Preface: TN Skills Manual July 2003

TN SKILLS MANUAL July 2003
PREFACE
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Prehospital care for the sick and injured has improved vastly in Tennessee since its introduction in 1972. This manual was developed and revised to reflect the changing nature of prehospital care and to both assist the Instructors delivery of and the students development of, the essential skills required to provide the proper care for an ill or traumatized patient. The procedures outlined in this manual may not always be applicable to every situation the Emergency Medical Technician may encounter. The Tennessee Department of Health, Division of Emergency Medical Services practical examination evaluates the students abilities to perform these skills using the procedures described. This manual is in accordance to the 1994 USDOT EMT Basic Curriculum, the 2002 EMT-Extended Skills Modules, and the 2002 Airway Supplement to the 1994 US DOT EMT Basic Curriculum. This skills manual provides a guideline for minimum behavioral psychomotor competencies. Didactics and competencies beyond this manual are required. Requirements for successful Psychomotor course completion include: Students must demonstrate proficiency in all skills in each testing session of selected topic areas and mastery of skills in the final examination. Utilize special remedial sessions to assist in the completion of a lesson or module of instruction. Pass/fail scores should be in accordance with accepted practices. Usage of skill measurement instruments within the D.O.T. curriculum or developed by the way of a valid process is strongly recommended to achieve maximum results with the students. The skills measurement instruments contained within the D.O.T. curriculum ARE NOT a teaching tool but a measurement tool. Both the 1994 D.O.T. EMT-Basic Curriculum and the 1999 D.O.T. EMT-Paramedic Curriculum recognize continuing education and skills refresher programs as key to ensure and maintain competency.
TABLE OF CONTENTS PREFACE AIRWAY 1. Airway Management and Respiratory Support 2. Oxygen Tank Operating Procedures 3. Oxygen Delivery 4. Oropharyngeal Airway 5. Nasopharyngeal Airway 6. Positive Pressure Ventilation Mouth to Mask (Pocket Mask) 7. Positive Pressure Ventilation Bag-Valve-Mask (BVM) Device 8. Double Lumen Airway - Combitube 9. Double Lumen Airway - PtL 10. Suctioning 11. Nebulizers 12. Inhalers PATIENT ASSESSMENT 13. Vital Signs 14. Patient Assessment 15. Information Reported to the Hospital by EMS Personnel BANDAGING 16. Amputation 17. Amputated Part 18. Eye Avulsion with Eyeball Extruding 19. Flail Chest 20. Head Bandage 21. Impaled Objects 22. Bleeding Control and Shock Management SPLINTING 23. General Rules for Splinting 24. Sling and Swathe for Upper Extremity 25. Foot or Ankle Splint 26. Pneumatic Anti-Shock Garment for Splinting BOARD IMMOBILIZATION 27. Radius/Ulna 28. Tibia/Fibula 29. Hip 30. Sager Traction Splint 31. Traction Splint 32. Joint Injury Splint SHOCK 33. Pneumatic Anti-Shock Garment Hypovolemia Management 34. Definitions of Terms 35. Math Calculation for Epinephrine 1:1,000 36. Subcutaneous Injection 37. Intramuscular Injection 38. Epinephrine 1:1000 Auto-Injector PACKAGING 39. Clam Shell Spinal Immobilization Device 40. Helmet Removal 41. Long Spine Board 42. Scoop Stretcher 3 2 5 6 7 9 11 13 15 17 19 22 27 29 31 33 34 36 43 46 47 48 49 50 51 52 53 56 57 58 60 61 64 65 67 69 71 73 76 77 78 81 82 83 86 90 92 93 95 97 100
EMT PHARMACOLOGY 43. Activated Charcoal 44. Aspirin 45. Bronchiodilator Albuterol 46. 50% Dextrose in Water 47. 25% Dextrose in Water 48. Epinephrine 1:1000 49. Nitroglycerine Tablet 50. Nitroglycerine Spray 51. Oxygen INTRAVENOUS THERAPY 52. Math Calculation/Intravenous Therapy Drip Rates 53. IV Bag Assembly and Set up 54. Obtaining IV Access 55. D50W and D25W Bolus 56. Discontinuing an Intravenous Line AUTOMATED EXTERNAL DEFIBRILLATION APPENDIX A - Application Process 57. Requirements to Become Licensed in TN 58. Understanding the Application Process 59. Checklist for EMT Licensure in TN APPENDIX B Renewal Process 60. When to Renew 61. How to Renew 62. Online Renewal Process 63. EMT-Basic National Registry Renewal APPENDIX C EMS Statutes and EMS Rules & Regulations 64. Emergency Medical Services Statutes 65. EMS Rules and Regulations 66. Destination Determinates 67. The Field Triage Decision Scheme 68. Health Insurance Portability and Accountability Act (HIPPA) 69. Domestic Violence APPENDIX D Miscellaneous Mark I Auto-Injector
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Change of Address Form IM Injection Skill Sheet
AIRWAY
AIRWAY MANAGEMENT AND RESPIRATORY SUPPORT A patient without an airway is a dead patient. Every patient must have a patent airway to survive. When the airway is obstructed, the EMT must clear it as soon as possible using the methods described in this section or other means within the EMTs Scope of Practice and in accordance with the Standard of Care. The only exception is situations where it is unsafe or the airway problem is such that it cannot be treated in the field and the patient must be transported immediately to a hospital. Once the airway is opened, the EMT must determine if breathing is adequate. Patients with inadequate breathing must be artificially ventilated using mouth-to-mouth, mouth-tomask, bag-valve-mask or a flow-restricted, oxygen powered ventilation device. If the patient has adequate breathing, the EMT must decide if oxygen is indicated. If oxygen is necessary, the EMT must select the appropriate device and follow the procedure for delivery. The EMTs responsibility for providing adequacy of airway, oxygenation, and ventilation is paramount to the sick or injured patient's well being and organ system integrity. In short, nothing other than immediate personnel safety takes priority over airway management and respiratory support of the sick or injured patient. The EMT must be well adept at early recognition of respiratory emergencies and highly proficient in the intervention and management of such emergencies. Attaining proficiency in the following skills and techniques will help assure the Emergency Medical Technician is prepared to meet the critical challenges of respiratory emergencies.
OXYGEN TANK OPERATING PROCEDURES Set-Up and General Administration GOAL To identify and properly assemble an oxygen delivery system to deliver oxygen to a patient OBJECTIVE Given an oxygen tank the EMT student will be able to properly identify and assemble an oxygen delivery system ready for oxygen administration within 5 minutes. EQUIPMENT Oxygen tank Oxygen regulator with regulator washer and gauges Oxygen tank wrench PROCEDURE: 1. 2. Remove protective seal. Observe for a static pressure date. Quickly open, then shut, the valve. This procedure is to blow out any foreign matter that could adversely affect the gauges and gauge readings. This is also known as cracking the tank. Attach regulator-flowmeter to tank. Ensure washer is between the tank port and the regulator. Align regulatorflowmeter to tank port utilizing the Pin Index System. Only hand-tighten the regulator-flowmeter to the tank. Open valve to ensure there are no leaks and to ensure tank pressure is at least 500 psi. If a leak exists, remove regulator and repeat the process. Attach oxygen delivery device to regulator-flowmeter. Open regulator- flowmeter to desired setting (LPM). Apply oxygen device to patient. When complete, remove device from patient, turn off valve and remove all pressure from the regulator.
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GENERAL CONSIDERATIONS Change oxygen tanks when tank contains a minimum of 500 psi. Do not use tank beyond the Safe Residual Pressure of 200 psi.
Dry oxygen is not harmful in short term. A humidifier is needed only for patient on oxygen for a long time and is not generally needed for Prehospital care. Possible fire hazard due to continual leakage of oxygen. Possible fire hazard if tank/regulator parts are lubricated with oil products. Oxygen tanks are a possible projectile if tank tips over due to contents under high pressure. Tanks should be positioned/secured to prevent falling and to prevent blows to the valve-gauge assembly and secured during transport. Oxygen Cylinder Sizes A full tank is approximately 2000 psi. and varies with ambient temperature. Cylinder D E M G H Liters 350 625 3,000 5,300 6,900 PSI 2,000 2,500 2,000 2,500 2,000 2,500 2,000 2,500 2,000 2,500
OXYGEN DELIVERY Equipment for Oxygen Delivery to Patients who are breathing Adequately GOAL Provide adequate oxygen to patient OBJECTIVE: Given a simulated patient, the EMT student will be able to identify the proper oxygen delivery device and percent of oxygen delivery within 5 minutes. EQUIPMENT Body substance isolation Oxygen source Appropriate oxygen delivery device non-rebreather mask (NRB) nasal cannula (NC) PROCEDURE: 1. 2. 3. 4. 5. Gather and check equipment. Take body substance isolation precautions. Assess respiratory effort and record. Open oxygen tank valve all the way then back turn. Select the appropriate oxygen delivery device. a. Non-Rebreathing Face Mask 1. ensure proper fit of mask 2. connect NRB with tubing to the supplemental oxygen source 3. select proper flow rate, 12 - 15 liters per minute 4. inflate reservoir before placing mask on patient (a gloved finger inserted over inlet valve in mask will facilitate bag filling) 5. place strap behind head 6. seat mask on face & bend conforming metal piece to bridge of nose and snug strap 7. if the patient cannot tolerate a non-rebreather mask a nasal cannula should be applied 8. if bag deflates more than 1/3, increase oxygen rate - if already at 15 Lpm, patient may need PPV w/ BVM. Nasal Cannula 1. attach nasal cannula with tubing to supplemental oxygen source 2. set proper flow rate, 2-6 liters per minute 3. place prongs upward into nostrils 4. place narrow tubing to which the prongs are attached in nostrils 5. secure strap around patient ears. 6. snug under chin, using slip ring
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When complete, remove device from patient, turn off valve and remove all
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pressure from the regulator. (terminating oxygen therapy) TABLE OF DELIVERY DEVICES DEVICE Non-rebreather Nasal Cannula GENERAL CONSIDERATIONS Assure NO SMOKING in the ambulance. Smoking or any other use of tobacco products is prohibited inside or within ten (10) feet of an ambulance. Patients who are cyanotic, cool, clammy or short of breath need oxygen and should receive high concentration oxygen. Concerns about the dangers of giving too much oxygen to patients with history of chronic obstructive pulmonary disease (COPD) and infants and children have not been shown to be valid in the Prehospital setting. Capillary (airway) Dead Space is the area of dead space between the point of oxygen delivery and the alveoli. Fill this space in order for the patient to receive beneficial oxygen. Space includes oro/nasopharynx, pharynx, trachea, and bronchi. If breathing is inadequate and the patient is responsive, administer oxygen. All responsive patients breathing < 8 or >24 breaths per minute should receive high flow oxygen (defined as 15 LPM via NRB). - If the patient is unresponsive and the breathing is adequate, open and maintain the airway and provide high concentration oxygen. - If the breathing is inadequate, open and maintain the airway, assist the patients breathing and utilize ventilatory adjuncts. Use oxygen in all cases. - If the patient is not breathing, open and maintain the airway and ventilate using ventilatory adjuncts. Use oxygen in all cases. Any patient with a reduced minute volume must receive assisted ventilation with BVM and appropriate adjuncts. APPROXIMATE % 90 24 - 40 LITER FLOW/MIN 12-15 2-6
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OROPHARYNGEAL AIRWAY Oral Airway GOAL To prevent upper airway obstruction by the tongue OBJECTIVES Given a simulated patient, the EMT student will be able to state the indications and contraindications for using an oropharyngeal airway and demonstrate the proper selection and insertion of an oropharyngeal airway within 1 minute. INDICATIONS To assist in maintaining an open airway on unresponsive patients with or without trauma who are without a gag reflex, has an inadequate airway, or not breathing Patients with need for prolonged artificial ventilation Any patient ventilated with a BVM CONTRAINDICATIONS If oral airway is introduced into a conscious or semiconscious patient with an intact gag reflex, this device could cause vomiting or spasm of the vocal cords. Unable to introduce airway into oropharynx, secondary to massive trauma EQUIPMENT Body substance isolation Assorted oropharyngeal airway sizes Suctioning Equipment PROCEDURE: (EMT positioned superior to the head of the patient) 1. 2. 3. Take body substance isolation precautions. Select appropriate size airway: Measure from corner of the patients lips (mouth) to the bottom of the patients ear lobe or angle of jaw. Open the patients mouth. a. No suspected C-spine injury: Head tilt, chin lift. b. Suspected C-spine injury: Jaw thrust with head kept in neutral position. c. Infant: Sniffing position with chin lift maintaining head in neutral position. In the adult patient, to avoid obstructing the airway with the tongue, insert the airway with the tip facing toward the roof of the patients mouth.
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Advance the airway gently until the hard palate is met (resistance) then rotate airway 180 degrees so that it comes to rest with the flange on the patients teeth.
ALTERNATE INSERTION PROCEDURE 1. 2. Open mouth and retract tongue with tongue depressor Insert right side up. Use a tongue depressor to press the tongue down and forward to avoid obstructing the airway. Following natural curvature, advance airway until flange rests against teeth. This is the preferred method for airway insertion in an infant or child.
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RISK AND COMPLICATIONS Stimulation of gag reflex may increase risk of vomiting, aspiration, or laryngospasm. Be prepared to suction. If chosen airway is TOO SHORT: Tip may displace tongue into oropharynx obstructing airway or airway will not advance far enough to lift tongue. If chosen airway is TOO LONG: Tip may push epiglottis over glottic opening or induce laryngospasm. If the only choice is between the airway that is too long or the short, choose the airway that is TOO LONG. Measure from patients lips to the bottom of the patients ear lobe or angle of airway. Follow proper insertion techniques to the mark and prevent airway from advancing further GENERAL CONSIDERATIONS Provide supplemental oxygen by either NRB or BVM, based on patients condition Assist ventilations as needed and enough volume to ensure adequate chest rise Adult - 1 every 5 seconds Infant/Child - 1 every 3 seconds Be prepared to suction! A patient tolerating an oropharyngeal airway suggests the need for upgrading to an advanced airway such as a Double Lumen Airway Device. airway that is too the corner of the jaw and mark the secure airway to
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NASOPHARYNGEAL AIRWAY GOAL To prevent upper airway obstruction by the tongue OBJECTIVES Given a simulated patient, the EMT student will be able to state the indications and contraindications for using a nasopharyngeal airway and demonstrate the proper selection and insertion of a nasopharyngeal airway in 3 minutes. INDICATIONS Conscious patient with an intact gag reflex An inadequate airway due to relaxed tongue Patient with decreased level of consciousness who cannot tolerate the oropharyngeal airway Trismus, preventing oropharyngeal insertion Massive trauma to lower jaw, preventing insertion of oral airway CONTRAINDICATIONS Should not be used in suspected basilar skull fractures or obviously severe (frank) nasal injuries EQUIPMENT Body substance isolation Assorted nasopharyngeal airways Water soluble lubricant 4 x 4 Gauze Pad PROCEDURE: (Position EMT superior to the head of the patient) 1. 2. 3. Gather and check all equipment Take body substance isolation precautions. Select appropriate size airway. a. For correct length measure the distance from the tip of the nose to the tip of the patients earlobe b. For correct diameter - largest size that will easily insert into nostril, approximately size of patients little finger. Lubricate with water-soluble lubricant. a. place 4x4 in gloved hand b. apply generous amount of water soluble lubricant onto 4x4 c. leaving the hand and 4x4 flat, roll airway through lubricant ensuring a generous amount is applied
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Position patient's head a. No suspected C-spine injury: Head tilt, chin lift b. Suspected C-spine injury: Jaw thrust keeping head in neutral a position. c. Child (1-8 yr.) - Sniffing position with chin lift maintaining head in neutral position. Insert it posteriorly. Bevel should be toward the base of the nostril or toward the septum. NOTE: Soft pre-shaped airways are designed to insert into the right nostril. The pre-shaped design matches the natural curvature of the right nasal airway. Advance airway following natural curvature up to measured distance a. DO NOT force. b. If resistance is met, withdraw and attempt insertion through left nostril 1. Re-lubricate airway if necessary. 2. Insert airway with curvature toward the roof of the nostril gently into left nostril so that bevel faces the base of nostril or toward the nasal septum 3. Advance airway gently until resistance is met then rotate 180 degrees 4. Continue to advance airway up to measured distance
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RISK AND COMPLICATIONS Insertion too far or with an airway that is too long may stimulate gag reflex that may cause vomiting and aspiration or laryngospasm Always have suction prepared prior to insertion If chosen airway is TOO SHORT may not advance far enough for adequate airway. If chosen airway is TOO LONG tip may push epiglottis over glottic opening or induce laryngospasm. If the only choice is between the airway that is too long or the airway that is too short, choose the airway that is TOO LONG. Measure from the tip of the earlobe to the tip of the nostril and mark the airway. Follow proper insertion techniques to the mark and secure airway to prevent airway from advancing further Even though the airway is generously lubricated, it is still a painful stimulus and the nasal passages may still suffer trauma secondary to insertion. Be prepared for nosebleed.
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POSITIVE PRESSURE VENTILATION (PPV) Mouth to Mask (Pocket Mask) Ventilation GOAL To provide adequate oxygenation and ventilation for the patient OBJECTIVE Given a patient, the EMT student will be able to demonstrate the use of a pocket mask within 2 minutes. EQUIPMENT Body substance isolation "Pocket Mask" with Transparent material Oxygen connector port for adding supplemental oxygen One-way valve that diverts patient's exhaled air Filter Oxygen source Oropharyngeal or nasopharyngeal airway PROCEDURE: (EMT is positioned superior to the head of the patient) 1. 2. 3. 4. 5. Gather and check equipment Take body substance isolation precautions. Insert oropharyngeal or nasopharyngeal airway if indicated. (see pages 11-14) Connect oxygen inlet to oxygen source as soon as possible @ 15 Lpm. Ensure appropriate size mask for patients face and ensure good seal Position patient's head a. No suspected C-spine injury: Head tilt, chin lift b. Suspected C-spine: Jaw thrust with head in neutral position c. Infant: Sniffing position with chin lift maintaining head in neutral position. Place mask over mouth and nose forming a seal Ensure apex of mask is over the nose Make sure lower portion should fit between the lower lip and chin protuberance Using both hands, lift along the point or angle of the mandible with middle, ring and little fingers while pressing mask to face with index fingers and thumbs. a. If suspected spine injury, do not tilt head. Only lift along the angle of the jaw.
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If no suspected spine injury, lift the jaw into the mask as you tilt the victims head backward and place your remaining fingers under the angle of the jaw. While lifting the jaw, squeeze the mask with your thumbs to achieve an airtight seal between the mask and the victims face.
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Seal mouth around the one-way valve attached to the mask and give slow breaths by blowing your exhaled air into the valve. Ventilations should be delivered: 1. 1.5 - 2 seconds for adults 2. 1 - 1.5 seconds for pediatrics LOOK, LISTEN, and FEEL for adequate air exchange with each breath and record. a. LOOK for chest rise and fall b. LISTEN for exhaled air c FEEL for exhaled air Continue to ventilate at appropriate rate and enough volume to ensure adequate chest rise. a. Once every 5 seconds for adult b. Once every 3 seconds for child/infant
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GENERAL CONSIDERATIONS Ventilate the adult patient at a rate of 10 20 breaths per minute. Change to BVM as soon as possible. Observe for vomitus and be prepared for suction. 16 % oxygen is provided when ventilations are provided without supplemental oxygen. 50 - 60 % oxygen is provided when connected to supplemental oxygen. Mouth-to-mask ventilation provides more volume than bag-valve-mask ventilation.
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POSITIVE PRESSURE VENTILATION (PPV) Bag-Valve-Mask (BVM) Device GOAL To provide adequate oxygenation and ventilation for the patient in respiratory distress, arrest, or any other need of forced or assisted ventilations OBJECTIVE Given a simulated patient, the EMT student will be able to describe all parts and functions of the BVM device and demonstrate the use of a BVM device within 2 minutes. EQUIPMENT Body substance isolation Self-inflating BVM device with oxygen reservoir and true non rebreathing valve Adult BVM Volume: Approximately 1600 ml Child/Term Infant BVM Volume: minimum of 800 ml Delivery volume potential should be at least of device volume. A non-jam valve allowing maximum oxygen inlet flow of 15 liters per minute No pop-off valve or pop-off valve disabled Standard 15/22 mm fitting Proper fitting, transparent face mask Oxygen and oxygen connecting tubing Oropharyngeal or nasopharyngeal airway Stethoscope PROCEDURE: (Position the EMT superior to the head of the patient) 1. 2. 3. 4. Gather equipment and take body substance isolation precautions Insert oropharyngeal or nasopharyngeal airway based upon absence or presence of gag reflex. Assemble mask to bag-valve mask, and as soon as possible, connect oxygen reservoir to supplemental oxygen at 15 liters per minute. Position patient's head a. If no suspected C-spine injury: Head tilt, chin lift b. If suspected C-spine injury: Jaw thrust with head in neutral position c. Infant: Sniffing position with chin lift maintaining head in neutral position. Position thumbs over top half of mask, index and middle fingers over bottom half. Place apex of mask over bridge of nose, then lower mask over mouth and upper chin. If mask has large round cuff surrounding a ventilation port, center port over mouth. Lift the mandible at angle of the jaw utilizing the little, ring, and middle fingers. Simultaneously press the mask to face with index finger and thumb. (E C)
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Squeeze bag slowly until chest rises. Tidal volume should be titrated to provide sufficient ventilation to produce visible chest expansion. 1. 1.5 - 2 seconds, Adult 2. 1.0 - 1.5 seconds, Pediatric LOOK, LISTEN, and FEEL for adequate air exchange. a. LOOK for chest rise and fall b. LISTEN - Auscultate for air sounds over the stomach and at both sides of the chest c. FEEL for good bag-valve device compliance Continue to ventilate at appropriate rate. a. ADULTS: At least once every 5 seconds b. CHILD/INFANT: At least once every 3 seconds If chest does not adequately rise and fall with each ventilation, re-evaluate. a. If chest does not rise, reposition head. b. If air is escaping from under the mask, reposition fingers and mask. c. Check for obstruction. d. If chest still does not rise and fall, use alternative method of artificial ventilation, e.g. pocket mask, manually triggered device.
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GENERAL CONSIDERATIONS Provides less volume than mouth-to-mask. Gastric distention Increase inspiratory times to deliver the necessary tidal volume at low peak inspiratory pressures If possible, apply cricoid pressure or Sellick Maneuver (requires additional rescuer) Low ventilatory volume Squeeze bag with free hand against your leg or side to expel additional volume With two rescuers (preferred), use two hands to seal mask and a second rescuer to squeeze bag with both hands. Incorporate the use of an Automatic Transport Ventilator, if available, to provide adequate tidal volume while sealing mask with both hands. If difficulty exists in providing a leak proof seal to the face, resort to mouth-to-mask method. Observe for vomitus and be prepared for suction. ALWAYS reassess the patients ABCs, skin color, LOC and record. The flow restricted, oxygen-powered ventilation device procedure is for adult patient use only. The operational and procedural guidelines are similar to the BVM.
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DOUBLE LUMEN AIRWAY DEVICE Combitube GOAL To provide adequate oxygenation and ventilation for the patient in respiratory distress or arrest OBJECTIVE Given a simulated patient, the EMT student will be able to state the indications, contraindications, and demonstrate the insertion and removal of the airway device. INDICATIONS Patients 16 years or older experiencing apnea or inadequate spontaneous respiratory effort Absence of protective gag reflex When there is only one EMT available for transport. CONTRAINDICATIONS Under age 16 yrs. Under 5 feet tall Over 7 feet tall Gag reflex EQUIPMENT BSI Combitube Kit Bag Valve Mask Device (BVM) Appropriate size Oral airway Stethoscope Oxygen Cirrhosis of the liver Known esophageal disease Ingestion of caustic substance
Suction Device Rigid (Yankeur) suction tip # 18 French Levine Catheter Lubricate (water soluble jelly) 4x4s
PROCEDURE: (INSERTION) (EMT is positioned superior to the head of the patient) 1. 2. 3. Gather and check equipment. Take body substance isolation precautions. Hyperventilate/Oxygenate with BVM for at least 1 minute (24 breaths per minute) before attempting insertion (max. insert time 30 seconds) Obtain orders from Medical Control to insert device, unless Standing Orders exist. Prepare Combitube for insertion a. Remove from package and perform cuff test immediately prior to insertion (1) cuff test - inflate both cuffs to manufacturers recommended specifications to determine if leak exists. If no leaks are
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detected, deflate cuffs and proceed. Lubricate with water soluble lubricant (1) place 4x4 in gloved hand (2) apply generous amount of lubricant on 4x4 (3) holding hand with 4x4 and lubricant flat, roll device through lubricant to ensure a generous amount of lubricant is applied to the cuffs and tip
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Instruct temporary discontinuation of ventilations, removal of BVM, and oropharyngeal airway. Perform the Tongue / Jaw lift maneuver. Insert tube into mouth & advance gently, until the printed ring on the tube is aligned with the teeth or alveolar ridges. Inflate line 1, proximal cuff (blue pilot), with 100 ml. of air using 140 ml. syringe, removing the syringe from port post inflation. Do not discard syringe. Inflate line 2, distal cuff (white pilot), with approx. 15 ml. of air with the 20 ml. syringe removing the syringe from port post inflation. Do not discard syringe. Ventilate through tube #1 (blue tube) confirm breath sounds and chest rise (auscultate over gastric, upper and lower lung lobes bilaterally, and midaxillary bilaterally). a. If breath sounds positive and gastric negative, continue appropriate ventilatory support b. If breath sounds negative & gastric positive, ventilate through tube #2 (clear tube), confirm breath sounds and chest rise and continue with appropriate ventilatory support Pneumonic for Order of Insertion - VOLS Ventilate Orders Lubricate Stick it in Passive Gastric Decompression, as needed for acute gastric distention a. DO NOT interrupt ventilations while performing. b. Measure and lubricate an 18 French Levine suction catheter. 1. For approximate distance, measure distance from tip of tube not being used to ventilate the patient to tip of the ear lobe, earlobe to chin, and chin to xyphoid process. 2. Mark this distance on catheter. 3. Lubricate catheter with a water soluble lubricant. c. Insert catheter through the non-airway tube and advance catheter into the stomach up to the measured distance. Allow stomach to decompress and remove catheter, repeat prn. Slow and gentle pressure on abdomen may be necessary to assist with the decompression of the stomach.
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REMOVAL 1. State and observe indications for removal a. Patient regains consciousness b. Protective airway gag reflex returns Prepare suction Turn patient preferably on left side, unless contraindicated Deflate cuffs (proximal first) Perform Passive Gastric Decompression
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6. Remove Combitube with single motion on expiration, following natural curvature of pharyngeal area as patient exhales. 7. 8. 9. Suction as needed. Place patient on high flow / concentration oxygen, provide airway and ventilatory support as appropriate to patients condition. Continue close reassessment of airway status and respiratory system ABCs.
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PHARYNGEAL TRACHEAL LUMEN AIRWAY [PtL] GOAL To provide adequate oxygenation and ventilation for the patient in respiratory arrest or distress OBJECTIVE Given a simulated patient, the EMT student will be able to state the indications, contraindications, and demonstrate proper technique for inserting and removing the PtL airway. INDICATIONS Patients 16 years or older experiencing apnea or inadequate spontaneous respiratory effort Absence of protective gag reflex Copious oropharyngeal bleeding When there is only one EMT available for transport. CONTRAINDICATIONS Patients under 16 years old Under 5 feet tall Over 7 feet tall Gag reflex EQUIPMENT Body substance isolation Bag-Valve-Mask (BVM) device Oxygen and tubing Suction device Rigid (Yankeur) suction tip Stethoscope DESCRIPTION PtL is a single patient use device that is clean but not sterile The PtL is inserted blindly into the airway without direct laryngoscopy The PtL has a cuffed tube that can serve as either an esophageal obturator or an endotracheal tube Another cuff, which inflates in the oropharnyx results in isolation of the lower airway Three tubes are visible to the rescuer after insertion. The tubes are numbered (1, 2 and 3). Tube 1 allows the rescuer to orally inflate the two cuffs simultaneously PtL Airway Appropriate size oropharyngeal airway 4x4s 18 French Levine catheter Water Soluble Lubricant Cirrhosis of the liver Known esophageal disease Known caustic poison ingestion
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Tube 2 (green) extends to the isolated airway distal to the inflated cuff. When ventilated, this tube will ventilate the lungs if an esophageal intubation has occurred. Tube 2, which will always be in the oropharnyx, is the short tube. Tube 3 is the cuffed, long tube, which serves as the esophageal obturator, or endotracheal tube, depending on anatomical position. A plastic stylet aids in placement of the device and occludes the esophageal obturator tube. If tube 3 is placed in the trachea, the stylet is removed to allow tracheal ventilation. PROCEDURE (INSERTION) (Position the EMT superior to the head of the patient) 1. 2. 3. Gather and check all equipment. Take body substance isolation precautions. Oxygenate/ventilate the apneic patient with a BVM and oral airway (before each attempted insertion (limit insertion attempts to a maximum of 30 seconds). Assess breath sounds and record. Obtain orders for insertion from Medical Control unless Standing Orders exist. Prepare PtL for insertion a. Remove protective wrapping from the cuffs. (1) DO NOT perform a test inflation of the cuffs. Cuff integrity is determined at the factory. Routine inflation will increase the chance of the cuff tearing during insertion, and will weaken the cuffs. b. Assure the White Port Cap is in the closed position. c. Lubricate with water-soluble lubricant (1) place 4x4 in gloved hand (2) apply generous amount of lubricant on 4x4 (3) holding hand with 4x4 and lubricant flat, roll device through lubricant to ensure a generous amount of lubricant is applied to the cuffs and tip Instruct temporary discontinuation of ventilations, removal of BVM, and oropharyngeal airway Position head, in extension (except for trauma patient where neutral in-line position must be maintained). Hyperoxygenate / Hyperventilate with BVM for at least 1 minute (24 breaths per minute) before attempting insertion (max. insert time 30 seconds).
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Insert your thumb deep into the supine patients mouth. Grasp the tongue and lower jaw between your thumb and index finger and lift straight upward. In your other hand, hold the PtL Airway so that the curvature matches the direction of the natural curvature of the pharynx. Carefully insert the tip into the mouth to the right of the tongue following the natural curvature until mouthpiece flange rests on the teeth. Modest resistance will be met at the back of the oro pharynx. DO NOT use force! If the tube does not advance, either redirect the tube and attempt reinsertion after hyperoxygenation or withdraw and start over. Secure the neck strap. Inflate both cuffs simultaneously: a. Using a sustained breath into the #1 Inflation Valve. b. Ensure white cap is secure. c. Use puffs of air to increase pressure in cuffs to improve seal. d. Bag valve device inflation requires firm grip on tube # 1 since tubes do not match. e. Positive pressure is not recommended. Immediately attach bag-valve device and ventilate the #2 Short Green Tube and assess for chest rise. If the CHEST RISES, the #3 Long Clear Tube is in the esophagus. Continue ventilating through the #2 Short Green tube. Assess breath sounds, gastric sounds, and record. If the chest DOES NOT rise after ventilating tube # 3, retry tube #2, the #3 Long Clear Tube may be in the trachea. If the chest DOES rise remove the stylet and ventilate through the #3 Long Clear Tube. During lung inflation, listen to both sides of the chest and over the stomach with a stethoscope. Verify chest rise with each breath (ventilation). Auscultate over gastric, upper and lower lung lobes bilaterally, and mid-axillary bilaterally. LOOK, LISTEN, and FEEL for adequate air exchange. a. LOOK for chest rise and fall. b. LISTEN - auscultate for air sounds over the stomach and both sides of the chest. c. FEEL for good Bag-Valve Device compliance. Continue ventilations with oxygen supplement through the appropriate tube. After tube position is verified, air leakage must be identified. Trouble shoot by: a. Increasing cuff pressures. b. Increasing ventilation volumes. c. Tightening neck strap.
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18. 19.
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DECOMPRESS/EVACUATE STOMACH IF NECESSARY 1. Passive Gastric Decompression, as needed for acute gastric distention ONLY if tube lies in the esophagus. a. DO NOT interrupt ventilations while performing. b. Measure and lubricate an 18 French Levine suction catheter. 1. For approximate distance, measure distance from tip of tube # 3, to tip of ear lobe, earlobe to chin, and chin to xyphoid process. 2. Mark this distance on catheter. 3. Lubricate catheter with a water-soluble lubricant. c. Insert catheter through tube # 3 and advance catheter into the stomach to the marked distance. Allow stomach to decompress and remove catheter. Repeat as needed. Slow and gentle pressure on abdomen as may be necessary
2.
REMOVAL and PROCEDURE 1. Indications the PtL should be removed: a. Victim regains consciousness. b. Protective airway gag reflexes return. Prepare suction device. Turn patient on side (preferably left side) and make sure the stomach has been decompressed and gastric contents have been evacuated. Open the White Port Cap on the #1 inflation valve to deflate both cuffs. Ensure white slide clamp is open. Release neck strap. Instruct patient to exhale. As patient exhales, remove the PtL airway with a swift steady motion following natural curvature of airway. Simultaneously gently press on the stomach to assist the release of gastric contents. Suction as needed. Place patient on high flow, high concentration oxygen. Continue to monitor patient for adequate ventilation. Maintain patient position on the left lateral recumbent in order to monitor and ensure patent airway including vomitus / aspiration precautions.
2. 3. 4. 5. 6.
7. 8. 9. 10.
REPLACING THE PtL WITH AN ENDOTRACHEAL TUBE (ALS Assist) 1. Pass a gastric levine tube and apply suction to verify that the stomach has been decompressed.
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2.
To pass an ET tube while ventilating through the # 2 short green tube: a. Pinch the pilot balloon inflation line with the slide clamp (close the slide clamp) and open the white cap on the # 1 inflation valve line. The large oral cuff will deflate to atmospheric pressure. b. Insert laryngoscope and quickly intubate the trachea around the PtL Airway. c. Remove PtL if intubation is successful. If unable to intubate, deflate cuffs by opening the white slide clamp, remove the PtL and intubate patient.
3.
GENERAL CONSIDERATIONS Hypoxia will occur from interrupted ventilations during insertion. Limit attempts to less than 30 seconds. Do not administer drugs through the short green tube (#2) or the long clear tube (#3) if esophageal intubation occurs. Leave the stylet in place unless except when patient is tracheally intubated and during suctioning patient. TROUBLE SHOOTING: Make sure white port cap is closed or the oropharyngeal cuff will deflate. Make sure slide clamp control is open. This slide clamp control allows endotracheal intubation without removal of the PtL by allowing the proximal cuff to deflate while the distal cuff remains inflated. Frequently inspect Large (Proximal) Cuff and Pilot Balloon for leaks. Dentures, braces, or foreign bodies may cause tearing. Make sure the neck strap is secure. Re-inflate the cuffs or remove airway as needed.
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SUCTIONING GOAL Provide a clear airway by removing foreign matter, either solid or liquid OBJECTIVE Given a simulated patient, the EMT student will be able to assemble equipment, identify the need, and demonstrate proper suctioning techniques within 1 minute. EQUIPMENT Body substance isolation Suction device and tubing Rigid suction tip and assorted flexible catheters PROCEDURE: 1. 2. Check, assemble precautions. equipment, and take body substance isolation
Determine proper suction device and attach tubing. a. use rigid catheter when suctioning mouth of an infant or child b. avoid touching back of throat or stimulating gag reflex c. to suction nasal passages, use bulb suction or French catheter with low to medium suction Turn on and test suction unit by crimping suction tubing to ensure at least 300mmHg vacuum. Use only 1/2 power on infants. Measure length of suction tip from corner of mouth to ear lobe Insert catheter into oro/naso pharynx without suction and be careful not to stimulate gag reflex. Activate suction while removing the catheter from the airway. Move the catheter tip side to side. Suction for no longer than 15 seconds at a time until the airway is clear. a. In infants and children, suction no longer than 10 seconds. b. If the patient has secretions or emesis that cannot be removed quickly and easily by suctioning, the patient should be log rolled to the left and the oropharynx should be cleared. c. If the patient produces frothy secretions more rapidly than the suctioning can clear, suction for 15 seconds. Artificially ventilate for two minutes, then suction for 15 seconds. Repeat as necessary. Always hyperventilate and administer high flow oxygen after suctioning.
3. 4. 5. 6. 7.
8.
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CONSIDERATIONS No matter what the patient condition, the airway must remain patent at all times. Suction to remove blood, other liquids and or food particles, teeth, glass, vomit and any other particle that can pass through the suction catheter. Some suction devices are inadequate for removing large, obstructing, solid objects like teeth, foreign bodies and food. Suction immediately when a gurgling sound is heard with artificial ventilation.
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NEBULIZERS GOAL To relieve the bronchospasm due to allergens OBJECTIVE Given a simulated patient, the EMT student will be able to assemble nebulizers, identify the need, and demonstrate the proper technique for nebulizer treatment within 4 minutes. INDICATIONS Bronchial asthma and bronchospasm in emphysema and chronic bronchitis EQUIPMENT Sterile Saline Oxygen Connector Tubing Supplemental Oxygen Hand-Held Nebulizer cup with lid T-Piece Mouthpiece Medication PROCEDURE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Obtain orders from medical control to provide nebulizer treatment. Gather, check equipment, and take body substance isolation precautions. Briefly explain the procedure to the patient. Determine the correct medication, expiration, clarity, and dosage to be administered. Open the lid of the nebulizer and place the prescribed medication into the nebulizer. Carefully replace the lid to the nebulizer cup and securely attach the T-piece to the nebulizer. Insert the mouthpiece into the T-piece. Connect the connector tubing to the unit delivering oxygen source. Connect the other end of the connector tubing to the nebulizer. Turn the oxygen flow rate to: a. 6 liters per minute, or b. until appropriate mist is achieved, or
29
c. 11. 12. 13. 14. 15. 16. 17. 18.
according to the flow rate established in the updraft manufacturer's recommendations.
Instruct the patient to sit up as straight as possible for maximum chest expansion. Instruct the patient to hold the nebulizer upright and to close lips around the mouthpiece. Instruct the patient to inhale deeply and to hold breath for 10 seconds before exhaling if possible. Administer half of the medication. Assess patient for effect. Administer the remaining medication. Remain with the patient until the treatment is completed. Document how well the patient has tolerated the treatment. a. Assess and record breath sounds before and after each treatment. b. Note times each procedure was started and completed. c. Gather vital signs and focused reassessment and record findings. d. Patient may deteriorate and need positive pressure artificial ventilation. e. Include any signs of the medications effects. Administer additional medication as ordered by Medical Control.
19.
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INHALERS GOAL Provide breathing relief for patients with asthma experiencing difficulty breathing OBJECTIVE Given a simulated patient, the EMT student will be able to assemble the device and administer the aerosol medication within 1 minute. EQUIPMENT Metered Dose Inhaler Container of Medication Spacer device PROCEDURE 1. 2. Obtain orders from medical direction either on-line or off-line. Assure right medication, right patient, right route, and the patient is alert enough to use inhaler. Confirm that the patient is having breathing difficulty. Secure the airway, administer high flow oxygen, and assist ventilation as necessary. Check the expiration date of the inhaler. Determine if the patient has taken a prescribed beta-agonist inhaler. Ensure that the inhaler is at room temperature or warmer. An inhaler used straight out of the refrigerator may worsen bronchospasm. Shake the inhaler vigorously several times and before each use to mix the medication and the propellant. Remove oxygen adjunct from patient. Remove the cap from the mouthpiece and check mouthpiece for foreign objects. Attach the medication canister fully and firmly into the actuator: DO NOT twist the canister. Test the aerosol by spraying into the air. Remove oxygen from the patient and have the patient exhale deeply. Have the patient place mouthpiece fully into the mouth with his lips. Attach the spacer over the mouthpiece to enhance good dispersal of the medication into the lungs. Ask patient to breathe in deeply and slowly through his mouth while fully depressing the top of metal canister with index finger. Ask the patient to hold his breath as long as they comfortably can (at least 3 5
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3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
13. 14.
seconds). Before breathing out, remove the inhaler from the patients mouth and release your finger from canister. 15. After one to three minutes of medication administration, reassess the condition of the patient and record. a. Gather vital signs and focused reassessment and record findings. b. Patient may deteriorate and need positive pressure artificial ventilation. c. Assess and record breath sounds before and after each treatment. d. Note times each procedure was started and completed. e. Include any signs of the medications effects. If patients condition has not improved, shake inhalation aerosol again and repeat steps 12 through 14. Repeat only once. Clean inhaler with alcohol prep pad.
16. 17.
GENERAL CONSIDERATION The spacer device is an attachment between the inhaler and the patient that allows for more effective use of medication. Contents of Inhalation Aerosol are under pressure. - Do not puncture. - Do not use or store near heat or open flames. - Exposure to temperatures above 120 degrees F may cause bursting. - Never throw container into fire or incinerator. When not in use, keep cap on mouthpiece. When not in use, store between 15 degrees C and 30 degrees C (59 and 86 F). Failure to use aerosol product within the recommended temperature range may result in improper dosing. Infant and Child Considerations: - use of hand held inhalers is very common in children. - retractions are more commonly seen in children than adults. - cyanosis is a late finding in children. - very frequent coughing may be present rather than wheezing in some children. - emergency care with usage of handheld inhalers is the same of the indications for usage of inhalers are met by the ill child. Reassessment Strategies include: Gather vital signs and focused assessment Patient may deteriorate and need positive pressure artificial ventilation
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PATIENT ASSESSMENT
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VITAL SIGNS GOAL Determine the systolic and diastolic pressure exerted against the walls of the arteries by auscultation within +/- 10mm Hg OBJECTIVE Given a simulated patient, the EMT student will be able to determine the blood pressure within 1 minute. EQUIPMENT Pen and Report Form Sphygmomanometer Stethoscope Bandage Scissors PROCEDURE 1. 2. 3. 4. Take body substance isolation precautions. Calm and reassure the patient. Explain all procedures prior to performing them. Determine correct cuff size. The cuff bladder should be 20 percent wider than the diameter of the extremity Apply the center of the bladder over the brachial artery of the patient's left arm if not contraindicated by injuries or patient's position. Place the lower edge of the cuff, with its tubing connections, about 1 inch above the antecubital fossa. Wrap cuff evenly and snugly. Do not place the cuff over clothing or allow rolled up clothing to constrict arm. Cut away clothing if necessary. Position the gauge so that the viewer has a direct line of sight for an accurate reading. Position patient's arm level with his heart. Place stethoscope earpiece in your ears. The earpieces should be facing slightly forward in order to allow maximum benefit. While palpating the brachial or radial pulse with your fingertips, observe the gauge, close the thumb valve, and begin squeezing the bulb rapidly but smoothly until the sound of the pulse you are palpating disappears. Inflate 30 mm Hg higher. Place diaphragm of stethoscope over the brachial artery firmly enough to obtain a seal: but, lightly enough to avoid constricting the artery. The diaphragm is applied just below the cuff but not touching the cuff or tubing. Open the thumb valve slightly and maintain a constant deflation rate of approximately 2mmHg per second.
5. 6. 7.
8.
9.
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10.
While observing the gauge, listen for the onset of a dull tapping sound that is heard for two consecutive beats and note the gauge reading. This is the systolic blood pressure. A single beat is ignored and not considered the systolic blood pressure. Continue releasing the air until there is a disappearance of sound. This is the diastolic pressure. Observe the gauge reading. NOTE: On some patients, the tapping sound can be heard down to zero or below the true diastolic. In this case, listen for when the tone changes from taps to dull, muffed thuds and record this as the diastolic blood pressure.
11.
12. 13. 13.
Listen throughout the entire range of deflation until 20mm Hg below the level of the diastolic reading; then, fully deflate the cuff by opening the thumb valve. Remove the cuff and stethoscope. Record the two blood pressure readings, arm utilized, and the time as follows: 130/84-L.A.--14:30. NOTE: Blood pressure is recorded in even numbers, i.e. 130/84. If the gauge reading is between two indicator lines, use the upper number. Continue to reassure patient during transport and: a. monitor vitals at least every 5 minutes in critical or unstable patients. b. monitor vitals at least every 15 minutes in non-critical or stable patients.
15.
GENERAL CONSIDERATION In certain situations, the systolic blood pressure may be achieved by palpation. Feel for return of pulse with deflation of the cuff.
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PATIENT ASSESSMENT GOAL To identify problems / conditions which will direct the course of the prehosptial interventions and transportation of the sick or injured patient OBJECTIVE Given a simulated patient, the EMT student will be able to perform a patient assessment within 5 minutes. EQUIPMENT Body Substance Isolation (gloves, mask, eye protection etc.) Blood Pressure Cuff and Stethoscope Pen Light Ink Pen I. REVIEW DISPATCH INFORMATION Who, what, when, where, how much/many II. SCENE SIZE UP Take body substance isolation precautions. Determine if the scene is safe for the EMT and partner. Determine if there are any potential hazards. Determine the mechanism of injury (MOI)/nature of illness (NOI). Determine the number of patients. Determine need for additional help. Consider stabilization of spine. INITIAL ASSESSMENT Determine general impression of patient prior to verbal or physical contact. Introduce self with service, level of training and gain consent to treat. Gain consent by asking: May I treat you? Determine chief complaint of patient if possible /apparent life threats. Ask patient, family, friends, and bystanders if necessary. Determine responsiveness/level of consciousness (AVPU). Assess Airway & Breathing. a. Provide interventions for airway problems. b. Initiate appropriate oxygen therapy. c. Assure adequate ventilation. Assess Circulation. a. Assess/control major bleeding. b. Assess pulse. c. Assess skin (color, temperature and condition). Treat any immediate life threatening conditions such as, ABC problem, airway blockage, or flail chest, anaphylaxis, etc. Determine priority using patients status of ABCs, LOC, and chief complaint. Determine if medical or trauma, high or low priority, and transport decision.
III.
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IF TRAUMA HIGH PRIORITY: IV. Perform Rapid Trauma Assessment A. B. C. D. E. F. G. H. I. J. K. V. Assess the head for DCAP-BTLS. Assess the neck for DCAP-BTLS, JVD, and tracheal deviation. Assess the chest for DCAP-BTLS. Assess the abdomen for pulsating mass, point and rebound tenderness, distention, and DCAP-BTLS. Assess the pelvic area for DCAP-BTLS. Assess the lower extremities for DCAP-BTLS and distal PMS for presence and equality. Assess the upper extremities for DCAP-BTLS and PMS. Assess the posterior aspect of the body for DCAP-BTLS. Assess baseline vital signs: blood pressure, pulse and respirations. Obtain SAMPLE history from bystander, family, or friends prior to leaving. Provide necessary medical care and prepare for transport.
Transport A. B. Treat secondary injuries as priority allows. Perform Detailed Physical Exam. 1. Assess the head for DCAP-BTLS, eyes, ears, nose, and mouth/throat. 2. Assess the neck for DCAP-BTLS, JVD, and tracheal deviation. 3. Assess the chest for DCAP-BTLS, auscultate breath sounds, rate, quality, and expansion equality. 4. Assess the abdomen for DCAP-BTLS. 5. Assess the pelvic area for DCAP-BTLS. 6. Assess the lower extremities for DCAP-BTLS and distal PMS for presence and equality. 7. Assess the upper extremities for DCAP-BTLS and PMS. 8. Assess the posterior aspect of the body for DCAP-BTLS. 9. Re-assess vital signs: blood pressure, pulse, and respirations. Perform Ongoing Assessment. 1. Repeat the Initial Assessment. 2. Repeat Vitals. 3. Check Interventions. NOTE: Re-evaluate vital signs and ABCD's at least every 5 minutes on critical patients and at least every 15 minutes on non-critical patients.
C.
IF TRAUMA LOW PRIORITY: IV. Perform Focused History Physical Exam A. Assess history of present illness, chief complaint with signs and symptoms. 1. Assess SAMPLE History. 2. Perform Further Patient Assessment on Area of Chief Complaint: a. assess the head if necessary. b. assess the neck if necessary. c. assess the chest if necessary. d. assess the abdomen if necessary. e. assess the pelvis if necessary.
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B. C.
D.
f. assess the extremities if necessary. g. assess the posterior body if necessary. 3. Assess baseline vital signs. 4. Provide emergency medical care based on signs and symptoms in consultation with either online or offline medical direction. Transport 1. Treat secondary injuries as priority allows. Perform Detailed Physical Exam 1. Assess DCAP BTLS including: a. assess the head if necessary. b. assess the neck if necessary. c. assess the chest if necessary. d. assess the abdomen if necessary. e. assess the pelvis if necessary. f. assess the extremities if necessary. g. assess the posterior body if necessary. Perform Ongoing Assessment. 1. Repeat the Initial Assessment. 2. Repeat Vitals. 3. Check Interventions. NOTE: Re-evaluate vital signs and ABCD's at least every 5 minutes on critical patients and at least every 15 minutes on non-critical patients.
IF MEDICAL HIGH PRIORITY: IV. Perform Rapid Assessment A. B. C. D. E. F. G. H. I. J. K. L. V. VI. Assess the head for DCAP-BTLS. Assess the neck for DCAP-BTLS, JVD, tracheal deviation. Assess the chest for DCAP-BTLS. Assess the abdomen for pulsating mass, point and rebound tenderness, distention, DCAP-BTLS. Assess the pelvic area for DCAP-BTLS. Assess the lower extremities for DCAP-BTLS and distal PMS: for presence and equality. Assess the upper extremities for DCAP-BTLS and PMS. Assess the posterior aspect of the body assessing for DCAP. Assess baseline vital signs: blood pressure, pulse and respirations. Obtain SAMPLE history from patient if possible, bystander, family, or friends prior to leaving. Obtain OPQRST history from patient if possible, bystander, family, or friends prior to leaving. Provide necessary medical care and prepare for transport.
Transport Perform Ongoing Assessment A. B. C. Repeat the initial assessment. Repeat vitals. Check interventions.
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NOTE:
Re-evaluate vital signs and ABCD's at least every 5 minutes on critical patients and at least every 15 minutes on non-critical patients.
IF MEDICAL LOW PRIORITY: IV. Perform Focused History Physical Exam A. Assess history of present illness, chief complaint with signs and symptoms. 1. Assess O-P-Q-R-S-T 2. Assess SAMPLE history. 3. Perform further patient assessment on area of chief complaint. a. Assess the head if necessary. b. Assess the neck if necessary. c. Assess the chest if necessary. d. Assess the abdomen if necessary. e. Assess the pelvis if necessary. f. Assess the extremities if necessary. g. Assess the posterior body if necessary. 4. Assess baseline vital signs. 5. Provide emergency medical care based on signs and symptoms in consultation with either online or offline medical direction. Treat secondary illness as priority allows.
V. VI.
Transport a.
Perform Ongoing Assessment a. Repeat the initial assessment. b. Repeat vitals. c. Check interventions. NOTE: Re-evaluate vital signs and ABCD's at least every 5 minutes on critical patients and at least every 15 minutes on non-critical patients
REMEMBER:
Things not looked for are often not found.
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PATIENT ASSESSMENT Review Dispatch Information
Scene Size Up BSI Safe Scene / Hazards Determine N.O.I. / M.O.I. Number of Patients / Additional Help Consider C-Spine
Initial Assessment General Impression Introduction Determine Chief Complaint Determine Level of Consciousness (AVPU) Assess ABC's Provide Immediate Life threatening Interventions Prioritize using ABC, LOC, and C/C Determine Trauma vs. Medical Determine Priority - High vs. Low Trauma Medical
High Priority
Low Priority
Low Priority
High Priority
Rapid Trauma Assessment Rapid Medical Assessment Focused Focused (DCAP-BTLS) (DCAP-BTLS) History History Baseline Vitals Baseline Vitals S.A.M.P.L.E. S.A.M.P.L.E. Critical Interventions Assess Area of Chief Complaint Assess Hx of Present Illness O.P.Q.R.S.T. Prepare for Transport S.A.M.P.L.E. O.P.Q.R.S.T. Critical Interventions Baseline Vitals S.A.M.P.L.E. Prepare for Transport Provide Interventions Further Assess C/C Areas PRN Baseline Vitals Transport Provide Interventions Treat secondary injuries as Priority Allows
Transport
Detailed Exam If High Priority Repeat R.T.A+HEENT Auscultate DCAP-BTLS Plus Reassess Vitals Detailed Exam If Low Priority Trauma Reassess C/C Areas PRN Ongoing Assessment Repeat Initial Assessment Repeat Vital Signs Check Interventions Treat Secondary Illness as Priority Allows
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Pneumonics for Focused History Allergic Reaction History Exposed to How Exposed Effects Progression Interventions Behavioral How do you feel Suicidal tendencies Threat to self or others Medical problems Intervention Cardiac Onset Provokes Quality Radiates Severity Time Interventions Poisoning / OD Substance When Exposed How much Over what time period Interventions Estimated weight Effects Environmental Source Environment Duration Loss of Conscious Effect - General or Local
Mental Status Describe Episode Onset Duration Symptoms Trauma Interventions Seizures Fever
Obstetrics Are you pregnant How long Pain or Contractions Bleeding or discharge Need to push Last period Crowning
Respiratory Onset Provokes Quality Radiates Severity Time Interventions
Other Pneumonics S.A.M.P.L.E. Signs and Symptoms Allergies Medications Past Medical History Last Meal Events Prior To O.P.Q.R.S.T. Onset Provokes Quality Radiates Severity Time A.V.P.U. Alert Verbal Pain Unresponsive D.C.A.P.-B.T.L.S. Deformities Contusions Abrasions Penetrations Burns Tenderness Lacerations Swelling T.I.C. Tenderness Instability Crepitus
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INFORMATION REPORTED TO THE HOSPITAL BY EMS PERSONNEL GOAL Provide effective radio (pre-arrival) and transfer of information to receiving personnel OBJECTIVE Given a simulated situation and patient information, the EMT student will be able to effectively communicate with the dispatcher and hospital. EQUIPMENT Two-way radio Patient Care Report PROCEDURE 1. 2. Ensure radio is on and volume is properly adjusted. Monitor (listen to) the channel at least 15 seconds before transmitting to avoid interfering with other radio traffic. Plan message before pushing the transmit switch. This will keep the transmission brief and precise. The radio report is to take less than 30 seconds. The obvious exception is when the EMT needs to consult Medical Direction. Press the transmit button (PTT) on the radio microphone, then wait 2 seconds before beginning the message. This will allow the radio to charge to full power. Hold the microphone 2" - 3" slightly lower than the level of your mouth. Speak clearly and calmly into the microphone. Speak at a moderate and understandable rate. Address the unit being called; then give the name of the unit calling (and number, if appropriate) where the transmission is being originated. Acknowledge a transmission as soon as possible and utilize the echo principle. Especially use the echo principle when receiving directions from medical control. This confirms accurate reception and understanding. Speak clearly and slowly, in a monotone voice and clear text. Use plain English. Do not use meaningless phrases, slang, or complex codes. Avoid words that are difficult to hear, such as "yes" and "no." Use ''affirmative" and "negative." Keep all messages brief and do not waste airtime. phrases like be advised or show me. Do not use meaningless
3.
4.
5. 6.
7.
8. 9. 10.
Protect patient privacy by not using patients name, social security number, insurance status, or any other potentially personally identifying information. Avoid showing negative emotions, such as anger or irritation, when transmitting. Courtesy is presumed; therefore, saying please" or "thank you" wastes air time.
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11. 12. 13. 14. 15. 16. 17.
When transmitting a number with two or more digits, say the entire number first and then each digit separately. Do not use profanity on the radio. This is a violation of FCC rules and can result in substantial fines and even loss of the service radio license. Use EMS radio frequencies for EMS communications. Do not use these frequencies for any other type of communications. Attempt to reduce background noise as much as possible. Move away from wind, noisy motors, or tools. Roll up windows. Turn music and other distracters down or off. When the transmission is finished, indicate by saying over. Get confirmation the message was received. Refer to local communications procedures and protocols.
Radio Report Format as approved by the Tennessee EMS Telecommunications Committee and the Tennessee EMS Board should include: a. ambulance unit number, and if requesting orders, the name of the EMT. b. patients age, sex, and if a pediatric patient, include the pediatric patients weight. c. medical patients, patients chief complaint and nature of illness and for trauma patients, mechanism of injury and suspected injuries. d. most recent complete set of vital signs if NOT within normal limits. e. treatment provided. f. only pertinent and brief history that will affect triage status.
g. patients physician if pertinent. h. for transfers, the referring facility/referring and receiving physicians. i. estimated time of arrival.
Radio Report Shall Not Include: a. b. c. d. sequential sets of vital signs if patients vitals are stable. entire medical history. allergies unless pertinent to a medication ordered by medical control. patients name, social security number, insurance status, or any other personally identifying information. e. EMS personnel are required to know and adhere to the patient privacy rule under the Health Insurance Portability and Accountability Act (HIPPA). See Appendix D.
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Patient information shall be provided in writing to the receiving hospital to include: a. identification of the ambulance service by name, address, and telephone number. b. chief complaint (or reason for transfer by ambulance). c. patients vitals signs including blood pressure, pulse, respiration, and pupils (equal, unequal, dilated, or constricted) when appropriate LOC and pain or other requested information. d. patient identification information, including name, gender, race, and date of birth e. date of transport noting the time of arrival on scene and the time of transfer to the receiving facility. f. signatures of the attending EMT or EMT-Paramedic, a representative of the receiving facility, and name of any health professional that provided orders for care. When Communicating With Medical Control Physician: a. give an accurate and complete report. b. echo orders and question unclear or inappropriate orders. c. report back when orders have been carried out and keep the physician informed, describing the patients response. d. protect patient privacy. NOTE: Communications whether written or spoken is a legal document. Radio communication and the written patient care report should coincide.
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BANDAGING
45
AMUPUTATION GOAL To control bleeding of the stump of an amputated limb OBJECTIVE Given a simulated patient, the EMT student will be able to apply a pressure dressing and bandage to the stump of an amputated limb within 5 minutes. EQUIPMENT: Body substance isolation Sterile dressings large enough to cover the wound 1 or 2 Roller gauze Tape Triangular Bandages PROCEDURE: 1. 2. 3. Take body substance isolation precautions. Place a bulky dressing over the wound and apply direct pressure. Apply roller gauze bandage by: a. anchoring roller gauze immediately proximal to wound. b. wrapping bandage to secure dressing to wound applying pressure as you wrap. c. with arm at 45 degree angle, secure the wrap proximal to the elbow with figure 8 technique to apply additional pressure. Secure end of bandage with tape or by tucking into bandage. Elevate injured area to a 45 degree angle with a sling and swathe. Reassess wound for bleeding and reinforce as needed with more dressing and bandage.
4. 5. 6.
GENERAL CONSIDERATIONS Flexing the proximal joint and wrapping the roller gauze proximal to the joint may apply more pressure to wound site and aid in controlling bleeding.
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AMPUTATED PART GOAL Preserve the amputated part for possible re-implantation OBJECTIVE Given a simulated amputated part, the EMT student will be able to prepare it for transport with the patient within 3 minutes. EQUIPMENT Body substance isolation Dressing large enough to cover amputated part Saline Solution Plastic bag large enough to hold part PROCEDURE: 1. 2. 3. 4. 5. Take body substance isolation precautions. Locate amputated part and remove loose debris. Wrap amputated part in dressing moistened in saline. Place in plastic bag and keep amputated part cool if possible, but, never place directly on ice. Transport with the patient.
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EYELID AVULSION WITH EYEBALL EXTRUDING GOAL To control bleeding of eyelid avulsion and protect extruded eyeball OBJECTIVE Given a simulated patient, the EMT student will be able to apply a dressing and bandage to the avulsed eyelid and extruded eyeball within 5 minutes. EQUIPMENT: Body substance isolation Gauze Ring (optional) Roller bandage PROCEDURE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Gather equipment and explain procedure to patient. Take body substance isolation precautions. Maintain cervical spine control. Control bleeding of avulsed eyelid avoiding pressure to eyeball. Fold a moistened 4x4's or use a ring of gauze and place around extruded eyeball Moisten a 4x4 with sterile saline and place over injured eyeball. Cover moistened 4x4 and injured eyeball with cup. Place 4x4 pads over uninjured eye to ensure eye does not open. DO NOT leave a patient alone who has both eyes covered. Secure 4x4 pads (or ring) and cup to the head utilizing roller bandage. Do not cover the ears. Reassess bleeding and reinforce as needed. Sterile 4x4 gauze Disposable cup Sterile saline
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FLAIL CHEST GOAL Properly stabilize a flail segment of the chest and provide supportive care for this patient OBJECTIVE Given a simulated patient, the EMT student will be able to recognize and stabilize a flail chest segment within 3 minutes. EQUIPMENT Body substance isolation Pillow or large bulky dressing Tape Triangle bandages Oxygen with delivery device PROCEDURE: 1. 2. 3. 4. 5. 6. 7. 8. Gather equipment. Take body substance isolation precautions. Apply high flow oxygen with non-rebreather mask. Expose injured site. Place pillow, bulky dressing, or sling and swathe (option for anterior flail segments) over the flail segment. Secure device used to stabilize the chest with tape, sling &, swathe triangle bandages. Reassess breathing and record. Transport patient in a semi-fowler's position or position of comfort.
GENERAL CONSIDERATION Place all patients on high flow oxygen. Clamshell devices are contra indicated by load and go situation.
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HEAD BANDAGE GOAL To control bleeding of a head wound OBJECTIVE Given a simulated patient, the EMT student will be able to apply a dressing and bandage to a head wound in 3 minutes. EQUIPMENT Body substance isolation Dressing large enough to cover wound Roller gauze Tape PROCEDURE 1. 2. 3. 4. 5. 6. 7. 8. Gather equipment. Take body substance isolation precautions. Maintain c-spine control. Assess LOC, pupillary response, and nose and ears for presence of cerebral spinal fluid and record. Apply direct pressure with dressing to wound without depressing the skull. Apply roller gauze (bandage) to hold dressing in place. Reassess LOC, pupils and bleeding and record. Reinforce dressing and bandage as needed.
GENERAL CONSIDERATIONS Apply direct pressure to wound to control bleeding only if depressed skull fracture is not suspected. Control bleeding from the edges of wounds by direct pressure.
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IMPALED OBJECTS GOAL To control bleeding at wound site, and provide stabilization of impaled object OBJECTIVE Given a simulated patient, the EMT student will be able to apply a dressing to the wound and stabilize the impaled object within 5 minutes. EQUIPMENT Body substance isolation Dressings large enough to cover the wound and surround the impaled object Tape Roller gauze PROCEDURE 1. 2. 3. 4. Gather equipment. Take body substance isolation precautions. Place dressing over the wound and around the impaled object. Apply roller gauze (bandage) to hold the dressing in place and secure the impaled object. Secure in three planes in an attempt to ensure stabilization of the impaled object. Tape or tuck loose ends of bandage. Re-evaluate for bleeding and record. Reinforce dressing and bandage as needed.
5. 6. 7.
GENERAL CONSIDERATIONS Pressure may be used around wound to aid in bleeding control. Do not wrap bandage over impaled object. Impaled object may be removed ONLY if airway is compromised.
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BLEEDING CONTROL AND SHOCK MANAGEMENT GOAL Provide control of external bleeding and proper treatment for a patient in hypovolemic shock OBJECTIVE Given a simulated patient needing bleeding control/shock management, the EMT student will be able to provide treatment to control external bleeding and know the steps to treat for hypovolemic shock. EQUIPMENT Body substance isolation Dressings and Bandages Roller gauze Tape Blankets Supplemental Oxygen with appropriate adjunct/delivery devices PROCEDURE 1. 2. 3. Gather equipment and take body substance isolation precautions. Maintain airway/artificial ventilation. Control Bleeding: (4 essential steps) a. b. c. d. apply finger tip (direct) pressure on point of bleeding with dressing. elevation of the bleeding extremity should be used secondary to and in conjunction with direct pressure. if diffuse bleeding is discovered, increase pressure with additional dressings and bandages. pressure points may be used in upper and lower extremities in conjunction with direct pressure and elevation. i Upper extremity brachial artery ii Lower extremity femoral artery
4.
Methods to control external bleeding if direct pressure is ineffective. a. Splints i. reduction of motion of bone ends will reduce the amount and aggravation of tissue damage and bleeding associated with a fracture ii. splinting will allow prompt control of bleeding associated with a fracture b. Pressure Splints i. pneumatic counterpressure devices (PASG) may be used as an effective pressure splint to help control severe bleeding due to massive soft tissue injury to the lower extremities or traumatic pelvic hemorrhage.
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c.
Tourniquet i. use only as a last resort to control bleeding of an amputated extremity when all other methods of bleeding control have failed ii. application of a tourniquet will cause permanent damage to nerves, muscles, and blood vessels resulting in the loss of an extremity iii. procedures for applying a tourniquet (a) use a bandage 4 inches wide and 6 8 layers deep. (b) wrap it around the extremity twice at a point proximal to the bleeding but as distal on the extremity as possible. (c) tie one knot in the bandage and place a stick or rod on top of the knot and tie the ends of the bandage over the stick in a square knot. (d) twist the stick until the bleeding stops. (e) once the bleeding has stopped, secure the stick or rod in position. (f) notify other emergency personnel who may care for the patient that tourniquet has been applied. - write TK on the patients forehead and the time the tourniquet was applied: (g) document the use of a tourniquet and the time applied in the prehospital patient report. iv. a continuously inflated blood pressure cuff may be used as a tourniquet until bleeding stops. v. precautions with the use of a tourniquet. (a) use a wide bandage and secure tightly. (b) never use wire, rope, a belt, or any other material that may cut into the skin and underlying tissue. (c) do not remove or loosen the tourniquet once it is applied unless directed to do so by medical direction. (d) leave the tourniquet in open view (DO NOT cover). (e) do not apply a tourniquet directly over any joint, but as close to the injury as possible.
GENERAL CONSIDERATIONS: Treat to Prevent Shock (hypoperfusion): a. b. c. d. body substance isolation precautions. maintain airway/artificial ventilation and apply high flow oxygen. control any external bleeding. if signs of shock (hypoperfusion) are present and the lower abdomen is tender and pelvic injury is suspected, apply and inflate the PASG if approved by medical direction.
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e.
elevate the lower extremities approximately 8 to 12 inches (trendelenburg). If the patient has serious injuries to the pelvis, lower extremities, head, chest, abdomen, or neck, elevate the spine board. splint any suspected bone or joint injuries. prevent loss of body heat by covering the patient with a blanket and placing a blanket under the patient. immediate transport and perform on going assessment.
f. g. h.
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SPLINTING
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GENERAL RULES FOR SPLINTING NOTE: * * * * * * * * * * * * * * * These rules are applicable for all splinting whether or not they are specifically listed in each skill. Assess pulse, motor, and sensation (PMS) distal to the injury prior to and following splint application and record findings. Immobilize the joint above and below the injury. Remove or cut away clothing. Do not splint prior to visualization of site. Cover open wounds with a sterile dressing. Apply moist dressing to protruding bones. If circulation is impaired, align with gentle traction before splinting unless pain is significantly increased. Splint from distal to proximal unless otherwise noted. Do not intentionally replace protruding bones. Pad each splint to prevent pressure and discomfort to the patient. Tie knots to the patient's lateral side, preferably in a void area. Pad void or pressure areas. Splint the patient before moving whenever possible. Splinting must immobilize the joint above and below the fracture or the bone above and below a dislocated joint. When in doubt, splint. If patient has signs of hypoperfusion, align and quickly secure normal anatomical position on a long spine board and transport. Elevate and apply ice to injuries involving extremities.
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SLING AND SWATHE GOAL To provide immobilization to an injured upper extremity OBJECTIVE Given a simulated patient, the EMT student will be able to apply a sling and swathe within 5 minutes. EQUIPMENT Body substance isolation Triangular bandages PROCEDURE 1. 2. 3. 4. 5. 6. Gather equipment. Take body substance isolation precautions. Expose the injury site. Assess pulse, movement, & sensation (PMS) distal to injury and record. Gently position forearm and maintain support of extremity until sling is secured. (refer to elevation guidelines) Properly position triangular bandage between the flexed forearm and torso with the point of the triangular bandage toward the elbow. Bring the ends of the bandage behind the neck. Drape the end of triangular across the uninjured shoulder. Tie the knot on the opposite side from the injury, padding appropriately. The sling should create a cradle effect. Secure the point of the triangular with a knot or pin. Ensure that the elbow is maintained in the sling at all times. Apply the swathe, approximately 3 inches in width, around the distal aspect of the injured humerus. a. Tie the swathe in such a manner that the knot does not create pressure. b. Pad as necessary. Reassess pulse, movement, & sensation (PMS) distal to the injury and record.
7. 8.
9.
GENERAL CONSIDERATIONS The swathe should not be in contact with the suspected fracture site. Tie knots in void areas and pad as needed. Utilize at least two swathes for better immobilization.
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Two swathe tied together may be needed for larger patient. ELEVATION GUIDELINES: a. Forearm - 60 degrees b. Humerus - 90 degrees c. Clavicle - 90 degrees d. Amputation - 45 degrees
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FOOT OR ANKLE INJURY GOAL To provide stabilization to an injured foot or ankle OBJECTIVE Given a simulated patient, the EMT student will be able to apply a splint to the injured ankle or foot within 5 minutes. EQUIPMENT Body substance Isolation One Pillow or blanket Three triangular bandages or roller gauze PROCEDURE: 1. 2. 3. 4. 5. 6. 7. 8. 9. Gather necessary equipment. Take body substance isolation precautions. Expose the injury site. Assess pulse, movement, and sensation (PMS) distal to the injury and record. Place foot in middle of pillow or blanket and fold around foot. Secure pillow or blanket with the three triangular bandages or roller gauze, distal to proximal. DO NOT cover the toes. Leave them exposed to assess PMS. Reassess pulse, movement, and sensation (PMS) distal to the injury and record. Elevate extremity at least 8 10 inches. Reassess pulse, movement, and sensation (PMS) distal to the injury and record.
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PNEUMATIC ANTI-SHOCK GARMENT (PASG) AS AIR SPLINT GOAL To properly apply the PASG for splinting of pelvic and lower extremity fractures OBJECTIVE Given a simulated patient, the EMT student will be able to properly apply the PASG within 5 minutes. EQUIPMENT Body substance isolation PASG Blood pressure cuff Stethoscope INDICATIONS Isolated fractures of legs without evidence of other internal injuries May be used for pelvic instability CONTRAINDICATIONS Internal injuries Bleeding that cannot be controlled MODIFIED APPLICATION: Do not inflate abdominal compartment in the following patients: 1. pregnancy. 2. those with impaled objects in the abdomen or over impaled object. 3. those with abdominal eviscerations. 4. with impaled object in leg. PRECAUTIONS: Penetrating thoracic trauma Abdominal Aortic Aneurysm (AAA) Closed head injuries PROCEDURE: 1. 2. 3. 4. Gather and check equipment. Take body substance isolation precautions. Assess blood pressure and pulse, movement, and sensation (PMS) in lower extremities. Record the findings. Remove patient's clothing or any objects from pockets that might puncture
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the PASG or cause pressure points. Assess areas. (In simulation ONLY, verbalize sweep the pockets) 5. 6. Unfold the garment with the inflation hoses toward the underneath side onto long spine board. Place patient on the garment by using method appropriate for injury: a. Use scoop stretcher to place patient on unfolded garment. b. Gently lift the lower extremities, slide the unfolded garment under the patient from the feet until the top edge of the garment lies just below rib cage. Enclose left leg, right leg and then abdomen attaching Velcro fasteners on each compartment. Attach all tubes from each compartment to the foot pump and open all stopcocks. Inflate garment until the wrinkles are out of the splint and thumb pressure on the inflated suit allows slight contact with the leg. Close all stop cocks. Re-assess blood pressure to ensure it does not increase more than 10 mmHg Systolic. Leave foot pump attached and place between patient's legs. Re-assess pulse, movement, and sensation (PMS) distal to the injury and record.
7. 8. 9. 10. 11. 12.
GENERAL CONSIDERATIONS Local protocols may determine the use of PASG. Use the proper size PASG on pediatric patients. PASG alone will not serve as a traction device. PASG used in hot/cold environment and altitudes may need adjustments. PASG General Considerations continued Use with traction splints: Apply the traction splint first, applying traction and securing leg straps. Then apply the trousers over the traction splint. Inflate the trousers in the appropriate sequence. Clean the PASG device with mild soap and water and air-dry. DO NOT USE BLEACH. DO NOT PLACE IN DIRECT SUNLIGHT.
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BOARD IMMOBILIZATION
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RADIUS / ULNA GOAL To provide immobilization of an injured forearm OBJECTIVE Given a simulated patient, the EMT student will be able to apply a board splint to the forearm in 10 minutes. EQUIPMENT Body substance isolation One fifteen inch padded board Two triangular bandages or more Two rolls of roller gauze PROCEDURE 1. Gather necessary equipment. 2. 3. 4. 5. 6. 7. 8. 9. Take body substance isolation precautions. Expose injury site. Remove any jewelry. Assess pulse, movement, and sensation (PMS) distal to the injury and record. With minimum movement, position the padded part of the board next to the anterior side of the forearm. Place hand in position of function inserting adequate padding in the palm to maintain position. Adjust board to extend slightly distal to the fingertips. Using the roller bandage, secure arm to board. a. Anchor at the wrist. b. Secure hand to board between two fingers and over end of board. c. Secure forearm, distal to proximal. d. Leave the fracture site exposed. e. Leave access for radial pulse check. Reassess pulse, movement, and sensation (PMS) distal to the injury and record. Apply sling and swathe and elevate forearm to 60 degrees. Reassess pulse, movement, and sensation (PMS) distal to the injury and record. BOARD IMMOBILIZATION
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10. 11. 12.
TIBIA / FIBULA GOAL To provide immobilization to a possible fracture OBJECTIVE Given a simulated patient, the EMT student will be able to immobilize a possible fractured lower extremity, utilizing padded boards, within 10 minutes. EQUIPMENT Body substance isolation Two 36" padded boards Four to Six triangular bandages Padding PROCEDURE 1. 2. 3. 4. Gather equipment. Take body substance isolation precautions. Expose injured site and assess pulse, movement, and sensation (PMS) distal to the injury and record. Using natural void areas place cravats under injured extremity. a. Two cravats above the knee b. Two cravats below the knee. i Avoid the knee. ii Place above the maleoli. iii Place at least one cravat above and at least one cravat below fracture site. (some patients/injuries may require two above and two below) Place a padded board on both sides of injured extremity. a. Padded side of splint placed against the injured extremity. b. Distal ends of boards should be approximately equal and distal of the foot. c. Pad the void areas and the groin. Secure boards with cravats. a. Distal to proximal. b. Knots tied to lateral side of injured extremity over board. Reassess pulse, movement, and sensation (PMS) distal to the injury and record. Elevate the extremity at least 8 10 inches. Reassess pulse, movement, and sensation (PMS) distal to the injury and record. Legs should be tied together to prevent movement. a. Gently move uninjured leg to injured leg, placing a pillow or rolled blanket between the legs.
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5.
6.
7. 8. 9. 10.
b.
Secure with remaining cravats: i One below the knee. ii One above the knee.
11.
Assess pulse, movement, and sensation (PMS) distal to the injury and record.
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BOARD IMMOBILIZATION HIP GOAL To provide immobilization to an injured hip OBJECTIVE Given a simulated patient, the EMT student will be able to immobilize the injured hip using board splints within 5 minutes. EQUIPMENT Body substance isolation One 54" padded board One 36" padded board Eight triangular bandages Padding Pillow or blanket PROCEDURE 1. 2. 3. 4. 5. Gather equipment. Take body substance isolation precautions. Expose the injury site and distal extremity. Assess pulse, movement, and sensation (PMS) distal to the injury and record. Using the natural void areas apply three cravats below the knee, three cravats above the knee. Apply two cravats above the waist. Do not restrict breathing and do not cover the knee. Place the 54" padded board in the axillary region a. Pad the proximal end. b. Board must extend past the knee. c. Padded side must be against the patient. d. Pad void areas. Place the 36" padded board, in the groin area. a. Pad the proximal end. b. Board must extend past the knee. c. Padded side must be against the patient's affected limb. d. Pad void areas. Secure the boards distal to proximal using: a. Two cravats below the knee and above the malleoli. b. Two cravats above the knee. c. Two cravats above the waist without restricting breathing. Reassess pulse, movement, and sensation (PMS) distal to the injury and
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6.
7.
8.
9.
record. 10. Place pillow or rolled blanket between the legs and secure with remaining cravats: a. One below the knee. b. One above the knee. Assess pulse, movement, and sensation (PMS) distal to the injury and record.
11.
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SAGER TRACTION SPLINT GOAL To provide for a single rescuer rapid immobilization to the middle one third of the injured femur OBJECTIVE Given a simulated patient, the EMT student will be able to immobilize an injured femur within 5 minutes. EQUIPMENT Body substance isolation Sager device with accessories Padding PROCEDURE 1. 2. 3. 4. Gather and check equipment. Take body substance isolation precautions. Assess pulse, movement, and sensation (PMS) distal to the injury and record. Seat the Ischial Perineal Cushion against the ischial tuberosity, with the shortest end of the articulating base towards the ground. Pad well. The pulley wheel should be on the same side and towards the injured extremity. Apply the Abductor Bridle (thigh strap) snugly around the upper thigh of the fractured extremity. Push the Ischial Perineal Cushion gently down while at the same time pulling the Abductor Bridle (thigh strap) laterally under the patients thigh. This will seat the lower end of the cushion comfortably against the ischial tuberosity. Tighten the Abductor Bridle snugly, lift the spring clip to extend the inner shaft until the pulley wheel is immediately distal to the patients heels. Position and apply the Malleolar Harness (ankle sling) snugly just above the ankle. Adjust Malleolar Harness (ankle sling) against sole of foot then attach to pulley. Extend shaft to amount of traction desired. 10% of body weight not to exceed 15 lbs. (7 kg) Re-check Abductor Bridle (thigh strap). Using natural void areas, place the elasticized cravats as follows:
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5. 6.
7. 8. 9. 10. 11. 12.
a. b. c. 13. 14.
One above the knee. One at knee. One below the knee at ankle.
Secure the elasticized cravats proximal to distal. Pad between the legs. Tie legs together at the ankles bringing the uninjured leg in a smooth motion to the injured leg. Hold feet together with your knees if necessary then secure straps. Re-assess pulley traction, pulse, movement, and sensation (PMS) distal to the injury and record. Elevate extremities at least 8 10 inches. Reassess pulley traction, pulse, movement, and sensation (PMS) distal to the injury and record. Transfer and secure torso to longboard. Secure splint to LSB to prevent movement of splint. Reassess circulatory movement and sensation distal to injury and record.
15. 16. 17. 18. 19. 20.
GENERAL CONSIDERATIONS Contraindicated in open fractures, injuries to the groin area, pelvis fractures from knee distally to ankle, injuries close to knee, injury to the knee, injury to the hip and injury to the pelvis. If partial amputation or avulsion with bone separation, the distal limb is connected only by marginal tissue; thus traction could cause a complete separation. USE WITH PASG DEVICE Apply the traction splint first, applying traction and securing leg straps. Then apply the trousers over the traction splint. Inflate the trousers in the appropriate sequence.
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TRACTION SPLINT GOAL To provide stabilization and immobilization to the middle one third of the femur OBJECTIVE Given a simulated patient, the EMT student will be able to apply a traction splint to an injured femur within 10 minutes. EQUIPMENT Body substance isolation 1/2 ring traction splint or mechanical traction (ratchet) device Four cradle devices (commercial or cravats) Ankle hitch (commercial or cravat) Ratchet device or windlass Padding Heel Stand INDICATIONS: Painful, swollen, deformed mid-thigh with no joint or lower leg injury CONTRAINDICATIONS: Injury to the knee or within one or two inches of the knee Injury to the hip Injury to the pelvis Partial amputation or avulsion with bone separation, distal limb is connected only by marginal tissue Lower leg or ankle injury PROCEDURE: 1. 2. 3. 4. 5. Gather and check equipment. Take body substance isolation precautions. Expose the injury site and distal extremity. Assess pulse, movement, and sensation (PMS) distal to the injury and record. Using the natural void areas: a. apply the ankle hitch with minimal movement. b. assure that the ankle hitch is properly padded and placed high on the ankle, superior to malleoli. Apply in-line continuous manual traction to leg: a. elevate 12 inches maximum. b. elevate 8 10 inches minimum. Draw manual traction until one of the following:
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6. 7.
a. b. c. d. 8.
Leg approximates normal length. Pain relieved. Pain unduly increases. Thigh muscles relax.
Prepare/adjust splint to proper length. Cover ischial ring on medial side with adequate padding prior to seating in groin. a. ensure splint is seated in groin. b. ensure the ischial pad (ring) is positioned at the proper angle. Properly secure the ischial strap over the thigh, padding as necessary. Secure ankle hitch to end of splint and draw mechanical traction. a. Elevate with heel stand or other device. b. Manual traction may be released, but the injured extremity must be held stable while cradle devices are secured. Apply cradle devices: a. Distal to proximal. b. Apply two cradles below the knee and two cradles above the knee. 1. One above and one below the fracture site. 2. Do not place cradle hitch on fracture site or the knee. 3. Pad if necessary. c. The bone should be in line with the splint bars. Re-assess each cradle device for tightness and bone alignment and record. Re-assess mechanical traction. a. If using a Thomas Ring, secure windless with a cravat or tape. Use a cravat and tape for any device as necessary. Re-assess pulse, movement, and sensation (PMS) distal to the injury and record. Release manual traction (if not released in step #10). Reassess circulation, movement, & sensation distal to injury and record. Transfer and secure torso to longboard to immobilize the hip. Secure splint to LSB to prevent movement of splint.
9. 10.
11.
12. 13.
14. 15. 16. 17. 18.
19. Re-assess pulse, movement, and sensation (PMS) distal to the injury and record.
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GENERAL CONSIDERATION During immobilization of an open femur, avoid pulling the bone ends back onto the skin. Stop traction when the bone ends begin to move. USE WITH PASG DEVICE: Apply the traction splint first, applying traction and securing leg straps. Then apply the trousers over the traction splint. Inflate the trousers in the appropriate sequence.
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JOINT INJURY SPLINT GOAL To properly apply a splint to a joint injury OBJECTIVE Given a simulated patient, the EMT student will be able to properly apply a splint to a joint injury within 5 minutes. EQUIPMENT Body substance isolation Triangular bandages appropriate for the injury Board splints appropriate for the injury PROCEDURE 1. 2. 3. 4. Gather and check equipment. Take body substance isolation. Apply manual stabilization Assess pulse, movement, and sensation (PMS) distal to the injury and record. a. if distal extremity is cyanotic or lacks pulses and no resistance is met then make one attempt to align with gentle traction. b. if alignment is unsuccessful, then splint in place and transport immediately c. contact medical control. d. document findings and actions. Immobilize the site of injury. Immobilize the bone above and below the site of injury. Re-assess pulse, movement, and sensation (PMS) distal to the injury and record.
5. 6. 7.
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SHOCK
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PNEUMATIC ANTI-SHOCK GARMENT (PASG) For Shock (Hypovolemia) GOAL To properly apply the PASG in order to control bleeding, treat traumatic hypotension and distributive shock (neurogenic and anaphylactic) OBJECTIVE Given a simulated patient, the EMT student will be able to properly apply the PASG within 5 minutes. EQUIPMENT Body substance isolation PASG INDICATIONS Hypoperfusion secondary to external hemorrhage that can be controlled Spinal Shock without evidence of other internal injuries Blood pressure of 50 mmHg Systolic or less obtained by mechanical means, OR systolic blood pressure unobtainable by auscultation or palpation Anaphylactic shock CONTRAINDICATION Absolute: Pulmonary edema Bleeding that cannot be controlled MODIFIED APPLICATION Do not inflate abdominal compartment in the following patients: 1. pregnancy. 2. those with impaled objects in the abdomen or over impaled object. 3. those with abdominal eviscerations. 4. with impaled object in leg. PRECAUTIONS Penetrating thoracic trauma Abdominal Aortic Aneurysm (AAA) Closed head injuries PROCEDURE 1. Gather and check equipment and take body substance isolation precautions. Blood pressure cuff Stethoscope
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2. 3. 4. 5. 6.
Assess pulse, movement, and sensation (PMS) distal to the injury and record. Evaluate the patient through at least the initial assessment. Assess vital signs and record. Remove patient's clothing or any objects from pockets that might puncture the PASG or cause pressure points (SWEEP). Unfold garment and lay it flat with the inflation hoses toward the underneath side onto a long board. Place patient on the garment by: [in order of preference] a. Use scoop stretcher to place patient on unfolded garment. b. Log roll the patient and slide garment under the patient so that the spine line is in proper position, with the top edge of garment just beneath the rib cage. Log roll the patient onto the garment. c. Gently lift the lower extremities, slide the unfolded garment under the patient from the feet until the top edge of the garment lies just below rib cage. Assess distal pulse, movement, and sensation (PMS) and record. Enclose left leg, right leg, and abdomen by attaching Velcro fasteners on each compartment. Attach all tubes from each compartment to the foot pump and open all stopcocks. Inflate garment slowly using the foot pump. Monitor patient's blood pressure. Inflate until one of the following occurs: a. systolic pressure reaches 80 90 mm/Hg. b. the relief valves release pressure. c. the velcro begins to crackle.
7. 8. 9. 10.
INFLATION PROCEDURE 11. 12. Inflate the garment slowly while monitoring the blood pressure. When the patients blood pressure reaches 80 - 90 mmHg: a. Close all stop cocks. b. Tape valves closed. Leave foot pump attached and place between patient's legs. Reassess pulse, movement, sensation (PMS) and record. Monitor and record all vital signs every 5 minutes and add pressure to the trousers as needed.
13. 14. 15.
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GENERAL CONSIDERATIONS Local protocols may determine the use of PASG. Evaluate patients chance of survival without the suit. The pressure inside the suit is not being monitored. Use the proper size PASG on pediatric patients. PASG is the preferred treatment for pelvic instability. When used with traction splints: Apply the traction splint first, applying traction and securing leg straps. Then apply the trousers over the traction splint. Inflate the trousers in the appropriate sequence. Clean the PASG device with mild soap and water and air-dry. DO NOT USE BLEACH and DO NOT PLACE IN DIRECT SUNLIGHT. Removal Procedure 1. PASG should never be removed in the field unless under the direct order of a physician. a. Should occur in a hospital setting. b. Should have at least two large bore IV s of Ringers Lactate, Normal Saline, or blood. i Infuse a minimum of 3 ccs per 1 cc blood loss. c. Obtain and closely monitor vital signs. Begin slow deflation of abdomen. a. Carefully monitor vital signs. Blood pressure, especially, is to be continuously monitored. i If BP falls 6 mm Hg Systolic or more, stop and infuse more fluid or blood until the vital signs stabilize again (this usually requires at least 200 cc) b. Each compartment should take at least 15 minutes per section to deflate. Proceed from the abdominal compartment to the right leg and then the left leg, continuously monitoring the blood pressure and stopping to infuse fluid when a drop or 6 mm Hg Systolic occurs. If the patient experiences a sudden precipitous drop in blood pressure while deflating, stop and re-inflate the garment.
2.
3.
4.
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DEFINITIONS OF TERMS Adrenaline - also known as epinephrine; used in the treatment of anaphylactic shock. Allergy - an altered reaction to body tissues to a specific substance (allergen) which in normal persons will cause no problems. Allergen a substance that enters the body by ingestion, injection, inhalation, or contact and triggers an allergic reaction. Allergic Reaction a misdirected and excessive response by the immune system to a foreign substance or an allergen. Anaphylaxis a severe allergic reaction that produces respiratory distress and shock (hypoperfusion). Anaphylactic Shock a hypoperfusion state that results from dilated and leaking blood vessels related to severe allergic reaction. The patient also experiences respiratory distress and hives. It is also called anaphylaxis or anaphylactic reaction. Antibodies special proteins produced by the immune system that search out antigens, combine with, and help to destroy them. Antigen a foreign substance that enters the body and triggers an immune response. Antihistamine - an agent which is used in the treatment of allergies because it counteracts the effects of histamine. Epinephrine - also known as Adrenaline, used in the treatment of anaphylactic shock. Histamine - a substance in the body found wherever tissues are damaged. Hives raised, red blotches associated with some allergic reactions. Intramuscular Injection used to deliver certain medications deep into the patients muscle fiber. Subcutaneous layer a layer of fatty tissue just below the dermis. Urticaria name given to the raised areas that occur on the skin associated with vasodilation due to histamine release. Commonly referred to as hives. Wheal - a sudden elevation of the skin, usually white in the center and pale red around it; a welt accompanied by itching. Wheezing - a whistling sound or sighing sounds heard on inhalation and exhalation and when having difficulty in breathing.
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MATH CALCULATION EPINEPHRINE 1:1,000 GOAL To enable the student to calculate the appropriate dose of epinephrine 1:1,000 OBJECTIVE Given a simulated patient, the EMT student will be able to calculate the appropriate drug dosage in 1 minute. EQUIPMENT Pencil Paper Calculator (optional) PROCEDURE: 1. 2. Dosage administration is based on patients weight in kilograms. Calculate weight in kilograms. Divide the patients weight by 2.2 to convert or calculate the patients weight in kilograms. 1 kilogram is equal to 2.2 pounds. (2.2 lbs = 1 kilogram) a. Example: Patient weighs 66 lbs. 66 divided by 2.2 = 30 kilograms 2. Dosage formula for amount administered in milliliters (ml) is 0.01 mg multiplied by the patients weight in kilograms: a. b. 0.01 X patients weight in kilograms = _______ ml 0.01 mg X 30 kg = 0.3 ml
GENERAL CONSIDERATION The maximum adult dose of epinephrine is 0.3 ml per injection. The dosage may be repeated in 5 - 20 minutes with medical orders.
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SUBCUTANEOUS INJECTION GOAL To properly prepare and administer a subcutaneous injection OBJECTIVE Given a simulated patient, the EMT student will be able to administer a subcutaneous injection within 5 minutes. EQUIPMENT Body substance isolation TB syringe 23/25 gauge 5/8" needle Medication Alcohol preps Band-Aid PROCEDURE (MEDICATION) 1. 2. 3. 4. 5. 6. Apply high flow oxygen with nonrebreather facemask. Gather and check equipment. Calculate desired medication. Obtain orders unless standing orders exist. Take body substance isolation precautions. Check medication for: a. correct drug (concentration or dilution). b. clarity of drug. c. expiration date. Explain procedure to patient. Explain possible side effects to the patient. Select site: a. Upper outer arm. b. Anterior thigh. c. Abdomen. d. Subscapular portion of back.
7. 8. 9.
PREPARE INJECTION SITE 10. Cleanse site with alcohol prep in a circular motion from center to outer area, at least 2 inches from center. Allow to air dry.
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11. 12. 13.
While allowing site to air dry, cleanse top of multidose vial with alcohol prep, OR Wrap top of ampule with alcohol prep and break off. Remove cap of needle and withdraw amount of medication needed from ampule or vial. Remove (evacuate) excess air from syringe.
GIVE INJECTION 14. 15. 16. Pinch fatty subcutaneous pad between index finger and thumb. With bevel of needle up, and using a darting motion, insert needle at a 45 to 90 degree angle. Release fatty subcutaneous pad and slightly aspirate while holding syringe with one hand: a. if blood appears in syringe, stop the injection, withdraw the needle, prepare another injection with new equipment, and inject another site. b. if syringe is clear, continue to step # 17. Inject medication slowly. Remove needle and gently massage area with alcohol prep. Do not recap needle after injection. Dispose of contaminated needle and syringe in sharps container. Cover injection site with band-aid.
17. 18. 19. 20. 21.
DOCUMENT - On Each Injection Patients Name Amount of Medication Site Time GENERAL CONSIDERATIONS The risk of the following exists when giving an injection: Giving wrong medication. Giving wrong dosage. Sticking yourself and others with contaminated needle. Reaction to medication. Always make sure of the five rights. Right Patient Right Medication Right Dosage Right Route Right Time SIDE EFFECTS OF EPINEPHRINE 1:1,000
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Medication Route Date Patients response
Increase in heart rate Increase in blood pressure Anxiety Palpitations Headache
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INTRAMUSCULAR INJECTION GOAL To properly prepare and administer an intramuscular injection OBJECTIVE Given a simulated patient, the EMT student will be able to administer a intramuscular injection within 10 minutes. EQUIPMENT Body substance isolation 20 25 gauge 1 to 3 length needle Medication PROCEDURE (MEDICATION) 1. 2. 3. 4. 5. 6. Apply high flow oxygen with nonrebreather facemask. Gather and check equipment. Calculate medication to be given. Obtain orders unless standing orders exist. Take body substance isolation precautions and ensure sterile technique. Check label on the medication bottle and the medication for: a. correct drug (concentration or dilution). b. any discoloration (clarity) of drug. c. expiration date. Draw up the medication into the syringe. During this time, explain both the procedure and the possible side effects to patient. Alcohol pads Band-Aid
7.
SELECT THE INJECTION SITE 8. 9. 10. Carefully select site so major blood vessels and nerves are avoided: a. Deltoid (Arm). A maximum of 1.0 cc may be administered here. Use different sites to prevent repeated injections in the same area and change sites with each injection. Do not use areas that are tender, scarred, swollen, or bruised.
PREPARE INJECTION SITE 11. Gently tap the injection site to stimulate the nerve endings and minimize pain when the needle is inserted then cleanse site with alcohol prep in a circular motion to a circumference of about 2 from center (injection site) to outer area. Allow to air dry.
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12. 13. 14. 15.
While allowing site to air dry, cleanse top of multidose vial with alcohol prep, OR wrap top of ampule with alcohol prep and break off. Remove cap of needle and withdraw amount of medication needed from ampule or vial. Remove excess air from syringe. Deltoid (Arm) Site for IM Injection a. b. Draw an imaginary box on the patients upper arm. The top boundary is two fingerbreadths below the Acromion Process. The lower boundary is a point in line with the patients axilla or an imaginary line running from the crease of the armpit, front to back. To determine the lateral or side borders, divide the arm into three equal sections, from dorsal to ventral. The desired site for the Deltoid Injection is in the center of the middle third. Using the desired Deltoid Injection site, stretch the skin tightly with one hand so that the injection site is (approximately) in the center of your fingers. Hold the syringe with your dominant hand like a pencil or dart, remove the needle sheath by slipping it between the free fingers of your nondominant hand and draw back the syringe. Position the syringe at a 90-degree to the skin surface, with the needle a couple of inches from the site. Warn patient of the nearing prick as you insert the needle with the bevel of the needle up and a darting motion. Then quickly and firmly thrust the needle through the skin and subcutaneous tissue, into the muscle. Support the syringe with your nondominant hand. Pull back slightly on the plunger with your dominant hand to aspirate for blood: 1. if blood appears in syringe, stop the injection, withdraw the needle, prepare another injection with new equipment, and inject another site. 2. if syringe is clear, continue to step # 17.
c.
d.
e.
f.
g.
16.
Release the skin and inject medication slowly. Hold onto the syringe to prevent it from moving. A slow, steady injection rate allows the muscle to distend gradually and accept the medication under minimal pressure. After the injection, gently but quickly remove the needle at a 90-degree angle. Immediately cover the injection site with an alcohol pad and apply gentle pressure or gently massage. This may help distribute the drug. Do not recap needle after injection. Dispose of contaminated needle,
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17. 18. 19.
syringe, and all other materials according to standard precautions and the EMTs employers policies. 20. Ensure bleeding has stopped and cover injection site with band-aid. a. If bleeding continues, re-apply pressure and reevaluate after 5 10 minutes. Repeat this step as necessary. b. If bruising occurs, an ice pack may be applied. c. An older patient may experience additional bleeding due to the decreased tissue elasticity. Reassess the patient. Observe for adverse reactions at the site for at least 10 30 minutes after injection. Document and record the process.
21. 22.
DOCUMENT - On Each Injection Patients Name Amount of Medication Site Time GENERAL CONSIDERATIONS The risk of the following exists when giving an injection: Giving wrong medication. Giving wrong dosage. Sticking yourself and others with contaminated needle. Reaction to medication. Always make sure of the five rights. Right Patient Right Medication Right Dosage Right Route Right Time SPECIAL CONSIDERATIONS Older patients have less muscle mass. Therefore, I.M. medications can be absorbed faster than expected. Always encourage the patient to relax the intended muscle. Injections into tense muscles are more painful than usual and may bleed more readily. Never inject into sensitive muscles, especially those that twitch or tremble when assessing landmarks and tissue depth. Injections into these areas may cause sharp and intense pain. Medication Route Date Patients response
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AUTO-INJECTOR GOAL To administer epinephrine by using an auto-injector OBJECTIVE Given a simulated patient who is showing signs of an anaphylactic reaction and has an auto - injector, the EMT student will be able to administer the epinephrine injection in an appropriate injection site following the directions of the manufacturer in less than one minute. EQUIPMENT Auto-injector: Directions are clearly defined on pen. PROCEDURE: 1. 2. 3. 4. Take body substance isolation precautions. Obtain order from medical direction. Obtain patients prescribed auto-injector. Ensure the prescription is written for the patient experiencing allergic reactions. Remove injector from box and check medication for: a. expiration date. b. cloudiness or discoloration. Remove safety cap from end of injector as indicated on side of injector. Select appropriate injection site: a. lateral portion of the thigh. b. midway between the waist and the knee. Check injector to see if it is loaded. Place the tip firmly against site as indicated on side of pen. Push hard until you hear or feel injector activate. Hold injector in place until the medication is injected or for a minimum of ten (10) seconds. Record activity and time. Properly discard injector in biohazard container.
5. 6.
7. 8. 9. 10. 11. 12.
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General Consideration Auto - injectors are packaged in adult and children dosages. Adult Dosage: Infant and Child Dosage: 0.3 mg in single dose 0.15 mg in single dose
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PACKAGING
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CLAM SHELL SPINAL IMMOBILIZATION DEVICE GOAL To provide a means of spinal immobilization for a patient in a sitting position during extrication OBJECTIVE Given a simulated patient, the EMT student will be able to properly apply the clam shell immobilization device within 10 minutes. EQUIPMENT Body substance isolation Approved clamshell device Accessory equipment Cervical collar adaptable to device Padding Triangular Bandages PROCEDURE: 1. 2. 3. Gather equipment and take body substance isolation precautions. Direct or maintain manual immobilization of the head and neck. Assess pulse, movement and sensation (PMS) of all extremities and record. a. Assess head and neck. b. Assess for tracheal deviation and JVD or any other abnormalities of the neck prior to moving to step # 4. Apply a cervical collar and reassess airway after application. Insert device between arms of partner (top portion first) and between the patient's back and the seat. Seat device in patient's axilla. Connect middle torso strap and tighten using a smooth pulling motion. Connect bottom torso strap and tighten. Connect groin straps by: (Make sure groin is well padded) a. Passing straps laterally to medially underneath leg. b. Remove slack by pulling the straps up through groin. c. Passing strap laterally and connect to the same side. Pull shoulder straps down over the chest. Connect and tighten the top torso strap over the shoulder straps.
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4. 5. 6. 7. 8. 9.
10. 11.
12. 13. 14. 15.
Re-assess breathing after tightening torso straps and record. Connect shoulder straps. Secure feet, knees and hands with cravats or device straps. Secure head to board: a. Attach appropriate straps to cervical collar. b. Apply forehead straps downward at a 20-degree angle. 1. Bring the board to the patients head. Do not bring patients head to the board. 2. Avoid extending or flexing the neck. Re-assess all straps and connections and record. Re-assess pulse, movement and sensation (PMS) of all extremities and record. Re-assess airway and record. Release manual immobilization.
16. 17. 19. 20.
GENERAL CONSIDERATIONS: This device does not effectively complete the spinal immobilization process. Move and secure the patient to long spine board to provide adequate spinal immobilization. Release the groin straps immediately upon moving patient to long spine board. Keep the patients knees bent upward, perpendicular to the long board until groin straps are released. Ensure straps have sufficient slack so as to not cause injury to the groin area. Perform rapid extrication methods instead of using this device if at anytime: 1. There is an immediate danger to the patient (fire, explosion, etc.). 2. The initial assessment indicates a condition (profound shock) that requires immediate intervention that cannot be accomplished in the vehicle.
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HELMET REMOVAL GOAL To appropriately remove a helmet on a possible cervical injured patient OBJECTIVE Given a simulated patient, the EMT student will be able to appropriately remove a helmet on a possible cervical injured patient within 5 minutes. EQUIPMENT Body substance isolation Vital sign equipment Cervical immobilization equipment INDICATIONS FOR REMOVAL Inability to assess and / or reassess airway and breathing Restriction of adequate management of the airway or breathing Improperly fitted helmet allowing for excessive patient head movement within the helmet. Proper spinal immobilization cannot be performed due to helmet. Cardiac arrest INDICATIONS FOR LEAVING HELMET IN PLACE Good fit with little or no movement of the patients head within the helmet. No impending airway or breathing problem. Removal would cause further injury to the patient. Proper spinal immobilization could be performed with helmet in place. No interference with the EMT-Basics ability to assess and reassess airway and breathing. GENERAL RULES FOR REMOVAL 1. 2. 3. 4. 5. 6. 7. Body substance isolation. Provide manual immobilization of cervical spine. Ensure careful evaluation of indications and contraindications of removal and record. Remove patients eyeglasses (if applicable) before removal of the helmet. One EMT-B stabilizes the helmet by placing his hands on each side of the helmet with the fingers on the mandible to prevent movement. Second EMT loosens the strap. The second EMT places one hand on the mandible at the angle of the jaw and the other hand posteriorly at the occipital region.
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8.
The EMT holding the helmet pulls the sides of the helmet apart and gently slips the helmet halfway off the patients head in a seesaw motion and then stops. The EMT maintaining stabilization of the neck repositions, slides the posterior hand superiorly to secure the head from falling back after complete helmet removal. The helmet is removed completely. The EMT then can proceed with spinal immobilization as indicated in the spinal immobilization section.
9.
10. 11.
GENERAL CONSIDERATION The technique for helmet removal depends on the actual type of helmet worn by the patient. Refer to the text and or Medical Control for specific approaches to the removal of different types of helmets.
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LONG SPINE BOARD GOAL To provide stabilization and immobilization to the head, neck, and torso and provide a means for lifting and moving patients OBJECTIVE Given a simulated patient, the EMT student will be able to immobilize a patient on the long spine board within 10 minutes. EQUIPMENT Body substance isolation Long Spine Board Rigid Cervical Collar 3- Straps - (9' in length) others acceptable Cravats Cervical Immobilization Device (commercial or towel/blanket rolls to be utilized with tape or cravats) Padding PROCEDURE: 1. 2. Gather equipment and take body substance isolation precautions. Direct or apply manual stabilization of the cervical spine in a neutral position. Place little finger along each side of the mandible and use the remaining fingers and thumbs to stabilize the head. Assess pulse, motor and sensation (PMS) of all extremities and record. Properly size and apply cervical immobilization device. a. Prior to applying cervical collar, assess the head and cervical area for abnormalities such as JVD or tracheal deviation. b. In infants and children, if the cervical immobilization device does not fit, use a rolled towel and tape to the board and manually support head. c. An improperly fit immobilization device will do more harm than good. d. Re-assess the airway. Position the device and place patient on long spine board. Utilizing one of the following methods: The method used must be decided based upon the situation, scene and available resources. Movement should be limited to the minimum amount possible. a. Scoop stretcher. b. Four man log roll i. one EMT must maintain in-line immobilization ii. EMT at the head directs the movement of the patient.
3. 4.
5.
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c. d. 6. 7.
one to three other EMTs control movement of the rest of the body. iv. quickly assess posterior body while pt is in the upward position if not already done in initial assessment. v. position the long spine board under the patient. vi. roll patient onto the board at the command of the EMT holding in-line immobilization. Linear drag. Standing position - quickly assess posterior body while pt is in the upward position. Position
iii.
Center patient on the board without using lateral movements. patient on board using the Z method.
Pad all void areas and pressure points between the patient and the board. a. Adult i. Under the head. ii. Voids under torso. Be careful of extra movement. b. Infant and Child pad under the shoulders to the toes to establish a neutral position Immobilize patient's torso to long spine board by placing at least three straps distal to proximal. a. Place one between the knee and ankle. Do not cover the knee or ankle. b. Place one at hip region. Do not restrict breathing or circulation. c. Place one between the manubrium and the umbilicus. Do not restrict breathing or circulation. Do not place strap over the xiphoid process. Do not place over the arms. d. Criss crossing the chest is acceptable. A fourth strap is required if using the criss cross method. e. Re-assess breathing and circulation. Immobilize patients head to the board. a. Commercial cervical immobilization device (CID). b. Towel/blanket rolls securing across the forehead and the second across the chin portion of the cervical collar. DO NOT place strap UNDER the chin. Manual immobilization of the patients head may be released after the patients head has been secured to the board. Certain situations may require extending the time of manual immobilization. Secure the patients ankles and wrists with cravats. Re-assess ABC's along with pulse, motor, and sensation (PMS) and record. Recheck all straps and cravats for security and record.
8.
9.
10.
11. 12. 13.
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GENERAL CONSIDERATIONS When neutral position of the head cannot be attained safely, immobilize the head as found. If board is too short for the patient, always center the head, neck, and spine on the board properly. The feet and lower legs may extend past the end of the board if necessary. If chinstrap is used, ensure the patient can open their mouth to prevent aspiration should vomiting occur. Accomplish this may by placing chinstrap over chin.
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SCOOP STRETCHER GOAL To provide an effective means of lifting and moving a supine patient without changing the patients position OBJECTIVE Given a simulated patient, the EMT student will be able to place and secure the supine patient on a scoop stretcher within 10 minutes. EQUIPMENT Body substance isolation Scoop stretcher 3 straps - (9' in length) 4 - 6 Cravats Padding PROCEDURE: 1. 2. 3. 4. Gather equipment and take body substance isolation precautions. Adjust scoop stretcher to accommodate height of the patient. Disconnect stretcher at both head and foot ends. Place one section of the stretcher on each side of the patient ensuring that the head and foot connections are located properly. (Do not pass stretcher halves across patient) Gently tilt patient slightly to the side and slide stretcher under the patient until it is properly in place with head connection centered above the patients head. Repeat step 5 for the opposite side. Secure head connection first, then the foot connection, being careful not to pinch the patient's back or buttocks. Secure patient's trunk to scoop stretcher by placing at least three straps distal to proximal. a. Place one between knee and ankle. Avoid over the knee or ankle. b. Place one at hip region. Do not restrict breathing. c. Place one across the chest. Be sure this strap in not over the arms and does not restrict breathing. Pad the patient appropriately. Secure ankles and wrists with cravats, assess PMS and record. Secure head (as needed) for spinal precautions.
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5.
6. 7. 8.
9. 10. 11.
12.
Reassess and recheck all connections, straps, PMS and record.
GENERAL CONSIDERATIONS The scoop stretcher is a spinal immobilization device without a long spine board. Hold and maintain manual immobilization until patient is completely secured to a long spine board if indicated. Never pass the stretcher over the patient. The weight capacity of the scoop stretcher is extremely important to the EMT. Therefore, the EMT shall obtain this information about the scoop stretcher being used by the EMTs employer.
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EMT PHARMACOLOGY
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Activated Charcoal (SuperChar, InstaChar, Actidose, Liqui-Char) Description: The medication of choice in the emergency medical care of ingested poisonings. Action: A specially distilled charcoal treated with superheated steam, is extremely porous and therefore can adsorb many times its weight in contaminants. The activated charcoal adsorbs the poison in the stomach, enhances elimination, and inhibits the poison from being absorbed into the body. It does not bind to alcohol, kerosene, gasoline, antifreeze, caustics or metals such as iron. Indications: Upon orders from Medical Direction, activated charcoal may be administered to patients who have ingested poisons by mouth. Contraindications: Patients without a gag reflex Patients with an altered mental status Patients who have ingested acids or alkalis Precautions: May cause vomiting May cause blackened stools Does not bind to alcohol, kerosene, gasoline, caustics, or metals such as iron Form: Pre-mixed bottle contains 12.5 grams of activated charcoal. The powder form should be avoided in the pre-hospital setting. Dosage: Administer 1 gram of activated charcoal per Kg unless otherwise directed by Medical Control. The usual adult dose is 25 50 grams. The usual pediatric dose is 12.5 25 grams. Route: Shake container thoroughly. Have patient drink slurry through a straw. If the patient vomits, notify medical control to authorize repeating the dose.
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Aspirin (ASA) (Bayer, St. Josephs) Description: Thrombolytic Actions: Reduces overall mortality from acute myocardial infarction (AMI). Reduces additional infarct. Reduces strokes. Blocks formation of Thromboxane A2 which causes platelets to aggregate and arteries to constrict. Indications: Therapy for all patients with new pain suggestive of AMI. Contraindications: Patients with acute ulcer disease, GI or other bleeding disorders Patients experiencing an Asthma attack If the patient has already had an ASA prior to arrival Known hypersensitivity of aspirin Precautions: Patients with a history of Asthma, verify patients known tolerance of aspirin. Doses higher than recommended can interfere with Prostacyclin production and benefits. Side Effects: At higher doses the following may occur: Sweating Nausea Fall in Blood Pressure GI bleeding Dosage: 160 mg to 325 mg as soon as possible and preferably chewable Route: Patients should chew one aspirin and take one by mouth
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Bronchiodilator - Albuterol (Proventil, Ventolin, Bronkosol, Alupent, Metaprel, etc) Description: A commonly prescribed bronchiodilator in pre-hospital care, Albuterol is administered with a small volume nebulizer, or metered dose inhaler. Action: Causes bronchiodilation with minimal side effects, reduces airway resistance, and duration is approximately five hours. Indications: Bronchial asthma or signs and symptoms of respiratory distress. Reversible bronchospasm associated with chronic bronchitis and cases of emphysema. Third drug for anaphylaxis. Contraindications: Patients with a known hypersensitivity to the drug Precautions: Palpitations, anxiety, nausea, and dizziness. Monitor vital signs. Use caution when administering to patients with history of cardiovascular disease or hypertension. Dosage: Nebulizer: Adult: 2.5 mg of the drug placed in 3 ml of normal saline for inhalation and administer by nebulizer @ 6 LPM, until appropriate mist is achieved or according to the flow rate established in the nebulizers manufacturers recommendations.
Metered Dose Inhaler: Shake inhaler vigorously several times and administer to the patient upon deep inhalation. The patient should hold their breath approximately 10 seconds to assure more effective use of medication. Route: Inhalation only
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Description:
50 % Dextrose in Water (D50W) To provide glucose for patients who have low blood glucose levels as determined by blood glucometer. Glucose is the principal energy source utilized by the brain and other tissues. Dextrose is used to describe the six-carbon sugar molecule that is the principal form of carbohydrate for the body.
Action: Rapid absorption of glucose by the cells in treatment of hypoglycemia. Indications: Known Hypoglycemia patient with coma Symptomatic known Hypoglycemia Contraindications: May be detrimental to patients experiencing cerebral ischemia and / or hemorrhage. D50W may increase cranial bleeding. Precautions: Localized irritation may occur when using smaller veins, which can cause tissue necrosis. Ensure patency of IV line prior to administration. Extravasation may occur which will cause tissue necrosis. Dosage: 25.0 grams (0.5g/mL) Standard dose of 50% Dextrose in symptomatic hypoglycemia is 25 grams (50 mls of a 50% solution) IV. If after 5 10 minutes and the first dose is ineffective, a second dose of 25 grams may be administered. Route: IV only DO NOT ATTEMPT TO MAINLINE -- D50W is very, very necrotic.
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25 % Dextrose in Water (D25W) Description: To provide glucose for primarily pediatric patients who have low blood glucose levels as determined by blood glucometer. Glucose is the principal energy source utilized by the brain and other tissues. Dextrose is used to describe the six-carbon sugar that is the principal form of carbohydrate for the body. Action: Rapid absorption of glucose by the cells in treatment of hypoglycemia. Indications: Known Hypoglycemia patient with coma Symptomatic known Hypoglycemia Contraindications: May be detrimental to patients experiencing cerebral ischemia and / or hemorrhage. D25W may increase cranial bleeding. Precautions: Localized irritation may occur when using smaller veins, which can cause tissue necrosis. Ensure patency of IV line prior to administration. Extravasation may occur which will cause tissue necrosis. Dosage: 2.5 grams (250 mg/mL) Standard dose of 25 % dextrose in symptomatic hypoglycemia is 2 4 ml/kg IV. If after 5 - 10 minutes and the first dose is ineffective, give second dose of 2 4 ml/kg IV. Route: IV only DO NOT ATTEMPT TO MAINLINE -- D25W is very, very necrotic.
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Epinephrine 1:1,000 Description: The drug of choice for the emergency treatment of severe allergic reactions (anaphylaxis) to insect stings or bites, foods, drugs, and other allergens. Action: A potent catecholamine which mimics the responses of the sympathetic nervous system and constricts blood vessels (dilates) to improve blood pressure. Reduces leakage from blood vessels, relaxes smooth muscles in the bronchioles, alleviates wheezing and dyspnea and stimulates the heartbeat (constricts blood vessels). Reverses the swelling and hives. Indications: Severe, systemic allergic reactions. The medication must be prescribed to the patient or the EMT shall obtain orders for administration via either Medical Control or standing orders from Medical Control Physician. Contraindications: There are no contraindications for epinephrine in a life-threatening allergic reaction. Precautions: Should not be added to solutions containing sodium bicarbonate (deactivated by alkaline solutions) May precipitate angina or Myocardial Infarction in susceptible patients. Anxiety, chest pain, palpitations, tachycardia, headache, pallor, dizziness, nausea and vomiting are some common side affects. Dosage: Contains 1 mg of the drug in 1 ml of solvent. The initial adult dose is 0.3 - 0.5 mg subcutaneous. The adult autoinjector dose is 0.3 mg. The initial pediatric dose is 0.01 mg/kg subcutaneous. The pediatric auto-injector dose is 0.15 mg. Consider repeating dose if patient exhibits no significant improvement after 5 10 minutes. Epinephrine acts quickly. It also is quickly used by the body; therefore, a repeat dosage may be necessary after 15 20 minutes. Contact Medical Control prior to additional doses. Route: Subcutaneaus Injection or Intramuscular Injection Nitroglycerin Tablet (NTG) (NitroStat, NitroDur, NitroBid)
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Description: Used in the management of chest pain associated with both Angina and Acute Myocardial Infarction. Action: A rapid smooth-muscle relaxant that causes decreased cardiac work. Dilates both arterial and venous vessels and causes venous pooling of blood. Causes vasodilation of coronary arteries; thus, increasing perfusion of ischemic myocardium. Pain relief occurs within two minutes and therapeutic effects can be observed up to 30 minutes later. Indications - must have all of the following criteria: Exhibits signs and symptoms of chest pain, and Has physician prescribed sublingual tablets or spray, and Has specific authorization by medical direction unless standing orders exist. Contraindications: Hypotension or blood pressure below 100 mmHg systolic Head injury or an increased intracranial pressure (ICP) Hypovolemia, severe bradycardia, or tachycardia Recent use (within 24 hours) of Viagra Infants and children Patient has already met maximum prescribed dose prior to EMT arrival Precautions: May induce headaches from vasodilation of cerebral vessels. Patients may build up a tolerance. The Medication deteriorates rapidly once bottle is opened. Secure the top immediately after obtaining dose. Ensure stock is current and fresh. Protect from light. Dosage: One tablet, sub-lingual (0.4 mg) Dose may be repeated every 3 - 5 minutes if no relief, BP > 100 mmHg systolic, and authorized by medical direction up to a maximum of 3 doses. Routes: Sublingually making sure patient does not swallow the tablet. Also available in patches, sprays, and ointment. Ointment/paste: Dosage is 1 - 2 inches of paste (6 - 12 mg) topically applied in a 4 inch circle on the chest.
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Nitroglycerin Spray (Nitrolingual Spray) / (Antianginal) Description: Used in the management of chest pain associated with both Angina and Acute Myocardial Infarction. The NTG spray is an aerosol preparation which delivers exactly 0.4 mg in each spray with a peak effect in two to four minutes. Action: A rapid smooth muscle relaxant that causes decreased cardiac work. Dilates both arterial and venous vessels and causes venous pooling of blood Causes vasodilation of coronary arteries; thus, increasing perfusion of ischemic myocardium. Pain relief occurs within two minutes and therapeutic effects can be observed up to 30 minutes later. Indications - must have all of the following criteria: Exhibits signs and symptoms of chest pain, and Has physician prescribed sublingual tablets or spray, and Has specific authorization by medical direction unless standing orders exist. Contraindications: Hypotension or blood pressure below 100 mmHg systolic Head injury or an increased intracranial pressure (ICP) Hypovolemia, severe bradycardia, or tachycardia Recent use (within 24 hours) of Viagra Infants and children Patient has already met maximum prescribed dose prior to EMT arrival Precautions: May induce headaches from vasodilation of cerebral vessels. Patients may build up a tolerance. The Medication deteriorates rapidly once bottle is opened. Secure the top immediately after obtaining dose. Ensure stock is current and fresh. Protect from light. Avoid contamination of cap. Wipe off cap with alcohol prep. Dosage/Route: 1 spray (0.4 mg) sublingual. No more than three (3) doses in 15 minutes. The spray should not be inhaled. Also available in tablets, patches, and ointment.
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Oxygen (O2) Description: Oxygen is the most important emergency drug. Oxygen is required by the body to facilitate the breakdown of glucose into usable energy form. Oxygen is odorless, colorless, and tasteless. Actions: Administration increases arterial oxygen tension. This increases the oxygen saturation available for hemoglobin. Oxygen is required by the cells for breaking down glucose into energy. Indications: Respiratory emergencies Hypoxemia Chest Pain Cardiac arrest Trauma Contraindication: NONE in the emergency setting Precautions: Patients with COPD may experience apnea. These patients chemoreceptors no longer influence breathing. They have a hypoxic drive for stimulus. Do not withhold oxygen from any patient. Prolonged administration of high flow oxygen to newborn infants can result in eye damage. Dosage: Cardiac Arrest - 100% or as close to that as possible (BVM) Hypoxia - 100% or as close as possible (BVM or 15 LPM / NRB) Chest Pain - 100 % or as close as possible (15 LPM / NRB) COPD 100% or as close as possible (15 LPM / NRB) 2-6 LPM via BNC IF patient cannot tolerate a NRB mask Be prepared to ventilate and intubate with a double lumen airway.
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INTRAVENOUS THERAPY
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MATH CALCULATION INTRAVENOUS THERAPY DRIP RATES GOAL To enable the student to calculate the appropriate drip rate to administer the amount of IV solutions as prescribed by the physician OBJECTIVE Given a simulated patient, the EMT student will be able to calculate the appropriate drip rate in 3 minutes. EQUIPMENT Pencil Paper Calculator (optional)
EMT-Basic students can utilize calculators for National Registry testing. However, NREMT prohibits their use in EMT-Paramedic testing. PROCEDURE: 1. Determine the size of drip chamber used. (a.k.a. drop factor) a. Micro drip chamber 60 drops (gtts) = 1 cc b. Macro drip chamber may vary. Obtain information from manufacture label. 1. Commonly used: 10, 15, 20, 30 gtts = 1 cc 2. 1 cc = 1 ml Calculate drops to be given per minute on the following formula: ccs to be administered (volume) X drop factor Time to be administered in minutes EXAMPLE: The physician orders 250cc (amount to be administered) Normal Saline administered over one hour (time to be administered). The drip chamber selected is a 10 drop set (drop factor). How many drops per minute is needed to reach this objective? 250 X 10 60 = 2500 60 = 41.66 or 42 gtts/min. = ___ gtts/min
2.
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PERIPHERAL INTRAVENOUS CANNULATION IN AN EXTREMITY IV BAG ASSEMBLY AND SET UP GOAL To properly assemble and prepare the IV bag and tubing OBJECTIVE Given a simulated patient, the EMT student will be able to assemble the IV bag and tubing, and all other equipment within needed to initiate an IV lifeline within 3 minutes EQUIPMENT Body substance isolation IV administration set IV fluid PROCEDURE 1. 2. 3. 4. Obtain orders from medical control online / off-line. Gather and check equipment. Take body substance isolation precautions. Open the outer bag using the pre-cut slit. a. use caution if using sharp objects to avoid puncturing the IV bag b. Inspect IV fluid for: i. correct fluid. ii. clarity. iii. expiration date. Select proper IV tubing set and remove from package. a. Completely untangle tubing. b. Slide the flow adjustment clamp up toward the IV tubing spike to allow the flow adjustment to the closed position. c. Ensure both end caps remain sterile even after removing the protective caps. Connect or spike the IV tubing to the IV bag. a. Remove the covering on the IV tubing at the top of the drip chamber to expose the beveled spike. This shall remain sterile. b. Hold the IV bag upside down and remove the plastic tab covering the IV port. This port shall also remain sterile. c. While holding the IV bag upside down, insert the IV tubing spike into the IV bag port pushing and twisting the spike until the spike penetrates the IV bag port seal. Turn the IV bag upright. a. Slowly squeeze the IV tubing drip chamber between the thumb and forefinger completely placing one side of the drip chamber against the other and hold for a couple of seconds.
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5.
6.
7.
b. 8.
Remove fingers from drip chamber. The IV fluid should fill to the drip chamber fill line.
Flush fluid thru IV tubing to evacuate air, keeping keep the end sterile. a. Open the flow adjustment. This will allow fluid from the IV bag through the drip chamber to push the air from the IV tubing. b. After the IV line is full of IV fluid and no air bubbles exist, turn the flow adjustment to the closed position. Hang the IV bag on an IV pole or other suitable device. Place the IV tubing end near the IV site. Prepare to initiate the IV.
9. 10. 11.
CONSIDERATIONS Do not delay patient transport to establish an IV in a High Priority patient. Assemble the IV bag and establish IV access simultaneously if adequate personnel are available. The EMT who gains IV access is ultimately responsible for the IV initiation process and thus documenting the IV initiation.
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PERIPHERAL INTRAVENOUS CANNULATION IN AN EXTREMITY OBTAINING IV ACCESS GOAL To properly obtain IV access in an extremity and adjust the IV infusion rate OBJECTIVE Given a simulated patient, the EMT student will be able to properly obtain IV access and properly adjust the IV infusion rate in an extremity within 3 minutes. EQUIPMENT Body substance isolation IV needle / catheter Venous tourniquet Tape (1 or 2) or Opsite type device Bandaids Gauze Pads Alcohol or Betadine Swabs PROCEDURE 1. 2. 3. Take body substance isolation precautions. Determine allergies. Prepare to initiate the IV. a. Place sharps container close to patient. b. Tear tape into or inch wide strips approximately 6 to 8 inches long, and place near where the IV will be initiated. An Opsite or other comparable device if available, may be opened and placed at this site. Use enough tape to secure IV site and tubing. c. Open alcohol pads or betadine swabs, bandaids, and gauze pads at this site. Expose the extremity where the IV will be initiated. Select a proposed site. The site is to be based on the patients condition. An IV first attempt miss in the AC, will prevent IV attempts distal to that site in the same arm. Therefore, in order of preference, the site should be: a. back of hand b. forearm c. antecubital (AC) Apply the venous tourniquet proximal to the elbow wrapping the tourniquet around the back of the extremity. a. Stretch both ends outward and upward toward the front of the extremity. b. Bring the ends toward each other and, while they are still pulled outward away from the arm, loop one end around the other like tying a shoelace. c. Tuck only the middle portion of one end under the crossover point using the index finger and leave a tail extended.
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4. 5.
6.
d. 7. 8.
Allow the tourniquet to rest against the extremity so that the crossover loop will hold its tightness against the skin.
Identify a suitable vein and specific site to cannulate. Palpate the vein at the proposed site to feel for any possible valves. Prepare the site for cannulation. a. Clean site with alcohol prep in a circular motion from center to outer area 3 4 inches and allow to air dry. This procedure may need to be repeated more than once to ensure site is clean. If using betadine swabs, allow betadine to stay on skin for a couple of minutes, then wipe clean in a swiping motion with alcohol. Select the appropriate size gauge catheter based upon the patients need or condition. Remove the IV needle and catheter from its package and take protective cap off the end of the needle and ensure the catheter remains sterile. a. Inspect the point of the needle and the tip of the plastic catheter for any defects. b. Twist the catheter hub and the flashback chamber in opposite directions to prevent the catheter hub from sticking to the metal needle. c. DO NOT slide the catheter over the point of the needle. This may cause catheter sheer, resultant injury, and death to the patient. The EMT is to hold the patients extremity with his nondominant hand near the area to be cannulated. The EMT is to use his thumb to stretch the skin while bending downward slightly the patients wrist. Be careful not to place thumb on the vein to be cannulated. This will cause blood flow to be occluded and the vein to flatten. Hold the catheter and needle bevel up at a 35 to 45 degree angle with the thumb and index finger of the dominant hand. Inform the patient they will feel a small prick sort of like a bee sting and avoid any motion. a. continue to calm and reassure patient throughout the entire event Entering the vein. (Option #1) a. Apply traction to the vein in the opposite direction of the insertion and with the needles point directly over the vein, quickly but carefully enter the needle into the skin and continue until the needle tip is on the wall of the vein. i. If using a hand vein, lower the angle of the IV needle toward the skin as the needle enters the vein to help avoid going through the vein. b. Slowly advance the needle through the veins wall and into the veins lumen, feeling for a pop as the needle passes through the vein. c. Observe for blood filling the catheters flashback chamber. i. If blood fills the chamber, stop needle insertion and slowly insert the catheter into the vein until the catheter hub rests against the skin. Skip to # 15. ii. If not, continue advancing the needle along the vein until blood begins to fill the flashback chamber. If successful, skip to # 15.
9. 10.
10.
11. 12.
13.
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iii.
If unable to locate the vein now, withdraw both needle and catheter simultaneously slightly from the vein without completely removing the needle/catheter from the skin and re-attempt the IV again. If needle/catheter is completely removed, get another needle/catheter and start over.
14.
Entering the vein. (Option #2) a. Enter the skin to the side of the vein. The angle and bevel position are the same. However, once entry to the skin is made, rotate the needle turn to ensure the bevel is away from the vein wall. b. Feel for a pop as the vein is entered. Once a flashback is achieved, align the angle of the catheter in the direction of the vein and remove the needle. Skip to # 15. Needle Removal. a. Apply slight pressure on the vein just proximal to the injection site. b. Prepare IV tubing end for connection to catheter. c. Slowly remove the IV needle, place in a sharps container and insert IV tubing into IV catheter hub and secure. d. Release the tourniquet by pulling on the tail piece to undo the half knot. Hold the IV tubing and catheter connection securely then slowly open the flow clamp. a. Slowly increase the rate to allow fluid to flow into the vein at a fast rate. Set the rate at TKO until IV is secure. b. Inspect site for signs of infiltration. i. If none, then set the desired IV drip rate and closely examine site for infiltration. (see Math Calculation, Intravenous Therapy Drip Rates) ii. If yes, turn off the flow and refer to IV infiltration protocol. c. Clean up any blood around injection site with gauze pad, alcohol pad, or Hydrogen Peroxide on gauze pad, cotton swab or other acceptable means. Secure the IV site with tape or Opsite type device. a. Place bandaid over puncture site. b. Take one strip of inch tape, slide it sticky side up under the IV tubing at catheter hub. c. Take care not to pull the catheter out of the patients arm, pull each end of the tape proximal and cross each tape tail to form an X and secure to the patients skin (chevron, U method or H method). d. This process may be repeated or place the second piece of tape directly over the first. e. Make a loop with the IV tubing and secure this using third piece of tape. f. Use the last piece of tape and secure tubing at a point 5 10 inches proximal to the third piece of tape. Continue to monitor the IV site for infiltration. Continue to monitor the IV for proper flow rate. Attempt an IV only twice. Allow partner (if licensed) to try after two attempts. TROUBLESHOOTING
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15.
16.
17.
18. 19. NOTE:
If IV fluid does not begin to flow, ensure the venous tourniquet has been released. The catheter bevel may be against the vein wall or against a valve. Pull back the catheter in 1/8 inch increments while slightly rotating the catheter. Stop and secure the IV in place when flow is achieved. Be careful not to pull the catheter out of the arm. Close visual inspection is required of both the injection site and the drip chamber. For an IV flowing only when the patients extremity is in a certain position (positional), consider utilizing an arm board. Secure the arm board to the patients extremity without interfering with the IV flow, venous blood flow, and the patients circulation. Drip chamber fills with fluid during transport: Turn off IV flow. Invert bag and squeeze fluid into bag until chamber is filled to the fill-line. Air in the IV line above the slide clamp: Pull line tight while being careful not to remove the line from the bag. Tap on the line to allow air to rise into the drip chamber. Remove large amounts of air using a needle and syringe.
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PERIPHERAL INTRAVENOUS CANNULATION IN AN EXTREMITY D50W AND D25W Bolus GOAL To properly administer a medication bolus through an established IV line in an extremity OBJECTIVE Given a simulated patient, the EMT student will be able to properly administer a medication bolus through an established IV line in an extremity within 3 minutes EQUIPMENT Body substance isolation Alcohol pads An established patent IV line Desired medication PROCEDURE 1. 2. 3. Take body substance isolation precautions. Determine allergies. Obtain orders from Medical Direction unless standing orders exist. a. Ensure the 5 Rs of medication administration. b. Rule out contraindications. c. Draw up or secure the correct medication and dose. Cleanse with an alcohol pad the IV tubings medication access port closest to the patient. Carefully insert the needle or syringe containing the prescribed dose of the medication into the rubber cap covering the access port. a. Kink the IV tubing above the injection site to prevent the medication from going away from the patient and possibly entering the IV drip chamber. Continue to hold IV line closed above the injection site. a. Administer the medication at the medications suggested administration rate through the access port into the IV line. b. After the desired medication amount has been administered, slowly remove the needle that contained the medication and properly dispose in a sharps container. c. Release the IV tubing back into the open flowing position and open the IV tubing flow adjustment ball to the wide open rate. This will flush the remaining medication from the IV line and push the medication into the patient. Flush with 5.0 to 10.0 ccs of fluid. Monitor the patient for signs of improvement or deterioration.
4. 5.
6.
7.
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8. 9.
Adjust the IV tubing IV flow adjustment ball to the previous drip rate. Document the drug given (name), concentration, dose, route, time, who administered the medication, effects, physician of record. Document should include other information per local protocol.
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DISCONTINUING AN INTRAVENOUS LINE GOAL To discontinue an IV when indicated OBJECTIVE Given a simulated patient, the EMT student will be able to recognize the need for and discontinue an IV within 5 minutes. EQUIPMENT Body substance isolation Alcohol or betadine prep Band-Aid or 2x2 dressing and tape INDICATIONS Amount of fluid to be administered IV line occluded Signs of Infiltration -Continued pain at IV site -Swelling and redness at site PROCEDURE 1. 2. 3. 4. 5. 6. 7. 8. Gather equipment and ensure proper body substance isolation precautions. Close flow regulator on IV tubing. Remove tape from IV site. Place alcohol or betadine prep over IV site. Remove IV catheter and properly dispose in sharps container. Apply pressure to site for few minutes for at least 3 5 minutes to control any bleeding from site. Apply bandage or dressing to site. Document removal: a. Time. b. Reason for removal. c. Amount of fluid remaining in IV bag.
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AUTOMATED EXTERNAL DEFIBRILLATION
Refer to current AHA Guidelines

GOAL To provide prompt defibrillation for patients who have confirmed circulatory arrest due to ventricular fibrillation OBJECTIVE Given a simulated patient, the EMT student will be able to administer the automatic external defibrillation procedure within 2 minutes. EQUIPMENT Body substance isolation precaution materials Automated External Defibrillator Blood Pressure Cuff and Stethoscope Mannequin for simulation of procedures PROCEDURE Use of automated external defibrillators during resuscitation attempts. OPERATIONAL STEPS 1. 2. 3. 4. 5. 6. 7. 8. 9. Take body substance isolation precautions. Arrive on scene and perform initial assessment. Stop CPR if in progress and verify pulselessness and apnea Have partner resume CPR. Attach device and turn on defibrillator power. Begin narrative if machine has tape recorder. Stop CPR. Clear patient. Ensure all clear. Any contact with the patient is dangerous. Initiate analysis of rhythm.
Machine advises shock. 1. Deliver shock. 2. 3. 4. 5. Re-analyze rhythm. If machine advises shock, deliver second shock. Re-analyze rhythm. If machine advises shock, deliver third shock.
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6.
Check pulse. a. Check breathing and pulse. i. If breathing adequately, give high concentration oxygen by nonrebreather mask and transport. ii. If not breathing adequately, artificially ventilate with highconcentration oxygen and transport. b. If no pulse, resume CPR for one minute. i. Repeat one cycle of up to three stacked shocks. ii. Perform one minute of CPR. iii. Make a transport decision. iv. Deliver a third set of shocks on scene pursuant to local medical control.
Standard Operational Procedures 1. Assuming no on-scene ALS, transport the patient when one of the following occurs: a. The patient regains a pulse. b. Six shocks are delivered. c. The machine gives three consecutive messages separated by one minute of CPR that no shock is advised. One EMT-Basic operates the defibrillator and one performs CPR Defibrillation comes first. Do not connect oxygen, or delay defibrillation. EMT-Basic must be familiar with device used in operational EMS setting. Avoid all contact with patient during analysis of rhythm. State "Clear the patient" before delivering shocks. No defibrillator is capable of working without properly functioning batteries. Check batteries at beginning of shift. Carry extra batteries. Place pads at least 5 inches from pacemaker or implanted defibrillator.
2. 3. 4. 5. 6. 7. 8.
Age and weight guideline 1. 2. Airway and artificial ventilation is of prime importance. Do not use automated external defibrillation in cardiac arrest in children under 8 years of age or less than 25 kg.
Persistent ventricular fibrillation and no available ALS backup. 1. After six shocks on scene, (three initial, three after one minute of CPR), make a transport decision.
2.
3. 4.
Deliver additional shocks at the scene or en route by approval of local medical direction.
Automated external defibrillators cannot analyze rhythm when emergency vehicle is in motion. Completely stop the vehicle in order to analyze rhythm if more shocks are ordered. Do not defibrillate in a moving ambulance due to safety.
Recurrent Ventricular Fibrillation - Defibrillation with No Available ACLS.

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1.
If enroute with unconscious patient check pulse frequently, at least every 30 seconds. If pulse is not present then: a. Stop vehicle. b. Start CPR if defibrillator is not immediately ready. c. Analyze rhythm. d. Deliver shock if indicated. e. Continue resuscitation as per protocol. If enroute with conscious patient having chest pain who becomes unconscious, pulseless and apneic then: a. Stop vehicle. b. Start CPR if defibrillator is not immediately ready. c. Analyze rhythm. d. Deliver up to 3 shocks, if indicated. e. Continue resuscitation as per protocol. If "no shock" message is delivered and no pulse is present: 1. start or resume CPR. 2. analyze rhythm until three consecutive "no shock" messages are given or 3. six shocks given or 4. patient regains pulse and continue transport.
2.
NOTE:
Single Rescuer with An Automated External Defibrillator 1. Follow sequence a. Perform initial assessment. b. Assure pulselessness, apnea. c. Turn on AED power. d. Attach device. e. Indicate analysis of rhythm. f. Deliver shock if necessary. g. Follow protocol. Defibrillation is initial step; Do not perform CPR prior to rhythm analysis. EMS system activation should not occur until "no shock indicated", pulse returns, three shocks are delivered, or help arrives. Pulse checks should not occur during rhythm analysis. Do not check pulse between stacked shocks 1 & 2 and stacked shocks 4 & 5. Coordination of ALS personnel or EMT-Paramedics when EMT-Basics are using automated external defibrillators. 1. 2. 3. 4. EMS system design establishes protocols. AED usage does not require ALS on scene. ALS should be notified of arrest events as soon as possible. Considerations for EMT-Basic transporting the patient or waiting for ALS to arrive on the scene to transport should be in local protocols established by medical direction.
2. 3.
Safety Considerations
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1. 2.
Water Metal
Post Resuscitation Care 1. After automated external defibrillation protocol is completed, patient may: a. Have pulses. b. Have no pulse with machine indicating "no shock indicated." c. Have no pulse with machine indicating shock. 2. If pulses return a. See airway module. b. See lifting and moving patients module. c. Consider awaiting ALS backup if appropriate. d. See transportation module. e. Continue to keep defibrillator device on patient en route. f. Perform focused assessment and reassessment en route. Other Considerations Remember the chain of survival: Early access, early CPR, early defibrillation and early advanced life support. Do not perform CPR at times shocks are delivered. Stop chest compressions and artificial ventilations when the rhythm is being analyzed and when shocks are delivered. No person should be touching patient when rhythm is being analyzed and when shocks are delivered. Defibrillation is more effective than CPR, so stopping CPR during the process is more beneficial to patient outcome. CPR may be stopped up to 90 seconds if three shocks are necessary. Resume CPR only after up to the first three shocks are delivered.
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APPENDIX A Licensure Application Process
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REQUIREMENTS FOR EMS PERSONNEL TO BECOME LICENSED IN TENNESSEE The information provided in this section of the manual is provided to help the EMT students to become licensed in Tennessee. To be eligible for EMT licensure in Tennessee the applicant must have successfully completed a Department of Transportation approved Emergency Medical Technician curriculum to include the TN EMT Basic Extended Skills curriculum within the past year. Those applying from outside Tennessee must have applied within six months from completion of the course. In order for you to be issued a Tennessee EMT License, you must: Submit all of the required documentation, Pay all required fees, Successfully complete all training required, Successfully complete any written or practical examinations required All documentation must be presented at the time of the written examination: Failure to submit the required documentation will result in the applicant being denied examination. Any questions concerning the application process should be addressed in writing to TN Department of Health Division of Emergency Medical Services Director of EMS Personnel Licensure Cordell Hull Building 1st Floor 425 Fifth Avenue North Nashville, TN 37247-0701 UNDERSTANDING THE APPLICATION PROCESS 1. The TN Division of EMS (TDH EMS) does not accept or send faxes to expedite applications. Allow fourteen working days for information mailed to TDH-EMS to be received and placed in a persons file. Federal Express or special courier services will not appreciably reduce the process time. If Federal Express or special courier services are used, the EMT is responsible for incurred charges. Federal Express or special courier services must be sent to: TN Department of Health Division of Emergency Medical Services Cordell Hull Building 1st Floor 425 Fifth Avenue North Nashville, TN 37247-0701 Absent any complicating factors, the average application processing time is sixty days. We will discuss application status with the applicant only. Please inform potential employers and any others that application status updates must be obtained from the individual applicant. Examination's results are provided by mail only. Examination scores or even "pass " or " fail" will not be given verbally. If an address change or name change occurs any time during the application process, personnel are required to notify the TDH-EMS in writing within 30 days of the change.
2. 3.
4. 5.
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6.
Applicants are recommended not to arrange or accept employment in Tennessee until granted a license by this agency. You may not practice until you have a license. Employers may confirm your license status through the web site under license verification-Personnel.
With everyones cooperation, the division will make every effort to expedite the application.
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APPENDIX B Renewal Process
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WHEN DO I RENEW???
The Tennessee Department of Health, Division of Emergency Medical Services (TDH-EMS renews EMT licenses in the EMT's birth month. The system was implemented to disseminate the mass number of renewals in June and December of each year. This system will allow the workload to be distributed over twelve months instead of two months. The system is very simple; personnels EMS license will expire on the LAST DAY of the individuals birth month. If the EMT was born in an even year, the license will expire in an even year. If born in an odd year, the license will expire in an odd year. Example, if born October 15, 1947 the license will always expire on October 31 of an odd year. On initial licensure, individuals may not get the full two years and others may receive more than two years in order to get them on the correct expiration cycle. Please check the new EMT License and make note of the THE EXPIRATION DATE. Please contact your Regional Consultant if you have questions regarding the process. HOW DO I RENEW . . . The most frequently asked question at the Department of Health, Division of Emergency Medical Service is How do I renew my EMT license?. There are three options available to accomplish EMT Renewal. These options are the renewal examination, Continuing Education Units (CEUs) or maintaining your National Registry Certification. Hopefully, the following information will answer some of the questions. I. RENEWAL EXAMINATION The first option is the renewal examination. The exam must be taken prior to the applicants expiration date and the applicant must pass with a score of 70 % or greater. a. The examination can be taken at anytime during the EMTs renewal cycle. It is highly recommended not to wait until the month prior to expiration to take the examination. Renewal examinations should be taken 60 90 days prior to expiration to insure adequate time to receive the grade and submit renewal requirements. The renewal examinations are usually given the first Thursday of each month. The examinations are normally given at the Regional Health Offices and begin at 9:00 a.m. Contact your Regional Consultant for the exact examination locations and times. All scores will be issued by mail approximately three to five weeks after the examination. SCORES WILL NOT BE GIVEN OVER THE TELEPHONE, FAX, or EMAIL. You may retest if needed. Retests are administered at the times explained in b.
b.
c.
d. II.
CONTINUING EDUCATION UNITS (CEU's) The second option is Continuing Education Units. Continuing Education is a structured educational and training experience for personal or professional development in which participants are presumed to have previously attained a basic level of education, training, or experience. A Continuing Education Unit (CEU) is a standard unit of measurement that quantifies continuing education and training activities while serving the diversity of providers, activities, and purposes in adult education. Therefore, the Division has developed the following guidelines as criteria to meet the requirement for license renewal.
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a.
One CEU is equal to ten contact hours of participation in an organized continuing education experience under responsible sponsorship, capable direction, and qualified instruction. The Division of Emergency Medical Services does not issue CEUs; we approve CEUs for licensure renewal. Agencies that can award CEUs are colleges, universities, proprietary schools, teaching hospitals, vocational-technical schools and other agencies that have meet the International Association for Continuing Education and Training (IACET) guidelines and criteria. CEUs must be recorded on official and original transcripts, certificates, or letters issued by a continuing education agency. The following information must be included with each record: the individual's name, the course title, the date(s) attended and the amount of CEUs awarded. CEUs must be attained during the individual's renewal cycle (normally 2 years). For example, if the applicants license expires March 31, 2003, courses obtained from April 1, 2001 through March 31, 2003 may be used. CEUs must be listed on the renewal form. Do not mail CEU forms with the renewal packet. The CEU certificates must be kept on file by the individual for four (4) years from last renewal and are subject to audit at any time. The Division mails the renewal form to the individual sixty days prior to their renewal date. It is the individual's responsibility to request and maintain all documentation from the continuing education issuing agency. CEUs obtained must be EMS related courses. They must be courses or classes that offer information that will increase the EMTs abilities, skills and or knowledge in pre-hospital care and in areas that are within the scope of practice for the EMTs type of licensure. An EMT may not use advanced skills instruction toward EMT renewal. Example of non-usable CEUs for EMT renewal; ACLS, PALS, (course or review), NALS, EKGs, Advanced Airway Management, etc. College credit courses may be used if they are EMS related and enhances prehospital performance. One semester hour of college credit is equal to 1.0 CEU. As an example, anatomy and physiology is awarded four semester hours, this is equivalent to 4.0 CEUs or 40 contact hours. IV Therapy Courses and Paramedic Courses may be used for CEUs. BTLS/PHTLS are courses pre-approved by the Division and for a maximum of 1.5 CEUs for EMT: and Pediatric BTLS is pre-approved for 0.8 CEUs. The letter/certificate of successful completion must be available if the individual is audited. EMT-Basics may use EVOC (up to 1.0 CEU). Original certificates or letters of completion from the issuing agency with the individual's name, the course title, date(s) attended and the amount of CEUs awarded must be issued. No photocopies of cards, letters, or certificates are acceptable. Rescue courses may be used, but the maximum number of CEUs allowed for renewal is 1.0 CEU. For example, a vehicle extrication course is awarded 1.6 CEUs from the educational institution, but only 1.0 CEU may be used. Courses following the TEMA, FEMA or the National Fire Academy curriculum may be used toward renewal. The courses must be relevant to pre-hospital medical care. To receive full CEU credit, the course must be at least 50% medical, otherwise only 1.0 CEU credits may be used toward renewal. Certificates or letters
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b.
c.
d.
e.
f.
g.
h.
i.
j.
of completion from the issuing agency with the individual's name, the course title, the date(s) attended and the amount of CEUs awarded must be issued. k. Defensive driving/EVOC and other approved driving courses may be used for renewal. The maximum CEUs awarded for the initial courses is 1.0 CEU. A defensive driving refresher course may be awarded 0.4 CEUs. The APCO and Medical Priority Dispatch courses may be used for renewal. A certificate or a letter of completion must be issued by the sponsoring agency with the individual's name, the course title, the date(s) attended and the amount of CEUs awarded hey will be accepted for full CEU credits awarded. An instructor may receive renewal credit for classes taught in EMS or CPR courses, if the sponsoring agency verifies the number of instructional hours. 0.1 CEUs is awarded for each 10 hours of verified instruction. Credit is not awarded for attending an instructor's course. National conferences and other state-sponsored conferences generally can be used for renewal. If contact hours are used they can be converted to CEUs (0.1 CEU = 1 contact hour). Continuing Medical Education (CMEs) and Continuing Nursing Education (CNE) programs may be used for renewal if the information will add to the EMS providers pre-hospital knowledge. Commercially prepared videotapes may be used for of the required CEUs only if CEUs are issued by an educational entity, or from a State approved vendor. The tapes must be current, and cover EMS related material. Magazine/Journal articles may not be used to meet renewal requirements. State approved online services may be used toward licensure renewal. An individual may obtain up to of the required CEUs utilizing State approved online services. Courses obtained MUST be within the Scope of Practice for the level of licensure being renewed. Inservice training may be used only if CEUs are awarded. Completing renewal requirements for the National Registry and providing proof of renewal by NREMT may satisfy renewal requirements for TN EMT Licensure at the individuals licensure level. All material submitted must be within the individuals Scope of Practice, but at least 50 % must be medical content within the Scope of Practice in nature. LICENSE RENEWAL SUBMISSION Tennessee licensed EMTs have two methods to submit license renewal requirements to the TDHEMS. Beginning in February 2002 the Department of Health, Division of Emergency Medical Services began allowing online renewal. The first option is the traditional mail method. Personnel receive the renewal packet in the mail approximately 60 days prior to expiration. Personnel shall then complete the required information which includes but is not limited to, making corrections / additions to the front page and listing the CEUs on the back page. The appropriate renewal fee and the properly executed forms are to be enclosed and return to Department of Revenue by Certified mail with Return Receipt Requested.
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m.
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p. q.
r. s.
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The second option is online renewal. Application may be made up to 120 days prior to the renewal date. The website is http://www.tennesseeanytime.org/hlrs. Instructions are listed on the next page. Regardless which licensure renewal method is chosen, personnel do not send copies of CEUs or contact hours unless requested to do so by the TDH-EMS. The Division will be conducting an audit on those renewing each month. If chosen in the audit, copies of renewal documentation (CEUs) will be required to be submitted. Those being audited will be provided with detail instructions in the request. The chances of audit are 10% no matter which renewal process is chosen. Audits can go back as far as four (4) years, therefore, personnel must maintain records for that period. Failure to produce records when requested is revocation of the individuals license. Please contact Donna Tidwell, Director of EMS Personnel Licensure, if there are any questions or for additional information.
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INSTRUCTIONS FOR ONLINE RENEWAL
Web site: www.tennesseeanytime.org

On the main page choose Renew a Health License to get to the appropriate option to either update Professional License information or to update Facility License information. STEP 1 LOG IN At the Log In screen, provide information about you or your facility. For professional licenses: 1) Select the appropriate board For facility licenses: 2) Select the appropriate profession 1) Select the board 3) Provide EMT license number 2) Select the type of facility and enter either: 3) Provide the license number the birth date and social security 4) The transaction Number from the number or renewal notice the Transaction Number from the renewal notice STEP 2 UPDATE PERSONNEL INFORMATION Enter changes or corrections in the boxes provided on this page. Changes or corrections to information for which there is not a box, contact the appropriate Board. DO NOT ADD TITLES or INITITALS TO YOUR NAME, i.e. Capt. Tom Hall or Sue Jones, EMT UPDATE CONFIRMATION After changes or corrections, a confirmation of update will be received. The confirmation page will provide eligibility status, the license renewal cost, and contact numbers for the appropriate Board. STEP 3 RENEWAL INFORMATION Review and answer questions and statements regarding renewal. By submitting this information, the EMT certifies that the information entered is true and correct and that the EMT has complied with all renewal requirements and, if applicable, satisfied all continuing education and competency requirements for the two (2) previous calendar years as set forth in the Tennessee Code Annotated and the Official Compilation Rules and Regulations of the State of Tennessee regulating the practice of the EMTs profession. Step 4 PAYMENT Enter credit/debit card payment information. RENEWAL CONFIRMATION Print the renewal confirmation and maintain this renewal confirmation. The confirmation confirms the EMTs renewal application has been accepted and will be fully posted into the Department's licensing system within 2 business days. A Renewal Certificate will be mailed as soon as the renewal application has been fully processed.
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Submit questions or concerns in writing. Courses not listed must be pre-approved. A written response must be received from the Division by the requestor(s) for an official response. Address written requests and or concerns to: Donna Tidwell, Director of EMS Personnel Licensure Division of Emergency Medical Services Cordell Hull Building, 1st Floor 425 Fifth Avenue North Nashville, TN 37247-0701
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EMT-Basic National Registry Re-registration Disclaimer: Personnel are responsible for remaining up-to-date with all licensure issues. Registrants are responsible to notify the NREMT of any change in address in writing or via their web site: www.nremt.org. Reregistration is an individual responsibility.
The Tennessee Division of Emergency Medical Services utilizes the National Registry written and practical examinations as the "state test" as part of the eligibility requirements to obtain EMT and or Paramedic licensure. Tennessee does not require Emergency Medical Technicians to maintain National Registry status. Personnel must obtain and maintain a Tennessee license in order to practice as an EMT in the state of Tennessee. The National Registry card alone is not certification to practice as an EMT at any level and or anywhere in this state. The individual EMT is personally responsible for keeping up with any changes in renewal requirements. National Registry renewal requirements are much different than those of Tennessee. Therefore, careful attention, planning, organization, and preparation are required in order to maintain both the TN License and the National Registry certification. National Registry re-registration is awarded on a biennial basis (once every two years) upon completion and verification of the required education and submission of the re-registration form and fee. To renew registration, the applicant must: 1. Be actively working within an emergency medical service, rescue service, or health/patient care activity. 2. Complete all continuing education requirements outlined in the reregistration brochure prior to the March expiration date. 3. Complete the reregistration report with appropriate signatures, requested verification and reregistration fee to the NREMT office. 4. Submit proper verification as stated or required. Note: Re-registration forms are mailed in November prior to the expiration date. Reregistration forms must be postmarked to the Registry office no later than the March 31 expiration date. Persons required to maintain National Registry as a condition of employment must submit reregistration material to the NREMT by mid February of the year of expiration. Regardless of when reregistration information is received or completed, registrants license EXPIRES midnight, March 31. There are no grace periods. Re-registration requirements include: 1. Completion of a state approved National Standard EMT-Basic refresher training program consisting of a minimum of 24 hours of didactic course work. Of the 24 hours, 16 hours must be from the six(6) modules as outlined below. The remaining eight(8) hours must reflect subject matter included in the 1994 EMT-Basic National Curriculum). Preparatory 1 hour Airway 2 hours Patient Assessment 3 hours Medical / Behavioral 4 hours Trauma 4 hours Obstetrics, Infants, and Children 2 hours Elective 8 hours from EMT Basic Curriculum TOTAL 24 hours
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2.
CPR credential current to March expiration date by the American Heart Association, the American National Red Cross, or the State EMS Office. Courses must include: Adult and Child 1 & 2 Rescuer CPR, Adult and Child Obstructed Airway, Infant Obstructed Airway, and Infant CPR. Additional 48 hours of continuing education as outlined in the reregistration brochures. All continuing education must have been completed within the current registration period. Continuing education completed prior to March 31st of the previous year of expiration will NOT be accepted. The registrants first reregistration may only include continuing education completed after the date of initial registration. Ex: Registrant expires March 31, 2005. Registrants new expiration date is March 31, 2007. The Registry WILL NOT accept any continuing education received on or prior to March 31, 2005 for the 2007 expiration. Any subject covered in any National Standard EMT-Basic Course or higher is accepted for continuing education credit. These topics may be presented utilizing critiques, didactic sessions, practical drills, workshops, seminars, or other approved in-service training. Topics not contained within the National Standard EMT curricula will require prior approval. Verification of EMT-Basic skills by signature of Training Program Director, Service Director of Operations or the Physician Director Successful completion of any of the following courses, with specified minimum number of hours, may be applied toward continuing education hours: Auto Extrication 16 hours Emergency Driving .. 12 hours Dispatcher Training . 12 hours Teaching CPR ... 12 hours A maximum of 24 hours in any one topic may be applied. Verification: The registrant must submit a certificate where applicable, in remaining cases, a statement outlining dates, times, and topical content on official letterhead signed by the registrants supervisor, training officer or medical director.
3.
4.
The National Registry DOES NOT accept the following as Continuing Education: - home study programs - performance of duty - volunteering with agencies - serving as a skills examiner - clinical rotations - first aid courses No registrant may obtain more than 24 hours of continuing education credit from one topic or one focus course. Ex: Haz-Mat awards 3.0 (30 hours) credit hours through approved agency. The maximum allowed by NREMT is 24 hours.
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APPENDIX C EMS Statutes EMS Rules and Regulations Destination Determinates Field Triage Decision Scheme
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APPENDIX D
MISCELLANEOUS
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MARK I AUTO-INJECTOR For Chemical Nerve Agent Exposure The Mark I kit consisting of one autoinjector of 2 mg Atropine Sulfate and one autoinjector of 600 mg Pralidoxime Chloride (2-PAM Cloride) may be administered by qualified emergegncy responders who have had adequate training on the on-site recognition and treatment of nerve agent exposure. Some classic symptoms of nerve agent exposure include: unexplained runny nose tightness in chest/difficulty breathing pinpoint pupils of the eye resulting in blurred vision drooling, excessive sweating nausea, vomiting and abdominal cramps involuntary urination and defecation jerking, twitching and staggering headache, drowsiness, coma convulsions stoppage of breathing Administration of the Nerve Agent Antidote Auto-Injector Kit (Mark I) and General Guidelines When a first responder arrives on a scene potentially contaminated with nerve agents, don protective mask and personal protective equipment. Responders that are in the HOT zone may initiate immediate treatment. EMS Personnel shall be limited to the COLD zone unless otherwise directed by the Incident Commander and or are properly trained and equipped to enter the HOT zone. If symptoms of nerve agent exposure occur, administer appropriate nerve agent antidotes. If nerve agent symptoms are still present after fifteen (15) minutes, repeat injections. If symptoms still exist after an additional fifteen (15) minutes, repeat injections for a third time. If after the third set of injections, symptoms remain, do not give any more antidotes but seek advice from medical direction. Patients responding favorably to administration of the nerve agent antidote auto-injector are to be closely monitored. Chemical exposure patients shall be decontaminated PRIOR to initiating transport.
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Mark I Auto-Injector The AtroPen The following are general guidelines on using the AtroPen Auto-Injector. Each auto-injector has user guidelines printed on the pen. 1. 2. 3. Remove Mark I kit from the protective pouch. Hold unit by plastic clip. Remove AtroPen from slot number 1 of the plastic clip. The yellow safety cap will remain in the clip and the AtroPen will now be armed. DO NOT hold unit by green tip. The needle ejects from the green tip. Grasp the unit and position the green tip of the AtroPen on victims outer thigh. Hold in place for ten (10) seconds to ensure Atropine has been properly delivered.
4. 5.
Mark I Auto-Injector The ComboPen The following are general guidelines on using the ComboPen Auto-Injector. Each auto-injector has user guidelines printed on the pen. 1. Remove 2-PAM Cloride ComboPen from slot number 2 of the plastic clip. The gray safety cap will remain in the clip and the ComboPenl will now be armed. DO NOT hold the unit by the black tip. The needle ejects from the black tip. Grasp the unit and position the black tip of the ComboPen on the victims outer thigh. Push firmly until auto-injector fires. Hold in place for ten (10) seconds to ensure Pralidoxime Chloride has been properly delivered. Practicing with Mark I Auto-Injector Trainers 1. 2. 3. 4. 5. 6. 7. 8. 9. Remove kit from protective pouch. Hold Mark I trainer by plastic clip. Remove AtroPen trainer from slot number 1 of the plastic clip. The yello safety cap will remain in the clip. Grasp the trainer and position the green tip of the AtroPen trainer on victims outer thigh. Push firmly until red prod ejects from unit. Remove ComboPen trainer form slot number 2 of the plastic clip. The gray safety cap will remain in the clip. Grasp the trainer and position the black tip of the ComboPen trainer on victims outer thigh. Push firmly until the white prod ejects from unit. Reset Mark I Auto-Injector Trainers.
2. 3. 4.
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Resetting the AtroPen Trainer 1. 2. 3. 4. 5. 6. Gently pull the green tip out about inch to expose the neck of the unit. Clamp open end of recocking tool on the neck of the AtroPen trainer below the green tip. Place red prod down on hard surface and apply pressure until you hear a click. Remove recocking tool. Slide AtroPen trainer back into the plastic clip slot number 1 and press end of the unit into the yellow safety cap. The stand-alone AtroPen trainer does not slide into a plastic clip.
Resetting the ComboPen Trainer 1. 2. 3. 4. 5. 6. 7. Place the black recocking cap over the safety end of the ComboPen Trainer. Rotate the black recocking cap until the two internal projections are aligned with the matching holes in the safety end of the training device. Firmly press the black recocking cap down as far as it will go. While holding the black recocking cap down, push the white prod against a hard surface, forcing the prod back into the trainer. A click will be heard when the device is recocked. Remove the black recocking cap. Slide the ComboPen Trainer back into the plastic clip slot number 2 and press end of unit into gray safety cap.
Note: The stand-alone ComboPen Trainer does not slide into a plastic clip. AtroPen and ComboPen are registered trademarks of Meridian Medical technologies, Inc. For additional information, see their website @ www.meridianmeds.com or contact: Meridian Medical Technologies, Inc. 10240 Old Columbia Road Columbia, MD 21046 Phone 1.800.638.8093
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State of Tennessee Department of Health
Division of Emergency Medical Services
Personnel are encouraged to utilize the online renewal and personal information process. Those not having access to the internet are to use this form to comply with TN EMS Rules and Regulations regarding proper notification of address and or name change. Mail to: State of Tennessee Department of Health Division of EMS Cordell Hull Building, 1st Floor 425 Fifth Avenue North Nashville, TN 37427-0701
Name as Shown on EMT License: License Number: I am changing my: Previous Name: Previous Address: Street Address City New Name: New Address: Street Address City State Zip Code State Zip Code Address Expiration Date: Name Other
Signature
Date
140
State of Tennessee Department of Health
Division of Emergency Medical Services INTRAMUSCULAR INJECTION SKILL EVALUATION

Student Name: Evaluator Pass Date: Retest Fail
Takes or verbalizes body substance isolation precautions Obtains order to administer medication Assembles equipment and supplies Checks medication for correct medication, concentration, expiration date, etc. Prepares vial and withdraws correct/desired medication dosage Removes excess air from syringe Explains process and possible side effects to patient Selects appropriate site Stretches or flattens the skin at the injection site Injects needle using a darting motion with needle at 90 degree angle Releases skin and aspirates: if blood appeared in syringe removes and applies direct pressure to the site with alcohol prep. If no blood appeared when aspirating, injected medication slowly Removes needle and applies pressure to area with alcohol prep DOES NOT recap needle after injection Disposes of contaminated needle and syringe in sharps container Covers injected site with bandage. Reassesses Patient for medication effects
Points Possible 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 14
Points Awarded
Critical Criteria:
Did not take, or verbalize body substance isolation Did not obtain orders Did not check medication properly Failed to use sterile technique Administered incorrect dosage Did not aspirate syringe prior to injection of medication Recapped or failed to properly dispose of syringe Did not reassess patient
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Preface: TN Skills Manual July 2003

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TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

Change of Address Form IM Injection Skill Sheet

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

c. 11. 12. 13. 14. 15. 16. 17. 18.

according to the flow rate established in the updraft manufacturer's recommendations.

TN SKILLS MANUAL July 2003

3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

12. 13. 13.

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

Things not looked for are often not found.

TN SKILLS MANUAL July 2003

PATIENT ASSESSMENT Review Dispatch Information

TN SKILLS MANUAL July 2003

Respiratory Onset Provokes Quality Radiates Severity Time Interventions

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

11. 12. 13. 14. 15. 16. 17.

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003

TN SKILLS MANUAL July 2003