ALS Skills List P-104

Question 0

Valsalva Maneuver

Answer 0

Indication: SVT

SO: Yes

Contraindication: none

Comments: most effective with adequate BP. D/C after 5-10 sec if no conversion.

Question 1

IO Vascular Access

Answer 1

Indications:
Fluid/Med admin in acute status pt when needed for definitive therapy and unable to establish venous access.

Peds Pt: unconscious

SO?: Yes

Contraindications:
Tibial Fx
Vascular Disruption
Prior attempt to place in target bone

Comments:
Splint Extremity
Observe for extravasation 
Don't infuse in fracture site
Neonate <28 days BHO
In conscious adult pt slowly infuse Lidocaine 2% 40mg IO prior to fluid administration.

Question 2

Spinal Stabilization

Answer 2

Indications:
Spinal pain of ?trauma 
MOI suggests ?potential spinal injury 
Acute neurological deficit 
Penetrating trauma with neurological deficit. 

SO: Yes

Contraindications: none

Comments:

• pregnant pts >6mo tilt 30 deg left lateral decubitus.
• optional if no neuro deficit AND all of the following are present and documented:
  1. awake, oriented to person, place, time.
  2. no drug/ETOH influence.
  3. no pain/tenderness of neck or back upon palpation.
  4. no significant competing, distracting pain.
  5. cooperative
  6. no language barrier

Peds pt:
N-no altered LOC
E- evidence of obvious injury absent
C- complete spontaneous ROM without pain
K- kinematic (mechanism) negative 

Children restrained in car seat may be immobilized and extricated in the car seat. If pt condition allows and immobilization is secure the child may remain in the car safety seat for transport.

Question 3

Needle Thoracostomy

Answer 3

Indication:
-severe resp. distress with diminished unilateral breath sounds and Pb < 70+2xAge in intubated or PPV pts.

SO: Yes
Contraindication: none

Comments:

• use 14g, 3.25in IV catheter
• insert into 2nd/3rd ICS mid-clavicular line on the involved side OR insert catheter into anterior axillary line 4th/5th ICS on involved side.
• tape catheter securely to chest wall and leave open to air.

Question 4

Intubation: ETAD/Combitube/King

Answer 4

Indication:
-apnea or ineffective respiration for unconscious pt or decreasing LOC.

SO: yes
Contraindication:
-Gag reflex
-pt 6ft
-ETAD
use small adult size tube in all pts under 6ft; report and document ventilation port number if ETAD.
-document and report LEADSD
-reconfirm and report EtCO2 and lung sounds after each pt movement and at turnover.
-if intubated pt is to be moved apply c-collar prior to moving.

Question 5

Intubation: ET/stomal

Answer 5

Indication:

• apnea or ineffective respirations for unconscious adult pt or decreasing Loc.
• if unable to adequately ventilate via BVM the unconscious ped pt who is apneic or has ineffective respirations.
• newborn deliveries if HR<60 after 30 sec of ventilation and if unable to adequately ventilate via BVM.
• to replace etad/perilaryngeal if ventilations inadequate or need ET suction.

SO: yes
Contraindications:
-?opioid OD prior to Narcan
-able to adequately ventilate the ped pt via BVM. 
-gag reflex 

Comments:

• 3 attempts per pt SO; additional attempts BHPO
• document and report LEADSD
• reconfirm and report EtCO2 and lung sounds after each movement and at turnover.
• extubation SO if placement issue, otherwise per BHO.
• ET depth pediatrics: age in years plus 10.
• if intubated pt is to be moved apply c-collar prior to moving.

Question 6

EtCO2 / Capnography

Answer 6

Indication:

• all intubated pts
• respiratory distress
• trauma

SO: yes
Contraindications: none

Comments:

• monitor continously after ET/ETAD/Perilaryngeal airway adjuncts insertion
• use early in cardiac arrest.

Question 7

Defibrillation

Answer 7

Indication:

• VT (pulseless)
• VF

SO: yes
Contraindications: none

Comments: in addition to NTG patches, remove chest transdermal medication patches prior to defibrillation.

Question 8

CPAP

Answer 8

Indication:

• age >15 years
• respiratory distress: CHF, COPD, asthma, pneumonia, or drowning.
• moderate to severe respiratory distress; retractions/accessory muscle use AND RR> 25 or SpO2< 95

Contraindications:

• possible pneumothorax
• facial trauma
• unable to maintain airway

Comments:

• CPAP may be used only in pts alert enough to follow direction and cooperate with the assistance.
• non verbal pts with poor head/neck tone may be too obtunded for CPAP.
• BVM assisted ventilation is the appropriate alternative.
• CPAP should be used cautiously for pts with ?COPD or pulmonary fibrosis, start low and titrate pressure.