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 Interosseous 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 finger breadths 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.

INTEROSSEOUS INFUSION (cont)

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

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. Interosseous 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

B. 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

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

D. 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. Other patients are in close proximity (less than 10 ft. away)

3. The room is small and no nitrous oxide alarm is monitoring the gas concentration in ambient air

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.

PULSE OXIMETRY (cont)

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.

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.

PULSE OXIMETRY (cont)

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

95% to 90% Mild to Moderate Hypoxemia - Check airway and increase oxygen support until ideal range is achieved

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

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

Below 85% 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

PULSE OXIMETRY (cont)

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

SPECIFIC INJURY

"DCAP - BTLS"

DETAILED EXAM COMPONENTS OF DETAIL DETAILED EXAM

NOT COMPLETED TO

THIS POINT

ON-GOING ASSESSMENT

COMMUNICATION & DOCUMENTATION