Nursing Resource Center
The prehospital health care team is made up of many different people. Fire, police, and emergency medical services (EMS) work together in order to safely provide quality health care to ill and injured persons. Within the medical component of the team, there are also several different team members.
There may be a first responder who initiates patient care prior to the arrival of the EMT. The EMT should be able to integrate his care into the care that has been initiated by the first responder. Similarly, if the patient requires advanced services, the EMT may call for assistance from an ALS provider. The importance of the EMT's ability to work well with the ALS personnel cannot be overstated.
If the EMT can anticipate what the ALS provider may need or be able to assist with specific procedures, the care of the patient will be accomplished more quickly and efficiently. The EMT and advanced provider should work together as a team to care for their patient.
While the importance of a basic life support (BLS) airway cannot be overemphasized, there are some circumstances in which a patient may need a more advanced airway. In some states, the EMT is permitted to perform endotracheal intubation. In the states where this is not permitted, the EMT should be familiar enough with the indications, contraindications, and technique that he can assist the advanced provider in the procedure.
Once a patient has been intubated, the advanced provider will often have additional work to do, such as administering medication or obtaining IV access. The EMT will likely be asked to provide ventilation for the intubated patient. Therefore, it is important for the EMT to be familiar with this skill.
While in most states EMTs are not trained to obtain IV access, it is useful for them to be familiar with the technique and able to assist by preparing the proper IV fluid. If allowed, the EMT may occasionally transport a patient with an IV line in place. While it is certainly not difficult, there are some things to consider while caring for the patient with an IV line.
Endotracheal intubation is the placement of a hollow plastic tube into the trachea to allow for direct ventilation of the lungs without gastric distension. This procedure can be done under direct visualization using a tool called a laryngoscope, or it is sometimes accomplished blindly, in the case of nasotracheal intubation.
The call was for a woman with difficulty breathing. EMS arrived to find Mrs. Anderson leaning over a small plastic bucket that was filled with facial tissues and pink frothy foam. She looked near death, and she could speak only in single words. The EMT, Ira, immediately placed the pulse oximeter on her finger, while Geo, the other EMT, prepared the non-rebreather mask. Then Ira listened to her lungs and heard loud crackles in all of her lung fields. The initial pulse oximeter reading was 84% on room air.
"Better get the BVM out," declared Ira. "I will contact Medcom and ask them what the ETA is for the paramedic." As Geo assembled the BVM, he started talking calmly to the patient, explaining that he was going to help her with her breathing. Then he placed the mask over her face. "Breathe easy, Mrs. Anderson. Let me help you," Geo implored. She was quickly becoming exhausted and had little fight left in her.
Patients who may be candidates for endotracheal intubation include those who cannot maintain a patent airway spontaneously or are in need of prolonged ventilatory assistance. Table C-1 lists conditions that would likely necessitate endotracheal intubation by a qualified provider.
| TABLE C-1 Conditions That Usually Require Endotracheal Intubation |
| Cardiac arrest |
| Respiratory arrest |
| Respiratory failure |
| Drug overdose |
| Persistent seizures |
| Severe head injury or facial injuries |
| Traumatic arrest |
Appendix A describes endotracheal intubation in detail. It is recommended that the EMT, even if he is not permitted to perform this technique independently, become familiar with this procedure.
One of the most obvious ways an EMT can facilitate endotracheal intubation is to adequately prepare the patient. If a patient is adequately prepared for this procedure, the risk of complication will be lessened.
The EMT should perform an initial assessment on his first encounter with the patient. The airway should be addressed with the plan to open, assess, suction, and secure as appropriate.
A head-tilt, chin-lift, or jaw thrust should be used as appropriate for the situation to initially open the airway. The EMT should assess for any fluids or particulate matter and suction if any is present. Details on these procedures are found in Chapter 7.
To more easily ventilate a patient, an oropharyngeal or nasopharyngeal airway should be placed as conditions require. Basic adequate ventilation should be provided by the EMT using a bag-valve-mask (BVM) device and 100% oxygen, while the advanced provider prepares his equipment for intubation.
To perform endotracheal intubation, the EMT must stop ventilating and remove the oral airway to allow the intubator access to the airway for laryngoscopy. Laryngoscopy is the procedure of using a laryngoscope to visualize the glottic opening. Typically, the procedure takes approximately 30 seconds to complete.
The use of a laryngoscope to view the lower airway structures.
Assessing and managing an airway can result in splashing of patient secretions. The EMT must remember to wear appropriate personal protective equipment, including gloves, mask, and goggles, during any airway procedures.
If it is suspected that the patient has a spinal injury, one EMT should be assigned to maintain spinal immobilization throughout the entire intubation. The best position for this provider is often at the patient's side.
Because the patient will not be receiving ventilation during the time the intubator is performing the intubation, it is useful to deliver as much oxygen as possible into the patient's lungs prior to the onset of the procedure. This can be easily accomplished by a 1- to 2-minute period of hyperventilation.
Hyperventilation is a faster rate of ventilation. This does not mean that the patient should be ventilated as fast as the BVM will refill. What it does mean is the EMT should count as he ventilates the patient to ensure a rate of ventilation that is higher than the usual rate. The rates of normal ventilation and hyperventilation are discussed in Chapter 8.
In addition to providing such preoxygenation, the EMT should ensure the airway is well suctioned and no liquid or particulate matter remains in the oropharynx, where it can obscure the view of the intubator and make the task more difficult. Preoxygenation is providing high-concentration oxygen to a patient for a period of time before a procedure, such as endotracheal intubation or suctioning, is performed.
When the intubator has all of his equipment prepared and is ready to begin the procedure, he should ask the EMT to step aside and stop hyperventilation. At this time, the EMT should remove the BVM from the patient's face and remove any oropharyngeal airway that may have been placed. He should then stand close by with the BVM ready to be used when needed.
During the intubation procedure, it is often helpful for the EMT to apply gentle, constant pressure over the cricoid ring. This cricoid pressure can serve to partially occlude the esophagus and prevent passive regurgitation during laryngoscopy. In addition, this pressure against the lower part of the larynx may put the glottic opening in a more easily viewed position for the intubator. Figure C-1 illustrates this procedure. cricoid pressure is a technique of applying pressure to the cricoid ring during ventilation to occlude the esophagus and prevent regurgitation.
During laryngoscopy, there are a few things the EMT can do to help the intubator achieve an adequate view of the glottic opening. The application of cricoid pressure is one technique that can be used.
Another technique is to pull the right upper lip up and away from the mouth (Figure C-2). This is useful because the intubator will be looking into the right side of the patient's mouth. The upper lip can provide an impediment to a clear view of the airway structures. Because the assisting EMT usually has a free hand, he can gently move the lip out of the way.
FIGURE C-2 The patient's upper lip can
sometimes block the view of the intubator.
Additionally, the advanced provider may require suction during the procedure. The EMT should have a Yankauer suction catheter within easy reach of the advanced provider and be prepared to turn on the suction power if needed.
Once the endotracheal tube (ETT) has been placed, the advanced provider will perform several techniques to confirm proper placement. Although it is the responsibility of the person who performs the intubation to ensure its proper placement, the EMT can assist with the completion of this by auscultation of the lungs and epigastrum, end tidal CO2 detection, syringe aspiration, and assessment of adequate chest rise. All of these techniques are described in Appendix A.
In addition, the EMT should reassess the patient's vital signs, including pulse oximetry, if available, to ensure improvement after the placement of the ETT.
It is sometimes helpful, even in the absence of spinal injury, to apply a cervical collar to the intubated patient to minimize neck and head movement. Excessive head movement can result in dislodgment of the endotracheal tube. Therefore, anything that will minimize such movement would be useful.
Once the ETT has been confirmed to be in the proper tracheal position, the EMT should assist in securing it in place. It is very important that the exact depth of the tube be noted immediately on confirmation of proper placement. This can be done by noting the numbered markings on the side of the plastic tube. The average tube depth for a woman is 21 cm, and the average tube depth for a man is 23 cm.
Once this depth has been noted, the tube should be secured in that position using tape or any commercial device meant for this purpose. After the tube is secured, the position again should be confirmed by looking at the markings on the tube and by reevaluating the patient.
If the intubator is an advanced provider, he may likely have to move on to other procedures, such as establishing an IV line, after completing intubation. The EMT will likely be asked to provide appropriate ventilation via the ETT.
Extreme care must be taken while handling this tube so it does not become misplaced. A misplaced endotracheal tube can cause the patient to become hypoxic.
When ventilating a patient through an ETT, a bag-valve device hooked up to 100% oxygen should be used. Usually the liter flow on the oxygen tank should be set at 15-25 lpm in order to get sufficient oxygen into the bag for delivery to the patient.
The EMT should use two hands to accomplish the task of ETT ventilation. One hand should be holding and squeezing the bag, while the other hand is against the patient's face, holding the base of the tube securely. No matter how efficient the tube securing method used, the tube can be easily dislodged if not securely held at all times.
Every few minutes, the EMT should assess the markings on the side of the tube to ensure the tube has not moved from its original position.
Ventilation should be performed at an appropriate rate for the age of the patient. The EMT should be careful to count the frequency of the ventilations delivered and keep them within the recommended rate at all times.
While delivering each ventilation, the EMT should note the resistance felt as he squeezes the bag. Any change in that resistance may mean that there is a problem with the tube placement or that the patient may have suffered a complication. The advanced provider should be made aware of any change in resistance as soon as it is noted.
As he ventilates the patient, if the EMT notes any accumulation of secretions within the tube, he may be asked to suction them out. Endotracheal suctioning is a sterile procedure that is easily done by the EMT. The technique is described in Appendix A of this text.
As with any other suctioning technique, the EMT should never suction for longer than 10-15 seconds, as the patient is not being ventilated during this time. It is sometimes useful to hyperventilate the patient for 1 minute prior to suctioning and then again for 1 minute after suctioning, to make up for the short time without oxygen delivery.
Part of an advanced assessment of the patient with a potential cardiac problem involves monitoring the heart's electrical activity. The EMT is taught to do this with an automatic defibrillator. The automatic defibrillator assesses the patient's heart rhythm through two large electrode pads that are placed on the chest, as described in Chapter 29.
If an EMT is caring for a victim of a cardiac arrest and there is an advanced provider on the scene as well, it is often useful for the EMT to use an automated external defibrillator (AED) to provide the cardiac rhythm assessment and defibrillation initially. This allows the advanced provider to perform other ALS tasks such as endotracheal intubation, IV access, and medication administration.
An advanced provider will assess the patient's heart rhythm with a different type of monitor. Most AEDs monitor the heart in one view or lead. That view is created between the two electrode pads that are applied to the chest.
A more advanced monitor can assess the heart with more than one view. A series of 3, 5, or even 10 or more electrodes can be placed on the patient's chest and attached to a monitoring device that can use these electrodes to generate a picture of the heart's electrical rhythm in many different views. This multiview picture of the heart's activity is useful in diagnosing different heart conditions.
Dan, the paramedic intern, was busy getting a history on Mr. Briggs, while Mohammed was standing on the sidelines watching. Mr. DeLeon, the paramedic in charge, asked Mohammed if he had ever put a patient on a heart monitor before. Mohammed answered, "No." "OK, kid," said Mr. DeLeon, "if you're going to do it, do it right."
With that introduction, DeLeon launched into a minilecture on electrode placement, topographic anatomy, and the importance of placing the electrodes correctly. Mohammed, listening closely, quickly picked up the information and started to apply the electrodes, while Dan started the IV.
(Courtesy of PhotoDisc.)
To understand what view of the heart is being monitored, the electrodes must be applied in very specific places. The application of these electrodes can easily be accomplished by an EMT.
The application of defibrillator pads was discussed in Chapter 29. Figure C-3 illustrates the proper placement of these two large electrodes. These electrodes should be placed onto dry skin and firmly applied so they are completely adherent to the chest wall.
FIGURE C-3 Proper positioning of the AED pads is crucial to successful
defibrillation. A and B show two proper ways
FIGURE C-4 Proper placement of cardiac electrodes for three-, four-, and five-lead
systems.
Most cardiac monitors used in the prehospital setting utilize three, four, or five electrodes to create several views of the electrical activity in the heart. This is useful in interpreting abnormal heart rhythms. Figure C-4 illustrates the proper position of these leads. Just as with the defibrillator pads, these electrodes should be applied to dry skin for the best result.
When a patient presents with signs and symptoms that may be consistent with a myocardial infarction, a paramedic may wish to obtain a twelve-lead ECG. A twelve-lead ECG or electrocardiogram is a collection of 12 views of the heart obtained by applying a series of 10 electrodes to the chest in predetermined places. Knowing what each view should look like, the paramedic can assess the ECG for abnormalities. Certain types of abnormalities can be diagnostic for an acute myocardial infarction.
While obtaining the twelve-lead ECG is important, the paramedic has several other tasks he must accomplish with the patient who is suspected of having an acute myocardial infarction. While the paramedic is establishing an IV line and administering medication, the EMT can be applying the electrodes so that a twelve-lead ECG can be done as quickly as possible.
It is critically important the electrodes be placed in the proper positions for the acquisition of the twelve-lead ECG. If they are placed improperly, they will generate a different view of the heart than the paramedic is expecting to see. This will prevent an accurate interpretation of the findings. Figure C-5 illustrates the proper positioning of the 10 leads for acquisition of a twelve-lead ECG.
FIGURE C-5 Proper positioning of the
10 electrodes used to obtain a twelve-lead
ECG.
While the application of electrodes is fairly universal from one brand of cardiac monitor to another, the actual monitor setup is vastly different depending on which model is used. If an EMT frequently interacts with a particular ALS service, it would be useful to become familiar with the start-up features of the ALS service cardiac monitors. Generally, after the electrodes are attached properly to the patient, the electrode cables will be plugged into the cardiac monitor. Then the monitor should be turned on.
For the best contact, the skin should be dry and free of excess hair prior to the application of the electrodes. A towel may be used to dry any excess perspiration from the patient's chest, and a razor may be used to carefully remove any hair that will significantly interrupt the ECG.
Different models have different features. Unless the EMT is familiar with the specific features of the monitor, the EMT should ask the ALS provider for further instruction. Application of the electrodes alone will serve to save time in acquisition of the twelve-lead ECG. Figure C-6 illustrates one type of cardiac monitor commonly used by prehospital providers.
FIGURE C-6 The EMT should become
familiar with the type of cardiac monitor
that is used most commonly by the
advanced level agencies with which he works. (Courtesy of Zoll Medical Corporation, Burlington, MA.)
An IV line is a small plastic catheter that is threaded over a needle into a vein, often in the arm. Its purpose is twofold. Blood samples can be removed from the vein through the catheter, and fluids and medications may be administered into the vein via the same route.
While most EMTs are not permitted to perform IV cannulation, it is helpful for them to be familiar with the procedure so that they may safely assist an advanced provider.
The first rule for the handling of sharp instruments, such as needles, is for the person who is responsible for using the instrument to ensure its safe disposal into a designated sharps container. Sometimes, at a scene or in an ambulance, this is not immediately possible. It should be done as soon as possible to avoid any potential injuries.
Arriving almost simultaneously with the call for an "unknown, man down in the mall, food court," EMT Sajan and Paramedic Pratt rode the escalator the last several yards to the food court.
Finding the scene was not hard. They simply looked for the crowd of people. In the center of the crowd on the floor was Dean Rome, a diabetic patient who was notorious for having "spells."
"Sajan, after you're done with your initial assessment, could you run a line out for me?" asked Pratt.
The handling of needles must always be done with extreme caution. Careless handling of used needles can result in an inadvertent needle-stick injury and dangerous exposure to potentially contaminated blood. Gloves should always be worn when an intravenous line is present and when handling sharp instruments.
The dos and don'ts for handling of sharp instruments are shown in Figure C-7.
FIGURE C-7 A. Never recap a used needle. B. Never stick a needle into a seat or mattress. C. Never throw a needle toward its disposal site. D. Always dispose of a sharp instrument in its approved container as soon as possible.
Although the EMT will not be establishing the IV line in most cases, preparing the patient for the procedure will decrease the time needed to complete the task by the advanced provider.
Most prehospital IV lines are initiated in the veins of the hands and arms. Therefore, it is necessary to remove any garments that have long sleeves that will hinder this process. Coats and sweaters should be removed if the climate allows. Sleeves can be rolled up, unless the clothing must be removed for some other purpose.
Once an IV catheter has been placed, it must be attached to sterile fluid-filled tubing so that blood does not leak out and medications may be given, if needed. The EMT can prepare the fluid-filled tubing while the advanced provider is placing the catheter into the vein.
As there are different types of fluid and tubing used for this purpose, the EMT should ask the advanced provider which fluid and tubing to set up. The EMT should carefully select the appropriate fluid and tubing.
The most common type of fluid is called normal saline (NS) and is made up of salt water that is 0.9% sodium chloride (NaCl). This fluid has salt in nearly the same concentration as blood and is frequently used to replace lost fluids into the vein.
A second commonly used IV solution is called lactated Ringers (LR). This is a combination of several electrolytes that also approximates the concentration of blood. The two types of fluid, LR and NS, are used in the same situations.
Another common fluid used in the field is called d5w (5% dextrose in water). This fluid is merely sugar water and is used when sugar is needed or an inert fluid is needed with which to mix another medication. Figure C-8 shows solutions commonly used in an emergency setting.
FIGURE C-8 Normal saline, lactated
Ringers, and D5W are intravenous solutions
that are commonly used in the emergency
setting.
The two types of IV tubing are designed to allow fluid administration at different rates. One type of tubing, called macrodrip tubing, allows large drops to come out of the bag of fluid, allowing very rapid administration of fluid if needed. Figure C-9 shows this tubing. The container for the tubing will most likely be labeled with a number. That number represents the number of drops that it takes coming out of this tubing to make 1 cc of the fluid. Macrodrip tubing has very few drops needed to make 1 cc, as the drops are very large. Ten or 15 drops/cc is typical of macrodrip tubing.
FIGURE C-9 Macrodrip tubing dispenses 10-15 large drops to equal 1 cc.
The other type of tubing that is commonly used is called microdrip tubing. This tubing creates very small drops, usually 60 drops in a cc. This tubing is used when only a small amount of fluid is expected to be needed. Figure C-10 shows microdrip tubing.
FIGURE C-10 Microdrip tubing dispenses 60 tiny drops to equal 1 cc.
Once the type of tubing and fluid is chosen, the EMT should remove the bag of fluid from its outer container and the tubing from its package. Just like when administering any medication, the EMT should check the fluid to be sure it is not expired. The expiration date is usually on the front of the bag.
Additionally, the fluid should be checked to be sure it is clear. NS, LR, and D5W are perfectly clear. If any discoloration is noted, the fluid should be discarded and another bag chosen.
Lastly, the bag should be checked for leaks. A leak in the bag may mean that the sterility of the fluid cannot be guaranteed. If a leak is suspected, the bag should be discarded and another chosen.
When assembling the tubing and the bag of fluid, the EMT should take care to keep the ends of the tubing sterile. This means that nothing should contact those ends so that they can stay as clean as possible and decrease any chance for infection in the patient. A contaminated IV can cause serious infection in the patient. Assembly of an IV line is demonstrated in Skill C-1.
After the IV fluid is running into the catheter, the advanced provider will secure the catheter and the tubing so they do not become dislodged (Figure C-11 on page 1041). Generally tape or a commercially made occlusive dressing is applied over the IV site and the tubing to prevent accidental dislodgment.
Once attached to the patient's IV catheter, the bag of fluid must always remain above the level of the heart. This will prevent any backup of blood into the tubing. Generally, the higher the bag is held, the faster the IV fluid can be run, assuming the drip chamber is left wide open.
Once the IV fluid is running into the patient's vein, it is important to ensure that the IV line is continuing to function properly. The flow regulator should be set by the advanced provider to allow a specific rate of IV fluid administration. The IV site should frequently be assessed for any signs of infiltration. Infiltration is the seeping of material intended for IV delivery into the soft tissues surrounding the vessel. This can occur if the vein tears or if the IV catheter becomes dislodged.
Some IV fluid is packaged inside a plastic wrapper. It may become humid inside that wrapper. Therefore, a small amount of condensation would be normal on the bag of fluid itself. No actively leaking liquid should be noted. If there is any doubt about the sterility of the fluid, it should be discarded.
Signs of infiltration include increasing pain or swelling at the IV site or difficulty infusing fluid. If the IV is believed to be infiltrated, the fluid should be shut down immediately. No further medication or fluid should be given into an infiltrated IV.
If an EMT is transferring a patient with an IV, he must repeatedly check the rate of the fluid dripping in the drip chamber. Any slowing of fluid may be due to a kink in the tubing, inadvertent closing of the flow regulator, or infiltration. Any speeding of the drip rate may be due to a change in the position of the patient or inadvertent alteration in the flow regulator setting.
It is wise to check the IV site for signs of infiltration with each set of vital signs. Any changes should be reported immediately.
PURPOSE: To assist the advanced EMT by preparing the IV solution for administration.
STANDARD PRECAUTIONS:
Intravenous fluid
Intravenous tubing
1 The EMT verifies that she has the right solution, that the solution is not expired, and that the solution is clear.
2 The EMT selects the correct IV tubing and removes it from the box. She moves the roller clamp proximal to the drip chamber and closes the roller clamp.
3 The EMT removes the tab from the solution, as well as removes the cap from the drip chamber end of tubing.
4 Without touching either sterile end, the EMT inserts the tubing spike into the appropriate port on the IV bag.
5 With the bag spiked, the EMT holds the solution upright and squeezes the drip chamber to allow it to fill halfway with solution.
6 Holding the fluid up with the tubing down, the EMT opens the flow regulator to allow fluid to fill the tubing slowly. The EMT recaps the sterile end once the IV tubing is flushed.
It is potentially dangerous to allow a large amount of air to enter an IV line. The EMT should ensure all the air bubbles have run out of the tubing prior to handing it to the advanced provider who will hook it to the IV. This can be done by following the preceding steps carefully. If air bubbles are seen in the tubing, the EMT should simply allow them to run out. The IV fluid should be run into a garbage bag or a towel, not onto the floor. A puddle of IV solution on the floor could result in someone slipping and falling.
FIGURE C-11 Properly securing an intravenous line can help to prevent its inadvertent removal.
The EMT will have many occasions to work with more advanced prehospital health care providers. His familiarity with ALS skills and his ability to assist ALS providers in their tasks will contribute to effective teamwork. Such teamwork will result in quality patient care.
Dougherty, J. E. (1986, April). The basically advanced provider. Emergency, 19(4), 14, 16. Haynes, B. E., & Pritting, J. (1999, October-December). A rural emergency medical technician with selected advanced skills. Prehospital Emergency Care, 3(4), 343-346.
Source: Beebe, Richard W.O., and Deborah L. Funk. Fundamentals of Basic Emergency Care. 2nd ed. Clifton Park, NY: Thomson Delmar Learning, 2005. 1122 pp.
