Section 7: Procedure Protocols Flashcards

Question

7.13 Tracheostomy Tube Change - PEARLS (9/27/22)

Answer 1

PEARLS: • More difficulty with changing the tube should be anticipated for sites that are immature (< 2 weeks old). Great caution must exercised in attempts to change immature tracheosto- my sites.

Answer 2

Indication: • Patient requiring medication administration via nebulized route. Contraindications: • None

Answer 3

Background: Certain medications may be administered via nebulization. Administration of medication via this route is advantageous in some clinical situations as the medication is deposited directly into the respiratory tract and thus higher drug concentrations can be achieved in the bronchial tree and pulmonary bed with fewer adverse effects than when the systemic route is utilized. Procedure: Non-Intubated Patient 1. Explain procedure to patient if applicable. 2. Determine baseline pulse rate, SpO2, PEFR (if to be measured), and auscultate lung sounds. 3. Confirm desired medication and absence of known allergy to selected medication. 4. Assemble small volume nebulizer (SVN). If a face mask is being utilized, attach the female fitting on the bottom of the mask directly to the male adapter on the medication port. 5. Instill the desired dose of medication, and if applicable, the appropriate amount of saline into the reservoir well of the SVN. 6. Attach oxygen supply tubing to the SVN. 7. Set oxygen flow rate per device specifications. 8. Ensure that medication is flowing prior to giving mouthpiece to the patient or applying the mask on the patient. 9. Place the mouthpiece in the patient’s mouth or position the face mask on the patient, instructing them to breathe normally and take a deep breath every 3-5 inhalations. 10. Discontinue treatment when solution is depleted. 11. Place patient on supplemental oxygen if indicated. 12. Reassess pulse rate, SpO2, PEFR (if to be measured), and auscultate lung sounds. 13. Document medication administration including dose and time as well as any patient response. Intubated Patient Follow steps 1-11 above for the non-intubated patient. 1. Attach the free end of the 6”corrugated tubing to the non-rebreathing exhalation port of the bag-valve-mask device. 2. Ensure the suctioning port (if present) on the 90° adapter is closed. 3. Hand ventilate the patient.

Answer 4

PEARLS: • Medications that can be administered per protocol include albuterol, ipratropium bromide, epinephrine, levalbuterol, and calcium gluconate.

Answer 5

Indication: • Patient requiring medication administration via a metered-dose inhaler. Contraindications: • None

Answer 6

Background: Certain medications may be administered via a metered-dose inhaler (MDI). Similar in nature to medication administration via a nebulizer, this route is advantages in some clinical situations as the medication is deposited directly into the respiratory tract and thus higher drug concentrations can be achieved in the bronchial tree and pulmonary bed with fewer adverse effects than when the systemic route is utilized. Procedure: Non-intubated Patient 1. Explain procedure to patient if applicable. 2. Determine baseline pulse rate, SpO2, PEFR (if to be measured), and auscultate lung sounds. 3. Confirm desired medication and absence of known allergy to selected medication. 4. Assemble the MDI (if required) and warm the MDI to hand or body temperature. 5. Hold the MDI upright and shake the canister vigorously to mix the contents. 6. Attach a spacer if one is to be used. 7. If able, position the patient in an upright position (45-90°). 8. Place the MDI approximately 4 cm from the patient’s open mouth. If a spacer is being utilized, place the spacer mouthpiece between the patient’s teeth and instruct the patient to close their lips around it. 9. Instruct the patient to exhale completely and then begin inhaling slowly while the MDI is actuated. The patient should continue to inhale to total lung capacity (TLC). Once TLC is reached, the patient should be instructed to hold their breath for ten seconds. 10. Place patient on supplemental oxygen if indicated. 11. Reassess pulse rate, SpO2, PEFR (if to be measured), and auscultate lung sounds. 12. Document medication administration including dose and time as well as any patient response.

Answer 7

PEARLS: • The use of a spacer makes the use of a MDI easier, particularly in children. • Spacers make it easier for medication to reach the lungs and results in less medication being deposited in the upper airway.

Answer 8

Indication: • Supraventricular tachycardia (HR>150, regular rhythm). Contraindications: • Patient age > 65. • History of transient ischemic attack or cerebrovascular accident (in the last three months) or carotid artery vascular disease/surgery. • Presence of a carotid bruit.

Answer 9

Background: Carotid Sinus Massage (CSM) triggers the baroreceptor reflex and results in increased vagal tone affecting the sinoatrial and atrioventricular nodes. CSM sometimes terminates supraventricular tachycardia. Procedure: 1. Assess patient for contraindications as above. 2. Initiate ECG monitoring. 3. Explain procedure to the patient. 4. Identify the carotid sinus location at midpoint between the angle of the mandible and the superior border of thyroid cartilage. 5. Massage the right carotid sinus 5 seconds while observing the ECG (massage firmly but gently, use the same pressure that would indent tennis ball, do not apply so much pressure to occlude carotid). 6. If there no response from massaging the right carotid sinus, massage the left carotid sinus for 5 seconds while observing the ECG. 7. Massage should be stopped immediately if neurological symptoms of any kind, syncope AV block or asystole develop. 8. Document procedure and patient response.

Answer 10

Indication: • Patient in cardiac arrest. Contraindications: • None

Answer 11

Background: Defibrillation is the unsynchronized random delivery of electricity to the myocardium. Defibrillation results in widespread depolarization of myocardial cells. This widespread depolarization can terminate ventricular fibrillation or ventricular tachycardia allowing the myocardium to regain normal electrical activity. When indicated, defibrillation should be performed immediately and without delay. In witnessed ventricular fibrillation, for every minute that passes between the onset of ventricular fibrillation and defibrillation, the survival rate decrease 7-10%. When bystander CPR is provided, the decrease in the survival rate is more gradual and averages 3-4% per minute. The delivery of unsynchronized electricity (defibrillation) is sometimes necessary when the delivery synchronized electricity (synchronized cardioversion) is not possible due to failure to sense (R waves) in the unstable patient with other tachydysrhythmias. Automated external defibrillators (AEDs) allow non- ALS EMS providers and members of the lay public to provide timely defibrillation. Procedure: 1. Ensure that chest compressions are adequate and interrupted only when absolutely necessary. If multiple providers are available, one provider should provide uninterrupted chest compressions while the AED is being prepared for use. 2. Apply electrical therapy pads per manufacturer recommendations. Use alternate placement configuration when implanted devices (implanted defibrillator or pacemaker) occupy preferred pad positions. If the patients age is <8 y.o., use pediatric pads if available or if device has “energy attenuation” function key, activate the key. 3. If present, remove any transdermal medication patches and wipe off any residue. 4. Power on the AED and follow prompts. 5. Keep interruption of chest compressions to a minimum. 6. If shock is advised, assertively state “All Clear” and visualize that everyone (including yourself) is clear and press the shock button. 7. If no shock is advised, immediately resume chest compressions. 8. Allow the AED to analyze when prompted (approximately two minute cycles). Repeat steps 6 and 7 as indicated.

Answer 12

PEARLS: • Pre and post-shock pauses should be minimized! Shorter peri-shock pauses (specifically pre-shock) are associated with greater survival from out-of-hospital cardiac arrest. • If pads touch due to patient size or use of a Lucas Device, use the AP configuration for pad placement. • For patients with implanted devices (defibrillators/pacemakers), pads can be placed in the AL or AP configuration. Attempt to avoid placing pads directly over devices. • In the AP configuration, one pad is placed over the left anterior mid chest next to the sternum and another pad is placed to the mid left posterior chest next to the spine. • For patients with refractory ventricular fibrillation, consider replacing or changing therapy pads with new ones and ensure good skin contact. Consider AP placement if AL placement is being used.

Answer 13

Indication: • Ventricular fibrillation or pulseless ventricular tachycardia. Contraindications: • None

Answer 14

Background: Defibrillation is the unsynchronized random delivery of electricity to the myocardium. Defibrillation results in widespread depolarization of myocardial cells. This widespread depolarization can terminate ventricular fibrillation or ventricular tachycardia allowing the myocardium to regain normal electrical activity. When indicated, defibrillation should be performed immediately and without delay. In witnessed ventricular fibrillation, for every minute that passes between the onset of ventricular fibrillation and defibrillation, the survival rate decrease 7-10%. When bystander CPR is provided, the decrease in the survival rate is more gradual and averages 3-4% per minute. The delivery of unsynchronized electricity (defibrillation) is sometimes necessary when the delivery synchronized electricity (synchronized cardioversion) is not possible due to failure to sense (R waves) in the unstable patient with other tachydysrhythmias. Procedure: 1. Ensure that chest compressions are adequate and interrupted only when absolutely necessary. 2. If not in place, apply electrical therapy pads in the anterior-lateral (AL) configuration. Place the lateral (apex) pad on the left anterior chest, just lateral to the left nipple in the mid-axillary line and the anterior pad in the right sub- clavicular area lateral to the sternum (the anterior-posterior [AP] configuration may be used if pads are already in place in this configuration). If present, chest hair should be shaved prior to pad application. 3. Select appropriate energy level. 4. Charge the defibrillator to selected energy level. Chest compressions should be continued while the defibrillator is being charged. 5. Once the defibrillator is charged, hold chest compressions, assertively state “All Clear” and visualize that everyone (including yourself) is clear. 6. Push the discharge button to deliver the countershock. 7. Once the countershock is delivered, immediately resume chest compressions (it may be desirable to have the chest compressor “hover” their interlocked hands over the chest while the countershock is delivered to minimize the length of post-shock pause). 8. Continue chest compressions and ventilations for two minutes. After two minutes of CPR, analyze the rhythm and check for pulse only if appropriate for the rhythm. 9. Repeat defibrillation every two minutes as indicated by the ECG and patient response. 10. Document procedure, including ECG rhythm, energy level and response.

Answer 15

PEARLS: • Pre and post-shock pauses should be minimized! Shorter peri-shock pauses (specifically pre-shock) are associated with greater survival from out-of-hospital cardiac arrest. In one study, pre-shock pauses >20 seconds had a 53% lower chance of survival compared to those with pre-shock pauses <10 seconds. For every 5 sec increase in shock pause, the chance of survival decreased by 18%. • If pads touch due to patient size or use of a Lucas Device, use the AP configuration for pad placement. • For patients with implanted devices (defibrillators/pacemakers), pads can be placed in the AL or AP configuration. Attempt to avoid placing pads directly over devices. • In the AP configuration, one pad is placed over the left anterior mid chest next to the sternum and another pad is placed to the mid left posterior chest next to the spine. • For patients with refractory ventricular fibrillation, consider replacing changing therapy pads with new ones and ensure good skin contact. Consider AP placement if AL placement is being used.

Answer 16

Indication: • Unstable patient with a tachydysrhythmia (atrial fibrillation with rapid ventricular response, supraventricular tachycardia, ventricular tachycardia). • Patient is not pulseless (the pulseless patient requires unsynchronized cardioversion i.e. defibrillation). Contraindications: • Repetitive, self-terminating, short-lived tachydysrhythmias (i.e. runs of non- sustained VT).

Answer 17

Background: In synchronized cardioversion the delivery of electricity is synchronized with the cardiac cycle so that delivery occurs during the absolute refractory period. This synchronization avoids shock delivery during the relative refractory portion of the cardiac electrical cycle, when a shock could produce ventricular fibrillation. Cardioversion is useful in the treatment of tachydysrhythmia (atrial fibrillation with rapid ventricular response, supraventricular tachycardia, ventricular tachycardia). Energy doses utilized for cardioversion are generally lower than those used for defibrillation. Procedure: 1. Explain procedure to patient if applicable. 2. Ensure standard resuscitation equipment is immediately available. 3. Consider pre-procedure sedation per the Patient Comfort Protocol if appropriate for the clinical situation and provider level scope of practice. 4. Attach ECG monitoring electrodes in the standard 4 lead configuration. 5. The preferred configuration for application of electrical therapy pads is the anterior-posterior (AP) configuration. In the AP configuration, one pad is placed to the anterior mid chest next to the sternum and another pad is placed to the mid left posterior chest next to the spine. Alternately, the anterior-lateral (AL) configuration may be utilized. In the anterior-lateral configuration, the lateral (apex) pad is placed on the left anterior chest, just lateral to the left nipple in the mid-axillary line and the anterior electrode is placed in the right subclavicular area lateral to the sternum. 6. Set the defibrillator to synchronized cardioversion mode and observe for R wave markers. If the R wave markers do not appear, or appear elsewhere on the ECG, select another lead or reposition the ECG electrodes. Increasing the gain to increase QRS amplitude may also be helpful. 7. Select desired energy level, charge the device and assertively state “All Clear” and visualize that everyone (including yourself) is clear. 8. Depress and hold the energy discharge button until discharge occurs (there may be a delay between depressing the energy discharge button and discharge). 9. Reassess the patient and the ECG rhythm. If the rhythm is unchanged and the patient’s condition is the same, repeat with escalating energy levels per appropriate protocol. In the event the patient’s rhythm deteriorates into ventricular fibrillation or pulseless ventricular tachycardia, immediately perform unsynchronized cardioversion (defibrillation). 10. Document procedure, including ECG rhythm, energy level and response.

Answer 18

PEARLS: • In the event cardioversion is unsuccessful after multiple attempts, consider replacing or changing therapy pads with new ones and ensure good skin contact. Consider AP placement if AL placement is being used. • For patients with implanted devices (defibrillators/pacemakers), pads can be placed in the AL or AP configuration. Attempt to avoid placing pads directly over devices. • In the AP configuration, one pad is placed over the left anterior mid chest next to the sternum and another pad is placed to the mid left posterior chest next to the spine. • Delivering electrical therapy at end expiration may decrease transthoracic resistance.

Answer 19

Indication: • Bradycardia with inadequate cardiac or cerebral perfusion as evidenced by hypotension, altered mental status, chest pain/discomfort, pulmonary edema, or other signs of shock. Contraindications: • Hypothermia with a core temperature < 86°F.

Answer 20

Background: Heart rate is a component of cardiac output (CO) [HR X SV = CO]. Many patients tolerate bradycardia (HR<60 in the adult) and experience no hemodynamic compromise, but some patients with profound bradycardia or those that are dependent on heart rate to maintain cardiac output may experience decreased cardiac or cerebral perfusion as a result of bradycardia. TCP is an option for treating bradycardia when it associated with hemodynamic compromise (decreased perfusion). TCP is considered equivalent to pharmacotherapy (atropine sulfate) and may be used immediately (in lieu of atropine sulfate) or in patients who do not respond to atropine sulfate. It should be noted that when there is impairment in the conduction system resulting in a high-degree block (e.g., Mobitz type II second- degree block or third-degree AV block), atropine sulfate is unlikely to be effective. Procedure: 1. Explain procedure to patient if applicable. 2. Attach ECG monitoring electrodes in the standard 4 lead configuration. 3. Apply pacing/multifunction therapy pads. Anterior-Posterior (AP) application is preferred for pacing. In the AP configuration, one pad is placed to the anterior mid chest next to the sternum and another pad is placed to the mid left posterior chest next to the spine. Alternately, the Anterior-Lateral (AL) configuration may be utilized. In the anterior-lateral configuration, the lateral (apex) pad is placed on the left anterior chest, just lateral to the left nipple in the midaxillary line and the anterior electrode is placed in the right sub- clavicular area lateral to the sternum. 4. Select pacing function on the monitor unit. 5. Set pacing rate to 70 bpm for an adult patient and 100 bpm for a pediatric patient. 6. Note pacing spikes on the screen. Beginning at the lowest mA setting possible, gradually increase the current until electrical capture occurs. In most patients capture will be achieved with an output of 50-100 mA. 7. Once capture electrical capture is achieved, check for corresponding mechanical capture as evidenced by a palpable pulse or presence of an oximetric (arterial) waveform. 8. Choose demand mode and verify sensing. The non-demand mode may be used when inhibition due to sensing of signals other than R waves, such as muscle artifact, or P or T waves (over sensing) and other troubleshooting measures are unsuccessful. 9. Assess patient response, including vital signs in response to pacing. 10. Consider the use of sedation and or analgesia if indicated per age appropriate Patient Comfort Protocol. 11. Document procedure including indication (initial ECG rhythm and hemodynamic status), pacer settings (mode, mA, rate) and the patient’s response to pacing.

Answer 21

PEARLS: • Adult pacing/multifunction therapy pads may be used in patients > 15 kg (33 lbs.) or 1 yo. • Avoid placement of pads over bony prominences of the spine or scapula. • Ensure good skin contact with pad application. Shave hair if situation permits. • Electrical capture is usually represented by a widening of the QRS complex and a tall, broad T wave. The deflection of the captured complex may be positive or negative. • If electrical capture occurs without corresponding mechanical capture, consider/rule out the following: hypovolemia, tension pneumothorax, pericardial tamponade, pulmonary embolus, extensive myocardial infarction, or profound acidosis. • Strong muscular contractions may make it difficult to accurately palpate a pulse. When pacing with the electrodes in the AP position, palpation of the carotid, brachial or femoral artery should be done on the patient’s right side and blood pressure should also be measured on this side. Utilize an oximetric (arterial) waveform to assist in identifying mechanical capture.

Answer 22

Indication: • Cardiac arrest. Contraindications: • LUCAS® patient <12 yo, AutoPulseTM and ROSC-UTM patient <18 yo. • Obviously pregnant patient. • Traumatic cardiac arrest. • Device does not fit patient.

Answer 23

Background: Currently available mechanical CPR devices include piston driven devices or load distributing band devices (LDB). To date there is no literature demonstrating outcomes related superiority of these devices when compared to manually performed CPR. The 2015 AHA Guidelines Update for CPR and ECC state “The use of LDB-CPR may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider (e.g., limited rescuers available, in a moving ambulance), provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices. The use of these devices are classified as a Class IIb recommendation (usefulness/efficacy is less well established by evidence/opinion). The procedure for the use of three common devices is detailed below. EMS providers may utilize other FDA approved mechanical CPR devices. The validation and documentation of the individual EMS provider’s competency utilizing a particular device is ultimately the responsibility of the service’s Medical Director. Procedure: LUCAS® 1. Ensure the operation knob is in the ADJUST position. 2. Assemble/prepare the device as per type being used (electric or pneumatic). 3. At the time of the next 2 minute CPR duty cycle pause, apply a posterior electrical therapy/defibrillation pad and place the patient on a backboard. 4. Place the back plate under the patient on backboard below the armpits. 5. Resume chest compressions. 6. Position the suction cup so the lower edge is immediately above the end of the sternum and the pressure pad is centered over the middle of the sternum. 7. Lower the suction cup and pressure pad to the point where it is just comes into contact with the patient’s lower chest. If the pad does not fit, resume manual chest compressions. 8. Turn the operation knob to ACTIVE. 9. Check the device for proper position. 10. Attach the stabilization straps. 11. To stop LUCAS operation, turn the operation knob to LOCK (this should only be done if the device is improperly placed, injury to the patient is occurring, to assess the patient, or when an AED is analyzing and charging). 12. If sustained return of spontaneous circulation is achieved, release and retract the “pressure pad” to allow for greater chest excursion and tidal volume during bag-valve-mask ventilation.

Answer 24

PEARLS: • Deployment or removal of external CPR devices should not significantly (>10 seconds) interrupt chest compressions. • System personnel should train with their respective devices to minimize deployment time and interruptions in chest compressions. • External CPR devices should never be left unattended or with an untrained provider. • Providers should be familiar with the specific device being utilized and should receive formal in-service training provided by their service specific to the device.

Answer 25

Indication: • Patient with altered mental status, signs/symptoms of hypoglycemia or diabetic ketoacidosis, patients with metabolic or endocrine disorders presenting with non- specific complaints, stroke assessment, and infants with hypothermia or bradycardia. Contraindications: • None

Answer 26

Background: Hypoglycemia is a potentially life threatening condition. The use of a glucometer for blood glucose analyses allows for the rapid determination of the blood glucose (bG) level in the field. Procedure: 1. Explain procedure to patient if applicable. 2. Blood samples for performing glucose analysis should be obtained using a capillary blood sample from a finger-stick or the heel in an infant. 3. Prepare site with alcohol or chlorohexidine. 4. Utilize lancing device and then place the correct amount of blood on the reagent test strip or on the glucometer per the manufactures recommendation. 5. Time the analysis per the manufactures recommendation. 6. Document bG reading and treat patient as indicated per age appropriate Diabetic Emergencies Protocol.

Answer 27

PEARLS: • QA should be performed on glucometers at least once every 7 days or as recommended by the manufacture and in the event clinically suspicious readings are noted. Documentation of QA must be maintained.

Answer 28

Indication: • Suspected tension pneumothorax. • Patient in traumatic cardiac arrest with chest or abdominal trauma with or without signs suggestive of tension pneumothorax. Contraindications: • None

Answer 29

Background: Tension pneumothorax may result from blunt or penetrating trauma. If allowed to progress, tension pneumothorax results in cardiovascular collapse. It is clinically identified by the presence of respiratory distress, hyperresonance to percussion on the affected side, decreased or absent breath sounds, jugular venous distention and hypotension. Tracheal deviation away from the affected side may be seen or palpated, but is a late clinical finding. In the intubated patient, decreased lung compliance may be noted. Tension pneumothorax should be considered in all cases of pulseless electrical activity (PEA) arrest. Procedure: 1. Position the patient in a supine position (if possible given situation and patient location). 2. Identify insertion site: 2nd intercostal space in the midclavicular line or the 4th-5th intercostal space in the anterior axillary line (the anterior axillary line location is preferred in obese patients). 3. Prepare the site with alcohol or chlorhexidine. 4. Insert a 14g 3.25” (or longer) decompression device or catheter over the needle device into the skin over the top of the rib located just below the intercostal space of choice. 5. Advance the device through the parietal pleura (a distinctive “pop” should be noted) until air or blood exits (do not continue to advance the needle at this point as there is risk of injury to the lung during re-expansion). 6. Advance the catheter (not the needle) to the chest wall. 7. Remove the needle, leaving the plastic catheter in place. 8. If available, a one way valve may be attached. 9. Document the procedure including clinical signs suggestive of tension pneumothorax, location of procedure, type and size of device used, and clinical response.

Answer 30

PEARLS: • In the neonate, utilize a 23g or 25g butterfly needle or a 20g or 22g catheter over the needle device. Both can be attached to a three-way stopcock and a syringe (a T-connector will be needed to attach a catheter over the needle device). • In the pediatric patient, utilize a 16g or 18g catheter over the needle device. • If the patient does not improve, consider decompressing the opposite side. • Some patients may require multiple decompressions on the same side.

Answer 31

Indication: • Ocular irrigation after chemical exposure/thermal injury. • Facilitate removal of non-embedded foreign material from the eye. Contraindications: • Patient < 8 years of age.

Answer 32

Background: The Morgan Lens is a sterile plastic device resembling a contact lens that fits over the eye similar to a contact lens. The device connects to irrigation tubing. The device allows for copious irrigation of the eye(s). Procedure: 1. Instill topical ophthalmic anesthetic in to the affected eye(s). 2. Mix 100 mg of LIDOCAINE (5ml of a 2% solution) in 1000 ml LACTATED RINGER’S SOLUTION. 3. Attach the Morgan Lens to a delivery set equipped with a macro drip chamber and open the flow control to start flow. 4. Instruct the patient to look down and insert the upper portion of the lens under the upper eye lid. 5. Instruct the patient to look up and retract the lower lid allowing placement of the lower portion of the lens under the lower lid. 6. Continue irrigation of the affected eye(s) using caution to ensure run off does not enter the unaffected eye. Do not allow the irrigation solution to run dry. 7. Tape the tubing to the patient’s face to prevent inadvertent removal. 8. Consider additional pain management as indicated. 9. To remove the lens, continue the flow of irrigation solution while instructing the patient to look up. Retract the lower lid and slide the lens from the upper lid. 10. All patients should be transported for evaluation for corneal injury.

Answer 33

PEARLS: • Once topical ophthalmic anesthetic is instilled, care should be taken that the patient doesn’t rub his/her eyes as damage can occur.

Answer 34

Indication: • Gastric decompression in the intubated patient. • Patient at high risk for aspiration due to vomiting. • Burns >20% total body surface area (TBSA). Contraindications: • History of gastric bypass surgery or recent gastric banding. • Caustic substance ingestion. • Maxillofacial trauma (nasal route). • Patient on warfarin or other anticoagulant/antiplatelet agents (nasal route, relative contraindication).

Answer 35

Background: Gastric decompression is indicated in all intubated patients. Additionally, gastric intubation/decompression should be considered in patient at high risk for aspiration due to vomiting and those with burns affecting >20% body surface area. When possible (intubated patient usually), the oral route is preferred over the nasal route due to the risk for infection. In the intubated patient, gastric decompression is a part of airway management as it decreases the risk for micro aspiration. In cardiac arrest gastric decompression eliminates the potential deleterious effects associated with gastric distention. Procedure: Oral Route 1. Select appropriate tube size (16-18fr for most adults, pediatric tube size may be estimated by the following formula: Age in years + 18 /2 (8 y.o. patient example: 8+16 = 24/2 = 12fr). 2. Estimate the insertion length by superimposing the tube over the patient’s body from the xiphoid to the angle of the jaw to the corner of the mouth (the insertion depth can be marked with tape). 3. Depress the tongue and insert the tube into the oropharynx. 4. Continue to advance the tube (the tube should be passed with a minimum of pressure, with laryngoscope assistance if necessary). 5. Advance the tube until gastric contents are returned or the desired depth of insertion is reached (if coughing occurs, halt insertion, retract the tube and reattempt insertion). 6. Confirm placement by auscultating for gastric sounds over the epigastrium while insufflating 20ml of air. Additionally, confirm placement by aspirating gastric contents. 7. Decompress the stomach of air and gastric contents by attaching the gastric tube to low suction or by manually aspirating with a large (Toomey) catheter tip syringe. 8. Secure the tube in place with tape. 9. Document gastric tube placement and confirmation by auscultation/aspiration of gastric content. The volume of liquid output should also be documented. Nasal Route 1. Select appropriate tube size (16-18fr for most adults, pediatric tube size may be estimated by the following formula: Age in years + 18 /2 (8 y.o. patient example: 8+16 = 24/2 = 12fr). 2. Estimate the insertion length by superimposing the tube over the patient’s body from the xiphoid to the angle of the jaw to the corner of the nare (the insertion depth can be marked with tape). 3. If the patient is awake and cooperative, the patient can be asked to breathe through each nostril while occluding the opposite nostril to determine which is more patent. 4. Prepare the selected nare by instilling several drops of OXYMETAZOLINE or PHENYLEPHRINE. 5. Lubricate the distal tip of the gastric tube with water soluble lubricant or 2% VISCOUS LIDOCAINE. 6. If the patient is awake, cooperative and able to sit upright, have them sit upright and flex their head forward (if not contraindicated). 7. Insert the tube into the selected nare and slowly advance the tube posteriorly parallel to the nasal canal (along the inferior aspect of the naris). The tube should not be directed upward as this may result in the tube being caught up in a blind recess at the middle turbinate. 8. The patient may gag as the tube approaches the larynx. If this occurs, temporarily halt advancement of the tube and instruct the patient to swallow. Advance the tube during swallowing as this will facilitate esophageal placement. 9. Advance the tube until gastric contents are returned or the desired depth of insertion is reached. 10. Confirm placement by auscultating for gastric sounds over the epigastrium while insufflating 20ml of air. Additionally, confirm placement by aspirating gastric contents. 11. Decompress the stomach of air and gastric contents by attaching the gastric tube to low suction or by manually aspirating with a large (Toomey) catheter tip syringe. 12. Secure the tube in place with tape. 13. Document gastric tube placement and confirmation by auscultation/aspiration of gastric contents. The volume of liquid output should also be documented.

Answer 36

Indication: • Patient exhibiting behavior or actions that may be dangerous to the patient or medical providers. Contraindications: • None

Answer 37

Background: Some patients may exhibit behavior or actions that may be dangerous to the patient or others. Any patient who may harm him or herself, or others, may be gently restrained to prevent injury to the patient or medical providers. Physical or chemical restraint must be humane and utilized only as a last resort. Other means to prevent injury to the patient or medical providers must be attempted first. These efforts may include reality orientation, distraction techniques, or other less restrictive therapeutic means. Procedure: 1. Attempt less restrictive means of managing the patient. 2. Request law enforcement assistance. 3. Ensure there are sufficient personnel available to physically restrain the patient safely. 4. Restrain the patient in a lateral or supine position. No devices such as backboards, splints or other devices should be placed on top of the patient. Patients will never be restrained in the prone position. 5. The patient’s upper extremities should be restrained with one arm at or above the level of the head and one arm at or below waist level if possible. 6. The restrained patient must be under constant observation by a licensed provider at all times. This includes ECG and SpO2 monitoring. Nasal waveform capnography may also be useful. 7. Extremities that are restrained will have a circulation check at least every 15 minutes. The first of these checks should occur as soon as possible after restraint application. This MUST be documented on the PCR. 8. Documentation on the PCR must include the reason for the use of restraints, the type of restraints utilized, and the time restraints were applied. 9. If the above actions are unsuccessful, or if the patient is resisting the restraints, chemical restraint should be utilized by advanced level providers in accordance with the Behavioral Emergencies Protocol or the Excited Delirium Protocol (chemical restraint may be considered earlier at the discretion of EMS providers). 10. If a patient is restrained by law enforcement personnel with handcuffs or other devices specific to law enforcement that EMS providers are unable to remove, a law enforcement officer must accompany the patient to the hospital in the transporting EMS vehicle or be immediately available.

Answer 38

Indication: • Suspected pelvic fracture. • Patient with blunt trauma (pedestrian struck, motorcycle crash, fall, and ejection) with hypotension or cardiac arrest. Contraindications: • Patient outside of appropriate body size/weight for specific device.

Answer 39

Background: Pelvic fractures occurring from anterior-posterior (AP) compression (open book), vertical shear or a combination of both of these patterns may be associated with major life threatening bleeding. AP compression (open book) fractures commonly result from auto-pedestrian collisions, motorcycle crashes, direct crushing injuries to the pelvis, or falls from >12 feet. Vertical shear fractures occur when a high energy force is applied in a vertical plane and one half of the pelvis shifts upward. Bleeding associated with pelvic fractures may be venous, arterial, or a combination of both. Application of a pelvic binder provides stabilization of the pelvis and decreases the pelvic volume. The larger the pelvic volume, the greater the potential for hemorrhage. This protocol outlines the application of two commercially available pelvic binders, the SAM SlingTM and the T-POD®. Procedure: SAM Sling II 1. Select appropriate size device for the patient’s estimated waist circumference. 2. Remove objects from patient’s pocket or pelvic area. 3. Place SAM SlingTM black side up beneath patient at level of greater trochanters. 4. Place black strap through buckle and pull completely through. 5. Hold the orange strap and pull the black strap in opposite direction until you hear and feel the buckle click. Maintain tension and immediately press the black strap onto the surface of the sling to secure (you may hear a second click as the sling secures). 6. Once applied, the SAM SlingTM should not be removed until the patient is in a definitive care setting and under the direction of a physician.

Answer 40

PEARLS: Pelvic fractures have a mortality rate of 5-50%, due mainly in part to the significant hemorrhage that may occur in the pelvis with minimal external signs. • Delay in stabilization of the pelvis allows for continued hemorrhage. • Excessive and repetitive manipulation (e.g. “rocking”) the pelvis should be avoided. “Rocking” the pelvis is not an appropriate assessment technique in the patient with a suspected pelvic fracture.

Answer 41

Indication: • Patient requiring medications via the intramuscular (excludes auto-injector) or subcutaneous route. Contraindications: • None

Answer 42

Background: The use intramuscular (IM) and subcutaneous (SC) injections are indicated for medications that are exclusively administered via these routes. Additionally, these routes provide an alternative to other routes (primarily the intravenous route) when other routes are unavailable. Due the rich blood supply to muscle, medications administered via the IM route are absorbed faster than those administered via the SC route. During shock states, the both the IM and SC routes are typically avoided as blood supply to both areas is reduced. Procedure: Intramuscular 1. Check the label, expiration date and appearance of the medication to be administered. 2. Confirm the Five “Rs”: Right patient, Right medication, Right dose, Right route, and Right time. 3. If applicable, explain the procedure to the patient. 4. Select injection site appropriate for medication and volume to be administered. Use a 25g needle for aqueous medications and a 21-22g needle for oily or thicker medications. The length varies by site (see table 1 below). 5. Using anatomic landmarks, identify the selected injection site: • Deltoid ⃝ Identify the bony portion of the shoulder where the clavicle and scapular meet [the acromioclavicular (AC) joint]. ⃝ Measure 2 fingers-width down from the AC joint. • Vastus lateralis ⃝ Located on the anterior and lateral aspects of the thigh. ⃝ Divide the area into thirds between the greater trochanter of the femur and the lateral femoral condyle. Injection site is the middle third. • Ventrogluteal ⃝ Place heel of your palm of your hand on the patient’s greater trochanter of the femur. ⃝ Place your index finger on the anterior superior iliac spine and spread your other fingers posteriorly. ⃝ Injection site is in the V formed between the index finger and the second finger. 7. With a circular motion starting from the selected site outward, prepare the site with alcohol or chlorhexidine. 8. With one hand, stretch or flatten the skin overlying the selected site. 9. In the other hand, hold the syringe like a dart and quickly insert the needle into the tissue and muscle at a 90° angle. 10. After the medication is injected, quickly withdraw the syringe and dispose of it properly. 11. Gently massage over the injection site to increase medication absorption. 12. Apply firm pressure over the site and apply an adhesive bandage. Subcutaneous (SC) 1. Check the label, expiration date and appearance of the medication to be administered. 2. Confirm the Five “Rs”: Right patient, Right medication, Right dose, Right route, and Right time. 3. If applicable, explain the procedure to the patient. 4. Identify the desired injection site. Common SC injection sites include the upper outer triceps area, the outer aspect of the upper thigh, and the upper buttocks. 5. With a circular motion starting from the selected site outward, prepare the site with alcohol or chlorhexidine. 6. Without contaminating the injection site, raise a fold of skin between your thumb and forefinger and insert the needle at a 45-90° angle. 7. After the medication is injected, quickly withdraw the syringe and dispose of it properly. 8. Apply firm pressure over the site and apply an adhesive bandage. Posterior Deltoid .5-1" Up to 2ml Vastus Lateralis 1-1.5" Up to 2ml Ventrogluteal 1-1.5" 2-5ml

Answer 43

PEARLS: • When administering IM or SC injections, aspirating to exclude inadvertent vascular placement of the needle is no longer recommended.

Answer 44

Indication: • Life threatening hemorrhage that cannot be controlled by other means. • Serious or life threatening extremity hemorrhage where conditions (patient location, tactical or hazmat environment) prevent the use of standard hemorrhage control techniques. • Life threatening condition(s) that require immediate attention and significant extremity hemorrhage where the use of a tourniquet is more expedient than standard hemorrhage control. Contraindications: • None

Answer 45

Background: Tourniquets have a long history in emergency care. In the recent past, it was taught that they should only be used as a “last resort.” However, due to increasing data from the battlefield, the threshold for tourniquet application should be very low. The mainstays for the control of hemorrhage from the extremities are direct pressure and tourniquet application. The use of elevation and pressure points are no longer recommended. While the Rhode department of Health Center for Emergency Medical Services does not endorse any particular brand of hemostatic tourniquet, is recommended that only tourniquets that have been evaluated and approved by the Committee on Tactical Combat Casualty Care (CoTCCC) be used. Procedure: Extremity Tourniquet Application 1. Place the tourniquet proximal to the wound. 2. Tighten the tourniquet until hemorrhage stops and there is loss of the distal pulse. 3. Secure the tourniquet(s). The tourniquet should be easily visible on the limb and should not be covered. 4. Note the time of tourniquet application. 5. If hemorrhage control is not achieved with the application of the 1st tourniquet, apply a 2nd tourniquet just distal to the first one (the first one should be left in place). 6. Do not remove a tourniquet once hemostasis has been achieved. 7. Provide wound care as per the Wound Care Procedure Protocol. 8. Provide analgesia as indicated as per age appropriate Patient Comfort Protocol. Junctional Tourniquets If available and providers are appropriately familiar with device operation and application, a junctional tourniquet may be used for junctional hemorrhage control.

Answer 46

PEARLS: • Delay in placement of a tourniquet for life threatening hemorrhage significantly increases mortality. Do not wait for hemodynamic compromise to apply a tourniquet. • Tourniquets should not be applied directly over the knee or elbow. If a wound is just distal to a joint, place the tourniquet just proximal to the joint. Additionally, do not put a tourniquets directly over a holster or a cargo pocket that contains bulky items. • Tourniquets should not be loosened to allow blood flow to return to the injured extremity. • Damage to the limb from tourniquet application is unlikely if it is removed in several hours. • It is to be expected that the patient will experience pain in the affected extremity after tourniquet application. • Currently CoTCCC approved tourniquets include the C-A-T (Combat Application Tourniquet) and the SOFTT (SOF Tactical Tourniquet).

Answer 47

Indication: • Patient requiring rapid medication administration when other routes are not immediately available. Contraindications: • None

Answer 48

Background: Intranasal medication delivery provides for the rapid administration of certain medications (naloxone, midazolam, fentanyl) when other routes are unavailable or unsafe. Procedure: 1. Draw up appropriate dose of medication into syringe (1 ml max). 2. Confirm the Five “Rs”: Right patient, Right medication, Right dose, Right route, and Right time. 3. Attach a mucosal atomization device to the syringe. 4. Using the free hand to hold the occiput of the head stable, place the tip of the mucosal atomization device snugly against the nostril aiming slightly up and outward (toward the top of the ear). 5. Briskly compress the syringe plunger. Then deliver half of the medication into the nostril. 6. Dispose of the syringe and atomizing device in an approved sharps container.

Answer 49

PEARLS: • Minimize the volume, and maximize concentration of medication (1/3 mL per nostril is ideal, 1 mL is max). • Maximize the total mucosal absorptive surface area. Atomize the medication (rather than dripping it in). Use both nostrils to double the absorptive surface area. Aim slightly up and outwards to cover the turbinates and olfactory mucosa. • Beware of abnormal mucosal characteristics. Mucous, blood and vasoconstrictors reduce absorption. Suction the nostrils or consider alternate drug delivery method in these situations.

Answer 50

Indication: Acute hypotension Contraindications: None

Answer 51

Background: The administration of vasopressors as a bolus dose for the management of acute hypotension is common practice in critical care and anesthesia practice. Vasopressors commonly administered in this fashion include phenylephrine, epinephrine, ephedrine, and less commonly, norepinephrine. Push-dose vasopressors are used as a bridge to the institution of a vasopressor infusion or to treat acute hypotension related to medication administration. Some vasopressors are available in push-dose concentration prefilled syringes, but they have a very short shelf life. Because of this, providers are frequently required to dilute vasopressors to create the appropriate concentration of the medication for push-dose use in the field and critical care transport setting. It is imperative that the provider ensures that the appropriate concentration of medication is being administered. Syringes containing push-dose vasopressors must be labeled with the drug name and concentration. Procedure: Epinephrine The push dose concentration (10 mcg/ml) of epinephrine is normally created by diluting epinephrine 1 mg/10 ml [100 mcg/ml] (previously referred to as epinephrine 1:10,000). Onset of action: 1 minute Duration of action: 5-10 minutes Adult dose: 10-20 mcg every 3-5 minutes Pediatric dose: 1 mcg/kg (0.1 ml/kg) every 3-5 minutes The create push-dose concentration (10 mcg/ml) epinephrine: 1. Fill a 10ml syringe with 9ml of 0.9% saline. 2. Into the syringe add 1ml of epinephrine (1mg/10ml) to create a concentration of 10 mcg/ml. 3. Label the syringe. If there is a shortage of prefilled syringes containing epinephrine 1 mg/10ml, you will must first create epinephrine 1mg/10ml prior to preceding with the above. To do this: 1. Draw up 1ml from a vial or ampule containing epinephrine 1 mg/ml (previously referred to as epinephrine 1:1,000) into a 10ml syringe. 2. Draw up and additional 9 ml of 0.9% saline into the same syringe. 3. You now have epinephrine 1 mg/10ml. Phenylephrine The push-dose concentration (100 mcg/ml) of phenylephrine is created by diluting phenylephrine 10 mg/ml. Onset of action: 1 minute Duration of action: 10-20 minutes Adult dose: 50-100 mcg every 2-5 minutes Pediatric dose: 5 mcg/kg [max single dose 100 mcg] every 5-10 minutes The create push-dose concentration (100 mcg/ml) phenylephrine: 1. Draw up 1ml of phenylephrine from a vial containing phenylephrine 10mg/ml. 2. Inject the 1ml (10mg) of phenylephrine into a 100 ml bag of 0.9% saline to create a concentration of 100 mcg/ml. 3. Draw up 10ml from the bag into a 10ml syringe (you now have 100 mcg/ml in the syringe). 4. Label the syringe.

Answer 52

PEARLS: • Phenylephrine is a pure α agent and it is devoid of any inotropic or positive chronotropic effects. Because profound α stimulation can result in reflex bradycardia, phenylephrine should be avoided in the setting of hypotension with significant bradycardia (use epinephrine instead). • Epinephrine is a α and β agonist, so it has positive inotropic, chronotropic and vasopressor properties at the dose utilized for push-dose administration.

Answer 53

Indication: • Primary venous access in a neonate ≤ ~ 1 week of age requiring resuscitation or emergent medication administration. Contraindications: • Peritonitis • Omphalitis • Necrotizing enterocolitis

Answer 54

Background: Cannulation of the umbilical vein provides vascular access in the neonate ≤ ~ 1 week of age requiring resuscitation or emergent medication administration. Cannulation of the umbilical vein should be reserved for the unstable patient in which peripheral or intraosseous access is unavailable. Procedure: 1. Double wrap a piece of umbilical tape around the base of the cord. 3. Utilize sterile technique (sterile gloves, mask, drapes) as much is possible. 3. Prepare the cord stump and surrounding abdomen with betadine solution. 4. If the stump is not fresh, cut the stump horizontally with a #15 scalpel approximately 1.5-2 cm from the abdominal wall. 5. If there is bleeding, hemostasis can be achieved by applying gentle tension on the umbilical tape. 6. Identify the umbilical vasculature. The two arteries are the thick-walled small vessels and the one thin-walled vessel is the vein. The umbilical vein (UV) is the largest of the three vessels and is usually located in the 12 o’clock position. 7. If present, utilizing forceps, gently remove and clots from the UV. 8. Utilizing forceps, open and dilate the vein (the vein is usually open and will not require dilation). 9. Insert an appropriately sized UV catheter (3.5fr for premature infants and 5fr for full-term infants). The catheter should be inserted just to the point that blood returns (low line placement). 10. Secure the catheter in place.

Answer 55

PEARLS: • Advancing the catheter beyond the point at which blood is returned may result in placement of the catheter in the portal vein. • Portal vein placement should be suspected if resistance to advancement is met. If portal vein placement is suspected, withdraw the catheter to the appropriate point.