1. Where the protocol stipulates "Evaluate patient’s general appearance and relevant history of condition.", the prehospital care giver is recommended to follow the following assessment mnemonics:

Provokes Medications

Quality Past medical history – specific to presenting complaint

Radiates Last meal

Severity Events leading to present illness

Time

Interventions

CHEST DECOMPRESSION

The treatment of tension pneumothorax involves decompression of the affected chest cavity to release the pressure that has developed.

Decompression can be achieved, with minimal risk, by the insertion of a 14 or 16 gauge needle into the second inter-costal space at the midclavicular line. Also an approach in the mid-axillary line between the fifth and sixth rib is possible, and considered safer by some physicians.

The needle must be inserted superior to the rib because the intercostal artery, vein and nerve follow the inferior portion of the rib.

INDICATION

Tension pneumothorax indicated by:

A. Diminished or absent lung sounds

B. Cyanosis and difficulty breathing

C. Distended neck veins

D. Tachycardia, tachypnea, hypotension, narrow pulse pressure

E. Tracheal shift to the unaffected side (May not always be present)

PROCEDURE

A. Prepare equipment: 14 gauge over the needle catherter, antiseptic solution

B. Locate site:

1. Second or third intercostal space, midclavicular

2. Fourth intercostal space between the forth and fifth rib, midaxillary

C. Prep site, if time permits

D. Insert the needle just superior to the rib until a rush of air is felt and/or heard

E. Secure needle in place

F. Support patient with 100% oxygen and transport without delay

CONTRAINDICATIONS

Insufficient training.

INDICATIONS

Unable to intubate by another route. This may be seen with:

A. Cervical spine injuries

B. Maxillo-facial trauma

C. Laryngeal trauma

D. Oropharyngeal obstruction from:

1. Edema from infection, caustic ingestion, allergic reaction, and/or inhalation injuries

2. Foreign body

3. Mass Lesion

E. Oral or nasotracheal intubation contraindicated for any reason

COMPLICATIONS

A. Postprocedure bleeding

B. Late bleeding

C. Abscess behind packing

D. Cellulitis of neck

E. Subcutaneous emphysema

F. Voice change

G. Feeling of lump in throat

H. Persistent stoma

I. Obstructive problems

J. Misplacement of the airway

CRICOTHYROTOMY (cont.)

NEEDLE CRICOTHYROTOMY PROCEDURE

If time permits, prep the area with appropriate antiseptic solution. Attach a 10 gauge, over the needle catheter to a syringe, and insert the needle through the cricothyroid membrane (CTM), directed caudally at a 45 degree angle, while aspirating. Aspiration of air indicates proper placement.

If the intention is to use this as a temporary means of oxygenation then the catheter should then be slid into place.

If the needle is going to be used as a guide for formal cricothyrotomy then the catheter should not be used in order to prevent the possibility of shearing off the catheter when the scalpel is used.

A jet ventilator should be used to provide sufficient volume of oxygen at a pressure of no more than 30 psi.

Needle cricothyrotomy is the preferred method in children less than 11 years of age.

SURGICAL CRICOTHYROTOMY PROCEDURE

Prepare the area with a betadine solution. Make a 2 to 4cm vertical skin incision over cricothyroid membrane. Once the membrane has been exposed, make a 1.5 to 2cm horizontal incision into the membrane and through to the trachea. Maintain a slight caudal direction, with the blade, to avoid damage to vocal cords.

Use forceps or dilator to spread the aperture in the CTM. Again, caution against vocal cord injury by angling instruments caudally.

If time does not allow or equipment is not available, the blunt end of the scalpel can be placed in the incision and twisted to open the aperture.

Insert an appropriate size endotracheal tube (6cm tube). Advance caudally and inflate balloon. When the tube is in place, check breath sounds and secure the tube.

ENDOTRACHEAL INTUBATION

INDICATION

Endotracheal intubation is to be utilized for any victim with respiratory arrest and/or insufficiency to achieve complete control over the airway. It protects the airway from aspiration of foreign material and it allows for intermittent positive pressure ventilation to be achieved with 100% oxygen. It makes the trachea and the respiratory tract available for suctioning, and also eliminates the problem of gastric distention.

HAZARDS

A. Esophageal intubation

B. Tracheal rupture

C. Right mainstem bronchus intubation

D. Broken teeth

E. Laryngospasms

F. Trauma to the oral-pharynx

G. Trauma or puncture of trachea due to misplacement of stylet

ORAL-TRACHEAL INTUBATION

A. Always begin artificial ventilation as soon as possible using mouth-to-mouth, nose-to-nose, bag-valve- mask or oxygen powered manually triggered ventilation device.

B. Assemble and ready equipment:

1. Endotracheal tubes of various sizes

2. Laryngoscope and blades

3. Malleable stylet

4. Magill forceps

5. 10cc syringe

6. Suction apparatus and catheters

7. Water soluble lubricant

8. ET tube tape

9. Oropharyngeal airway

C. Check cuff on tube for leaks and lubricate tube. Insert stylet into tube, if necessary.

D. Assemble laryngoscope and check bulb

E. Put victim's head in sniffing position. Do not allow the head to hang over the end of the table or bed; the occiput of the head should be on the same horizontal plane as the back of the shoulders, with the neck somewhat elevated.

ENDOTRACHEAL INTUBATION (cont.)

F. Holding the laryngoscope in the left hand, insert the blade to the right of the midline, moving the tongue up and to the left, with the blade ending up in the midline, giving clear visualization of the glottic opening

G. Suction the mouth and the pharynx

H. Visualize the epiglottis and vocal cords

I. Select the proper size tube and insert in with the right hand, starting at the corner of the mouth down into the trachea, past the vocal cords approximately 2 inches

J. Remove laryngoscope and stylet (if used), holding the tube securely with the right hand

K. Attempt to ventilate with mouth-to-tube or bag-valve-mask and check for breath sounds in BOTH lungs

L. If breath sounds are heard, inflate the tube's cuff with 6-10cc of air and secure the tube in place with oropharyngeal airway used as bite block

M. Maintain ventilation until adequate respirations resume or victim is delivered to an emergency department

N. Recheck lungs sounds and verify tube placement each time patient is moved or every 10 minutes

O. Document the intubation by noting the following:

1. Number of attempts

2. Person(s) making attempts

3. Size of tube used

4. Lung sounds before intubation

5. Lung sounds after intubation and time of each check

6. Measurement on tube at lips of patient when lung sounds are present

7. Any complications

NASOTRACHEAL INTUBATION

A. Nasotracheal intubation of the airway may be used when the patient has an unprotected, inadequate airway creating hypoxia

B. Nasotracheal intubation is indicated in:

1. Patients with spontaneous breathing when all other methods of airway control and oxygenation proved to be inadequate.

2. Trauma patients when C-spine manipulation must be kept to a minimum and all other methods of airway control and oxygenation prove to be inadequate.

C. Nasotracheal intubation is contraindicated in patients with fractures in the base of the skull or face, and in any patients who are apneic

D. Hazards of nasotracheal intubation include:

1. Nasal hemorrhage

2. Laryngeal damage due to increased manipulation

3. Rupture of cuff balloon from use of Magill forceps

ENDOTRACHEAL INTUBATION (cont.)

E. When attempting nasotracheal intubation:

1. Always begin basic airway control and oxygenation as soon as possible.

2. Assemble and ready equipment:

a. Endotracheal tubes of various sizes (ENDOTROL type)

b. Laryngoscope and blades

c. Magill forceps

d. 10cc syringe

e. Lidocaine jelly or water soluble lubricant

3. Determine size of tube based on size of nasal opening.

4. Check tube cuff for leaks and lubricate tube; seat 15mm connector firmly into tube

5. Holding tube in dominant hand, place thumb against the 15mm connector and index finger in the ring loop.

6. Insert the tube into the appropriate nostril and advance tube gradually, anterior to posterior, avoiding superior movement which will be met with resistance and could cause injury.

7. As the tube enters the pharynx, listen for breathing and pull on the tip control ring loop to turn the tube anterior towards the trachea

8. When the patient takes a breath, advance the tube into the trachea.

9. Listen for lung sounds, inflate the tube's cuff, maintain ventilation and oxygenation. Confirm tube placement with breath sounds, fogging of tube and end tidal CO2 monitoring.

10. Intubation attempt should not take longer than 30 seconds.

11. If any resistance is encountered during insertion, abandon procedure and utilize another method of airway control and oxygenation .

12. Recheck lung sounds and verify tube placement each time patient is moved or every 10 minutes

13. Document the intubation by noting the following:

a. Number of attempts

b. Person(s) making attempts

c. Size of tube used

d. Lung sounds before intubation

e. Lung sounds after intubation and time of each check

f. Measurement on tube at nose of patient when lung sounds are present

g. Any complications

ENDOTRACHEAL INTUBATION (cont.)

TUBE REMOVAL

If the patient begins to breathe spontaneously and effectively and is resisting the presence of the tube, removal of the tube may be necessary. The following procedures will be followed:

A. Explain procedure to victim

B. Prepare suction equipment with large-bore catheter and suction secretions from endotracheal tube, mouth and pharynx

C. The lungs should be completely inflated so that the patient will initially cough or exhale as the tube is taken from the larynx. This is accomplished in 2 ways:

1. The patient is asked to take the deepest breath they possibly can and, at the very peak of the inspiratory effort, the cuff is deflated and the tube removed rapidly; or

2. Positive pressure is administered with a hand-held ventilator and, at the end of deep inspiration, the cuff is deflated and the tube rapidly removed

D. Prepare to suction secretions and gastric content if vomiting occurs

E. Appropriate oxygen is then administered

F. The patient's airway is immediately evaluated for signs of obstruction, stridor or difficulty breathing. The patient should be encouraged to take deep breaths and to cough.

G. The patient is not to be left unattended until there is no doubt of their ability to function without the artificial airway.

TUBE SIZING

The size of tube that can be passed easily into most adults is 8.0 mm (id). Therefore this tube should be tried first on the average adult. The size of tube is judged by the size of the adult, not by age.

For children, the proper tube is usually equal to the size of the child's little finger. The following guide will also help in determining the proper size tube:

Premature........3mm (id) 18-24 months........5-6mm (id)

4-24 weeks....4mm (id) 2-4 years..............6mm (id)

6-12 months....4-5mm (id) 4-7 years.............6-7mm (id)

12-18 months....5mm (id) 7-10 years...........7mm (id)

All the above tube sizes are still dependent on the child's size in consideration of age.

Children before puberty should have a cuffless tube, or if the tube has a cuff it should not be inflated after insertion.

ENDOTRACHEAL INTUBATION (cont.)

ADMINISTRATION OF MEDICATION THROUGH ET TUBE

In the event an intravenous or intraosseous route for administration of medication cannot be established, but an endotracheal tube has been properly put in place, medications Such as Narcan, Atropine, Epinephrine and Lidocaine can effectively be administered through the tube. A commercially prepared ETT designed for endotracheal administration is preferred. This will allow for the administration of medication in accordance with current guidelines, and allow for simultaneous ventilation and medication administration.

The current guidelines state a catheter should be passed beyond the tip of the endotracheal tube, compressions stopped, and the medication sprayed quickly into the lower airway.

Medications should be administered at two (2) times the IV dosage and diluted with 10 ml of saline or sterile water before administration.

If the commercially prepared tube is unavailable, the following procedure should be followed:

1. Remove needle from syringe

2. Hyperventilate patient and make sure ET tube and airway are clear of mucous

3. Disconnect ventilation device from tube and squirt medication rapidly into tube

4. Reconnect ventilation device and rapidly ventilate patient to assure passage of medication down tube and airway

SPECIAL NOTE: Do not take longer than 15 seconds to administer medication in order to prevent hypoxia of the patient.

END TIDAL C02 MONITORING

In order to assure placement of the ET tube into the trachea after intubation, end tidal C02 monitoring will be done. This procedure will be achieved by using the Nellcor "Easy Cap" device on adults and the "Pedi-Cap" devices on children under 30 lbs.

This will be achieved through the use of an end tidal C02 detector after each intubation attempt.

Procedure for use:

A. Remove detector from package (Do not remove end caps until ready to use device)

B. Remove end caps immediately before use and shake device to introduce room air

C. Match initial color of the indicator to the purple color labeled "CHECK" on the product dome. If the purple indicator color is not the same or darker, do not use.

D. Insert endotracheal tube (Inflate cuff if tube is equipped with one)

E. Firmly attach detector between the endotracheal tube and the breathing device

F. Ventilate patient with six breaths of moderate tidal volume (may be done quickly). Interpreting result with less than six breaths can yield false results.

G. Compare color of indicator on full end-expiration to color chart on product dome. SEE ALGORITHM

ENDOTRACHEAL INTUBATION (cont.)

H. If initial intubation attempts fail, the detector can be used for re-intubation on the same patient provided the indicator color still matches the "CHECK" color standard on product dome

I. The detector may be left in place during ventilation to assist in monitoring tube placement

J. This device is not to be used for:

1. Detection of hypercarbia

1. Detect mainstem bronchial intubation
2. During mouth to tube ventilations

Intubate

Deliver 6 Breaths

Observe on full End-expiration

COLOR RANGE A COLOR RANGE B COLOR RANGE C

Pulmonary Perfusion

YES NO COLOR RANGE B

Re-laryngoscope to visualize Remove ET tube Is there clinical evidence of low pulmonary

ET tube through vocal cords Support ventilation - Re-intubate perfusion or hypocarbia

YES NO YES NO

Inadequate pulmonary perfusion Remove ET tube Confirm placement by Remove ET tube

YES

ET tube in trachea - Secure tube

EXTERNAL PACEMAKER

INDICATIONS

An external pacemaker may be used in the following situations:

A. Witnessed arrest with patients in asystole confirmed in two perpendicular leads

B. Patients with symptomatic bradycardia, unresponsive to Atropine

C. Additional patients at the discretion of the on-line Medical Control Physician

APPLICATION

In the conscious patient with bradycardia, the rate is to be set at 80 beats per minute and the current at 20 milliamperes, which is to be increased by 20 milliamperes every 10 seconds until capture is obtained.

Once electrical capture is obtained, check for mechanical capture (pulse).

The external pacemaker is only to be used on pediatric patients with On-line Medical direction.

Nitroglycerine patches are to be removed before pacing.

IV PROCEDURES

GENERAL CONSIDERATIONS

IVs will be started by the EMT-Intermediate and/or the Paramedic as allowed by each patient care protocol.

IV placement must not delay transport of any critical patient involved in trauma.

Generally, no more than two (2) attempts or more than five minutes should be spent attempting an IV. If unable to initiate IV line, transport patient and notify hospital IV was not able to be started.

IVs may be started on patients of any age providing there are adequate veins and patient's condition warrants an IV

Blood draws for hospital laboratory testing will not be required under this protocol.

IV SOLUTION

0.9% Sodium Chloride will be the only fluid used in the pre-hospital setting under this protocol. Sodium Chloride solution is provided in 250ml bags and 3cc syringes for TKO IVs and 1000ml bag for fluid replacement.

The solution is to be infused as directed by specific treatment protocols.

IV TUBINGS

The following tubing will be used for this protocol:

A. For all adult fluid lines, use regular administration set (15 drop) tubing.

B. For child and infant patients, use 15 drop set with 3-way stopcock and extension tubing.

IV PROCEDURES (cont.)

MECHANICS FOR STARTING PERIPHERAL IV

A. Prepare equipment

B. The initial attempt should be the dorsum of hand. Further attempts should proceed to the forearm; do not use the antecubital fossa unless necessary

C. Apply tourniquet

D. Cleanse site with alcohol.

E. First attempt at insertion on an adult patient should ideally be:

1. 16ga IV catheter for trauma patients

2. 18ga IV catheter for medical patients

G. Attach IV tubing

H. Secure IV using appropriate measures to insure stability of the line

I. Check for signs of infiltration

J. Adjust flow rate

K. Document IV procedure on run sheet.

MECHANICS FOR STARTING EXTERNAL JUGULAR IV LINE

A. Locate external jugular vein

B. Cleanse site with alcohol.

C. Select IV catheter

1. On adults, a large bore (16ga or 18ga) may be used

2. Use 2" IV catheter when available

D. Position yourself at patient's head

E. Turn patient's head so as to maximally expose vein and minimize interference of jaw

F. Cannulate the vein by directing the needle caudal at an angle nearly parallel to the neck

G. Attach IV tubing

H. Secure IV using appropriate measures to insure stability of the line

I. Check for signs of infiltration

IV PROCEDURES (cont.)

J. Adjust flow rate

K. Document IV procedure on run sheet.

MECHANICS OF STARTING SALINE LOCK

A. Prepare equipment: Purge air from PRN adapter with approximately 1cc NS.

B. The initial attempt should be the dorsum of hand. Further attempts should proceed to the forearm;

the antecubital fossa should not be used for saline locks.

C. Apply tourniquet

D. Cleanse site with alcohol.

F. Secure IV using appropriate measures to insure stability.

G. Check for signs of infiltration

H. Document IV procedure on run sheet.

DOCUMENTATION

ALL IV attempts must be documented with the following elements:

A. When successful:

i. time IV was started

ii. type and amount of solution hung and infused during run

iii. flow rate

iv. size of catheter or needle used

v. location of IV site

vi. Initials of all EMT's who attempted and/or started IV

vii. Signature of EMT In-charge of run

B. When unsuccessful:

i. time IV was attempted

ii. type of solution

iii. size of catheter or needle used

iv. location of attempted site

v. Initials of all EMT's who attempted and/or started IV

vi. Signature of EMT In-charge of run

C. Record all IV medications given

i. Name of medication

ii. Dosage and amount given

iii. Time ordered (if applicable)

iv. Time given

v. Initial of all EMT’s who administered medication

vi. Signature of EMT In-charge of run

INTEROSSEOUS INFUSION

INDICATIONS

A. To establish parenteral means to administer fluids, blood products and parenteral medications, and to draw blood (except for CBC's)

B. May be used in any instance that an IV route would be appropriate

C. Its use should be considered after two IV attempts have failed or if no peripheral IV sites are found

D. This procedure is indicated primarily in children

CONTRAINDICATIONS

A. Osteomyelitis or cellulitis over the proposed site

B. Fracture at or above the proposed site

C. Previous IO attempt at the proposed site

EQUIPMENT

A. 16ga Intraosseous Needle

B. Betadine and Alcohol

C. IV setup

D. Syringe for aspiration

C. Lidocaine prn

PROCEDURE

A. Prepare as for a surgical procedure, using sterile technique

B. Attempt to have feet in flexed position against board or sandbag

C. If the patient is alert, consider using a local anesthetic

D. The preferred site is the proximal anteromedial tibia, 1-3 cm below the tibial tuberosity

Secondary site is the distal femur, midline, 3 cm above condyle

E. Needle insertion varies between seventy and ninety degree angle to the skin surface, approximately one to two fingerbreadths distal to the tibial tuberosity. With a straight steady push and/or rotary motion, push needle through subcutaneous tissue and bone until a drop or pop is felt.

F. Once the needle has reached the bone marrow, saline should be injected via syringe to clear needle and then aspiration should be attempted. The infusion should flow freely without evidence of subcutaneous infiltration.

G. The needle should feel firm in position and stand upright without support.

INTEROSSEUS INFUSION (cont)

H. Infusion via this route is the same as venous access without limit to rate of administration, drugs pushed or fluid type infused.

I. After removing needle (for successful or unsuccessful attempt), apply pressure to area for five minutes and apply dressing to area.

J. Intraosseus infusions of fluid may cause subcutaneous infiltration, osteomyelitis or subcutaneous infections.

PNEUMATIC ANTI-SHOCK GARMENT

INDICATION

A. Class I - Usually indicated, useful and effective

* Hypotension due to ruptured AAA

B. Class IIa - Acceptable, uncertain efficacy, weight of evidence favors usefulness and efficacy

* Hypotension due to suspected pelvic fracture

* Anaphylactic shock (unresponsive to standard therapy)

* Otherwise uncontrollable lower extremity hemorrhage

* Severe traumatic hypotension (palpable pulse, blood pressure not obtainable)

C. Class IIb - Acceptable, uncertain efficacy, may be helpful, probably not harmful

* Elderly

* History of congestive heart failure

* Penetrating abdominal injury

* Paroxysmal supraventricular tachycardia (PSVT)

* Gynecologic hemorrhage (otherwise controlled)

* Hypothermia-induced hypotension

* Lower-extremity hemorrhage (otherwise uncontrolled)

* Pelvic fracture without hypotension

* Ruptured ectopic pregnancy

* Septic shock

* Spinal shock

* Urologic hemorrhage (otherwise uncontrolled)

* Assist intravenous cannulation

D. Class III - Inappropriate option, not indicated, may be harmful

* Adjunct to CPR

* Diaphragmatic rupture

* Penetrating thoracic injury

* Pulmonary edema

* To splint fractures of the lower extremities

* Extremity trauma

* Abdominal evisceration

* Acute myocardial infarction

* Cardiac tamponade

* Cardiogenic shock

* Gravid uterus

CONTRAINDICATIONS

A. Acute cases of Pulmonary Edema

B. Pregnancy - Do not inflate abdominal section

C. Cardiogenic Shock

D. Open wounds of the chest

PASG (cont.)

APPLICATION

Unfold PASG completely and lay on a stretcher or backboard. Then:

A. Put patient on the PASG face up (supine) so that the top of garment will be just below the last rib

C. Check the victim's vital signs and breath sounds. If symptoms of blood loss are present, inflate PASG.

Attach foot pump to PASG at the valves and inflate each section, starting with the leg sections, until:

patient’s systolic BP reaches 100, velcro fasteners crackle, air escapes the safety valves and/or bleeding stops

D. IF USING A SPLINT, INFLATE ONLY UNTIL GARMENT IS FIRM

E. Close valves, leave hoses and pump attached for transport

REMOVAL

PASGs should not be deflated until:

A. A physician is present and has taken charge of the patient, and

B. Fluids are available for transfusion

The urge to deflate the garment to inspect the wounds should be suppressed. Electrocardiograms and x- rays can be taken and Foley catheters can be inserted while PASG is still on and inflated.

In cases where bleeding is initially present, or hypovolemia is suggested by evident external blood loss, the garment should not be deflated until replacement therapy has begun. Deflation before volume replacement may lead to further shock to a possibly irreversible degree. If the situation permits, gradual deflation with concurrent fluid administration is advisable.

NITRONOX

(Nitrous Oxide - Oxygen Administration)

Nitronox is a self-administered analgesic gas containing a mixture of 50% oxygen and 50% nitrous oxide. Nitronox is supplied in a carrying case containing two cylinders, one of nitrous oxide and one containing oxygen, with a mixing valve and supply tubing. These agents are mixed on administration to deliver a 50% concentration of each to the patient. Negative pressure is required to open the valve, so the patient must have an airtight seal at the face mask.

INDICATIONS

Nitronox should be given to any patient who is alert and complaining of severe pain.

Examples: Abdominal pain

Chest pain secondary to infarction or angina

Acute urinary retention

Fractures

Severe burns

Kidney stones

Musculoskeletal trauma

CONTRAINDICATIONS

Nitronox is not to be used in patients with these conditions:

Altered level of consciousness

Head injuries

Chest injuries (blunt or penetrating)

intoxication

Maxillofacial injuries

Psychiatric problems

COPD (because of the 50% oxygen mixture)

Pediatric patients under 12 years of age

Pregnancy

Respiratory distress

APPLICATION

A. Instruct patients to administer Nitronox to themselves by placing the mask tightly against their face and breathing deeply and slowly

B. Allow mask to fall away from face spontaneously when effects are felt

C. Check Blood Pressure - Nitronox may cause BP to drop in some cases

NITRONOX (cont)

SPECIAL CONSIDERATIONS

A. Nitronox should never be administered by the EMT or Paramedic. Only self-administration by the patient is to be used.

B. Upon administration of Nitronox, constantly monitor patient to see he does not fall asleep with mask in place.

C. The side effects of Nitrous Oxide, in addition to analgesia, include light-headedness, drowsiness, and very occasionally nausea and vomiting. Changes in heart rate and respiratory rate are minimal.

D. Nitrous Oxide and Oxygen are both non-flammable gases, but both support combustion. For this reason do not use Nitronox in areas where there is a combustion hazard.

E. SPECIAL NOTE TO EMT'S AND PARAMEDICS:

There is an increased risk of liver cancer and birth defects to individuals who are exposed to repeated applications of Nitrous-Oxide. For this reason Nitronox should be used in a well-ventilated environment.

SAFETY ISSUES

A. The Nitronox unit must be stored in the EMS vehicle with its gas cylinders in an "OFF" position when not in use

B. The unit must not be used in any environment where:

1. There are possible ignition sources

2. There is inadequate ventilation

C. The unit should not be used if the mixture pressure is not in the 30-35 PSI range

D. Any problem with the mechanical status of the apparatus shall be immediately reported to the person in charge, so appropriate evaluation and/or repair can be made before further use

PULSE OXIMETRY

GENERAL CONSIDERATIONS

Pulse oximetry is used in conjunction with other assessment processes to determine the actual available oxygen in the blood for use by body tissue. Pulse oximetry measures the oxygen saturation of the red blood cells, (%SpO2).

Studies have shown that EMS personnel are fairly accurate in the assessment and treatment of patients in profound hypoxia. However in mild to moderate hypoxic states, EMS personnel sometimes do not react until the patient has progressed to profound hypoxia. Signs of progressive hypoxia need to be identified rapidly and the condition treated before profound hypoxia occurs.

Use of pulse oximetry in conjunction with other assessment processes may sometimes identify those patients in mild to moderate hypoxia, and with proper intervention profound hypoxia can be prevented.

If available, pulse oximetry should be used on all patients. Pulse oximetry should be maintained and evaluated until the patient is delivered to the Emergency Department.

REMEMBER, INITIATE NORMAL AIRWAY AND OXYGENATION SUPPORT REGARDLESS OF THE AVAILABILITY OF PULSE OXIMETRY.

NEVER BASE ANY TREATMENT OR OXYGEN THERAPY SOLELY ON THE

READING FROM THE PULSE OXIMETER.

PROCEDURE

A. Select sensor and apply according to manufacturer's recommendations. The following should be noted:

1. Finger Clip Sensors - These are designed for spot-check monitoring of older pediatric and adult patients and/or continuous monitoring less than 30 minutes where patient movement is not expected.

a. Insert finger (preferably left or right index finger) completely into sensor, keeping fingernail side facing the sensor top. It is specifically recommended that the thumb not be used in the finger clip sensor.

b. For best results when using the finger clip in longer term monitoring or with active patients, secure the sensor cable independently from the sensor, preferably around the base of the finger. Make sure blood supply to the finger is not impaired by the application of the tape.

2. Flex Sensor - This sensor is designed for monitoring pediatric and adult patients in which moderate patient movement is expected.

a. Position the sensor on the top and bottom of the end of the finger or toe. Place the light emitter portion on the finger/toe-nail side and the detector of the side opposite of the nail, making sure to align the emitter and detector through the tissue.

b. Secure the sensor with 3M Micropore tape, making sure not to restrict blood flow. Attach the sensor cable independently at the base of the finger, again being careful not to restrict blood flow.

PULSE OXIMETRY (cont)

3. Infant and Neonatal Sensors - These sensors are designed for continuous monitoring of infants and neonates since fingertip monitoring is impractical.

a. The infant sensor is designed for application on the big toe of infants greater than 2 kilograms (5 pounds).

b. The neonatal sensor is designed for application on the foot of infants less than 2 kilograms in weight.

c. Apply and secure these sensors as described for the flex sensor, being sure not to restrict blood supply to the monitored area.

4. Ear Clip Sensor - This sensor is used when finger clip sensing is not possible. Be sure to clean the ear lobe with alcohol before applying the sensor. Be aware pierced ears may allow some light to pass directly to the detector and result in an inaccurate reading.

5. Reflectance Sensor - This sensor is used on well vascularized skin surfaces in adult patients only. This method is not preferred in the pre-hospital setting.

B. Turn oximeter on and verify operation according to manufacturer's operating procedure.

C. A relative operation check can be achieved by applying the sensor to your own finger.

D. Always cleanse sensor site of blood and dirt for reliable reading. Some fingernail polishes may have to be removed to obtain a reading.

E. Apply sensor to patient and obtain reading.

Interpretation of Reading:

100% to 96% Ideal Range - Maintain oxygen and airway support methods being used

89% to 85% Moderate Hypoxemia - Aggressive airway and oxygen support is essential

Look for and treat cause: i.e. COPD, metabolic imbalance, peripheral vascular shutdown

Below 85% SEVERE-BE PREPARED TO INTUBATE AND/OR ASSIST VENTILATION

RECOGNITION OF AIRWAY DIFFICULTY

&

APPROPRIATE INTERVENTION

APPLY PULSE OXIMETER

BELOW 85% 85% TO 89% 90% TO 95% 96% TO 100%

VENTILATE ASSIST INCREASE MAINTAIN

VENTILATION

INTUBATE AIRWAY AIRWAY

& & & INCREASE INCREASE OXYGEN OXYGEN OXYGEN OXYGEN SUPPORT SUPPORT

CONSIDERATIONS

A. Hypovolemic, hypothermic, and peripheral vascular disease patients may not be suitable candidates for pulse oximetry due to peripheral shutdown

B. Be aware that there may be a 30 to 60 second delay between changes in %SpO2 conditions and pulse oximetry readings

C. A pulse must be detected by the oximeter to determine the %SpO2

D. Pulse oximetry is not indicated in carbon monoxide poisoning

E. COPD patients will normally have a low %SpO2 and should not be treated in accordance with this guideline

PATIENT ASSESSMENT

SCENE SIZE-UP

"B S I"

SAFE SCENE UNSAFE SCENE

CONTROL SCENE

MOVE PATIENT

CORRECT HAZARD

INITIAL ASSESSMENT

GENERAL IMPRESSION

MENTAL STATUS

AIRWAY

CIRCULATION

IDENTIFICATION OF PRIORITY

EVALUATE MECHANISM

OF INJURY

& IMMOBILIZE SPECIFIC INJURY

"DCAP - BTLS"

DETAILED EXAM COMPONENTS OF DETAIL DETAILED EXAM

NOT COMPLETED TO

THIS POINT

ON-GOING ASSESSMENT

COMMUNICATION & DOCUMENTATION

An instrument for establishing a temporary percutaneous cricoid or tracheal airway.

1. Test the needle for air leaks prior to use by placing a sterile gloved finger over the tip. Air aspiration with the syringe should produce a vacuum.
2. Test the cuff of the tube and then deflate cuff.
3. Pinch the skin over the cricothyroid membrane or trachea and make a one to two cm. vertical incision in the midline.
4. Insert the needle through the incision perpendicular the airway. Draw air with the syringe to confirm needle placement.
5. Remove the syringe and incline the needle to 45 degrees towards the carina before threading the filiform portion of the dilator into the airway through the needle. The device is used with the thumb on the knob while the second and third fingers are curved under the flange of the tube. Force is applied with the thumb.
6. Squeeze the wings and open them outward to split and remove the needle. It’s helpful if a second rescuer holds the device in place while the operator uses both hands to remove the needle.
7. Exert pressure and force the dilator into the airway and place the tube into a functional position, with the face plate against the skin.
8. Remove the dilator.
9. Inflate the cuff ( 1 to 8cc ) and attach BVM.
10. Assess lung sounds and check for leakage around the tube.
11. Secure tube in place with umbilical tape that is provided.

1. Retracting the leader portion of the dilator back through the unsplit needle can result in sheering off the leader with a resultant tracheal foreign body.
2. Insertion of the device through the thyroid cartilage can injure the vocal cords.

The prehospital care provider is cautioned that a patient may have no overt signs or symptoms of cervical injuries or fractures. Cervical spine clearance does not negate the need for further assessment by a physician or for X-rays. WHEN IN DOUBT, IMMOBILIZE AND TRANSPORT.

No

No

No

No

No

No

1. Insertion

1. Instill two drops of Tetracaine into the affected eye(s).
2. Attach a macro drip set to a 1000 ml bag of NS, attach the Morgan Eye Lens and flush the line.
3. Have the patient look down, insert the lens under the upper lid. Have the patient look up, retract the lower lid and drop the lens in place.
4. If both eyes are affected, repeat steps 1-3 above and attach a second setup or a "Y" tubing to the single bag of saline.
5. Open the roller clamp wide open and instill 1000 ml NS per eye. Medical control may order a second liter for each eye.
6. If the patient’s medical condition permits, it is helpful to place the patient in a slight Trendelenberg position. This will allow the outflow to run off the end of the cot, rather than down on the patient’s body. Place a container for collection beneath the head of the cot.

1. Removal