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Emergency Medical Technician toEmergency Medical TechnicianKansas EMS Scope of Practice Transition Project

EMT

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All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form without written permission from the copyright owner or completion of a Kansas Board of EMS approved Train the Trainer program. Additional illustration and photo credits in the support materials of this document constitute a continuation of this copyright page.

The information in this lesson plan is based on the most current recommendations of responsible medical sources. The Kansas Board of Emergency Medical Services, the Friesen Group, and all curricula reviewers, however, make no guarantee as to, and assume no responsibility for, the correctness, sufficiency, or completeness of any information or contents in this program. Local agencies and individuals teaching or participating in this course should ensure their own safety and operate under the medical oversight of their local physician medical direction or the medical direction of the agency/program delivering this education.

This material is intended as a guide to facilitate the bridging of existing certified technicians to the new scope of practice in Kansas EMS. It is not intended as a statement of the standards or absolute practices of care required in any particular situation. Circumstances and the patient's condition can and will vary widely from one situation to another. This course material does not represent or advise emergency medical personnel of any legal authority to perform the activities or procedures discussed in this material. Legal authority and permission to practice emergency medical care must be determined at the local level.

All patients and providers described in this material are fictitious.

Copyright © 2010, Kansas Board of EMS

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Module 1: Airway and BreathingModule 2: AssessmentModule 3: Pharmacological InterventionsModule 4: Emergency Trauma CareModule 5: Emergency Medical Care

EMT Modules

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EMTModule 1: Airway and Breathing

5Small Volume Nebulizer

• Small volume nebulizer are devices that contain a small chamber for fluid based medications to be placed. By flowing oxygen or air through the chamber at a sufficient rate, the fluid medication is aerosolized into a vapor mist that can be administered to the patient as they breath.

• Before beginning the administration of medication through a small volume nebulizer, ensure that appropriate (BSI) are in place and utilized.

• While the equipment that you will be using is not expected to remain sterile, it is important that you keep it clean. Replace any contaminated items.

• Reasons why small volume nebulizers may be used? Used in bronchial asthma and other reversable bronchospasm that is associated with chronic bronchitis and emphysema.

6Nebulizer

• During treatment have the patient breath in deeply if tolerated.

• Some patients may want to hold the nebulizer. If so let them.

• Repeat dosages. Check local protocols.

7Nebulizer With Mask

* Some patients such as the Elderly and Children may benefit with the use of a facemask when using a nebulizer

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LABSmall Volume Nebulizer

• BSI percautions• Physical Exam / History• Vitals• Oxygen if needed• Obtain need for Nebulized treatment• Standing orders or online medical direction• 5 rights (Patient, Medication, Dose, Route, Time.• Assemble Kit• Add medication• Connect Oxygen• Flow rate 6 - 8 LPM for 5 – 10 minutes. • Repeat Exam / Vitals

9BVM with Nebulizer

* If the tidal volume (normal inspiration/ventilation) is to low or respiratory rate is to slow. You may need to use a nebulizer with BVM. Check local protocols.

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LABBVM with Small Volume Nebulizer

• BSI precautions• Provide oxygen• Perform history / exam• Vitals• Standing orders, online medical control• Gather necessary equipment Oxygen, Nebulizer kit, BVM,

Medication• Medication expiration• 5 rights• Assemble kit to BVM add medication• Connect O2 to BVM 15 LPM.• Connect O2 to Nebulizer 6-8 LPM.• Ventilate 8-10 times a minute

11Magill’s Forceps

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1

21

2

Adult

/Child

Infa

nt

13

The EMT must always be able to

Visualizethe entire forceps.

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LABMagill’s Forceps

1. BSI precautions 2. Identify choking patient 3. Follow BLS guidelines4. Conscious Adults and Children receive abdominal thrusts5. Unconscious Adults and Children receive chest thrusts6. Infants receive back blows and chest thrusts 7. Grasp magills8. Open mouth 9. Insert magills10. Suction11. Reassess patient12. Provide Interventions

15Manually Triggered Ventilator

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Mouth-to-mask

Two person bag-valve-mask

One-person bag-valve-mask

Mouth to Mouth without a barrier device

MTV

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Indications . . . Contraindications &

Complicationsof the MTV

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LABManually Triggered Ventilator

19Automatic Transport Ventilator

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Depth

and

R a t e

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Indications . . . Contraindications &

Complicationsof the Automatic Transport Ventilator

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LABAutomatic Transport Ventilator

SEE SKILL SHEET

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GastricDecompression

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Initial steps in the management of

Gastric Distention

Reposition Airway Ventilate SlowlyCricoid Pressure

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Reposition AirwayA poor airway promotes gastric distention

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Cricoid PressureCloses off the esophagus and

routes air to lungs

Cricoid Pressure

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Cricoid Pressure Ventilate Slowly

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Manual

Decompression

of the stomach

Cricoid Pressure

29Gastric Tubes

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OG NG

EMT Use of Gastric Tubes

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NG TUBESParamedic use only!

Indication:*Gastric destintion is present and interfering with ventilations.*When patients will be ventilated for long period of time.

Contraindication:*Caution in esophageal disease or esophageal traum.*Facial trauma.*Esophageal obstruction.

Advantages:*Tolerated by alert patients.*Doesn’t interfere with intubation.*Mitigates recurrent gastric distention.*Patient can still talk.

Disadvantages:*Uncomfortable for patients.*May cause patient to vomit.*Interfere with BVM,MTV,ATV.

Complications: Nasal gastric trauma from poor technique. ET placement.

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OG TUBES

Indication:*Threat of aspiration.*Need to decrease pressure of the stomach on the diaphram.*Patient is unconscious.

Contraindication:*Caution in esophageal disease or esophageal trauma.*Esophageal obstruction.

EMT is allowed to use this device.

Advantages:*May use larger tubes.*Safer to insert in patients with facial Fractures.*Lower risk of nasal bleeding.

Disadvantages:*Uncomfortable for conscious patients.*May cause retching and vomiting with patients that have intact gag reflex.

Complications: Patient may bite the tube.

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LABOrogastric Tubes

Not all supraglottic airways allow for the insertion of gastric tubes. The airways that do so include:*Combitube*King Airway*Esophageal Gastric Tube Airway*Laryngeal Mask Airway

Once the EMT has taken care of the ABC’s, they will develop and idea of whether there is a threat from gastric distention. Threats that indicate the need for gastric decompression.*Inability to adequatley ventilate due to increased lung resistance.*Vomiting.

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End-Tidal

CO2 Monitoring

CO2 Monitoring/Caponography:*The amount of end tidal CO2 is an accurate indicator of the ability of the patient to exchange O2 for CO2 at the alveoli/capillary level. EMT’s can use this tool as a mechanism to assess the placement of airway devices as well as to guide them in the provisions of effective CPR.

35Colorimetric Device

Colorimetric devices use a chemically treated paper that responds to the level of CO2 in the air that interacts with the paper in the colorimetric device. The higher the CO2 level, the more color change.

36Capnograph

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Legend

Litmus Paper

Exhaled Air Flow

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Read-out

Detector

Capnometer allows EMT’s to assess.*Airway placement.*Dislodgement of ET tube.*Effectiveness of CPR.*Spontaneous circulation (ROSC).*Efficacy of breathing treatments.

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Wavefo

rm C

om

ponents A-B is the inspiration/dead space marker

B-C is the exhalation upstroke

C-D is the continuation of exhalation

D is the end tidal value (peak)

D-E is the inspiration washout

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a b

c d

e

CO2

Time

Norm

al W

avefo

rm*A-B is the inspiration/dead space exhalation marker.*B-C is the exhalation upstroke where gases from lungs are detected.*C-D is the continuation of exhalation.*D is the end tidal value where peak CO2 is found*Efficacy of breathing treatments.

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a b

c d

e

CO2

Time

Poor

Wavefo

rm

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Numeric Readouts

Waveform Display

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Airway Placement

Confirmationusing End-Tidal CO2

The supraglottic airways placed by EMT’s are generally built such that they may be used in either the trachea or esophogus. The EMT must know in which location the tube is placed and ventilate appropriatley with the device. Using some form of end tidal CO2 monitoring allows the EMT to guage the effectiveness of the airway based off the amount of CO2 return.

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Ensuring adequate

Ventilationsusing End-Tidal CO2

The EMT can use the end tidal CO2 readings as a mechanism to avoid hyperventilation or hypoventilation of the patient.

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Early indication of

ROSCusing End-Tidal CO2

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EtCO2

12

Early indication of

INEFFECTIVECompressions

EtCO2

24EtCO2

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EtCO2

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Effectiveness of CPR:1. End tidal CO2 measure to assist in ventilation.a. Target value normal range 35-45 ETCO2.b. Hyperventilation the number will fall.c. Hypoventilation the number will rise.2. End tidal CO2 measure to assist in compressionsd. Correlation with ETCO2 dropping ineffective CPR.e. Switching rescuers should result in increase

ETCO2.

47Capnography Case Studies

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LABEnd-Tidal CO2 Monitoring

49Pulse Oximetry

50How Pulse Oximetry Works

LED Detector

Light

51What is normal?

Equal to or greater than

94%

52Pulse Oximeter

53Pulse Oximeter

54Assessing Results

Scene Size Up (No Pulse Oximetry)

Initial Assessment (May include use of the pulse oximeter)1. Airway 2. Breathing (Observe, Estimate, Listen, Oximeter)3. Circulation4. Disability (LOC)5. Expose and Examine

History and Physical Assessment (Pulse oximeter)

Detailed Assessment (Pulse oximetry)

On-Going Assessment (Pulse oximetry)

55Assessing Results

> 95 % “Normal”

91% - 94% Mild hypoxia.

86% - 90% Moderate hypoxia.

< 85% Severe hypoxia.

(Bledsoe, Porter & Cherry, 2007, 463)

56Oximetry – Troubleshooting

57Oximetry – 3 Basic Rules

Assess and treat patient, not the oximeter

Never withhold oxygen if S/S of hypoxia or hypoxemia are present – regardless of the reading on the oximeter

Pulse oximeters measure saturation of the hemoglobin, not oxygenation or ventilation.

58Oximetry – Documentation

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LABPulse Oximetry

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EMTModule 2: Assessment

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62

2/3

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LABNon-Invasive Blood Pressure Monitoring

One of the key concerns has been reliability of the non-invasive measurement as compared to manual auscultation. Rule of thumb. When you find a NIBP reading out of normal range for the context of your patient, double check it with a manual BP.

Appropriate cuff should cover 2/3 of the upper arm.

HAVE THE STUDENTS USE THE FORMULARY OVER THE MEDICATIONS TO STUDY AND FILLIN THE WORK BOOK AFTER THIS CLASS IS OVER. HAVE THEM TAKE IT HOME. SO NEXT CLASS CAN TAKE TEST, ASK QUESTIONS, FOCUSE MORE ON THE SKILL.

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EMTModule 3: Pharmacological Intervention

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WhyMedications?

See EMR transition media for the Five rights. Use EMT pages 66-73 for the medication formulary.

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5Rights

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RightMedication

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RightPatient

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RightDose

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RightRoute

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RightTime

72EMT Medication Routes

ORAL IM INHALATION

73Forms of Medication

SOLUTION TABLET/PILL PASTE

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EMT Medication

Sc pe

75Albuterol Sulfate

76Aspirin

77Atropine Sulfate

78Epinephrine

79© Enject

GlucagonAuto-Injector

(Soon Available)

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81Pralidoxime (2-PAM)

82Mark 1 or Duodote Kit

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Mark 1 Kit1 2

3

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8

84

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Setting the Stage for the

Administrationof Medication

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LABMedication Administration

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EMTModule 4: Emergency Trauma Care

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Pelvic WrapSplint

Any pelvic fracture is at risk for significant blood loss and the emt must stabalize the fracture appropriatley.Pelvic fractures can be splinted in a number of ways.*PASG*Sheet wrap*Inverted KED*Commercial pelvic splint

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90

91

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LABPelvic Splinting

PASG:*When using this as a splinting device, the EMT should apply the device and inflate it only enough to provide stabilization. When using the device, it is best placed on a long spine board before the patient is log rolled. The device is fastened around the patient and inflated to allow for immobilization.Sheet Wrap:*When using a sheet wrap the procedure is straight forward.1. Take a cloth and fold it into a 8” wide, flat band.2. Center it under the buttocks so that when wrapped it will cover the greater

trochanters.3. Wrap the sheet across the symphysis pupis and tie with a half knot.4. Tighten it to stabilize the pelvis.5. Secure with safety pins.6. Move patient to LSB.KED:Invert the KED use the body portion to secure the pelvic region. Move to LSB.

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EMTModule 5: Emergency Medical Care

94Applying Cardiac Leads

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RA LA

LL

-- -+

+ +

I

II III

Ground

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4 Lead

WHITE BLACK

REDGREEN

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12 Lead

WHITE

BLACK

RED

GREEN

V1V2

V3

V4V5V6

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LABEKG Leads

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Blood

GlucometerSee EMR transition media for glucometer and diabetic emergencies.

100The Body’s Glucose Needs

Insulin on receptoropens glucose channel

InsulinGlucose

Glucosechannel

Insulinreceptor

Body Cell Nucleus

Glucose enters cell

101Normal Blood-Glucose Levels

Infant 40 – 90 mg/dL

Child < 2 years 60 – 100 mg/dL

Child > 2 years to Adult 70 – 105mg/dL(Pagana & Pagana, 1997, 427)

102Critical Values

Newborn < 30 and > 300 mg/dL

Infant < 40 mg/dL

Adult Female < 40 and > 400 mg/dL

Adult Male < 30 and > 300 mg/dL(Pagana & Pagana, 1997, 427)

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Types of

Diabetes

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Clinical

Presentation

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Emergency Care of

Diabetes

106How a Glucometer Works

107When to Use the Glucometer

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109Puncture Sites

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111

112

113

114

115

116Maintenance and Use

117Trouble Shooting

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Oral

Glucose Administration

119Diabetic Case Studies

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LABBlood Glucometer

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UrinaryCatheters

122Texas Catheter

123Foley Catheter

124Monitoring

125Handling

126Documentation

127Complications

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LABUrinary Catheter Monitoring

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Photography and Image Credits©Duodote Slide 70 © Enject Slide 68 © iStock Photography. Used with permission. No resale or reproduction of these images is permitted. Slides: 29, 83, © Jeremy Hoose and Destry Lynn (Labette Health EMS) Used with permission. No resale or reproduction of these images is permitted. Slides 19, 109,110, 111, 112, 113, 114, 115 © Jon E. Friesen, Used with permission. No resale or reproduction of these images is allowed without express permission of the photographer. Slides: 6,7,9, 11, 12, 15, 35, 36, 37, 38, 40, 41, 42, 45, 47, 50, 51, 61, 62, 64, 65, 66, 67, 69, 70, 71, 72, 77, 78, 79, 82, 84, 85, 88, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 107, © Lippincott Williams & Wilkins. Used with permission. No resale or reproduction of these images is permitted. Slide 83,