees. You may be able to feel the inter-tubercle groove.

4. Rotate arm back to the original position for insertion. The insertion site is 1 – 2 cm lateral to the inter-tubercle groove.

ii. Proximal Tibia Site

1. Identify the tibial tuberosity located 2 finger-breaths below the base of the patella.

2. The insertion site is 1 – 2 cm medial from this bony prominence on the superior portion of the flat aspect of the proximal tibia. Rotating the leg laterally can aid in positioning the site anterior.

c. Cleanse site using antiseptic agent and allow to air dry thoroughly.

d. Connect appropriate needle set driver and stabilize.

e. Remove needle cap and position the driver at the insertion site with the needle set at a 90 degree angle to the bone surface.

f. Gently pierce the skin with the needle tip until the tip touches the bone.

g. The 5 mm mark must be visible above the skin for confirmation of adequate needle length.

h. Gently drill into the bone 2 cm or until the hub reaches the skin in an adult.

i. Stop when you feel the loss of resistance.

j. 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. k. The needle should feel firmly seated in the bone (1st confirmation of placement).

l. Secure site with EZ stabilizer and connect primed EZ-connect extension set to the hub, firmly secure by twisting clockwise.

m. If patient is conscious administer, Lidocaine 2% 40 mg for adults (0.5mg/kg for pediatrics (max initial dose 40mg)), slow IO over 120 seconds for anesthetic effect prior to the saline flush. May repeat at 20mg for adults. Peds repeat dose is half of the initial dose.

n. Flush the catheter with 10 mL Normal Saline adults (5 mL pediatric); look for infiltration (2nd confirmation of placement).

o. Begin infusion utilizing a pressure delivery system and continue to monitor extremity for complications.

p. Most pre-hospital fluids or medications approved for intravenous (IV) use may be given IO.

Question 21

CIRCULATION: BLOOD ADMINISTRATION

(clinical indications)

Answer 21

Clinical Indications:

 Any of the following may necessitate the need for the administration of blood in a hypotensive patient:

o Blunt or penetrating trauma to the torso.

o Obvious massive external blood loss from any site.

o Abdominal or thoracic aneurysm with suspected dissection

o Significant GI bleeding.

o Intracranial hemorrhage or other types of uncontrolled/non-compressible bleeding in the presence of elevated PT/INR.

o Other unspecified conditions with direct physician order.

 Absolute Criteria:

o Patient has persistent hypotension.

Adults - SBP < 90 mmHg or MAP <65 after 2L of crystalloid.

Pediatrics - signs of shock after two challenges of 20 ml/kg of crystalloid infused.

In cases of extremis, proceed directly to blood product administration concurrent with crystalloid administration.

Question 22

CIRCULATION: BLOOD ADMINISTRATION

(procedure adult)

Answer 22

Adult Patients

1. Administer 2 liters of warmed crystalloid solution via large bore IV/IO. If the patient is in extremis and massive bleeding is suspected, blood products can be initiated concurrent with the administration of the crystalloid solution.

2. Continue resuscitation with crystalloid solution and transfuse 2 units type “O” Negative Packed Red Blood Cells along with 2 units Type AB Fresh Frozen Plasma via large bore IV or IO. .

3. Monitor patient for signs and symptoms of transfusion reaction. If symptoms of transfusion reaction are present STOP the blood products and administer Methylprednisolone (Solumedrol) 125 mg IO/IV and Diphenhydramine (Benadryl) 50 mg IO/IV. Follow Adult: Anaphylactic Shock/Allergic Reaction Protocol.

Question 23

CIRCULATION: BLOOD ADMINISTRATION

(procedure pediatric)

Answer 23

Pediatric Patients

1. Administer 2 challenges of 20 ml/kg of crystalloid solution.

2. Continue resuscitation with crystalloid solution and transfuse 10 ml/kg type “O” Negative PRBC’s along with 10ml/kg type “AB” Fresh Frozen Plasma via large bore IV/IO. Use a syringe to draw the blood products from the bag to administer volumes less than one unit.

3. If additional boluses are deemed necessary by the medical crew, a physician order is required.

4. Monitor patient for signs and symptoms of transfusion reaction. If symptoms of transfusion reaction are present STOP the blood products and administer Methylprednisolone (Solu-Medrol) 2 mg/kg IO/IV (max of 125 mg) and Diphenhydramine (Benadryl) 1 mg/kg IO/IV (max of 30 mg). Follow Pediatric: Anaphylactic Shock/Allergic Reaction Protocol.

Question 24

CIRCULATION: BLOOD ADMINISTRATION

(FFP ONLY)

Answer 24

Procedure for Administering FFP only:

 FFP should be administered for patients with intracranial hemorrhage or other types of uncontrollable/non-compressible bleeding in the presence of elevated PT/INR.

 FFP should also be administered for any patient who is known to be on anticoagulant therapy and has a suspected head injury.

o Adult patients should receive 2 units FFP and pediatrics should receive 10 ml/kg FFP.

o If additional boluses are deemed necessary, a physician order is required for pediatrics.

o The administration of PRBC’s in these circumstances should be guided by the orders above.

o If patient does not meet criteria for PRBC administration, FFP may be given alone.

Notes:

 All blood products should be administered through the inline fluid warmers and extra care should be taken to prevent hypothermia.

 If the patient is in extremis and massive bleeding is suspected, blood products can be initiated concurrent with the administration of the crystalloid solution.

Question 25

CIRCULATION: BLOOD ADMINISTRATION

(documentation requirements)

Answer 25

Documentation Requirements:

 Patient hypotension documented after required bolus of crystalloid administered

 Proper use of protocol for patient with above criteria.

 Transfusion reaction observation, critical during the first 15 minutes of administration.

Question 26

CIRCULATION: BLOOD ADMINISTRATION

(Administering TXA)

Answer 26

Procedure for Administering Tranexamic Acid (Cyklokapron®)

 Patient presents with signs and symptoms of hemorrhagic shock (SBP <90 mmHg and HR >110, major blunt or penetrating torso or pelvic fracture. Within the first 3 hours of the time of the injury.

 One or more major amputations, and /or evidence of severe bleeding, external manual efforts to control the hemorrhage have been instituted. Within the first 3 hours of the time of the injury.

 Tranexamic Acid (Cyklokapron) 1 gram mixed in 100 ml NS or LR administered over 10 minutes. Write time of administration on the 100cc bag and leave bag hanging for added documentation at receiving facility.

 Ensure that the receiving facility is made aware the TXA administration in the prehospital report and that it is in the oral report given at bedside.

 The repeat or second dose of TXA will require speaking with the receiving MD.

Question 27

CIRCULATION: INTRAVENOUS INFUSION

(indications)

Answer 27

Clinical Indications:

 Any patient where intravenous (IV) access is indicated

Question 28

CIRCULATION: INTRAVENOUS INFUSION

(procedure)

Answer 28

Procedure:

1. Saline locks may be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the clinician.
2. May use intraosseous (IO), external jugular (EJ), or preexisting venous catheter where threat to life exists and no obvious peripheral site is noted according to the Circulation: Alternate IV Site Procedures.
3. Use the largest catheter bore necessary based upon the patient’s condition and size of veins.
4. In post-mastectomy patients, avoid IV, blood draw, injection, or blood pressure in arm on affected side.
5. Prep the IV site with an alcohol wipe.

Question 29

CIRCULATION: INTRAVENOUS INFUSION

(procedure Bolus)

Answer 29

6. IV Bolus rates:

a. Adult: 250-1000ml

b. Pediatric/Infant: 20 ml/kg

c. Neonate: 10 ml/kg d. May repeat fluid boluses for continued decreased perfusion

7. Follow Blood Administration protocol if appropriate

8. IV rates should be calculated using the 4:2:1 rule.

9. Consider a second IV line.

Notes:

 For patients under 12 years old, use the 4:2:1 Rule to calculate maintenance fluids:

 1 – 10 kg: 4 ml/kg/hr

 10 – 20 kg: 2 ml/kg/hr

 > 20 kg: 1 ml/kg/hr

 For pediatric inter-facility transfers, the preferred maintenance fluid is D5 1/2NS