Procedures

Supraglottic airway

Indications

Contraindications

Technique (roughly)

Precautions

Indications

• If unable to intubate/intubation going to be difficult and rapid airway necessary

• Pulseless arrest when attempting to intubate will interrupt CPR

• Pediatric patients

Contraindications

• Gag reflex

• Caustic ingestion

Technique (roughly)

Precautions

NPPV (CPAP)

Indications

Contraindications

Technique (roughly)

Signs of improvement

Signs of deterioration

What to do if deteriorating

Indications

Moderate to severe respiratory distress with at least two of the following:

• Rales

• Dyspnea with hypoxia (less than 90% despite O2)

• Dyspnea with inability to speak full sentences

• Accessory muscle use

• Respiratory rate with tachypnea age despite O2

• Diminished tidal volume

Contraindications

• Respiratory or cardiac arrest

• Hypotension for age

• ALOC leading to unable to follow commands

• Vomiting

• Upper GI bleed

• Suspected pneumothorax

• Trauma

• Patient size or anatomy prevents adequate masks seal

Technique (roughly)

• Place patient supine

• Explain procedure

• Assess vitals (including ETCO2)

• Apply mask

• Start with lowest effective settings and titrate up

Signs of improvement:

• Reduced dyspnea

• Reduced verbal impairment, resp rate, heart rate

• Increased SPO2

• Stabilized blood pressure

• Appropriate ETCO2 values and waveform

• Increased tidal volume

Signs of deterioration:

• Decreased LOC

  • Sustained or increased HR, RR or decreased BP

  • Sustained low or decreasing SPO2

  • Rising ETCO2/other signs of ventilatory failure

  • Diminished or no improvement in tidal volume

If deteriorating:

• Troubleshoot equipment

• Consider intubation

• Consider possible pneumothorax

• Consider hypotension from PPV

Capnography

Indications

Contraindications

Technique (roughly)

3 determinants of ETCO2

Considerations;

• If sudden loss of ETCO2

• If high (value?)

-If low (value?)

-in cardiac arrest

Indications

• MANDATORY: to evaluate and confirm placement of ANY advanced airway to exclude esophageal intubation

• to identity late endo tube or advanced airway dislodgement

• to monitor ventilation and perfusion

• after sedation

• after patient receives respiratory depressant meds

Contraindications

• None

Technique (roughly)

• Put it on

3 determinants:

• Alveolar perfusion

• Pulmonary perfusion

• Metabolism

Sudden loss:

• Tube dislodged

• Circuit disconnected

• Cardiac arrest

High (> 45mmHg)

• Hypoventilation/CO2 retention

Low (< 25mmHg)

• Hyperventilation

• Low perfusion (shock, sepsis, PE)

In cardiac arrest:

• ETCO2 good determinant of quality CPR (reliant on blood flow)

• If ETCO2 dropping, switch out person doing CPR

• If ETCO2 not >10mmHg after 20 mins of quality CPR, probable poor outcome

• Sudden rise may indicate ROSC

IO catheter placement

Indications

Contraindications

Technique (roughly)

Precautions

Indications:

Rescue or primary vascular access device when peripheral not obtainable in critical patient with any of following:

• Cardiopulmonary arrest or impending arrest

• Profound shock with severe hypotension and poor perfusion

• Hypoglycemia with severe symptoms (I.e. unresponsive) and no venous access

• Any other scenarios NOT indicated for emt IV)

Complications:

• Fracture

• Compartment syndrome

• Infection

Contraindications

• Fracture of target bone

• Cellulitis

• Total knee replacement

Restraints

Indications

Precautions

Documentation

Complications

Indications

• Patient significantly impaired who lacks decision making capacity regarding his or her own care

• Violent, combative, or uncooperative behavior who does not respond to verbal deescalation

• Patient suicidal

Precautions

• Search patient for weapons

Documentation

1. Justification for restraints

2. Efforts to deescalate prior to restraints

3. Type of restraints

4. Condition of patient in restraints

5. Condition of patient during handoff

6. Any injury to patient or personnel

Complications

• Aspiration

• Nerve injury

-Underlying conditions (trauma, hypoxia, hypoglycemia, hyperthermia, hypothermia, drug ingestion, intoxication, or other medical conditions

Taser probe removal

Indications

Contraindications

Technique

Indications

• Taser probe in skin

Contraindications

• Probe embedded in eye, genitals, or other major neuromuscular structures (transport to ED for removal)

Technique

• Confirm taser is shut off and barb cartridge disconnected

• Stabilize skin around taser site with your hand, user other hand or pliers to grasp probe

• In one uninterrupted motion, pull probe out maintains 90 degree angle to the ski. Avoid twisting or bending

• Repeated for additional probes

• Once all probes removed, inspect them to make sure they are intact. If probe not intact or suspicion one is not intact, patient must be transported

• Cleanse probe site and surrounding skin and apply sterile dressing

• Advise patient to watch for signs of infection (increased pain at sight, redness, swelling, fever)

Pain management

Goal of pain management

Assessment

Documentation

Considerations in elderly/frail patient

Goal

• Comfort measures as first line

• Goal is tolerable pain, not necessarily pain free

Assessment

• Determine pain level

• Categorize as mild, moderate, or severe

  • Over reliance on pain scores may lead to inadequate pain control in stoic patients or over sedation in patients reporting high levels of pain. Use subjective and objective findings

  • For pediatrics, pain scale recommended. Pain score 0-3 is mild pain, scores from 4-6 moderate, 7-10 severe

Documentation

• Assessment of pain before and after med admin

• After IV admin, reassess pain every 5 mins

Consideration

• Consider ½ dose