Task Analysis for Paramedic Students Cowley Cowley College
College
Statement of Accreditation The Cowley College Paramedic Program is accredited by the Commission on Accreditation of Allied Health Education Programs (www.caahep.org) upon the recommendation of the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP).
Chris Cannon & Slade Griffiths (2011). Task Analysis for Pre-hospital Providers (5th Ed). Cowley County Community College: Arkansas City, KS.
Table of Contents Bag-Valve-Mask (BVM) ...... 5 Retrograde Intubation ...... 6 Cricothyrotomy ...... 8 Transtracheal Jet Insufflation ...... 9 Endotracheal Intubation ...... 10 CowleyBlind Nasotracheal ET Intubation ...... 12 Endotracheal Extubation ...... 14 Esophageal Obturator Airway (EOA) ...... 15 Magill Forceps ...... 17 Nasopharyngeal Airway ...... 18 Oropharyngeal Airway (OPA) ...... 19 Peak Expiratory Flow Rate ...... 20 Combitube Airway ...... 21 Tracheal Suctioning ...... 26 Blind Nasotracheal Suctioning ...... 27 Nebulized Breathing Treatment ...... 28 Valsalva Maneuver ...... 29 Carotid Sinus Massage ...... 30 Synchronized Cardioversion Using Paddles ...... 31 Defibrillation (Unsynchronized Countershock)College Using Paddles ...... 32 Remote Synchronized Cardioversion Using Fastpatch or Combo Patch ...... 33 Remote Defibrillation Using Fastpatch or Combo Patch ...... 34 External Cardiac Pacing Using Quikpace or Combo Patch ...... 35 Acquiring a 12-Lead ECG ...... 37 Biomedical Communications ...... 38 Patient Assessment -- History (SAMPLE) ...... 39 Patient Assessment – Trauma Patient ...... 40 Patient Assessment – Medical Patient ...... 42 Administration of Medication Through ET Tube ...... 44 External Jugular Vein Catheterization ...... 45 IM Injection ...... 46 Intracardiac Injection ...... 47 Pericardiocentesis ...... 48
Intraosseous Infusion ...... 49 EZ-IO ...... 50 IV Venipuncture ...... 51 SQ Injection ...... 53 Air Splint Application ...... 54 Chest Decompression ...... 55 CowleyKendrick Extrication Device (KED) ...... 56 Kansas Short Spine Board ...... 57 Long Spine Board Application ...... 58 Patient Handling ...... 60 Pneumatic Anti-Shock Garment ...... 61 Rapid Auto Extrication ...... 63 Rigid Splint ...... 64 Sling and Swathe ...... 65 HARE Traction Splint ...... 66 Gastric Lavage ...... 67 Urinary Catheterization ...... 69 Nasogastric Tube ...... 76 IV Medication Administration ...... 79 Appendix A – AHA CPR Procedures Evaluation Forms ...... 80 Appendix B – First Skill Check List ...... College 82 Appendix C – Final Skill Check List ...... 88 Appendix D – Simulated Patient Scenarios: Didactic ...... 94 Appendix E – Simulated Patient Scenarios: Hospital Clinicals ...... 96 Appendix F – Simulated Patient Scenarios: Field Internship ...... 98
To complete the paramedic course, the student must successfully* perform all designated skills found in this guide while evaluated by faculty before entering the clinical rotation and again before the conclusion of the program. *successfully is defined as: A. Skill is performed accurately. B. No main steps of skill are omitted. C. Skill performance would not cause patient harm (if applicable).
CowleyWhen the student is evaluated in the clinical or field setting, preceptors should use this guide to determine competent skill performance.
Note: An IV or injection attempt occurs when the needle enters the cutaneous tissue. An ET intubation attempt occurs when the blade is placed in the patient’s mouth.
College
Bag-Valve-Mask (BVM)
Activity Critical Performance
1. Select/assemble equipment 1.1 Select bag, reservoir and proper size mask. Attach mask and reservoir to appropriate parts on bag. Insert oral airway. 1.2 Put on gloves and goggles. Cowley 2. Apply supplemental 02. 2.1 Open O2 tank by turning inlet valve counterclockwise to pressurize regulator. 2.2 Connect tubing from port on bag to connector of O2 regulator. 2.3 Set liter flow at 15 L/M by turning flow regulator valve clockwise.
3. Apply and maintain face-to-face seal. 3.1 Work facing top of patient's head. 3.2 Position mask by placing pointed end of mask over the patient's nose until mask is sealed firmly against bridge of nose. 3.3 Place two (2) or three (3) fingers under mandible and bring chin to mask until face-to-face mask seal is made. 3.4 Head must be maintained in extension throughout this procedure.
4. Ventilate for one (1) minute. 4.1 While maintaining face-to-mask seal with one hand, squeeze bag rhythmically at least once every five (5) seconds achieving 800 mL tidal volume on manikin for three (3) ventilations. 4.2 Allow bag to refill slowly and completely. College4.3 Watch for gastric distention evidenced by increased resistance to BVM ventilation. 4.4 Continue ventilation for 1 minute.
5. Reassess patient status. 5.1 Stop CPR, reassess breathing and circulation. 5.2 Give two (2) breaths and have assistant continue single rescuer CPR as necessary. Prepare for insertion of esophageal obturator airway, if appropriate. 5.3 Recheck ABCs every few minutes as necessary.
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Retrograde Intubation
Activity Critical Performances
1. Determine need to perform procedure. 1.1 The patient’s airway cannot be managed by less invasive airway maneuvers, thus this procedure can be considered. 1.2 It is generally not recommended for patients Cowley who are not spontaneously breathing.
2. Gather and prepare equipment. 2.1 Gather the following equipment: a. BVM b. Oxygen c. Bacteriocidal prep d. Endotracheal tube appropriate for patient e. 12 to 14 gauge over-the-needle catheter f. 10 mL syringe g. Guidewire (a J-wire at least 24" in length) h. Hemostat I. Stethoscope j. Dressing materials 2.2 Attach syringe to over-the-needle catheter. 2.3 Arrange all needed equipment near the patient’s head. 2.4 Put on gloves and goggles.
3. Locate and cleanse membrane. 3.1 Locate the cricothyroid membrane between the thyroid and cricothyroid cartilages. 3.2 Prepare the skin with antiseptic solution.
4. Advance catheter/stylet. 4.1 Insert the 12 to 14 gauge catheter, with syringe attached, into the membrane at a 45 Collegedegree angle towards the head aspirating with the syringe as the needle is advanced. 4.2 The needle is inserted in the bevel up position. 5. Aspirate free air and advance catheter. 5.1 Aspiration of air indicates that the catheter is in the trachea. 5.2 As air is aspirated from the syringe, advance the catheter fully while holding the needle in position. Withdraw the needle and syringe.
6. Advance guidewire. 6.1 Gently advance the J-wire. 6.2 Watch in the oropharynx for the wire. 6.3 When visualized, grasp the J-wire with hemostat. 6.4 Pull the J-wire out of the patient’s mouth, taking care to not pull it completely through the catheter in the neck.
6
Retrograde Intubation (continued)
Activity Critical Performance
7. Position and place endotracheal tube. 7.1 Place the J-wire (which is at the patient’s Cowley mouth) through the lumen of the entire ET tube or through the Murphy eye and through the entire ET tube. 7.2 Grasp both ends of the J-wire. 7.3 Slide the tube into the patient’s oropharynx until you meet resistance (at the level of the cricothyromembrane).
8. Withdraw catheter and guidewire and make 8.1 Withdraw the guidewire and catheter. final tube placement. 8.2 At the same time, put slight distal pressure (push) on the ET tube. 8.3 As the J-wire is removed, you will note decreased resistance -- advance the ET tube into the correct position (normally 19 - 23 cm for an adult).
9. Inflate cuff. 9.1 Inflate the cuff with eight (8) to ten (10) milliliters of air. (Low pressure cuffs may take more volume to inflate.)
10. Auscultate BBS and epigastrium. 10.1 Check for placement of the ET tube while ventilating with bag valve mask checking for chest rise and also auscultating lung fields and epigastrium. College 11. Hyperventilate patient. 11.1 Hyperventilate patient and assist ventilations.
12. Secure tube. 12.1 Secure ET tube with tape or holder.
13. Auscultate BBS and epigastrium. 13.1 After tube is secured in place, re-evaluate chest rise and auscultate for bilateral breath sounds.
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Cricothyrotomy
Activity Critical Performance
1. Assemble equipment. 1.1 Gather the following equipment a. scalpel b. 5.5 or 6.0 pediatric ET tube c. sterile gauze sponges d. bacteriocidal prep Cowley e. skin retractor (tracheal hook) if available 1.2 Put on gloves and goggles
2. Locate the cricothyroid membrane. 2.1 Hyperextend the patient's neck (if neck trauma is not suspected). 2.2 Identify the membrane.
3. Prepare the skin. 3.1 Scrub the area with an antibacterial solution.
4. Incise the skin and cricothyroid membrane. 4.1 Stretch the skin over the membrane. 4.2 Make a longitudinal cut through the skin. 4.3 Sponge away blood as necessary. 4.4 Once the skin is incised, cut through the cricothyroid membrane. 4.5 Rotate the scalpel 90° so as to enlarge the opening.
5. Insert the tube. 5.1 Withdraw the scalpel. 5.2 Insert the largest ET tube possible. 5.3 Inflate ET tube cuff.
6. Auscultate for breath sounds. 6.1 Apply BVM and ventilate. 6.2 Auscultate for breath sounds over both lung fields and epigastrium. College 7. Secure tube. 7.1 Pack around incision with sterile dressing. 7.2 Secure tube with tape. Be sure not to occlude venous or arterial flow through the neck.
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Transtracheal Jet Insufflation
Activity Critical Performances
1. Prepare equipment. 1.1 Prepare TTJI setup by attaching a “Y” adaptor to oxygen tubing with soft rubber tubing attached to one stem of the “Y.” The soft tubing should be attached to the IV Cowley catheter once it is inserted. An alternative setup is accomplished by cutting a notch into oxygen tubing. The distal end of the oxygen tubing is attached to a 3.5 mm ET tube adaptor. The adaptor will fit into the IV catheter. 1.2 Attach a 10 - 30 mL syringe to a 10 - 14 ga. IV catheter. 1.3 Make available a 30 - 60 PSI oxygen source. 1.4 Put on gloves and goggles.
2. Locate and cleanse membrane. 2.1 Locate the cricothyroid membrane between the thyroid and cricothyroid cartilages. 2.2 Prepare the skin with antiseptic solution.
3. Advance catheter/stylet. 3.1 Insert a 12 to 14 gauge catheter, with syringe attached, into the membrane, aspirating with the syringe as the needle is advanced. 3.2 The needle is inserted inferiorly, bevel up, at a 60° angle.
4. Aspirate free air. 4.1 As air is aspirated from the syringe, advance the catheter while holding the needle in Collegeposition. Withdraw the needle.
5. Attach TTJI setup. 5.1 Attach TTJI setup to catheter and to oxygen. Turn oxygen on flush.
6. Ventilate the patient. 6.1 Ventilate the patient six (6) times a minute, five (5) seconds per ventilation, either by occluding whistle tip or by turning O2 supply on and off. 6.2 Check for ventilation of both lungs by observing and auscultating the chest, and observing for chest movement. 6.3 Tape the catheter in place, avoid kinking. 6.4 If chest continues to expand during procedure and does not fall during expiration, discontinue ventilations and perform surgical cricothyrotomy.
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Endotracheal Intubation
Activity Critical Performances 1. Assemble and check equipment. 1.1 Student assures adequate oxygenation and ventilation is in progress prior to intubation. 1.2 Student assembles all equipment and has readily accessible (including suction). 1.3 Student connects laryngoscope blade and needle and handle, and checks light Cowley (“white, bright & tight”). 1.4 Student inflates endotracheal tube cuff to check for leaks, then deflates keeping the syringe attached to the inflation port with eight (8) to ten (10) mLs of air in the syringe. Keeps sterile. 1.5 Student lubricates the tube as needed. 1.6 Student inserts stylet, as needed. 1.7 Put on gloves and goggles.
2. Hyperventilate patient. 2.1 Student has partner hyperventilate patient with 100 percent oxygen, one (1) ventilation per second for five (5) ventilations (if appropriate). The student then will ask the assistant to count to 15, one number per second, as ordered. For an adult, hyperventilation refers to 20 ventilations per minute.
3. Position head and mouth. 3.1 Student properly places the head and neck by flexing the neck forward and extending the head backward. Occiput of the head should be somewhat on the same horizontal plane as the back of the shoulders (sniffing position). CollegeConsider aligning the auditory meatus with the anterior shoulder. 3.2 Student opens the mouth with finger-scissor maneuver if necessary.
4. Insert laryngoscope and visualize cords, 4.1 Student holds laryngoscope in left hand, keeping laryngoscope off teeth. thumb pointing up parallel with handle, little finger resting on or near the blade. 4.2 Student inserts laryngoscope in right side of mouth moving tongue to the left. A. Straight blades: Student should advance the blade observing for the epiglottis. When epiglottis visualized, place tip of blade under the epiglottis. Student should push the laryngoscope upward inferiorly until the cords are visualized. B. Curved blade: Student should advance the blade until it seats in the vallecula. The laryngoscope should be pushed upward and inferiorly at a 45° angle until the cords are visualized.
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Endotracheal Intubation (continued)
Activity Critical Performances
5. Insert tube. 5.1 Student inserts the endotracheal tube gently through the vocal cords into the upper trachea stopping when the cuff passes inferiorly to the cords. Cowley 5.2 Student removes laryngoscope holding the tube in place.
6. Inflate cuff. 6.1 Student inflates the cuff with eight (8) to ten (10) milliliters of air. (Low pressure cuffs may take more volume to inflate.)
7. Auscultate BBS and epigastrium. 7.1 Student checks for placement of the ET tube while ventilating with bag valve mask checking for chest rise and also auscultating lung fields and epigastrium.
Entire process of intubation from cessation of manual ventilation to successful intubation should take no more than 15 seconds.
8. Hyperventilate patient. 8.1 Student returns ventilation to partner having partner hyperventilate one (1) ventilation per second for five (5) seconds.
9. Secure tube. 9.1 Student inserts oral airway. 9.2 Student correctly secures tape in place, preferably by running tape around neck, wrapping the Collegetube with the free end of the tape.
10.1 After tube is secured in place, re-evaluate 10. Auscultate BBS and epigastrium. chest rise and auscultate for bilateral breath sounds following taping the tube. Note tube depth, normally 19 - 23 cm for an adult.
DO NOT INTERRUPT OXYGENATION AND VENTILATION LONGER THAN 15 SECONDS TO INTUBATE. DO NOT STOP CPR TO INTUBATE. IF UNABLE TO INTUBATE THE PATIENT WITHIN 15 SECONDS, BACK OUT AND VENTILATE PATIENT AGAIN WITH 100 PERCENT OXYGEN. CHANGE SOMETHING (BLADE, TECHNIQUE, ETC.) AND ATTEMPT INTUBATION AGAIN. HYPERVENTILATION CAN HAVE DETRIMENTAL EFFECTS ON THE PATIENT: HYPOCARBIA, DECREASED BP AND CEREBRAL BLOOD FLOW AND “AUTO-PEEP”.
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Blind Nasotracheal ET Intubation
Activity Critical Performances 1. Assemble and check equipment. 1.1 Student assures adequate oxygenation and ventilation is in progress prior to intubation. 1.2 Student assembles all equipment and has readily accessible (including suction). 1.3 Student inflates endotracheal tube cuff to check for leaks, then deflates keeping the Cowley syringe attached to the inflation port with eight (8) to ten (10) mL of air in the syringe. Keeps sterile. 1.4 Student applies lubricant as needed. Considers lidocaine jelly or alpha stimulating agent. 1.5 Put on gloves and goggles.
2. Hyperventilate patient. 2.1 Student has partner hyperventilate patient with 100 percent oxygen, one (1) ventilation per second for five (5) ventilations. The student then will ask the assistant to count to 15, one number per second, as ordered. For an adult, hyperventilation refers to 20 ventilations per minute. 3. Position head. 3.1 Student places patient’s head in a neutral position. 4. Select nostril. 4.1 Student selects the larger nostril. 5. Insert tube. 5.1 Student inserts tube into nostril with flanged Collegeend of tube along the floor of nostril or facing septum. 5.2. Student advances tube in an anterior to posterior direction. 5.3 As the tube drops into posterior oropharynx, the student listens for ventilation sounds through the tube. 5.4 With the patient’s next inspiration, the student rapidly advances the tube into the glottic opening (patient’s typically cough, buck or strain with tracheal placement -- gag with esophageal placement). 6. Inflate cuff. 6.1 Student inflates the cuff with eight (8) to ten (10) milliliters of air. (Low pressure cuffs may take more volume to inflate.) 7. Auscultate BBS and epigastrium. 7.1 Student reassesses for placement of the ET tube as previously completed.
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Blind Nasotracheal ET Intubation (continued)
Activity Critical Performances
8. Hyperventilate patient. 8.1 Student returns ventilation to partner having partner briefly hyperventilate.
Cowley 9.1 Student correctly secures tape in place, 9. Secure tube. preferably by running tape around neck, wrapping the tube with the free end of the tape.
10. Auscultate BBS and epigastrium. 10.1 After tube is secured in place, re-evaluate chest rise and auscultate for bilateral breath sounds following taping the tube.
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13
Endotracheal Extubation
Action Critical Performance 1. Strongly consider leaving the patient intubated. 1.1 Extubation may induce cardiac dysrhythmias and laryngospasm, to name only two of the numerous complications.
2. Assess patient. Cowley 2.1 Hypoxemia, hypercarbia, acid-base anomalies and shock should be ruled out prior to extubation. The patient should: A. Be completely weaned from mechanical ventilation. B. Be conscious and possess competent pharyngeal reflexes. C. Be capable of producing an effective cough. D. Have adequate motor control. E. NOT have serious cardiac dysrhythmia. F. Not have abdominal distension. G. Have stable vital signs. H. Have a patent IV. I. Have acceptable respiratory parameters: 1. Minute volume of at least 90 mL/kg. 2. Forced vital capacity (sighing volume) of 15 mL/kg. 3.1 Explain the procedure. Preoxygenate with 100% 3. Prepare patient. oxygen for 2 - 3 minutes. Place patient in semi Fowler’s or high Fowler’s position.
4. Suction patient. 4.1 Suction the endotracheal tube (See ET Collegesuctioning). 4.2 Reoxygenate with 100% oxygen. 4.3 Suction mouth and oropharynx to remove secretions that may have accumulated.
5. Change suction catheters. 5.1 Any further suctioning should be done with a sterile catheter.
6. Attach BVM to ETT. 6.1 Attach BVM and deliver a maximal inflation or ask patient to inspire maximally.
7. Deflate cuff. 7.1 Deflate cuff as patient receives the above mentioned ventilation.
8. Remove ETT. 8.1 Gently remove the ETT.
9. Suction. 9.1 Suction mouth and oropharynx, PRN.
10. Apply supplemental oxygen. 10.1 Apply the appropriate concentration of oxygen.
11. Assess patient 11.1 Assess ventilations and observe for stridor or increasing hoarseness. Assess vital signs.
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Esophageal Obturator Airway (EOA)
Activity Critical Performances
1. Assemble and check equipment. 1.1 Assume CPR is in progress. Connect EOA to mask. Insert syringe into valve with slight (and gentle) twisting motion. Check tube cuff by inflating it with 25 - 35 mL of Cowley air. Detach syringe, check for slow deflation of cuff. Listen for leaks at the cuff. 1.2 Inflate mask only until firm enough to maintain face-to-mask seal. Listen to mask for air leaks. 1.3 Completely withdraw air from tube. 1.4 Remove and reset syringe with 35 mL of air and reattach it to cuff inflation valve. 1.5 Prepare and test suction by turning machine power switch on and check for proper operation. Turn machine off until ready for use. 1.6 Apply lubricant liberally to the lower 1/3 of tube as needed. 1.7 Place stethoscope around neck (rescuer’s or assistant’s). 1.8 Put on gloves and goggles.
2. Insert EOA. 2.1 Alert assistant that hyperventilation is to be done. 2.2 Hyperventilate patient by ventilating five (5) times between compressions. It may be Collegenecessary to slow compression rate to facilitate these ventilations. 2.3 Ensure neutral head position by manually repositioning patient’s head. 2.4 Grasp tube just below the mask with two (2) or three (3) fingers (“pencil hold”). 2.5 With other hand perform jaw life maneuver. Insert tube following normal curvature of the airway. 2.6 Gently advance tube into the esophagus until mask rests against patient’s face. 2.7 Seal mask on face and give three (3) ventilations into the port.
3. Assess ventilations. 3.1 Assess breath sounds while ventilating into tube. Listen with stethoscope over each lung field and once over epigastrium. Watch for chest to rise.
4. Inflate cuff. 4.1 Inflate cuff with 25 - 35 mL air; remove syringe.
15 Esophageal Obturator Airway (EOA) (continued)
Activity Critical Performances 5. Reassess breath sounds 5.1 Reassess breath sounds after cuff inflation by again ventilating into tube/mask port and listening over Cowley both lung fields and epigastrium. Observe for gastric distention. 5.2 Hyperventilate patient. 6. Resume two (2) rescuer CPR PRN. 6.1 Instruct assistant to begin. 6.2 Connect bag mask unit to mask/tube port and continue ventilating at least once every five (5) seconds. 6.3 Assess adequacy of ventilations and compressions frequently during resuscitation. 7. Recognize need for removal. 7.1 Recognize need to remove EOA when patient starts biting or retching on tube; grasping at mask; airway is secured with endotracheal tube (by hospital or ALS personnel); or elapsed time is approaching two (2) hours. 8. Turn patient on side. 8.1 Turn patient to side using a log roll technique. 8.2 Turn on suction unit. 9. Remove EOA. 9.1 Remove mask from tube. 9.2 With plunger or syringe pushed in as far as it will go, attach syringe gently to tube port and withdraw Collegeair from cuff. 9.3 Inspect pilot cuff near inflation port to see if all air from cuff has been expelled. Pilot balloon should be completely flat. 9.4 Detach syringe and withdraw the EOA carefully, but quickly. Follow normal curvature of upper airway. 9.5 Measure suction catheter (yankaeur for oropharyngeal suctioning) as for OP airway. 9.6 Suction oropharynx paying particular attention to dependent portion of the airway. May not be needed. 9.7 Limit suctioning to fifteen (15) seconds at a time if possible. 10. Assess patient status. 10.1 Talk to patient. Establish level of consciousness. 10.2 Reassess ABCs. Check the adequacy of airway, breathing (rate and depth) and circulation (rate and quality). Treat as needed. 11. Apply supplemental oxygen. 11.1 Assess for evidence of hypoxia 11.2 Apply O2 at 10 - 15 LPM by mask.
16 Magill Forceps
Activity Critical Performance
1. Attempt to clear airway manually. 1.1 Attempt to clear airway with appropriate AHA algorithm. 1.2 Put on gloves and goggles.
Cowley2. Prepare equipment. 2.1 Gather laryngoscope blade and handle. Check light. 2.2 Select appropriate size Magill forceps. 2.3 Acquire suction.
3. Visualize obstruction. 3.1 Put head in sniffing position. 3.2 Insert blade in right side of mouth, sweep left. 3.3 Keep off teeth, avoid prying motion. 3.4 Visualize epiglottis and obstruction.
4. Insert forceps and remove obstruction. 4.1 Hold Magill forceps with right hand, laryngoscope in left. 4.2 Grasp obstruction. 4.3 Remove obstruction.
5. Assess patient’s condition. 5.1 Check for air exchange. 5.2 Check respiratory sounds 5.3 Check blood pressure, pulse, and respiratory rate.
6. Start oxygen therapy or ventilatory 6.1 Hyperventilate with BVM if respiratory rate assistance. is insufficient. College6.2 Apply 100% oxygen per mask as needed.
17 Nasopharyngeal Airway
Activity Critical Performances
1. Select appropriate airway. 1.1 Measure airway from patient’s naris to angle of jaw, select appropriate diameter. 1.2 Apply lubricant as needed. Consider lidocaine jelly or alpha stimulating agent. Cowley 1.3 Put on gloves and goggles.
2. Insert airway. 2.1 Insert the tube posteriorly, not superiorly. 2.2 If resistance is encountered, try other nare -- do not force.
3. Verify position. 3.1 If properly inserted, the flange of the airway should rest on the naris.
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18 Oropharyngeal Airway (OPA)
Activity Critical Performances
1. Select airway. 1.1 Select proper size airway by A. Placing flat bit (flange) portion of the airway at corner of patient’s mouth and end of curve at angle of jaw; or Cowley B. Placing flange of airway at corner of patient’s mouth and end of curve at tip of ear. The airway should follow the natural contour of the oropharynx. 1.2 Put on gloves and goggles.
2. Insert airway. 2.1 Insert airway properly using one of the following methods. A. Insert with top of airway toward the roof of the mouth until it contacts the posterior pharyngeal wall. At this point, the airway is rotated 180 degrees and insertion completed when the flange of the airway rests on the patient’s lips; or B. Insert the top of the airway toward the cheek. When in contact with posterior pharyngeal wall, it is rotated 90 degrees and insertion completed when flange rests on patient’s lips; or C. Using a tongue depressor, depress patient’s tongue, visualize the patient’s airway and insert OPA until it rests on patient’s lips. This is the preferred method for pediatric Collegepatients.
3. Monitor airway status. 3.1 Assess patient’s airway for signs of retching or vomiting following insertion.
19 Peak Expiratory Flow Rate
Activity Critical Performances
1. Observe universal precautions. 1.1 Protect self and patient from spread of infection. 2. Assemble equipment. 2.1 Place disposable mouthpiece on peakflow Cowley meter. 2.2 Zero the meter. 2.3 Place nose clip.
3. Instruct and position patient. 3.1 Position patient in semi-Fowler’s position. 3.2 If patient is critically ill, fatigued, somnolent, or unable to hold meter, proceed directly to the treatment. 3.3 Instruct patient to inhale deeply, place noseclip, and exhale quickly and forcefully into the meter, sealing lips around mouthpiece.
4. Have patient exhale into meter. 4.1 Have patient perform 3.3.
5. Repeat two times, record best of two 5.1 Have patient repeat twice and record the best attempts. of two attempts with one minute between attempts. 5.2 Patient treatment with high flow O2 and breathing treatment may be initiated between attempts.
College6.1 After breathing treatment is complete (6 - 10 6. Repeat procedure after administration of minutes), repeat PEFR and document any breathing treatment. change.
20 Combitube Airway
Activity Critical Performances
1. Body Substance Isolation in accordance with 1.1 Whenever the Combitube is inserted or local protocols. removed, gloves, mask and goggles shall be worn.
Cowley2. Adequately ventilate patient. 2.1 Open the patient’s airway using the proper method.
If trauma has been ruled out: Hyperextend the head using the head tilt, chin lift method. Insert oral airway.
If trauma is suspected: Open patient’s mouth with cross finger technique or tongue-jaw lift. Insert oral airway.
2.2 Apply and seal Bag-Valve Mask. 2.3 Ensure oxygen liter flow of 15 LPM or greater. 2.4 Ventilate as patient condition indicates. 2.5 Observe patient for chest rise. 2.6 Maintain ventilations.
3. Open the airway device. 3.1 Remove the Combitube from the package.
4. Check cuffs and pilot balloons for leaks. 4.1 Test both cuffs. 4.2 Check pharyngeal cuff by attaching the large Collegesyringe to Line #1 with a slight twisting motion and inflate with 100 mL of air. 4.3 Remove syringe and check pilot bulb on Line #1. 4.4 Listen and observe for leaks in the cuff and pilot balloon. 4.5 Insert depressed large syringe into Line #1 with a slight twisting motion. 4.6 Pull back on syringe plunger until the 100 mL of air is aspirated from the pilot balloon and cuff. 4.7 Remove syringe from Line #1. 4.8 Refill the syringe with 100 mL of air. 4.9 Check distal cuff by attaching small syringe to Line #2 with a slight twisting motion and inflate with 15 mL of air. 4.10 Remove syringe and check pilot bulb on Line #2. 4.11 Listen and observe for leaks in the cuff and pilot balloon.
21 Combitube Airway (Continued)
Activity Critical Performance
4.12 Insert depressed small syringe into Line #2 with a slight twisting motion. 4.13 Pull back on syringe plunger until the 15 mL Cowley of air is aspirated from the pilot balloon and cuff. 4.14 Remove syringe from Line #2. 4.15 Refill the syringe with 15 mL of air. Set the syringe nearby. 5. Lubricate the distal tip. 5.1 Lubricate the distal end of the tube with water soluble lubricant such as KY jelly, Lubifax or Surgilube. 6. Place prepared Combitube. 6.1 The Combitube should be placed in an accessible position that enables picking it up and inserting with little extraneous motion. 7. Prepare suction. 7.1 Prepare and test suction device.
8. Hyperventilate patient. 8.1 Instruct assistant to hyperventilate the patient. 8.2 Apply and seal BVM. 8.3 Ventilate the patient four times (allow a compression after each breath if CPR is in progress.)
9. Maintain head in hyperextended or neutral 9.1 Maintain head tilt/chin lift if trauma has been position. ruled out. 9.2 If trauma is suspected: CollegeHave a partner stabilize the head in the neutral position.
10. Remove oropharyngeal airway. 10.1 Refer to Oropharyngeal Airway Task Analysis. 11. Prepare patient for Combitube insertion. 11.1 Open the airway, using the appropriate method.
Perform tongue-lift or tongue-jaw lift without head tilt for suspected trauma patients.
Manually stabilize head in neutral position.
22 Combitube Airway (Continued)
Activity Critical Performance
To perform tongue lift: Grasp tongue with thumb and forefinger, moving it forward and out of the way. A dry 4x4 may be used Cowley to assist grasping the tongue.
Perform tongue-jaw lift if trauma is not suspected.
Hyperextend the patient’s head.
Insert your thumb deep into the supine patient’s mouth; grasp tongue and lower jaw between thumb and index finger and lift straight upward.
12. Insert Combitube. 12.1 Hold the Combitube in your free hand so that it curves in the same direction as the natural curvature of the pharynx. 12.2 Insert the tip into the mouth and advance gently until the printed rings are aligned between the teeth or alveolar ridges. 12.3 Do not force the Combitube. If the tube does not advance easily, redirect it or withdraw and reinsert after hyperventilating the patient. 12.4 Inflate pharyngeal cuff by attaching large syringe to Line #1 with a slight twisting motion and inflate with 100 mL of air. 12.5 Remove large syringe from Line #1. 12.6 Inflate distal cuff by attaching small syringe to Line #2 Collegewith a slight twisting motion and inflating with 15 mL of air. 12.7 Remove small syringe from Line #2.
13. Confirm location of the tube. 13.1 Ventilate forcefully into the long blue connecting tube #1. 13.2 Observe for chest rise. 13.3 If chest rise is present: Auscultate breath sounds over lung fields bilaterally and over the epigastrium while providing ventilations with breaths or with oxygen delivered from a bag-valve device or positive pressure ventilator through the long, blue #1 tube. 13.4 If chest rise is absent while ventilating tube #1. Immediately begin ventilation through the clear #2 tube.
23 Combitube Airway (Continued)
Activity Critical Performance
13.5 Observe for chest rise. 13.6 If chest rise is present: Auscultate breath sounds over lung fields bilaterally and over the epigastrium. Cowley 13.7 Deliver ventilations with high flow oxygen delivered from a Bag-Valve device or positive pressure ventilator through Tube #2.
14. Unable to ventilate tube through either tube. 14.1 Remove Combitube and try a different airway device.
15. Chest rise and bilateral breath sounds are 15.1 Ventilate adult at least once every 5 seconds. present.
16. Check for tube displacement. 16.1 Check rings for proper alignment with teeth. 16.2 Auscultate breath sounds and epigastrium.
17. Removing Combitube. 17.1 Recognize the need for removing the Combitube: when the patient regains consciousness, bites or retches on the tube, grasping at the tube or an endotracheal tube is in place. 17.2 Use special precautions when removing the Combitube. Whenever Combitube is inserted or removed, gloves, mask and goggles shall be worn. 17.3 Turn patient onto side. College17.4 Ready suction equipment. 17.5 Disconnect Bag-Valve device. 17.6 Connect the depressed large syringe to Line #1 with a slight twisting motion. 17.7 Pull back on the syringe plunger until the 100 mL of air is aspirated from the pilot balloon and cuff. Ensure that pilot balloon is flat. 17.8 Connect the depressed small syringe to Line #2 with a slight twisting motion. 17.9 Pull back on the syringe plunger until the 15 mL of air is aspirated from the pilot balloon and cuff. 17.10 Withdraw the Combitube following the normal curvature of the upper airway.
18. Suction as needed. 18.1 Suction as needed.
19. Return patient to supine position. 19.1 Log roll patient.
20. Reassess Airway. 20.1 Look, listen and feel.
24 Combitube Airway (Continued)
Activity Critical Performance
21. Reassess Breathing. 21.1 Assess rate and depth.
22. Reassess Circulation. 22.1 Assess rate and quality.
Cowley23. Assess for hypoxia. 23.1 Assess skin color, oral membranes and nail beds. Obtain Sa02 if protocols allow.
24. Apply oxygen. 24.1 Apply supplemental oxygen in accordance with local protocols.
College
25 Tracheal Suctioning
Activity Critical Performances
1. Prepare the patient. 1.1 Preoxygenate the patient when possible with 100% oxygen. 1.2 While an assistant ventilates, assemble the equipment and put on sterile gloves. Cowley 1.3 Place patient on EKG monitor. 1.4 Put on goggles.
2. Advance catheter. 2.1 Have the assistant disconnect the bag. 2.2 Introduce catheter (with suction off) into the tube, without allowing the catheter to touch outside of tube. 2.3 Advance the catheter as far as possible with the suction off.
3. Suction. 3.1 Apply intermittent suction while slowly withdrawing the catheter, rotating it as it is withdrawn (must not take longer than 10 seconds).
4. Reoxygenate. 4.1 The assistant reoxygenates the patient as in Step 1. College
26 Blind Nasotracheal Suctioning
Activity Critical Performance
1. Assess need for endotracheal suctioning. 1.1 Note evidence of secretions in tracheobronchial tree. Encourage patient to deep breathe and cough; if unable, proceed with suctioning.
Cowley2. Prepare patient. 2.1 Elevate patient’s head. 2.2 Preoxygenate patient whenever possible. 2.3 If tolerated by patient, insert a soft nasopharyngeal airway. 2.4 Place on ECG monitor. 2.5 Ideally, patient should have a patent IV.
3. Prepare equipment. 3.1 Turn on suction. 3.2 Place lubricant on sterile 4x4. Consider lidocaine jelly or alpha stimulating agent. 3.3 Put on sterile gloves. 3.4 Using dominant hand, roll catheter (Adult 14 -16 Fr.) in lubricant.
4. Insertion. 4.1 Insert into nasal passage gently 8 - 10 cm without suction applied. 4.2 Advise patient to breathe deeply and slowly, while listening for airway sounds transmitted from catheter. (If sounds are absent, withdraw into pharynx and try again as you may be in the esophagus.) 4.3 Continue to advance catheter into trachea, withdrawing 1 - 2 cm if obstruction is met at Collegecarina.
5. Suction. 5.1 Apply intermittent suction with sterile hand while rotating catheter. 5.2 Do not suction for more than 5 - 10 seconds. 5.3 Repeat only if necessary
6. Reoxygenate patient. 6.1 Hyperventilation is utilized to reduce suction induced hypoxia.
27 Nebulized Breathing Treatment
Activity Critical Performances
1. Assemble equipment. 1.1 Universal precautions. 1.2 Connect oxygen tubing to flow meter and set at 6 - 8 LPM. 1.3 Connect mouthpiece and reservoir tube to “T” piece. Cowley 2. Assess and prepare patient. 2.1 Confirms patient allergies. 2.2 Listen to breath sounds. 2.3 Place patient in sitting position. 2.4 Instruct patient how to hold nebulizer.
3. Prepare medication. 3.1 Add the medication solution to the nebulizer reservoir. 3.2 Attach nebulizer reservoir to “T” piece. 3.3 Connect oxygen tubing to “T” piece or bottom of nebulizer reservoir.
4. Administer medication. 4.1 Instruct patient to place mouthpiece in mouth and breathe through mouth. 4.2 Monitor breath sounds at about the halfway point of administration (about 5 - 7 minutes). 4.3 Administration is complete when all 3 mL of medication is emptied from nebulizer reservoir.
5. Reassess patient. 5.1 Listen to breath sounds and note improvement or need for further Collegeintervention.
28 Valsalva Maneuver
Activity Critical Performance
1. Prepare the patient. 1.1 Start oxygen therapy and establish an intravenous infusion. Have atropine and external pacemaker readily available. 1.2 Monitor ECG rhythm and vital signs. 1.3 Explain the procedure to the patient. Cowley 2. Ask patient to start the maneuver. 2.1 With the patient in a sitting position, ask the patient to strain against a closed glottis for several seconds.
Do not allow the patient to strain against the closed glottis for more than several seconds and have the patient stop this procedure if any different signs or symptoms occur.
3. Observe monitor. 3.1 Continuously watch for ECG changes, stop if rate decreases. 3.2 Record ECG tracing.
4. Repeat as needed. 4.1 If needed, repeat the procedure after two or three minutes if vital signs remain stable. College
29 Carotid Sinus Massage
Activity Critical Performances
1. Prepare the patient. 1.1 Place patient supine. 1.2 Hyperextend the neck. 1.3 Turn the patient’s head to left side. 1.4 Attach EKG monitor. 1.5 Start oxygen administration and IV infusion. Cowley Have atropine and external pacemaker readily available. 1.6 Ensure that procedure is not contraindicated.
2. Locate the carotid pulse. 2.1 Palpate the carotid pulse on both sides (not simultaneously) to verify that they are equal. 2.2 Auscultate for bruits bilaterally.
3. Massage the right carotid artery. 3.1 Place index and middle fingers over the carotid artery below the angle of the jaw as high up as possible. 3.2 Massage the artery for 5 to 10 seconds by forcibly rubbing up and down on the carotid.
4. Check monitor. 4.1 Check monitor for EKG rhythm. Record EKG strip.
5. Repeat as needed. 5.1 Repeat the procedure on the left side after Collegetwo or three minutes, if indicated.
30 Synchronized Cardioversion Using Paddles
Activity Critical Performances
1. Verify rhythm. 1.1 Student should state the rhythm. 1.2 Student should run strip. 1.3 Student should take pulse.
2. Prepare monitor and patient for 2.1 Turn on power to defibrillator. Cowleycardioversion. 2.2 Engage synchronizer control. 2.3 Premedicate patient as needed.
3.1 Observe for flashing of synchronizer button 3. Verify and document that synchronizer is or other indication that the monitor is sensing sensing. the R wave. 3.2 Run ECG tracing.
4.1 Apply electrode paste to paddles as needed. 4. Prepare and apply paddles. 4.2 Place paddles or pads on chest in appropriate position.
Anterolateral: a. Place (- or sternum) paddle at right of sternum, just inferior to clavicle. b. Place (+ or apex) paddle lateral to left nipple, in the midaxillary line (at approximately 5th ICS)
Anterior-Posterior: a. Place one paddle at precordium. b. Place the other paddle at the posterior infrascapular area. College
5. Administer countershock. 5.1 Charge to appropriate energy level. 5.2 Verify that all personnel are clear of patient. 5.3 Shout “Clear.” 5.4 Press and hold discharge buttons.
6. Verify patient’s status. 6.1 Check monitor. 6.2 Check pulse.
31 Defibrillation (Unsynchronized Countershock) Using Paddles
Activity Critical Performances
1. Verify rhythm and determine need for 1.1 Student should state the rhythm. defibrillation. 1.2 Student should run ECG tracing. 1.3 Student should check pulse.
Cowley2. Prepare and apply paddles. 2.1 Apply electrode paste to paddles as needed. 2.2 Place paddles or pads on chest in appropriate position.
Anterolateral: a. Place (- or sternum) paddle at right of sternum, just inferior to clavicle. b. Place (+ or apex) paddle lateral to left nipple, in the midaxillary line (at approximately 5th ICS)
Anterior-Posterior: a. Place one paddle at precordium. b. Place the other paddle at the posterior infrascapular area.
3. Administer countershock. 3.1 Charge to appropriate energy level. 3.2 Verify that all personnel are clear of patient. 3.3 Shout “Clear.” 3.4 Press both discharge buttons.
4. Verify patient’s status. 4.1 Check monitor. 4.2 Check pulse (if appropriate). College
32 Remote Synchronized Cardioversion Using Fastpatch or Combo Patch
Activity Critical Performances 1. Verify rhythm. 1.1 Student should state the rhythm. 1.2 Student should run strip. 1.3 Student should take pulse.
2. Prepare the patient’s chest. 2.1 Clean and dry the skin. 2.2 Snip or shave hair if needed. Cowley 3. Connect patient. 3.1 Snap cables onto pad. 3.2 Slowly peel backing from the pad. 3.3A Apply pads firmly to patient in the anterolateral configuration. (Preferred) a. Sternum pad below the right clavicle just to the right of the sternum. b. Apex pad on the lower rib margin with the center of the pad on the mid-axillary line (approximately V6). 3.3B Apply pads firmly to the patient in the anterior/posterior configuration. a. Anterior pad over the apex of the heart. Center of the pad at the 5th or 6th intercostal space mid-clavicular line. b. Posterior pad below the scapula to the left of the spinal column
4. Select a lead. 4.1 Press “Lead Select” to select lead with tallest QRS complex.
5. Select synch mode. 5.1 Push “synch” button look for synch mode indicator on screen. College 6. Ensure and document sensing of QRS 6.1 Observe monitor for synch markers on each complex. QRS complex. Adjust the ECG size up or down until marker occurs within the QRS complex. 6.2 Run ECG tracing.
7. Confirm need for synchronized 7.1 Reassess the patient and ECG. cardioversion. 8.1 Select energy by using the “Energy Select” dial 8. Cardiovert. located on sternum paddle. 8.2 Charge the machine by pushing and releasing the “Charge” button on the apex paddle. 8.3 Warn personnel on scene you are preparing to shock and ensure that no one is touching the patient. Shout “clear.” 8.4 Deliver the shock by pushing discharge buttons on both paddles simultaneously and holding in this position until the shock is delivered. 8.5 Repeat steps 5 - 8 if subsequent synchronized cardioversions are needed.
33 Remote Defibrillation Using Fastpatch or Combo Patch
Activity Critical Performances
1. Verify rhythm and determine need for 1.1 Student should state the rhythm. defibrillation. 1.2 Student should run ECG tracing. 1.3 Student should check pulse.
2. Prepare the patient’s chest. 2.1 Clean and dry the skin. Cowley 2.2 Snip or shave hair if needed.
3. Connect patient. 3.1 Snap cables onto pad. 3.2 Slowly peel backing from the pad. 3.3A Apply pads firmly to patient in the anterolateral configuration. (Preferred) a. Sternum pad below the right clavicle just to the right of the sternum. b. Apex pad on the lower rib margin with the center of the pad on the mid-axillary line (approximately V6). 3.3B Apply pads firmly to the patient in the anterior/posterior configuration. a. Anterior pad over the apex of the heart. Center of the pad at the 5th or 6th intercostal space mid-clavicular line. b. Posterior pad below the scapula to the left of the spinal column.
4. Select paddles. 4.1 Press “Lead Select” until paddles are shown if you wish to monitor through the patches. It is not necessary if limb leads are placed and leads I - III are selected for monitoring. College 5. Determine need for defibrillation. 5.1 Assess the patient and ECG.
6. Defibrillate. 6.1 Select energy by using the “Energy Select” dial located on sternum paddle. 6.2 Charge the machine by pushing and releasing the “Charge” button on the apex paddle. 6.3 Warn personnel on scene you are preparing to shock and insure that no one is touching the patient. Shout “clear.” 6.4 Deliver the shock by pushing discharge buttons on both paddles simultaneously.
7. Verify patient’s status. 7.1 Check monitor. 7.2 Check pulse (if appropriate).
34 External Cardiac Pacing Using Quikpace or Combo Patch
Activity Critical Performance 1. The technician describes the indications for pacing. (symptomatic bradycardia and/or heart block)
Cowley2. Technician describes patient preparation to 2.1 Monitoring patient with patient cable/EKG include: electrodes. 2.2 Adjusting EKG/QRS amplitude so the monitor identifies the QRS complex. 2.3 Cleaning the chest and clipping across hair prior to pacing pad placement.
3. Pacing electrode placement: the technician 3.1 ANTEROLATERAL PLACEMENT: describes appropriate placement of pacing 3.1.1 Places negative electrode on left anterior pads for anterior and anterior/posterior chest, mid axillary over 4th ICS. placements. 3.1.2 Places positive electrode on right anterior chest, subclavicular. If Quikpace patches are used, the best location 3.2 ANTERIOR/POSTERIOR PLACEMENT: for placement is anterior/posterior. 3.2.1 Places the negative electrode on anterior If Combo patches are used, the best location chest, halfway between xiphoid process and for placement is anterolateral. left nipple with upper edge of the electrode below the nipple. 3.2.2 Places the positive electrode on the left posterior chest beneath the scapula and lateral to the spine.
4. Pacing Procedure. 4.1 Turns power source on. 4.2 Connects ECG electrodes to patient cable Collegeand to patient. 4.3 Prepares skin for electrodes by clipping hair and cleaning skin with alcohol wipe and allowing to dry. 4.4 Connects pacing cable to PACE connector on monitor side of the Life Pak. 4.5 Connects pacing electrode to pacing cables. 4.6 Places pacing electrodes on patient’s chest according to appropriate pad placements. 4.7 Pushes PACER button ----adjacent indicator will illuminate. 4.8 Selects pacing rate to 80. 4.9 observes cardioscope for sensing of QRS complex and adjusts ECG size and lead to accommodate sensing. 4.10 Activates pacing by pushing the start/stop button --adjacent indicator will flash on and a positive spike will be seen on the ECG display with each delivered pacing stimulus.
35 External Cardiac Pacing Using Quikpace or Combo Patch (continued)
4.11 Adjusts current in increments of 20 MA until an MA strength of 60 MA is reached, then increase in 5 MA increments while observing cardioscope for evidence of electrical capture --assesses patient’s pulse for perfusion and correlation with cardioscope. Cowley 4.12 Technician records pacing by pushing record button. 4.13 Technician terminates pacing by pushing start/stop button --adjacent indicator will go off.
5. Consider administration of Valium/Versed 5.1 Evaluates patient’s pain tolerance. or opiod for pain control.
College
36 Acquiring a 12-Lead ECG
Activity Critical Performance
1. Prepare the patient. 1.1 Explain procedure to reduce anxiety. 1.2 Clean and dry the skin. 1.3 Snip or shave hair if needed.
2. Prepare monitor. 2.1 Turn power ON and adjust CONTRAST as Cowley needed. 2.2 Insert limb lead and the precordial lead attachments into the main ECG cable. 2.3 Place cable into connector on LP 11. 2.4 Attach a new electrode to each of the 10 lead wires.
3. Place electrodes on patient. 3.1 Place limb leads on the extremities (not torso). 3.2 Place the precordial leads: V1: 4th ICS, RSB V2: 4th ICS, LSB V3: Directly between V2 and V4 V4: 5th ICS, MCL V5: Level with V4 at left anterior axillary line V6: Level with V5 at left midaxillary line Note: Proper placement is essential. When placing electrodes on female patients, always place leads V3 - V6 under the breast.
4. Perform 12-lead assessment. 4.1 Encourage the patient to remain as still as possible. 4.2 Stop external motion/movement. College4.3 Depress 12 LEAD once to acquire and print the ECG report.
37 Biomedical Communications
1. Identify unit.
2. Provide: a. brief situational description (assault, MI, etc.) b. LOC Cowleyc. age d. sex
3. Past medical history and medications, allergies
4. Chief complaint(s): a. Onset of problem b. Provocative/palliative factors c. Quality d. Region/radiation e. Severity f. Time g. Associated symptoms h. Pertinent negatives
5. Patient’s vitals: a. BP b. pulse c. respiratory rate d. level of consciousness e. skin College f. pupil status g. O2 saturation h. EKG i. CO2
6. Relay pertinent secondary survey findings.
7. a. Treatment given prior to contacting the hospital and results of that treatment b. treatment requested c. mode of transport (PRN)
8. ETA
9. Allow hospital to respond and repeat back any orders
10. Advise hospital of plan of treatment during transport
38 Patient Assessment -- History (SAMPLE)
1. Ascertain chief complaint
2. History of present illness (HPI) -- expansion of the chief complaint -- (OPQRST-ASPN) a. Onset -- What were you doing? Sudden or gradual onset? b. Provocation/Palliation -- What makes it better (or worse)? Cowleyc. Quality -- What does it feel like? d. Region/Radiation -- Where is symptom? Does it radiate? e. Severity -- How bad is the pain? (Scale of 1-10 with 10 worst) f. Time -- When did the symptoms begin? How long? Intermittent/constant? g. Associated Symptoms -- Are symptoms commonly associated with this condition present? h. Pertinent Negatives -- Are any likely associated symptoms absent?
3. Allergies
4. Medications a. Name and dosage b. Compliance
5. Medical history; (PMHx) specifically: a. Endocrine (diabetes and thyroid) b. CVD (failure or hypertension) c. CAD d. Epilepsy e. Pulmonary disease f. Surgical or trauma history College g. Other conditions
6. Last oral intake
7. Events leading to current situation
39 Patient Assessment – Trauma Patient
Cowley
College
40 National Registry of Emergency Medical Technicians Advanced Level Practical Examination
PATIENT ASSESSMENT - TRAUMA
Candidate: ______Examiner: ______Date: ______Signature: ______Scenario # ______Possible Points Time Start: ______NOTE: Areas denoted by “**” may be integrated within sequence of Initial Assessment Points Awarded Takes or verbalizes body substance isolation precautions 1 SCENE SIZE-UP Determines the scene/situation is safe 1 Determines the mechanism of injury/nature of illness 1 Determines the number of patients 1 CowleyRequests additional help if necessary 1 Considers stabilization of spine 1 INITIAL ASSESSMENT/RESUSCITATION Verbalizes general impression of the patient 1 Determines responsiveness/level of consciousness 1 Determines chief complaint/apparent life-threats 1 Airway 2 -Opens and assesses airway (1 point) -Inserts adjunct as indicated (1 point) Breathing -Assess breathing (1 point) -Assures adequate ventilation (1 point) 4 -Initiates appropriate oxygen therapy (1 point) -Manages any injury which may compromise breathing/ventilation (1 point) Circulation -Checks pulse (1point) -Assess skin [either skin color, temperature, or condition] (1 point) 4 -Assesses for and controls major bleeding if present (1 point) -Initiates shock management (1 point) Identifies priority patients/makes transport decision 1 FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID TRAUMA ASSESSMENT Selects appropriate assessment 1 Obtains, or directs assistant to obtain, baseline vital signs 1 Obtains SAMPLE history 1 DETAILED PHYSICAL EXAMINATION Head -Inspects mouth**, nose**, and assesses facial area (1 point) 3 -Inspects and palpates scalp and ears (1 point) -Assesses eyes for PERRL** (1 point) Neck** -Checks position of trachea (1 point) 3 -Checks jugular veins (1 point) College -Palpates cervical spine (1 point) Chest** -Inspects chest (1 point) 3 -Palpates chest (1 point) -Auscultates chest (1 point) Abdomen/pelvis** -Inspects and palpates abdomen (1 point) 3 -Assesses pelvis (1 point) -Verbalizes assessment of genitalia/perineum as needed (1 point) Lower extremities** 2 -Inspects, palpates, and assesses motor, sensory, and distal circulatory functions (1 point/leg) Upper extremities 2 -Inspects, palpates, and assesses motor, sensory, and distal circulatory functions (1 point/arm) Posterior thorax, lumbar, and buttocks** -Inspects and palpates posterior thorax (1 point) 2 -Inspects and palpates lumbar and buttocks area (1 point) Manages secondary injuries and wounds appropriately 1 Performs ongoing assessment 1
Time End: ______TOTAL 43
CRITICAL CRITERIA ____ Failure to initiate or call for transport of the patient within 10 minute time limit ____ Failure to take or verbalize body substance isolation precautions ____ Failure to determine scene safety ____ Failure to assess for and provide spinal protection when indicated ____ Failure to voice and ultimately provide high concentration of oxygen ____ Failure to assess/provide adequate ventilation ____ Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock [hypoperfusion] ____ Failure to differentiate patient’s need for immediate transportation versus continued assessment/treatment at the scene ____ Does other detailed/focused history or physical exam before assessing/treating threats to airway, breathing, and circulation ____ Orders a dangerous or inappropriate intervention
You must factually document your rationale for checking any of the above critical items on the reverse side of this form.
© 2000 National Registry of Emergency Medical Technicians, Inc., Columbus, OH All materials subject to this copyright may be photocopied for the non-commercial purpose of educational or scientific advancement. p301/8-003k Patient Assessment – Medical Patient
Cowley
College
42 National Registry of Emergency Medical Technicians Advanced Level Practical Examination
PATIENT ASSESSMENT - MEDICAL
Candidate: ______Examiner: ______Date: ______Signature: ______
Scenario:______Possible Points Time Start: ______Points Awarded Takes or verbalizes body substance isolation precautions 1 SCENE SIZE-UP Determines the scene/situation is safe 1 CowleyDetermines the mechanism of injury/nature of illness 1 Determines the number of patients 1 Requests additional help if necessary 1 Considers stabilization of spine 1 INITIAL ASSESSMENT Verbalizes general impression of the patient 1 Determines responsiveness/level of consciousness 1 Determines chief complaint/apparent life-threats 1 Assesses airway and breathing -Assessment (1 point) 3 -Assures adequate ventilation (1 point) -Initiates appropriate oxygen therapy (1 point) Assesses circulation -Assesses/controls major bleeding (1 point) -Assesses skin [either skin color, temperature, or condition] (1 point) 3 -Assesses pulse (1 point) Identifies priority patients/makes transport decision 1 FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT History of present illness -Onset (1 point) -Severity (1 point) -Provocation (1 point) -Time (1 point) 8 -Quality (1 point) -Clarifying questions of associated signs and symptoms as related to OPQRST (2 points) -Radiation (1 point) Past medical history -Allergies (1 point) -Past pertinent history (1 point) -Events leading to present illness (1 point) 5 -Medications (1 point) -Last oral intake (1 point) Performs focused physical examination [assess affected body part/systemCollege or, if indicated, completes rapid assessment] -Cardiovascular -Neurological -Integumentary -Reproductive 5 -Pulmonary -Musculoskeletal -GI/GU -Psychological/Social Vital signs -Pulse (1 point) -Respiratory rate and quality (1 point each) 5 -Blood pressure (1 point) -AVPU (1 point) Diagnostics [must include application of ECG monitor for dyspnea and chest pain] 2 States field impression of patient 1 Verbalizes treatment plan for patient and calls for appropriate intervention(s) 1 Transport decision re-evaluated 1 ON-GOING ASSESSMENT Repeats initial assessment 1 Repeats vital signs 1 Evaluates response to treatments 1 Repeats focused assessment regarding patient complaint or injuries 1 Time End: ______CRITICAL CRITERIA TOTAL 48 _____ Failure to initiate or call for transport of the patient within 15 minute time limit _____ Failure to take or verbalize body substance isolation precautions _____ Failure to determine scene safety before approaching patient _____ Failure to voice and ultimately provide appropriate oxygen therapy _____ Failure to assess/provide adequate ventilation _____ Failure to find or appropriately manage problems associated with airway, breathing, hemorrhage or shock [hypoperfusion] _____ Failure to differentiate patient’s need for immediate transportation versus continued assessment and treatment at the scene _____ Does other detailed or focused history or physical examination before assessing and treating threats to airway, breathing, and circulation _____ Failure to determine the patient’s primary problem _____ Orders a dangerous or inappropriate intervention _____ Failure to provide for spinal protection when indicated You must factually document your rationale for checking any of the above critical items on the reverse side of this form. © 2000 National Registry of Emergency Medical Technicians, Inc., Columbus, OH All materials subject to this copyright may be photocopied for the non-commercial purpose of educational or scientific advancement. p302/8-003k Administration of Medication Through ET Tube
Activity Critical Performances
1. Prepare for procedure. 1.1 Prepare flush (10 mL of N.S. for adults and several milliliters for pediatric patients). 1.2 Prepare appropriate E.T. delivery device. 1.3 Confirms patient allergies.
Cowley2. Hyperventilate patient. 2.1 Hyperventilate patient.
3. Administer medication. 3.1 Administer the medication via any of the acceptable three options listed below. 3.2 Flush with N.S. after medication administration.
4. Hyperventilate patient. 4.1 Ventilate for 3 - 4 insufflations.
Endotracheal Administration of Medications (options for proper utilization)
Administer the medication through a long, thin catheter which is placed down the tube.
Place a 20 gauge needle through the E.T. tube with a heparin lock device attached to the needle hub. Administer the medication into the lock -- this will partially aerosolize the medication.
Use a commercially prepared E.T. tube which has a port designed for administering medications via the tube. College
44 External Jugular Vein Catheterization
Activity Critical Performances
1. Prepare vein. 1.1 Patient supine at least 15° head down position, head turned away toward side. 1.2 Cleanse skin, use lidocaine if patient is awake and large bore needle is used.
Cowley2. Position catheter/stylet. 2.1 Align needle in the direction of the vein with the point aimed toward the ipsilateral shoulder. The point should lie over the vein or immediately lateral to the vein.
3. Make venipuncture. 3.1 Make venipuncture midway between the angle of the jaw and mid-clavicular line tourniqueting the vein lightly with one finger above the clavicle. 3.2 Note blood return.
4. Advance catheter/stylet into vein. 4.1 Advance catheter/stylet into vein lumen about ½ cm.
5. Advance catheter. 5.1 Advance catheter. 5.2 Tamponade vein distal to catheter tip with finger.
6. Attach IV tubing. 6.1 Remove stylet. 6.2 Attach IV tubing. 6.3 Release finger maintaining venous obstruction. College6.4 Secure IV site.
45 IM Injection
Activity Critical Performances
1. Prepare for injection. 1.1 Confirms patient allergies. 1.1 Student evaluates appropriate injection site (deltoid muscle, upper outer quadrant of gluteus). 1.2 Selects appropriate syringe and needle (21 Cowley ga., 1 - 1.5 inch). 1.3 Checks medication label, computes the dosage, correctly draws up the dosage. 1.4 Cleanse the injection site. 1.5 Expels any air from the syringe. 1.6 Sketch skin over the injection site.
2. Inject medication. 2.1 Insert needle at a 90° angle. 2.2 Aspirates syringe. 2.3 Injects medication.
3. Withdraw needle. 3.1 Withdraws needle smoothly. 3.2 Apply pressure over site.
College
46 Intracardiac Injection (reference only)
Activity Critical Performances
1. Assemble equipment. 1.1 Assemble 18 ga 3-1/2" (8.9 cm) needle attached to syringe with medication to be injected. 1.2 Make available appropriate antiseptic. Cowley 2. Ascertain allergies. 2.1 Confirms patient allergies.
3. Locate area. 3.1 Locate area left at xiphoid process 1 cm below costal margins.
4. Cleanse area. 4.1 Cleanse area with appropriate antiseptics.
5. Insert needle. 5.1 Align needle at a 45° angle. Advance about 1 cm to a point just below the ribs. Align needle in a 20° to 30° angle with reference to the chest/abdomen wall and advance toward the ipsilateral shoulder. Aspirate while advancing needle.
5.1 Stop insertion once blood is aspirated into syringe. 5.2 If no blood appears, slowly withdraw needle maintaining suction, then repeat.
6. Observe blood return. 6.1 Rapidly inject dosage.
7. Inject medication. 7.1 Smoothly remove needle in identical plane of Collegeinsertion.
8. Withdraw needle. 8.1 Rapidly withdraw needle.
47 Pericardiocentesis (reference only)
Activity Critical Performances
1. Assemble equipment. 1.1 Assemble 18 ga 3-1/2" (8.9) needle attached to syringe with medication to be injected. 1.2 Make available appropriate antiseptic.
Cowley2. Locate area. 2.1 Locate area left at xiphoid process 1 cm below costal margins.
3. Cleanse area. 3.1 Cleanse area with appropriate antiseptics.
4. Insert needle. 4.1 Align needle at a 45° angle. Advance about 1 cm to a point just below the ribs. Align needle in a 20° to 30° angle with reference to the chest/abdomen wall and advance toward the ipsilateral shoulder. Aspirate while advancing needle.
5. Observe blood return. 5.1 Stop advancing once blood is aspirated into syringe. 5.2 If no blood appears, slowly withdraw needle maintaining suction, then repeat.
6. Aspirate blood. 6.1 Aspirate blood until no return is noted.
7. Withdraw needle. 7.1 Smoothly remove needle in identical plane of insertion.
College
Activity Critical Performance
1. Prepare equipment 1.1 Gather 14 - 16 gauge IO needle, 20 mL syringe, extension tubing, saline, IV solution, IV tubing and prep equipment. 1.2 Fill syringe with saline, attach IV extension tubing to the syringe and fill tubing with Cowley saline. 1.2 If bone marrow needle is utilized, it should be adjusted to its shallowest setting. 1.3 Assemble IV solution, tubing.
2. Locate site for injection. 2.1 Locate tibial tuberosity. 2.2 Space off 1 - 2 finger widths below tuberosity in the medial aspect.
3. Insert needle. 3.1 Cleanse area. 3.2 Position needle with slight inferior angle, perpendicular to tibia. 3.3 Hold needle between first two fingers by the needle hub if a bone marrow needle is utilized. 3.4 Insert with firm rotating motion until a “give” is felt or until needle is fully inserted.
4. Verify needle location. 4.1 Confirmation of correct placement can be noted in the following ways: a. Attach the 20 mL syringe filled with normal saline which is attached to IV extension tubing onto the needle and College aspirate. If in proper position, red bone marrow may be aspirated. Flush the solution into the bone and look for infiltration. b. “Nail in board” appearance. c. Feeling a pop when entering medullary cavity. d. Fluid runs without edema at site.
5. Attach and anchor IV tubing. 5.1 Attach IV tubing to the extension tubing already attached to the IO needle. 5.2 Open flow clamp. 5.3 Tape needle in place, looping tubing. 5.4 Apply bulky dressing for support. 5.5 Apply padded rigid splint. 5.6 Do not cover needle site.
6. Medication administration. 6.1 Administer medications, as needed, similar to I.V. administration.
49 EZ-IO Activity Critical Performance
1. Determine patient need. 1.1 Traditional vascular access techniques are not possible. 2. Rule out contraindications to the device. 2.1 Fracture (fluid may extravasate into subcutaneous tissue). 2.2 Excessive tissue and/or absence of adequate anatomical landmarks. Cowley 2.3 Infection at the area of insertion. 2.4 Previous, significant orthopedic procedure at the site (IO in past 24 hours, prosthetic limb or joint).
3. Insert appropriate size catheter. 3.1 Observe BSI precautions. 3.2 Maintain aseptic technique during usage. 3.3 Locate proximal tibia insertion site. 3.4 Prepare insertion site. 3.5 Prepare infusion system. 3.6 Ensure that the driver and needle are securely seated. 3.7 Remove and discard the needle set safety cap from the IO needle set installed on the EZ-IO power driver. 3.8 Insert EZ-IO into proper site.
4. Remove power driver and stylet 4.1 Lift power driver straight up.
5. Confirm catheter stability. 5.1 Catheter should be firmly in place.
6. Attach EZ-Connect extension set to catheter 6.1 DO NOT ATTACH A SYRINGE DIRECTLY hub’s luer lock. TO THE EZ-IO CATHETER HUB (Doing so Collegemay cause enlargement of the hole at the insertion site and possible extravasation).
7. Flush the EZ-IO. 7.1 EZ-IO AD (adult) 10 ml NS. 7.2 EZ-IO PD (pediatric) 5 ml NS. 7.3 Consider preservation free IO Lidocaine for conscious patients prior to flush.
8. Attach IV tubing. 8.1 Infuse IV fluid. A pressure bag may be useful.
9. Apply dressing. 9.1 Cover site.
10. Removal. 10.1 Gently twist clockwise while slowly applying traction to the catheter. DO NOT rock or bend the catheter during this procedure.
50 IV Venipuncture Activity Critical Performances
1. Apply tourniquet. 1.1 Place TQ under proximal third of extremity. 1.2 Grasp ends of TQ with two hands. 1.3 Stretch TQ to about three times its original length. 1.4 While maintaining traction on TQ bring the hands together in front of the extremity. Cowley 1.5 While maintaining traction, cross ends of TQ, grab both ends in one hand where TQ ends cross. 1.6 While maintaining traction, fold about one half of the end nearest to you under the band circling the extremity. 1.7 Release traction.
2. Prepare vein. 2.1 Utilizing the fingers, tap the vein four or five times in about three or four seconds. 2.2 Prepare site with antiseptic solution.
3. Prepare catheter. 3.1 Pick up the catheter and remove the needle guard; place catheter in dependent hand. 3.2 Inspect catheter for defects. 3.3 Hold catheter with the thumb on top and the forefinger on the bottom. The needle bevel should be up.
4. Pull traction. 4.1 Utilizing the nondependent hand, pull the skin taut in the area selected for venipuncture.
5. Position catheter stylet. College5.1 Gently place the stylet point one-half centimeter lateral the vein or above the vein. 5.2 Adjust the stylet so that it is held at no more than a 20 degree down angle in respect to the vein.
6. Insert the catheter/stylet. 6.1 Rapidly insert the catheter/stylet through the skin. 6.2 Slightly angle the catheter/stylet toward the vein. 6.3 Advance the catheter in a rapid motion into the vein until flashback is noted (a pop may be felt as needle penetrates vein wall). 6.4 Adjust the catheter parallel to the vein lumen.
7. Advance the catheter/stylet into vein. 7.1 Advance the catheter about one-half centimeter into the lumen of the vein.
51 IV Venipuncture (continued)
Activity Critical Performance
8. Release traction. 8.1 Release skin traction.
9. Advance catheter. 9.1 While holding the catheter stylet with the nondependent hand, advance the catheter Cowley into the vein until no further advancement is possible. 9.2 Hold catheter and stylet with one hand.
10. Release TQ. 10.1 With free hand, grasp the short end of the TQ and pull, releasing TQ.
11. Connect tubing. 11.1 With two fingers of the free hand, tamponade off the vein just proximal to the end of the catheter. 11.2 Release support of the catheter and remove the stylet with that hand. 11.3 Connect IV tubing. 11.4 Release pressure above catheter tip. 11.5 Secure IV site. College
52 SQ Injection
Activity Critical Performances
1. Prepare for injection. 1.1 Confirms patient allergies. 1.2 Medication administration. 1.3 Student evaluates appropriate injection site (upper arm, abdomen). 1.4 Selects appropriate syringe and needle (25 Cowley ga. ½ inch). 1.5 Checks medication label, computes the dosage, correctly draws up the dosage. 1.6 Cleanse the injection site. 1.7 Expels any air from the syringe. 1.8 Pinch skin.
2. Inject medication. 2.1 Insert needle at 45° angle. 2.2 Aspirates syringe. 2.3 Injects medication.
3. Withdraw needle. 3.1 Withdraws needle smoothly. 3.2 Apply pressure over site.
College
53 Air Splint Application (reference only)
Activity Critical Performances
1. Support the limb. 1.1 The injured limb should be supported at the fracture site and adjacent area by an assistant. Cut away clothing. 1.2 Align a limb that has been severely deformed Cowley with gentle in-line manual traction.
2. Perform neurovascular exam. 2.1 Check distal pulse. 2.2 Check sensation. 2.3 Check motor movement. 2.4 Check for capillary refill. 2.5 Dress open wounds.
3. Prepare the splint. 3.1 Student should correctly choose the appropriate size air splint for the fracture.
4. Position the splint. 4.1 For forearm and wrist injuries, the student should place the splint so that the student’s hand is through the narrow wrist end of the splint. 4.2 For forearm and wrist injuries, grasp the patient’s hand as one would in shaking hands. With the free hand, position the splint along the arm. The assistant’s hands are now inside the splint applying manual support. 4.3 Make sure the fingers are enclosed within the splint. 4.4 For leg injuries, the limb should be lifted and Collegethe air splint positioned by the student. Care should be exercised to assure the heel is well positioned in the heel of the splint.
5. Inflate splint. 5.1 Student should inflate or direct the inflation of the splint until finger pressure will make a slight dent in the splint.
6. Perform neurovascular exam. 6.1 Check motor function. 6.2 Check sensation. 6.3 Check capillary refill. 6.4 Observe color.
54 Chest Decompression
Activity Critical Performances
1. Assemble equipment. 1.1 Gather 1 ½ - 2" large bore IV catheter, one way valve made from finger of a glove or premade, antiseptic prep, rubber band or tape.
Cowley2. Locate and prepare puncture site. 2.1 Locate juncture of third rib and mid-clavicular line. 2.2 Clean the skin in the puncture area with an appropriate antiseptic solution.
3. Insert catheter/stylet. 3.1 Position catheter/stylet at the top of the third rib perpendicularly to the chest wall. 3.2 Advance the catheter/stylet over the top of the third rib into the second intercostal space. 3.3 A “pop” should be felt when the pleural space is accessed. 3.4 Advance the catheter while holding the stylet stationary. 3.5 Remove stylet. 3.6 Listen for a “hiss” of trapped air which verifies existence of pneumothorax.
4. Attach one-way valve. 4.1 Cut the middle finger from a sterile glove making the finger as long as possible. 4.2 Cut a small hole in one end of glove. 4.3 Attach open end to catheter hub with tape or rubber band.
NOTE: The one-way valve can also be Collegefashioned by cutting the middle finger from a sterile glove passing the catheter/stylet all the way through the cut finger puncturing the end of the glove with the stylet.
5. Secure the catheter. 5.1 Secure the catheter and one-way valve in place with tape. 5.2 Check for air movement.
6. Check for relief of tension pneumothorax. 6.1 Auscultate BBS. 6.2 Check vital signs. 6.3 Check trachea.
55 Kendrick Extrication Device (KED)
Activity Critical Performances
1. Assess patient status and provide initial 1.1 Perform patient assessment (including resuscitation. neurovascular status) while assistant maintains C-spine support. (See patient assessment task analysis.)
Cowley2. Measure and apply C-collar. 2.1 Properly apply a correctly sized C-collar.
3. Prepare and place extrication device. 3.1 Maintain proper cervical support. 3.2 Arrange device and straps for placement. 3.3 Support patient’s torso. 3.4 Person at head gives three (3) count to coordinate move. 3.5 Move patient as a unit. 3.6 Maintain support of head and torso during placement of device. 3.7 Move patient as a unit back to the device on a three (3) count.
4. Secure torso to device. 4.1 Release leg straps from supports and place out of the way. 4.2 Wrap chest supports around torso with KED snug under arm pits. 4.3 Buckle chest straps. 4.4 Pad groin areas. 4.5 Place leg straps under the patient’s legs. 4.6 Secure leg straps around the leg to the same side or opposite side.
5. Secure head to board. 5.1 Pad existing space behind neck and head Collegewithout flexion or hyperextension. 5.2 Wrap head supports around head. 5.3 Place and secure forehead strap and C-collar to board.
6. Readjust straps as needed. 6.1 Tighten top chest strap. 6.2 Recheck all straps for proper application and correct fit.
7. Check neurovascular status of all extremities. 7.1 Complete a neurovascular check of all extremities.
56 Kansas Short Spine Board (reference only)
Activity Critical Performances
1. Assess patient status and provide initial 1.1 Perform patient assessment (including resuscitation. neurovascular status) while assistant maintains C-spine support.
Cowley2. Measure and apply C-collar. 2.1 Properly apply a correctly sized C-collar.
3. Prepare and place short spine board. 3.1 Maintain proper cervical support. 3.2 Arrange board and straps for placement 3.3 Support patient’s torso. 3.4 Person at head gives three (3) count to coordinate move. 3.5 Move patient as a unit. 3.6 Maintain support of head and torso during placement of short board. 3.7 Slide center board into proper position. 3.8 Move patient as a unit back to the board on a three (3) count.
4. Secure torso to board. 4.1 Loosely fasten chest straps. 4.2 Pad groin areas (as needed). 4.3 Position groin straps from uninjured side and secure. 4.4 Tighten chest straps without compromising breathing.
5. Secure head to board. 5.1 Pad existing space behind neck and head without flexion or hyperextension. 5.2 Place head support cushions on shoulders Collegeand secure to board. 5.3 Place and secure forehead and C-collar straps to board.
6. Check and readjust straps. 6.1 Recheck all straps for proper application and correct fit.
7. Check neurovascular status of all extremities. 7.1 Complete a neurovascular check of all extremities.
57 Long Spine Board Application
Activity Critical Performances
1. Apply cervical collar, perform neurovascular 1.1 Student should correctly apply cervical collar check. assuring proper fit and patency of airway. 1.2 Manually support head. 1.3 Perform neurovascular check: a. distal pulse. Cowley b. motor function. c. sensation. d. capillary refill.
2. Position rescuers. 2.1 Student should position rescuers at shoulders and hips of patient. If available, a rescuer should be positioned to move the board under the patient.
3. Position board. 3.1 Student places long spine board flat on ground or floor next to victim. The bottom edge of the spine board should be positioned slightly below the patient’s buttocks.
4. Roll patient as a unit. 4.1 Student log rolls victim to side on command as a unit. The student at the victim’s head should issue the command to move the patient.
5. Roll patient onto board. 5.1 Board should be slid in position as close as possible to the patient. The bottom of the board should be slightly below the patient’s buttocks. 5.2 On command, as a unit, the patient should be rolled back onto the board. College 6. Slide patient onto board. 6.1 Student should direct assistants to prepare to slide patient. 6.2 One assistant should move the upper torso, and one should move the pelvis. The student should support the head. 6.3 On the student’s command, the patient should be slid about 12 - 18" onto the board. 6.4 The student should redirect positioning of assistants if necessary. 6.5 On command, the patient should be moved the rest of the way onto the board.
7. Immobilize the patient. 7.1 The student should direct or maintain support of the head. 7.2 The student should direct immobilization of the body as follows: a. strap above the patient’s knees. b. across the patient’s hips. c. across the chest and arms below the shoulders.
58 Long Spine Board Application (continued)
7.3 The head should be immobilized to the spine board utilizing foam blocks or blanket roll, and tape. 7.4 The feet and hands should be secured as Cowley needed.
8. Perform neurovascular check. 8.1 Perform neurovascular check as follows a. distal pulse. b. motor function. c. sensation. d. capillary refill.
College
59 Patient Handling
Activity Critical Performances
1. Obtain needed equipment and one assistant. 1.1 Weighted manikin weighing approximately 145 pounds. 1.2 LSB. 1.3 Ferno Washington patient transporter. Cowley 1.4 Ambulance vehicle.
2. Place weighted manikin on LSB on floor and place cot in lowest position beside LSB.
3. Lift LSB to cot. 3.1 Student at patient’s head counts 1-2-3 lift. 3.2 Student lifts with legs keeping back straight. 3.3 Student lifts smoothly, safely, and without undue exertion.
4. Lift cot to highest position. 4.1 Student at head of cot. 4.2 Student lifts with legs keeping back straight.
5. Load cot into ambulance vehicle. 5.1 Student at foot of cot. 5.2 Student lifts until all four wheels are off ground. 5.3 Student grasps wheel release lever. 5.4 Assistant retracts wheel carriage. 5.5 Student guides cot into brackets. 5.6 Student latches cot securely.
6. Unload cot from ambulance vehicle. 6.1 Student at foot of cot. 6.2 Student unlatches cot and slides from unit. College6.3 Student grasps wheel release lever and assistant lowers wheels. 6.4 Student removes cot from unit directing assistant to release safety latch.
60 Pneumatic Anti-Shock Garment (reference only, no longer used in the pre-hospital setting)
Activity Critical Performances
1. Identify need for PASG. 1.1 Evaluate the following criteria: a. mechanism of injury Cowley b. pulse c. respirations d. level of consciousness e. skin changes 1. capillary refill 2. color 3. diaphoresis 4. temperature f. blood pressure g. lung sounds 1.2 Compare assessment findings with criteria for need. If patient meets criteria without contraindications or with physician concurrence for use in relative contraindications, prepare PASG for application. 1.3 Criteria for need: a. systolic BP < 90 mm Hg b. pulse > 120 c. decreased LOC d. pale, cool, moist skin e. capillary refill > 2 seconds f. increased respiratory rate 1.5 Some recommend that these only be used for unstable pelvic fractures with shock, used as an Collegeair splint or as a device for pressure dressings.
2.1 Remove patient’s clothing. 2. Prepare PASG for application. 2.2 Apply sterile dressing to wounds. 2.3 Place patient on/in PASG. Maintain spinal integrity throughout procedure.*
3.1 Locate costal margin and ensure that PASG is 3. Assure correct position and fit. placed below the ribs. 3.2 Align center of pants with patient’s spine. 3.3 Wrap pants around legs and abdomen. Secure Velcro fasteners.
4.1 Attach inflation hoses. 4. Connect system. 4.2 Close abdominal hose stopcock and open leg hose stopcocks. * Kansas allows three methods of PASG application. a. open face tug b. log roll c. pants style application
61 Pneumatic Anti-Shock Garment Skill Criteria (continued)
Activity Critical Performances
5. Begin inflation. 5.1 Inflate leg compartments until one of three events occurs: a. patient’s condition improves (BP Cowley elevates to 100 mm Hg or better). b. pop-off value releases. c. Velcro fasteners begin slipping. 5.2 Close leg hose stopcocks. 5.3 Document inflation time.
6. Assess patient. 6.1 Reassess BP, pulse, and respirations. 6.2 Confirm need for abdominal compartment inflation.
7. Continue inflation if necessary. 7.1 Open stopcock on abdominal compartment hose. 7.2 Inflate as above. 7.3 Close stopcock. 7.4 Document inflation time.
8. Assess patient. 8.1 Reassess patient’s BP, pulse, and respirations. 8.2 Monitor pressure in garment. College
62 Rapid Auto Extrication
Activity Critical Performances
1. Assure cervical stabilization. 1.1 Student one positions himself/herself behind the patient’s head ensuring cervical stabilization, directs application of C-collar.
Cowley2. Position assistants. 2.1 Student one directs students two and three to a position beside the patient, one on either side. 2.2 Student one directs student four to a position outside the car near the exit point. Student four should be directed to place the long spine board in a position where the patient can be removed to the board. 3. Rotate patient. 3.1 Student one directs students two and three to turn the patient’s torso and hips, legs respectively on command. 3.2 Student one counts to three and the patient is rotated as a unit to a position where the patient’s back is facing the long spine board. 4. Reposition assistants. 4.1 Once rotated, student one directs student three to take head support, student four to take back support. 4.2 Students one and two take position to support the long spine board. 5. Lower patient. 5.1 Student one directs the students three and Collegefour to gently lower the patient as a unit onto the long spine board. The patient should pivot at the hips only. 5.2 Once the patient is supine on the board, student one should direct that head support be re-established. 6. Slide patient. 6.1 Student one directs that the patient be moved in the long axis to a position where he/she is fully on the board. This positioning should involve several movements. The patient should not be positioned on the board in one movement. 7. Remove patient. 7.1 The board is then removed from the car and placed on the ground or cot.
63 Rigid Splint
Activity Critical Performances
1. Support limb. 1.1 Student should direct manual support of the fracture site.
2. Perform neurovascular. 2.1 Check sensation. Cowley 2.2 Check distal pulse. 2.3 Check motor function. 2.4 Check capillary refill.
3. Prepare splint. 3.1 Select the appropriate splint of the appropriate size. 3.2 Adjust straps as needed. 3.3 Gather elastic gauze or tape as needed.
4. Position splint. 4.1 Gently lift the limb while supporting the fracture site and adjacent area. 4.2 Position the splint under the limb and supporting hands. 4.3 Once the splint is in position, manual support should be gently withdrawn and the limb allowed to rest in the splint which is supported manually. 4.4 Adjust splint so that the fingers are accessible for neurovascular checks.
5. Secure splint. 5.1 Secure limb to splint with tape or elastic gauze.
6. Perform neurovascular exam. College6.1 Check sensation. 6.2 Check distal pulse. 6.3 Check motor function. 6.4 Check capillary refill.
64 Sling and Swathe
Activity Critical Performances
1. Manually support fracture. 1.1 Student should direct manual support of fracture.
2. Perform neurovascular exam. 2.1 Check distal pulse. Cowley 2.2 Check capillary refill. 2.3 Check motor function. 2.4 Check sensation. 2.5 Dress wounds.
3. Prepare sling. 3.1 Student removes restrictive jewelry from patient. 3.2 Student should tie a knot in the apex of the sling if a triangular bandage is used.
4. Position sling. 4.1 Student positions the injured arm with the long axis to the body bending the elbow while properly supporting the injury site, and places forearm in a comfortable position across the chest at a 45° angle. 4.2 Position the sling with the patient’s elbow resting securely in the sling.
5. Secure sling. 5.1 Secure the sling with a square knot if a triangular bandage is utilized. Care should be given so as to ensure the knot doesn’t rest under the neck of the supine patient.
6. Apply swathe. College6.1 If triangular bandage is utilized, fashion a cravat about 6" wide. 6.2 Position the swathe around the torso, over the injured arm, and under the uninjured arm. 6.3 Secure the swathe with a square knot. 6.4 Care should be taken so as to not place a narrow swathe directly over a fractured area.
7. Perform a neurovascular exam. 7.1 Check distal pulse. 7.2 Check motor function. 7.3 Check capillary refill. 7.4 Check sensation.
65 HARE Traction Splint
Activity Critical Performances
1. Assess patient status. 1.1 Perform patient assessment and cut away clothing. 1.2 Assess neurovascular status.
Cowley2. Prepare splint. 2.1 Maintain support of fracture site, if necessary. 2.2 Adjust splint length on uninjured side to 12" beyond end of foot using ischial tuberosity as proximal landmark. 2.3 Align Velcro straps. 2.4 Release traction strap from ratchet with strap over bar. 2.5 Apply ankle hitch.
3. Apply manual traction. 3.1 Apply manual traction with one hand above the patient’s calf and one hand near fracture site.
4. Position splint under injured leg. 4.1 Lift patient’s injured leg just enough to allow the placement of the splint. 4.2 Place splint under injured leg moving from the foot toward the ischial tuberosity. 4.3 Position splint against ischial tuberosity and secure with ischial strap. (Padding of femoral artery is optional.) 4.4 Raise elevation stand.
5. Apply ankle hitch and mechanical traction. College5.1 Apply appropriate size ankle hitch around ankle with D-rings matched below the foot. 5.2 Connect S-hook on traction strap to D-rings and apply mechanical traction. Apply only enough traction to maintain limb alignment and alleviate some of the patient’s pain.
6. Secure Velcro straps. 6.1 Secure top Velcro strap above fracture if possible; if not, leave strap under fracture for support. 6.2 Secure Velcro straps just above and below knee and above ankle.
7. Assess neurovascular check. 7.1 Assess pulse, capillary refill, sensation and motor functions on the injured leg.
66 Gastric Lavage
Activity Critical Performances
1. Prepare equipment. 1.1 Prepare irrigation setup. Begin with 1 L NS in irrigation bottle or bag elevated 18" - 24" above patient. 1.2 Open lavage tube and measure length of tube to be inserted. Measure from tip of nose to Cowley ear lobe to xiphoid. 1.3 Lubricate distal 6 - 8" of tube. 1.4 Secure cup of water and straw. 1.5 Put on gloves and goggles.
2. Prepare patient. 2.1 Explain procedure to patient. 2.2 Restrain patient if potentially necessary. (Be sure to restrain all extremities on same side of cot so that patient may be turned on side if necessary.) 2.3 Conscious: On left side, head down and extended slightly over the end of bed/cot. (This position allows pooling of gastric contents and limits passage into the duodenum.) 2.4 Decide upon oral or nasal route. 2.5 Assure patency of naris and choose most patent naris. NASAL: Insert tube. 3.1 Ease tube gently into most patent naris. 3.2 Initially direct tube superiorly 2 - 3 cm., then posteriorly. A slight rotational motion may facilitate passage of the tube through the naris and along the nasal floor to the pharynx. College3.3 Instruct the patient to begin drinking water swallowing frequently and breathing through the mouth as soon as he/she feels the tube in the back of the throat. ORAL: Insert tube. 4.1 Remove dentures if present. 4.2 Insert bite block. 4.3 Insert tube through bite block. Ensure that patient head is slightly flexed. 4.4 Instruct patient to swallow frequently and breathe through the nose as soon as he/she feels the tube in the back of his/her throat. Check placement. 5.1 Inject air into tube while auscultating epigastrium. Lavage. 6.1 Infuse fluid. 6.2 Suction fluid. 6.3 Repeat lavage as necessary.
67 Gastric Lavage (Continued)
Activity Critical Performances
7. Infection control. 7.1 Remove gloves and dispose of equipment. 7.2 Wash hands.
8. Documentation. 8.1 Record type and size of catheter inserted, Cowley route of insertion, amount and type of fluid used for lavage, characteristics of lavaged fluids.
College
68 Urinary Catheterization
Activity Critical Performances
1. Assess status of patient: 1.1 When patient last voided (indicates bladder fullness). 1.2 Level of awareness or developmental stage (reveals patient's ability to cooperate). Cowley 1.3 Mobility an d physical limitations of patient (affects way patient will be positioned). 1.4 Patient's sex and age (determines catheter size to use: No. 8-10 Fr is generally used for children, no. 14-16 Fr for women and no. 12 Fr may be considered for young females, and no. 16-18 Fr is used for males unless a larger size is ordered by the physician). 1.5 Distended bladder (causes pain). 1.6 Any pathologic condition that may impair passage of catheter (e.g. enlarged prostate, scarring, impaired skin integrity). 1.7 Allergies (e.g. antiseptic, tape, latex).
2. Review patient's medical record, including 2.1 Determine purpose of inserting catheter: physician's order. preparation for surgical procedure, urinary irrigations, collection of sterile urine Specimen or measurement of residual urine.
3. Gather necessary equipment and supplies. 3.1 Locate the prepackaged catheterization set, which contains: a. sterile gloves b. sterile drapes, one fenestrated c. lubricant d. antiseptic cleansing solution College e. cotton balls f. forceps g. prefilled syringe with normal saline to inflate balloon of indwelling catheter h. catheter (be sure it is the correct size and type needed - if not, gather one which is) I. specimen container, label, and plastic bag j. sterile drainage tubing and collection bag k. receptacle or basin (usually bottom of catheterization tray) May also need: a. extra help b. light source c. disposable gloves, basin with warm water, soap, washcloth, towel d. tape, safety pin, elastic band
69 Urinary Catheterization (Continued)
4. Explain procedure to patient. 4.1 Reduces anxiety and promotes cooperation throughout procedure.
5. CATHETERIZATION PROCEDURE: 5.1 Wash hands. 5.2 Close curtains/door to provide privacy. 5.3 Facing patient, stand on left side of bed if Cowley right-handed (on right side if left-handed). Clear bedside table and arrange equipment. 5.4 Raise side rail on opposite side of bed and then raise bed to appropriate working height. 5.5 Place waterproof pad under patient. 5.6 Position patient.
Female patient: a. Assist to dorsal recumbent position (supine with knees flexed). Ask patient to relax thighs so as to externally rotate them. b. Position female patient in side- lying (Sims') position with upper leg flexed at knee and hip if unable to be supine. If this position is used one must take extra precautions to cover rectal area with drape during procedure to reduce chance of cross- contamination. Male patient: a. Assist to supine position with thighs slightly abducted. 5.7 Drape patient to facilitate procedure while Collegemaintaining privacy. 5.8 Using disposable gloves, wash perineal area with soap and water as needed; dry. 5.9 Position lamp to illuminate perineal area. 5.10 Open catheterization kit according to directions while maintaining sterile field. 5.11 Don sterile gloves. 5.12 Organize supplies on sterile field. 5.13 Ensure that inflatable balloon of indwelling catheter is intact by injecting with fluid until inflated. Then aspirate all fluid out of inflated lumen.
6. CATHETERIZATION OF MALE PATIENT: 6.1 Apply sterile drape over thighs just below penis. Pick up fenestrated sterile drape, allow it to unfold, and drape it over penis with fenestrated slit resting over penis.
70 Urinary Catheterization (Continued)
6.2 Place sterile tray and contents on sterile drape between thighs. 6.3 Determine that catheter tip is properly lubricated: 12.5 - 17.5 cm (5 - 7 inches). 6.4 Cleanse urethral meatus: a. If patient is not circumcised, retract foreskin with nondominant hand. Grasp penis at shaft just below Cowley glans. Retract urethral meatus between thumb and forefinger. maintain nondominant hand in this position throughout procedure. b. With dominant hand pick up cotton ball with forceps and clean penis. Move cotton in circular motion from meatus down to base of glans. Repeat cleansing two more times using clean cotton ball each time. 6.5 Pick up catheter with gloved, dominant hand 7.5 to 10 cm (3 to 4 in) from catheter tip. Hold end of catheter loosely coiled in palm of dominant hand. Place distal end of catheter in urine tray receptacle if only doing a straight cath or if a different size/type of catheter was necessary. (Most kits for indwelling catheterization have the tubing and collection bag already attached.) Holding catheter near tip allows easier manipulation during insertion into meatus and prevents distal end from striking contaminated surface. College6.6 Insert catheter: a. Lift penis to position perpendicular to patient's body and apply light traction. b. Ask patient to bear down as if to void and slowly insert catheter through meatus. (Relaxation of external sphincter aids in insertion.) c. Advance catheter 17.5 to 22.5 cm (7 to 9 in) in adult and 5 to 7.5 cm (2 to 3 in) in young child, or until urine flows out catheter's end. If resistance is felt, withdraw catheter; do not force it through urethra. When urine appears, advance catheter another 5 cm (2 in). d. Lower penis and hold catheter securely in nondominant hand.
71 Urinary Catheterization (Continued)
Place end of catheter in urine tray receptacle if collecting specimen only. Remove straight, single-use catheter when have specimen, withdrawing slowly but smoothly until removed. e. Inflate balloon of indwelling catheter:
Cowley i. While holding catheter with thumb and little finger of nondominant hand at meatus, take end of catheter and place it between first two fingers of nondominant hand. ii. With free, dominant hand, attach syringe to injection port at end of catheter. iii. Slowly inject to amount of solution. If patient complains of sudden pain, aspirate back solution and advance catheter further. iv. After inflating balloon fully, release catheter with nondominant hand and pull gently to feel resistance. f. Return foreskin to natural position. NEVER leave it retracted. 6.7 Place drainage bag below the level of the Collegebladder. 6.8 Tape catheter tubing to top of thigh or lower abdomen (with penis directed toward chest). Allow slack in catheter so movement does not create tension of catheter. 6.9 Be sure there are no obstructions or kinks in tubing. Place excess coil of tubing on bed and fasten it to bottom sheet with clip from drainage set or with rubber band and safety pin. 6.10 Place patient in position of comfort and return bed to lowest position. 6.11 Remove gloves and dispose of equipment, drapes, urine in proper receptacles. 6.12 Instruct patient against pulling on catheter. 6.13 Wash hands.
7. CATHETERIZATION OF FEMALE PATIENT: 7.1 Allow top edge of drape to form cuff over both hands. Place drape down bed between patient's thighs. Slip cuffed edge just under buttocks, taking care not to contaminate.
72
Urinary Catheterization (Continued)
7.2 Pick up fenestrated sterile drape and allow it to unfold without touching an unsterile object. Apply drape over perineum, exposing labia and being sure not to touch contaminated surface. 7.3 Place sterile tray and contents on sterile drape between thighs. Cowley 7.4 Determine that catheter tip is properly lubricated: 2.5 to 5 cm (1 to 2 in). 7.5 Cleanse urethral meatus: a. With nondominant hand carefully retract labia to fully expose urethral meatus. Maintain position of nondominant hand throughout procedure. b. With dominant hand pick up cotton ball with forceps and clean perineal area, wiping front to back from clitoris toward anus. Use new clean cotton ball for each wipe: along near labial fold, directly over meatus, and along far labial fold. 7.6 Pick up catheter with gloved, dominant hand 7.5 to 10 cm (3 to 4 in) from catheter tip. Hold end of catheter loosely coiled in palm of dominant hand. Place distal end of catheter in urine tray receptacle if only doing a straight cath or if a different size/type of catheter was necessary. (Most kits for indwelling catheterization have the tubing Collegeand collection bag already attached.) Holding catheter near tip allows easier manipulation during insertion into meatus and prevents distal end from striking contaminated surface. 7.7 Insert catheter: a. Ask patient to bear down gently as if to void and slowly insert catheter through meatus. b. Advance catheter approximately 5 to 7.5 cm (2 to 3 in) in adult, 2.5 cm (1 in) in child, or until urine flows out catheter's end. When urine appears, advance catheter another 5 cm (2 in). Do not force against resistance. c. release labia and hold catheter securely with nondominant hand (bladder or sphincter contraction may cause accidental expulsion of catheter).
73
Urinary Catheterization (Continued)
7.8 Place end of catheter in urine tray receptacle if collecting specimen only. Remove straight, single-use catheter when have specimen, withdrawing slowly but smoothly until removed. 7.9 Inflate balloon of indwelling catheter: a. While holding catheter with thumb and little finger of nondominant Cowley hand at meatus, take end of catheter and place it between first two fingers of nondominant hand. b. With free, dominant hand, attach syringe to injection port at end of catheter. c. Slowly inject total amount of solution. If patient complains of sudden pain, aspirate back solution and advance catheter further. d. After inflating balloon fully, release catheter with nondominant hand and pull gently to feel resistance. 7.10 Place drainage bag below the level of the bladder. 7.11 Tape catheter tubing to inner thigh with strip of nonallergenic tape. Allow for slack so movement of thigh does not create tension on catheter. 7.12 Be sure there are no obstructions or kinks in tubing. Place excess coil of tubing on bed and fasten it to bottom sheet with clip from drainage set or with rubber band and safety pin. College7.13 Place patient in position of comfort and return bed to lowest position. 7.14 Remove gloves and dispose of equipment, drapes, urine in proper receptacles. 7.15 Instruct patient against pulling on catheter. 7.16 Wash hands.
8. Evaluate patient and catheter/drainage system. 8.1 Palpate bladder and ask if patient remains uncomfortable. 8.2 Observe character and amount of urine in drainage system. 8.3 If no urine is present, catheter may be in vaginal opening if female and not advanced far enough if male. An absence of urine from bladder usually indicates that catheter is not advanced to the bladder or the patient has oliguria secondary to renal disease, shock, or decreased cardiac output.
74 Urinary Catheterization (Continued)
9. Documentation 9.1 Record: type and size of catheter inserted, amount of fluid used to inflate balloon, characteristics of urine, amount of urine retrieved.
RULES: NEVER insert a Foley if blood is present at the meatus of a trauma patient. Cowley ALWAYS return foreskin to natural position. NEVER allow urine in tubing or bag to back flow into the patient (this occurs if the bag is raised above the level of the bladder). This could cause an infection.
College
75 Nasogastric Tube
Activity Critical Performance
1. Prepare equipment and supplies: 1.1 Gather the following: a. #14 or 16 Fr NG tube(smaller for a child) b. water-soluble lubricating jelly c. stethoscope d. tongue blade e. flashlight f. catheter tip syringe Cowley g. 1 in (2.5 cm) wide hypoallergenic tape h. safety pin and rubber band I. clamp, drainage bag, or suction machine j. disposable gloves k. bath towel l. emesis basin with ice (optional) m. glass of water with straw n. facial tissues o. normal saline p. tincture of benzoin (optional)
2. Explain procedure to patient. 2.1 Reduces anxiety.
3. Position patient. 3.1 Position patient in high Fowler's position with pillows behind head and shoulders. Raise bed to its highest horizontal level.
4. Catheter insertion: 4.1 Wash hands. 4.2 Assemble equipment at bedside and place on side of bed nearest technician. 4.3 Provide privacy (close door if possible). College4.4 If NG tube is too pliable, place in emesis basin and cover with ice (optional). 4.5 Place bath towel over patient's chest; give facial tissues to patient. 4.6 Apply disposable gloves. 4.7 Instruct patient to relax and breathe normally while occluding one naris. Then repeat this action for other naris. Select nostril with greater air flow. (Right naris is usually larger.) 4.8 Measure distance to insert tube by placing tip of tube at patient's nose and extending tube first to tip of earlobe and then from earlobe down to xiphoid process of sternum. 4.9 Mark length of tube to be inserted with piece of tape or note distance of point from next tube marking.
76
Nasogastric Tube (Continued)
4.10 Curve 4-6 in (10-15 cm) of end of tube with water-soluble lubricating jelly. 4.11 Lubricate 3-4 in (7.5-10 cm) of end of tube tightly around index finger; then release. 4.12 Initially instruct patient to extend his neck back against pillow; insert tube slowly through naris with curved end pointing downward. Cowley 4.13 Continue to pass tube along floor of nasal passage aiming down toward ear. When resistance is felt, apply gentle downward pressure to advance tube (do not force past resistance). 4.14 If resistance is met, withdraw tube, allow patient to rest, re-lubricate tube and insert into other naris. 4.15 Continue insertion of tube until just past nasopharynx by gently rotating tube toward opposite nares. a. Stop tube advancement, allow patient to relax, and provide tissues. b. Explain to patient that next step requires him/her to swallow. 4.16 With tube just above oropharynx, instruct patient to flex head forward and dry swallow or suck in air through straw. Advance tube 2.5-5 cm (1-2 cm) with each swallow. If patient has trouble swallowing and is allowed fluids, offer glass of water. Advance tube with each swallow of water. College4.17 If patient begins to cough during insertion, pull tube back slightly. 4.18 If patient continues to gag, check back of pharynx using flashlight and tongue blade. 4.19 After patient relaxes, continue to advance tube desired distance.
5. Check tube placement. 5.1 Ask patient to talk. 5.2 Check posterior pharynx for presence of coiled tube. 5.3 Attach syringe to end of NG tube. Place diaphragm of stethoscope over upper left quadrant of abdomen just below costal margin. Inject 10-20 mL of air while auscultating abdomen. 5.4 Aspirate gently back on syringe to obtain gastric contents.
77
Nasogastric Tube (Continued)
5.5 If tube is not in stomach, advance another 2.5-5 cm (1-2 in) and repeat steps 5.3 and 5.4 to check tube position. Remove tube if in the lungs.
6. Anchor tube. 6.1 After tube is inserted, either clamp end or connect it to drainage bag or suction machine. Cowley 6.2 Tape NG tube to patient's nose; avoid putting pressure on nares. Cut 4 in (10 cm) long piece of tape. Apply small amount of tincture of benzoin to lower end of nose and allow to dry (optional). Place one end of tape over nose and wrap opposite split ends around tube as it exits nose. 6.3 Fasten end of NG tube to patient's gown by looping rubber band around tube in slip knot. Pin rubber band to gown (provides slack for movement).
7. Position patient. 7.1 Unless physician orders otherwise, head of bed should be elevated 30 degrees. 7.2 Return bed to lowest position.
8. Infection control. 8.1 Remove gloves and dispose of equipment. 8.2 Wash hands.
9. Documentation. 9.1 Record naris used (including unsuccessful attempts), type and size of tube inserted, marking on tube at level of naris, placement assessment, amount of suction and type College (constant vs low intermittent), amount and characteristics of contents retrieved immediately after suction attached.
78
IV Medication Administration
Activity Critical Performances
1. Prepare for procedure. 1.1 Confirms patient allergies. 1.2 Checks medication label, computes the dosage and correctly draws up medication (if not a preload syringe). 1.3 Cleanses injection port with alcohol. 1.4 Uncaps needle. Cowley 1.5 Purges air from syringe. 1.6 Pinches I.V. tubing above medication port. 1.7 Inserts needle into the medication administration port.
2. Inject medication. 2.1 Injects medication at the proper administration rate. 2.2 Open IV flow rate to flush the line.
3. Conclude procedure. 3.1 Dispose of syringe in proper container. 3.2 Document time of medication administration. 3.3 Assess efficacy of medication administration.
Note: If using an IV piggyback administration, one must place the proper medication amount in the bag, invert the bag several times to mix, connect IV tubing to bag and then into the patient’s IV line (use 3-way stopcock or place needle on the end of the IV tubing). The infusion must be set at the proper rate and, if a needle piggyback is used, it must be taped in place. College
79
Appendix A – AHA CPR Procedures Evaluation Forms
Cowley
College
BLS for Healthcare Providers Course 1- and 2-Rescuer Adult BLS With AED Skills Testing Sheet See 1- and 2-Rescuer Adult BLS With AED Skills Testing Criteria and Descriptors on next page
Student Name: ______Test Date: ______
CPR Skills (circle one): Pass Needs Remediation AED Skills (circle one): Pass Needs Remediation ✓ CowleySkill Critical Performance Criteria if done Step correctly 1-Rescuer Adult BLS Skills Evaluation During this first phase, evaluate the first rescuer’s ability to initiate BLS and deliver high-quality CPR for 5 cycles. 1 ASSESSES: Checks for response and for no breathing or no normal breathing, only gasping (at least 5 seconds but no more than 10 seconds) 2 ACTIVATES emergency response system 3 Checks for PULSE (no more than 10 seconds) 4 GIVES HIGH-QUALITY CPR:
• Correct compression HAND PLACEMENT Cycle 1:
• ADEQUATE RATE: At least 100/min (ie, delivers each set of 30 chest compressions in Cycle 2: Time: 18 seconds or less)
• ADEQUATE DEPTH: Delivers compressions at least 2 inches in depth (at least 23 out of 30) Cycle 3:
• ALLOWS COMPLETE CHEST RECOIL (at least 23 out of 30) Cycle 4:
• MINIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds Cycle 5: Second Rescuer AED Skills Evaluation and SWITCH During this next phase, evaluate the second rescuer’s ability to use the AED and both rescuers’ abilities to switch roles. 5 DURING FIFTH SET OF COMPRESSIONS: Second rescuer arrives with AED and bag-mask device, turns on AED, and applies pads College 6 First rescuer continues compressions while second rescuer turns on AED and applies pads 7 Second rescuer clears victim, allowing AED to analyze—RESCUERS SWITCH 8 If AED indicates a shockable rhythm, second rescuer clears victim again and delivers shock First Rescuer Bag-Mask Ventilation During this next phase, evaluate the first rescuer’s ability to give breaths with a bag-mask. 9 Both rescuers RESUME HIGH-QUALITY CPR immediately after shock delivery: Cycle 1 Cycle 2 • SECOND RESCUER gives 30 compressions immediately after shock delivery (for 2 cycles)
• FIRST RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) AFTER 2 CYCLES, STOP THE EVALUATION • If the student completes all steps successfully (a ✓ in each box to the right of Critical Performance Criteria), the student passed this scenario. • If the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance Criteria), give the form to the student for review as part of the student’s remediation. • After reviewing the form, the student will give the form to the instructor who is reevaluating the student. The student will reperform the entire scenario, and the instructor will notate the reevaluation on this same form. • If the reevaluation is to be done at a different time, the instructor should collect this sheet before the student leaves the classroom. Remediation (if needed): Instructor Signature: ______Instructor Signature: ______Print Instructor Name: ______Print Instructor Name: ______
Date: ______Date: ______
© 2011 American Heart Association
90-1036_BLS_InstMnl_Part_3.indd 23 1/13/11 9:48 AM BLS for Healthcare Providers Course 1- and 2-Rescuer Adult BLS With AED Skills Testing Criteria and Descriptors
1. Assesses victim (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene): • Checks for unresponsiveness (this MUST precede starting compressions) Cowley• Checks for no breathing or no normal breathing (only gasping) 2. Activates emergency response system (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene): • Shouts for help/directs someone to call for help AND get AED/defibrillator 3. Checks for pulse: • Checks carotid pulse • This should take no more than 10 seconds 4. Delivers high-quality CPR (initiates compressions within 10 seconds of identifying cardiac arrest): • Correct placement of hands/fingers in center of chest –– Adult: Lower half of breastbone –– Adult: 2-handed (second hand on top of the first or grasping the wrist of the first hand) • Compression rate of at least 100/min –– Delivers 30 compressions in 18 seconds or less • Adequate depth for age • Adult: at least 2 inches (5 cm) • Complete chest recoil after each compression • Minimizes interruptions in compressions: –– Less than 10 seconds between last compression of one cycle and first compression of next cycle –– Compressions not interrupted until AED analyzing rhythm –– Compressions resumed immediately after shock/noCollege shock indicated 5-8. Integrates prompt and proper use of AED with CPR: • Turns AED on • Places proper-sized pads for victim’s age in correct location • Clears rescuers from victim for AED to analyze rhythm (pushes ANALYZE button if required by device) • Clears victim and delivers shock • Resumes chest compressions immediately after shock delivery • Does NOT turn off AED during CPR • Provides safe environment for rescuers during AED shock delivery: –– Communicates clearly to all other rescuers to stop touching victim –– Delivers shock to victim after all rescuers are clear of victim • Switches during analysis phase of AED 9. Provides effective breaths: • Opens airway adequately • Delivers each breath over 1 second • Delivers breaths that produce visible chest rise • Avoids excessive ventilation
90-1036_BLS_InstMnl_Part_3.indd 24 1/10/11 4:49 PM BLS for Healthcare Providers Course 1- and 2-Rescuer Infant BLS Skills Testing Sheet See 1- and 2-Rescuer Infant BLS Skills Testing Criteria and Descriptors on next page
Student Name: ______Test Date: ______1-Rescuer BLS and CPR Skills (circle one): Pass Needs Remediation 2-Rescuer CPR Skills Bag-Mask (circle one): Pass Needs Remediation Cowley 2 Thumb–Encircling Hands (circle one): Pass Needs Remediation Skill ✓ if done Step Critical Performance Criteria correctly 1-Rescuer Infant BLS Skills Evaluation During this first phase, evaluate the first rescuer’s ability to initiate BLS and deliver high-quality CPR for 5 cycles. 1 ASSESSES: Checks for response and for no breathing or only gasping (at least 5 seconds but no more than 10 seconds) 2 Sends someone to ACTIVATE emergency response system 3 Checks for PULSE (no more than 10 seconds) 4 GIVES HIGH-QUALITY CPR: • Correct compression FINGER PLACEMENT Cycle 1: • ADEQUATE RATE: At least 100/min (ie, delivers each set of 30 chest compressions in Cycle 2: Time: 18 seconds or less) • ADEQUATE DEPTH: Delivers compressions at least one third the depth of the chest Cycle 3: (approximately 1½ inches [4 cm]) (at least 23 out of 30) • ALLOWS COMPLETE CHEST RECOIL (at least 23 out of 30) Cycle 4: • MINIMIZES INTERRUPTIONS: Gives 2 breaths with pocket mask in less than 10 seconds Cycle 5: 2-Rescuer CPR and SWITCH During this next phase, evaluate the FIRST RESCUER’S ability to give breaths with a bag-mask and give compressions by using the 2 thumb–encircling hands technique. Also evaluate both rescuers’ abilities to switch roles. 5 DURING FIFTH SET OF COMPRESSIONS: SecondCollege rescuer arrives with bag-mask device. RESCUERS SWITCH ROLES. 6 Both rescuers RESUME HIGH-QUALITY CPR: Cycle 1 Cycle 2 • SECOND RESCUER gives 15 compressions in 9 seconds or less by using 2 thumb– encircling hands technique (for 2 cycles) XX • FIRST RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) AFTER 2 CYCLES, PROMPT RESCUERS TO SWITCH ROLES 7 Both rescuers RESUME HIGH-QUALITY CPR: Cycle 1 Cycle 2 • FIRST RESCUER gives 15 compressions in 9 seconds or less by using 2 thumb–encircling Time: Time: hands technique (for 2 cycles) • SECOND RESCUER successfully delivers 2 breaths with bag-mask (for 2 cycles) XX AFTER 2 CYCLES, STOP THE EVALUATION • If the student completes all steps successfully (a ✓ in each box to the right of Critical Performance Criteria), the student passed this scenario. • If the student does not complete all steps successfully (as indicated by a blank box to the right of any of the Critical Performance Criteria), give the form to the student for review as part of the student’s remediation. • After reviewing the form, the student will give the form to the instructor who is reevaluating the student. The student will reperform the entire scenario, and the instructor will notate the reevaluation on this same form. • If the reevaluation is to be done at a different time, the instructor should collect this sheet before the student leaves the classroom. Remediation (if needed): Instructor Signature: ______Instructor Signature: ______Print Instructor Name: ______Print Instructor Name: ______
Date: ______Date: ______
© 2011 American Heart Association
90-1036_BLS_InstMnl_Part_3.indd 25 1/13/11 9:48 AM BLS for Healthcare Providers Course 1- and 2-Rescuer Infant BLS Skills Testing Criteria and Descriptors
1. Assesses victim (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene): • Checks for unresponsiveness (this MUST precede starting compressions) Cowley• Checks for no breathing or only gasping 2. Sends someone to activate emergency response system (Steps 1 and 2, assessment and activation, must be completed within 10 seconds of arrival at scene): • Shouts for help/directs someone to call for help AND get AED/defibrillator • If alone, remains with infant to provide 2 minutes of CPR before activating emergency response system 3. Checks for pulse: • Checks brachial pulse • This should take no more than 10 seconds 4. Delivers high-quality 1-rescuer CPR (initiates compressions within 10 seconds of identifying cardiac arrest): • Correct placement of hands/fingers in center of chest –– 1 rescuer: 2 fingers just below the nipple line • Compression rate of at least 100/min –– Delivers 30 compressions in 18 seconds or less • Adequate depth for age –– Infant: at least one third the depth of the chest (approximately 1½ inches [4 cm]) • Complete chest recoil after each compression • Appropriate ratio for age and number of rescuers –– 1 rescuer: 30 compressions to 2 breaths • Minimizes interruptions in compressions: –– Less than 10 seconds between last compressionCollege of one cycle and first compression of next cycle 5. Switches at appropriate intervals as prompted by the instructor (for purposes of this evaluation) 6. Provides effective breaths with bag-mask device during 2-rescuer CPR: • Provides effective breaths: –– Opens airway adequately –– Delivers each breath over 1 second –– Delivers breaths that produce visible chest rise –– Avoids excessive ventilation 7. Provides high-quality chest compressions during 2-rescuer CPR: • Correct placement of hands/fingers in center of chest –– 2 rescuers: 2 thumb–encircling hands just below the nipple line • Compression rate of at least 100/min –– Delivers 15 compressions in 9 seconds or less • Adequate depth for age –– Infant: at least on third the depth of the chest (approximately 1½ inches [4 cm]) • Complete chest recoil after each compression • Appropriate ratio for age and number of rescuers –– 2 rescuers: 15 compressions to 2 breaths • Minimizes interruptions in compressions: –– Less than 10 seconds between last compression of one cycle and first compression of next cycle
26
90-1036_BLS_InstMnl_Part_3.indd 26 1/10/11 4:49 PM
Appendix B – First Skill Check List
Cowley
College
Cowley County Community College & AVTS Paramedic Program
Skill Proficiency Verification - Before Clinicals Begin
CowleyName ______
The I/C or Lab Assistants will sign and date the form only to verify performance which meets the standards established by the program. Skills which are inadequately performed will not be documented as being completed. Each skill must be performed successfully at least one time. IO placement, neonatal endotracheal intubation, infant endotracheal intubation, child endotracheal intubation, and adult endotracheal intubation must be successfully demonstrated five times.
Students must demonstrate 100% competency on the skill performance before entering the clinical aspect of the program. The signature of the I/C or Lab Assistant signifies successful performance.
A copy of the completed form shall be kept in the student’s individual file.
College
Date Fully Completed by Student ______
Accepted by Cowley Faculty ______Signature of Instructor
PROCEDURE SIGNATURE AND DATE
Primary Assessment (medical)
Patient Assessment (trauma)
History Taking CowleyBiomedical Communication SQ Injection
IM Injection
IV Venipuncture
Blood Sampling
External Jugular IV
Oral Airway
Nasal Airway
BVM
ET Placement (neonatal number 1) ET Placement (neonatal number 2) College ET Placement (neonatal number 3)
ET Placement (neonatal number 4)
ET Placement (neonatal number 5)
ET Placement (infant number 1)
ET Placement (infant number 2)
ET Placement (infant number 3)
ET Placement (infant number 4)
ET Placement (infant number 5)
ET Placement (child number 1)
ET Placement (child number 2)
ET Placement (child number 3)
PROCEDURE SIGNATURE AND DATE
ET Placement (child number 4)
ET Placement (child number 5)
ET Placement (adult number 1) CowleyET Placement (adult number 2) ET Placement (adult number 3)
ET Placement (adult number 4)
ET Placement (adult number 5)
Nasotracheal ET Placement
Magill Use
ET Suctioning
Nasotracheal Suctioning
ET Medications
ET Extubation PtL Airway College Combitube Airway
EOA/EGA
Defibrillation (with paddles)
Defibrillation (with patches)
Cardioversion (with paddles)
Cardioversion (with patches)
External Pacing
Acquire a 12-Lead ECG
Valsalva
C.M.
IO Infusion (number 1 - Cook)
PROCEDURE SIGNATURE AND DATE
IO Infusion (number 2 - Jamshedi)
IO Infusion (number 3 - EZ IO)
IO Infusion (number 4 - EZ IO) CowleyIO Infusion (number 5 - EZ IO) Cricothyrotomy
Chest Decompression
Breathing Treatment
PASG
HARE Traction
Rigid Splint
Sling and Swathe
Long Board
KED Rapid Extrication College Adult CPR
Adult Two-Rescuer CPR
Adult Conscious FAO
Child CPR
Child Conscious FAO
Infant CPR
Infant Conscious FAO
NG Tube Placement
Foley Catheter Placement
I.V. Medication Administration
CPAP Administration
PROCEDURE SIGNATURE AND DATE
Other:______
Other:______
Other:______CowleyOther:______Other:______
College
Appendix C – Final Skill Check List
Cowley
College
Cowley County Community College & AVTS Paramedic Program
Skill Proficiency Verification - Before Program Conclusion
CowleyName ______
The I/C or Lab Assistants will sign and date the form only to verify performance which meets the standards established by the program. Skills which are inadequately performed will not be documented as being completed. Each skill must be performed successfully at least one time. IO placement, neonatal endotracheal intubation, infant endotracheal intubation, child endotracheal intubation, and adult endotracheal intubation must be successfully demonstrated five times.
Students must demonstrate 100% competency on the skill performance before entering the clinical aspect of the program. The signature of the I/C or Lab Assistant signifies successful performance.
A copy of the completed form shall be kept in the student’s individual file.
College
Date Fully Completed by Student ______
Accepted by Cowley Faculty ______Signature of Instructor
PROCEDURE SIGNATURE AND DATE
Primary Assessment (medical)
Patient Assessment (trauma)
History Taking CowleyBiomedical Communication SQ Injection
IM Injection
IV Venipuncture
Blood Sampling
External Jugular IV
Oral Airway
Nasal Airway
BVM
ET Placement (neonatal number 1) ET Placement (neonatal number 2) College ET Placement (neonatal number 3)
ET Placement (neonatal number 4)
ET Placement (neonatal number 5)
ET Placement (infant number 1)
ET Placement (infant number 2)
ET Placement (infant number 3)
ET Placement (infant number 4)
ET Placement (infant number 5)
ET Placement (child number 1)
PROCEDURE SIGNATURE AND DATE
ET Placement (child number 2)
ET Placement (child number 3)
ET Placement (child number 4) CowleyET Placement (child number 5) ET Placement (adult number 1)
ET Placement (adult number 2)
ET Placement (adult number 3)
ET Placement (adult number 4)
ET Placement (adult number 5)
Nasotracheal ET Placement
Magill Use
ET Suctioning
Nasotracheal Suctioning ET Medications College ET Extubation
PtL Airway
Combitube Airway
EOA/EGA
Defibrillation (with paddles)
Defibrillation (with patches)
Cardioversion (with paddles)
Cardioversion (with patches)
External Pacing
PROCEDURE SIGNATURE AND DATE
Acquire a 12-Lead ECG
Valsalva
C.M. CowleyIO Infusion (number 1 - Cook) IO Infusion (number 2 - Jamshedi)
IO Infusion (number 3 - EZ IO)
IO Infusion (number 4 - EZ IO)
IO Infusion (number 5 - EZ IO)
Cricothyrotomy
Chest Decompression
Breathing Treatment
PASG
HARE Traction Rigid Splint College Sling and Swathe
Long Board
KED
Rapid Extrication
Adult CPR
Adult Two-Rescuer CPR
Adult Conscious FAO
Child CPR
Child Conscious FAO
PROCEDURE SIGNATURE AND DATE
Infant CPR
Infant Conscious FAO
NG Tube Placement CowleyFoley Catheter Placement I.V. Medication Administration
CPAP Application
Other:______
Other:______
Other:______
Other:______
Other:______
College
Appendix D – Simulated Patient Scenarios: Didactic
Cowley
College
Cowley College Paramedic Program
Simulated Patient Scenarios - Didactic
During the course of the paramedic program, students are required to serve as a team leader, assess programmed patients or manikins, consider differentials, make decisions relative to interventions and transportation, provide the Cowleyinterventions, use proper patient packaging and transportati on, work as a team and practice various roles for common emergencies. These will be provided throughout the entire program. During each section of the program (didactic, clinical and field internship), students are required to perform at least four scenarios (one each: cardiac arrest, medical emergency, trauma emergency, and pediatric/neonate) which are objectively graded by the faculty. Students must perform with at least 80% accuracy without any detrimental “unacceptable actions” while evaluated by faculty.
SCENARIO TYPE SIGNATURE AND DATE
Cardiac Arrest
Medical Emergency
Trauma Emergency
Pediatric/Neonate
College
Appendix E – Simulated Patient Scenarios: Hospital Clinicals
Cowley
College
Cowley College Paramedic Program
Simulated Patient Scenarios – Hospital Clinicals
During the course of the paramedic program, students are required to serve as a team leader, assess programmed patients or manikins, consider differentials, make decisions relative to interventions and transportation, provide the Cowleyinterventions, use proper patient packaging and transportation, work as a team and practice various roles for common emergencies. These will be provided throughout the entire program. During each section of the program (didactic, clinical and field internship), students are required to perform at least four scenarios (one each: cardiac arrest, medical emergency, trauma emergency, and pediatric/neonate) which are objectively graded by the faculty. Students must perform with at least 80% accuracy without any detrimental “unacceptable actions” while evaluated by faculty.
SCENARIO TYPE SIGNATURE AND DATE
Cardiac Arrest
Medical Emergency
Trauma Emergency
Pediatric/Neonate
College
Appendix F – Simulated Patient Scenarios: Field Internship
Cowley
College
Cowley College Paramedic Program
Simulated Patient Scenarios – Field Internship
During the course of the paramedic program, students are required to serve as a team leader, assess programmed patients or manikins, consider differentials, make decisions relative to interventions and transportation, provide the Cowleyinterventions, use proper patient packaging and transportation, work as a team and practice various roles for common emergencies. These will be provided throughout the entire program. During each section of the program (didactic, clinical and field internship), students are required to perform at least four scenarios (one each: cardiac arrest, medical emergency, trauma emergency, and pediatric/neonate) which are objectively graded by the faculty. Students must perform with at least 80% accuracy without any detrimental “unacceptable actions” while evaluated by faculty.
SCENARIO TYPE SIGNATURE AND DATE
Cardiac Arrest
Medical Emergency
Trauma Emergency
Pediatric/Neonate
College