End-Tidal-Carbon-Dioxide detection (EtCO₂) should be used to confirm the initial placement of all advanced airways (in addition to physical exam) per EtCO₂ standard operating procedure, on any ambulance that has the capability of performing capnography. Continuous EtCO₂ monitoring should be used throughout patient encounter on ALL patients with advanced airways.

 

Advanced airways are to be confirmed and secured prior to moving the patient. Any time the patient has been moved (i.e. from the scene to the vehicle, in the vehicle, from the vehicle to the ED) the airway placement is to be re-confirmed.

 

Documentation on the run sheet is to include:

 

1. Bilateral breath sounds, absence of epigastric sounds
2. Size of advanced airway. For ET tubes document depth of insertion in centimeters.
3. Method of securing the advanced airway
   
4. ETCO₂ measurement (initial reading and any changes during patient encounter)

Confirmation signature of successful placement of an advanced airway (ETT, King, LMA, Cric) at the receiving facility is required upon arrival in the Emergency Department. If the EMS provider fails to get the airway confirmed at the receiving facility or if the confirming entity assesses that the device is misplaced a copy of the patient care report must be made available to provider agency supervisory personnel and the Medical Director within 24 hours.

Normal Waveform

 

"Shark Fins" - indicates bronchospasm

 

Displaced ET tube/Apnea

 

Hypoventilation

 

Hyperventilation

 

Air trapping or indadequate exhalation as in COPD or asthma

ALS

 

1. Position adult patient (age greater than 8 years) by hyperextending the neck unless c-spine concerns mandate neutral positioning.

 

2. Locate the cricothyroid membrane.

 

3. Clean the incision site, if possible.

 

4. Incise the skin vertically over the membrane.

 

5. Bluntly dissect down to the cricothyroid membrane.

 

6. Incise the lower portion of the membrane horizontally with scalpel and rotate the blade 90^o.

 

7. Enlarge and maintain the opening with hemostats or the end of the scalpel.

 

8. Insert cuffed endotracheal tube and inflate cuff.

 

9. Confirm correct placement by use of the EtCO₂, if available, or Esophageal Detector Device/colorimetric ETCO₂ detector and auscultating for breath sounds over both lungs and stomach.

 

10. Cover wound with occlusive dressings and secure the tube.

 

11. Reassess breath sounds.

 

Complications of Cricothyrotomy

 

Hypoxemia
Hybercarcia (CO₂ toxicity)
Perforation of the esophagus
Hemorrhage
Injury to the thyroid/parathyroid glands
Subcutaneous and mediastinal emphysema
Infection
Damage to tracheal cartilage involving disruption of vocal cords

 

If cricothyrotomy is attempted, a copy of the run record must be made available to the Medical Director through the CQI Coordinator within 24 hours of the run.

 

ALS

 

1. Position pediatric patient (age 8 years or less) by hyperextending the neck unless c-spine concerns mandate neutral positioning.

 

2. Locate the cricothyroid membrane.

 

3. Clean the puncture site, if possible.

 

4. Connect a syringe to the end of the catheter/needle.

 

5. Insert the catheter/needle into the cricothyroid space at less than 90 degrees to the longitudinal axis of the neck and caudally. Maintain suction with the syringe until air freely flows into the syringe or until bubbles are noted (if the syringe is partially filled with saline)

 

6. Advance the catheter over the needle, and then remove the needle.

 

7. Reconfirm placement with free-flow aspiration or the syringe bubble technique.

 

8. Attach a mechanism to provide high flow oxygen through the catheter (e.g., a 3.0 ET tube adapter plus BVM or an oxygen supply tubing, 3-way stopcock, and extension set) and begin oxygenation.

 

9. Watch for prompt chest inflation and auscultate for breath sounds over both lungs and stomach.

 

10. Secure the catheter carefully; avoiding kinking the cannula.

 

11. Reassess breath sounds.

 

Complications of Cricothyrotomy

 

Hypoxemia
Hybercarcia (CO₂ toxicity)
Perforation of the esophagus
Hemorrhage
Injury to the thyroid/parathyroid glands
Subcutaneous and mediastinal emphysema
Infection
Damage to tracheal cartilage involving disruption of vocal cords

 

 

If cricothyrotomy is attempted, a copy of the run record must be made available to the Medical Director through the CQI Coordinator within 24 hours of the run.

 

Indication: Along with medical (pharmacologic) management, treatment for respiratory distress as evidenced by:

 

Persistent dyspnea/hypoxemia
History consistent with heart failure, volume overload, COPD or asthma exacerbation
Drowning

Patients must meet the following criteria for CPAP administration:

 

1. Age greater than or equal to 18 y/o

 

2. Has the ability to maintain and protect an open airway

 

3. Systolic BP at or above 90 mm Hg

 

4. Pulse oximetry < 92% on 100% oxygen plus at least two (2) of the following:

 

Severe or sudden onset of shortness of breath
RR rate > 25/minute
Use of accessory muscles
Dyspnea at rest
Rales or wheezes

 

Contradictions

 

1. Respiratory or cardiac arrest
2. Agonal respirations
3. Suspected or confirmed pneumothorax or penetrating chest trauma
4. Inability to maintain a patent airway
5. Any impediment to proper mask placement or seal (facial trauma, stroke, facial anomalies, epistaxis)
6. Tracheostomy
7. Persistent nausea and vomiting/Upper GI bleeding
8. Inability to comply with the device due to severe anxiety or altered mental status

 

Procedure

 

1. Assure patent airway, place patient on EKG monitor and pulse oximetry; capnography if available.

 

2. Explain procedure to the patient and reassure.

 

3. CPAP does not replace pharmacology – initiate medications first if applicable:

 

1. If suspected cardiogenic pulmonary edema and SBP > 90 mm Hg, administer three 0.4 mg doses of NTG SL and repeat three 0.4 mg doses every 3 minutes if SBP remains at or above 90 mm Hg and patient remains dyspneic.

 

1. Remember to avoid the use of NTG in the setting of Viagra, Levitra, Cialis, or other ED drug use.

 

2. If asthma or COPD is suspected, administer 5 mg albuterol and 0.5 mg ipratropium per nebulizer and repeat as needed if the patient remains dyspneic (not to exceed 3 doses of ipratropium).

 

3. If the 2^nd round of pharmacologic therapy (above) fails to resolve the patient’s dyspnea, and they remain hypoxemic (oxygen saturation < 92% on 100% oxygen), then CPAP may be initiated.

 

4. Ensure adequate oxygen supply to device, if needed, set manufacturers recommended liter flow.

 

5. Place mask and hold in place as patient adjusts to ventilatory support. Encourage patient to breathe deeply.

 

6. Secure mask, check for air leaks and if recommended by manufacturer, increase liter flow as needed.

 

7. Contact receiving hospital as early as possible to allow Respiratory Therapy to prepare their equipment.

 

8. Monitor and document patient VS and pulse oximetry (watch for decreased respiratory rate and/or mental status).

 

9. If patient deteriorates, remove device and consider BVM ventilations or ET intubation.

 

Documentation

 

Documentation should include all of the following:

 

1. CPAP level (cm H₂O)
2. SpO₂ every 5 minutes
3. Vital signs (HR, RR, BP)
4. Response to treatment including, SpO₂, RR and work of breathing
5. Adverse reactions
6. Clinical Impression on patient care form (respiratory distress and/or CHF/Asthma/COPD)

ALS

 

1. Auscultate the chest to confirm which side has a suspected tension pneumothorax (indicated by absence/decrease in breath sounds, hypotension, and significant respiratory distress)

 

2. Locate the second intercostal space at the midclavicular line.

 

3. Clean the skin.

 

4. For adults, insert a 3.25” 14-gauge needle over the superior border of the 3^rd rib perpendicular to the floor/cot and with the bevel pointing toward the midline. Do not insert needle medial to the nipple line. For pediatric patients, use a 14- or 16-gauge needle that is no longer than 1.5 inches in length. 
   

 

When the needle reaches the visceral pleura, you may feel a “pop” and/or air may rush out

 

5. An alternative needle decompression location may be authorized by the agency’s medical director.

 

6. Reassess and re-auscultate for improvement of breath sounds, pulse, respirations, and blood pressure.

 

7. Remove the needle and tape the catheter in place.

 

8. Reassess and re-auscultate for improvement of breath sounds, pulse, respirations, and blood pressure.

 

Complications

 

Hemorrhage from laceration of intercostal vessels
Hemorrhage from laceration of a pulmonary vessel
Puncture of the lung

 

If needle decompression is attempted, a copy of the run record must be made available to the Medical Director through the CQI Coordinator within 24 hours of the run.

 

ALS

 

Criteria: Any patient 18 years or older with a non-traumatic presentation of atropine-refractory symptomatic bradycardia

 

1. Assess for signs of instability.

 

1. Heart rate < 60/min and
2. SBP < 90 mmHg and
3. Signs and symptoms of shock

 

2. Apply pacing electrodes.

 

1. The anterior-posterior (AP) placement of the pacing electrodes is preferred. If absolutely necessary, anterior-anterior (AA) placement may be used.

 

Anterior-Posterior Placement

 

1. Place negative electrode on left anterior chest halfway between the xyphoid process and the left nipple with the upper edge of the electrode below the nipple line.

 

2. Place the positive electrode on the left posterior chest beneath the scapula and lateral to the spine.

 

Anterior-Anterior Placement

 

1. Place negative electrode on left chest, midaxillary over the fourth intercostal space.

 

2. Place positive electrode on anterior right chest, inferior to clavicle.

 

3. This position should only be used if AP placement is not possible.

 

3. Pacing procedure:

 

1. Maintain EKG monitoring during pacing procedure.

 

2. Attach pacing electrodes and connect pacing cable to pacemaker.

 

3. Power up pacemaker.

 

4. Observe monitor for a "sense” marker. One mark should appear on each QRS complex. If it does not appear or only appears intermittently, the pacemaker is not sensing the intrinsic rhythm of the patient. Adjust EKG size (larger) or change from Lead II to Lead I or III in order to achieve sensing. If more than one sensing mark appears for each QRS, the EKG size is probably too high. If intrinsic beats are not present, omit this step.

 

5. Adjust pacing rate to 70 bpm.

 

6. Adjust milliamp (mA) output to start at 10 mA. Gradually increase mA until electrical capture is noticed on the monitor

 



 

7. Assess for mechanical capture by checking for a pulse and blood pressure.

 

If electrical capture is present but no pulse is present, increasing the mA is of no benefit.

 

8. Record time of application and obtain rhythm strips before and after application.

 

If the patient's intrinsic rate exceeds the pacing rate, the pacemaker will sense the activity and not discharge.

 

Musculoskeletal discomfort may accompany external pacing. If this is a problem and the patient's vital signs will allow it, sedation and/or analgesia may be appropriate.

ALS

 

1. Prepare the IO insertion device and needle

 

2. Locate insertion site

 

1. Proximal humerus (preferred)

 



 

2. Tibia plateau

 

3. Cleanse insertion site.

 

4. Stabilize extremity and insert the needle following the manufacturer’s recommendations.

 

5. Remove driver from needle set while stabilizing catheter hub

 

6. Remove stylette from needle set and secure until it can be placed in a sharps container.

 

7. Confirm placement. It may be possible to aspirate bone marrow at this point with a 20 or 30 mL syringe.

 

8. If the patient is awake and alert administer prime all tubing with lidocaine instead of saline and 2 mL 2% lidocaine slowly over 60 seconds, then allow 30-60 seconds for the lidocaine to affect the visceral nerves. Follow with a brisk 10 mL saline flush. Another 1 mL 2% lidocaine may be administered in the same manner.

 

9. Connect primed IV line and begin infusion

 

10. Place a pressure bag (or IV infusion pump) on solution being infused where applicable

 

11. Secure tubing and dress site using commercial stabilizer if available, secure tubing

 

12. Frequently monitor IO catheter site and patient condition

 

Complications

 

Abscess from prolonged insertion
Leakage around the needle with compartment syndrome
Tibia fractures
Osteomyelitis from prolonged insertion
Potential injury to the bone marrow cavity
Skin necrosis

ALS

 

1. Place the child in the supine position.

 

2. Identify the tibia tuberosity, 1-3 cm below the tuberosity on the medial surface of the tibia, approximately one finger's breath below and just medial to the tuberosity.

 

1. Alternatively, 1 - 2 cm proximal to the medial malleolus on the anteromedial surface of the distal tibia.

 

3. Clean the skin.

 

4. The leg should be supported on a firm surface. Grasp the thigh and knee above and lateral to the insertion site. Do not allow any portion of your hand to rest behind the insertion point.

 

5. With the stylette in place, insert the needle at a 90^o angle to the skin.

 

1. Using gentle pressure that is steady, begin to advance the needle through the skin until you touch the bone, then check needle depth. If at least 5mm of needle remains exposed (the last black line) drill through the bone.

 

2. Stop advancing the needle when a sudden decrease in resistance to forward motion of the needle is felt. Do not pull back or recoil when entering the medullary space. Unscrew the cap and remove the stylet. It may be possible to aspirate bone marrow at this point with a 20 or 30 mL syringe.

 

6. Stabilize the IO.

 

7. If the patient is awake and alert, prime all tubing with lidocaine instead of saline and administer 1 mL 2% lidocaine over 60 seconds, and then allow 30-60 seconds to affect the visceral nerves. Follow with a brisk 10 mL irrigation of saline. A second dose of 0.5 mL 2% lidocaine may be repeated in the same manner

 

8. Check for any signs of increased resistance to injection, increased circumference of the soft tissues of the calf, or increased firmness of the tissue.

 

1. The needle is in the bone marrow when:

 

1. there is a lack of resistance

 

2. the needle passes through the cortex

 

3. the needle stands upright without resistance

 

4. there is no infiltration

 

5. blood and marrow are aspirated (less common)

 

6. fluid flows freely through the needle without evidence of subcutaneous infiltration

 

9. Attach the IV tubing and begin the infusion. A pressure infusion bag or in-line 60 mL syringe may be required to infuse the solution.

 

10. If unsuccessful, remove the needle and move to the other leg.

 

11. Secure tubing and use commercial stabilizer if available or secure with tape.

 

Complications

 

Abscess from prolonged insertion
Leakage around the needle with compartment syndrome
Tibia fractures
Osteomyelitis from prolonged insertion
Potential injury to the bone marrow cavity
Skin necrosis

ALS

 

PVADs (pre-existing vascular access devices) include any indwelling catheter/device placed into one of the central veins to provide vascular access for those patients requiring long term intravenous therapy and hemodialysis shunts or grafts.

 

1. Types of Catheters

 

1. External indwelling catheters/devices

 

1. Heparin/Saline Lock - A temporary venous catheter placed in a peripheral vein and occluded with a cap. Heparin or saline is instilled periodically to maintain its patency. It may be accessed directly through the injection cap.

 

2. Peripherally inserted central catheter (PICC) - a long catheter inserted in the upper arm or antecubitally into the subclavian vein or superior vena cava. It may be accessed through the injection cap.

 

3. “Broviac®”, “Hickman®”, “Groshong®”, and others - a long catheter that is inserted into the right atrium through a central vein. The catheter enters the skin through an incision in the chest. The line may be heparinized and may be accessed directly through the injection cap. These catheters are usually multi-lumened and any lumen can be used, but a red-colored port is preferred.

 

2. Internal indwelling devices – NOT TO BE USED

 

1. Internal subcutaneous infusion ports - an access device embedded subcutaneously and must be accessed through the skin using special equipment.

 

2. Hemodialysis fistula or graft - A permanent access device that diverts blood flow from an artery to a vein and is usually located in the forearm or upper arm. It is used for dialysis.

 

2. Indication for use of external indwelling catheters/devices (other than a heparin/saline lock, which may be used as needed):

 

1. Cardiac arrest

 

2. Other emergent need to administer fluids and/or medications:

 

1. which can only be given by the IV route, and

 

2. a peripheral IV site is not readily/immediately available (after 2 tries), and

 

3. intraosseous access is not appropriate due to the patient’s condition, and

 

4. with approval by on-line medical control.

 

3. All ALS medications and fluids (approved for IV administration) may be given through a PVAD.

 

3. Procedure for external indwelling catheters/devices:

 

1. Assemble necessary equipment

 

1. 10 mL syringe
2. 0.9 normal saline for injection
3. IV tubing and fluid
4. alcohol wipes
5. 18 gauge needles

 

2. Disconnect any existing IV lines.

 

3. Prepare syringe with 10 mL NS and set up IV line.

 

4. Clean injection cap or needleless-port with alcohol wipe.

 

If there is a red port, use this preferentially

 

5. If clamped, unclamp catheter.

 

6. Slowly inject 5 ml of saline – if resistance is met, discontinue procedure.

 

7. Attach IV tubing to port (using an 18 ga. Needle if an injection cap is in place) and initiate fluid and/or medication therapy

 

8. Flush line with IV fluid after medication administration.

 

Complications

 

1. Infection. Due to the location of the catheter end, strict adherence to aseptic technique is crucial when handling these devices. The injection cap or needleless port must be cleansed thoroughly. Sterile gloves are preferred. Care must be used not to contaminate the needle used to access the line or the IV tubing used.

 

2. Air embolism. These devices provide a direct line into the circulation; therefore the introduction of any air into the device will go straight to the heart. Do not ever remove the injection cap or needleless port from the catheter. Do not allow IV fluids to run dry. Clear all air from the IV tubing and syringes prior to administration of fluids or medications.

 

3. Thrombosis. Improper handling and maintenance of the device may dislodge a clot causing pulmonary embolus or vascular damage. Check patency of the line by slowly injecting 5 mL of NS. Do not inject medications or infuse fluids if resistance is met when establishing patency of the catheter. Flush line with 5 mL of normal saline after medication administration.

 

4. Catheter damage. These catheters are meant for long-term use. They usually require an invasive or surgical procedure and are costly to insert. Care must be taken to avoid any damage to the catheter. If damage to the catheter outside the skin occurs, immediately clamp the catheter between the skin exit site and the damaged area to prevent air embolism or blood loss. Always use a 10 mL or larger syringe to prevent catheter damage from excess pressure when injecting directly. Use caution when inserting the needle into the injection port.

ALS

 

Criteria: Any patient with refractory ventricular fibrillation or pulseless ventricular tachycardia that has not responded to ≥3 standard defibrillation attempts (i.e. - NO break in Vfib/tach)

 

1. Ensure all necessary cardiac arrest interventions have been applied up to this point.

 

1. Uninterrupted and effective CPR

 

2. Defibrillation at maximum output for at least 3 shocks (including first responder AED shocks.)
   This first set of pads is referred to as “Pads-A”.

 

3. Administration of Amiodarone 300mg

 

4. Consideration of possible causes of cardiac arrest

 

2. Prepare sites for attachment of an additional set of external defibrillation pads.

 

1. Appropriately dry the desired sites on A/P chest.

 

2. Minimize interference of hair and other obstacles to good pad adhesion.

 

3. Apply a new set of external defibrillation pads in the anterior/posterior position while assuring they do not contact the initial set of pads. This second set of pads if referred to as “Pads-B”. 
   

 

4. Perform Alternate Vector Defibrillation FIRST. Using the same monitor, change the defibrillator cable to connect “Pads-B” and defibrillate once using maximum energy setting.

 

5. E. If Alternate Vector Defibrillation unsuccessful, set up for Double Sequential Defibrillation with second monitor. One monitor will be connected to “Pads-A” and the second monitor connected to “Pads-B”. 

 

1. Designate a primary monitor to obtain all event recording and data capture

 

2. Primary monitor shall be the ONLY monitor uploaded or included in the ePCR.

 

6. Select maximum energy setting for both devices. Charge devices 15 seconds in advance of the anticipated break in CPR.

 

1. Ensure that chest compressions continue while the device is charging.

 

7. At the designated time in the compression cycle discontinue compressions and assess rhythm.

 

8. If a shock is indicated, assertively state, “CLEAR” and visualize from the patients head to toe to make certain no one is touching the patient and deliver the Double Sequential Defibrillation by depressing both shocks simultaneously.

 

9. Once criteria for Double Sequential Defibrillation have been met, all subsequent shocks delivered shall be administered using this method.

 

 

 

 

 

If a patient is in significant respiratory distress, is not breathing or is in cardiac arrest with a tracheostomy, replacement of the tracheostomy tube may be lifesaving. BLS providers should immediately direct trained caregivers to replace trach tube. ALS providers should locate emergency replacement trach tubes that are usually kept near the patient and attempt tube replacement.

 

BLS

 

1. Existing Tracheostomy Care

 

Suctioning

 

1. Utilize appropriate PPE.

 

2. Suction tracheostomy as needed using appropriate sized soft suction catheter.

 

1. Sterile technique is preferred when suctioning. Clean technique may also be utilized if sterile technique cannot be performed

 

2. Pre-oxygenate if at all possible.

 

3. Suction no more than 4-6” or until resistance is felt. For pediatric patients, refer to safe suction card for appropriate suction depth. If a “safe suction card” is not available suction the tracheostomy approximately the estimated length of the tube. Providers may measure the suction catheter on a spare tracheostomy tube or obturator. If an obturator is used to measure length add approximately 1-1/2 cm

 

4. Apply suction only after insertion and upon withdrawing the catheter.

 

5. Suction for no more than 10 seconds at a time.


 

Ventilation

 

1. Most adult tracheostomy tubes require an inner cannula to adapt to a standard BVM. Pediatric tracheostomy tubes naturally attach to a standard BVM. The use of omni-flex/accordion tubing can make attaching easier and give better flexibility

 

2. Utilize capnography when ventilating a patient using an existing tracheostomy.

 

Displaced Tracheostomy Tube

 

1. In the event of tracheostomy tube dislodgement ALS intervention is preferred.

    

2. BLS providers may place a gloved finger or palm over the stoma area and provide BVM ventilations via nose and mouth until ALS arrives or if the patient is breathing adequately provide supportive care.

 

1. If ventilation via the nose and mouth does not work use a small BVM mask and ventilate over the stoma.

 

2. In some cases it may be necessary to occlude the nose and mouth to obtain chest rise.


 

ALS

 

1. 1. If the patient is breathing inadequately determine if a spare tracheostomy tube is available on the scene - (if no spare tracheostomy present go to Step 4)
   

 

2. Insert the new tracheostomy tube using the same size of the existing trach tube into the existing stoma carefully and secure into place. If tube does not fit, skip to step 3
   

 

1. For adults, a soft suction catheter may be inserted thru the new tracheostomy tube and used as a guide (see photo)

 

2. If patient is still in distress, attempt suctioning to appropriate depth

 

3. If patient does not respond to suctioning after an appropriate amount of time or suction catheter does not reach correct depth go to Step 3

 

4. Confirm the placement utilizing waveform capnography

 



 

3. Same sized Trach Tube does not fit: Utilize the smaller/emergency trach tube

 

1. Insert the new tracheostomy tube using the existing stoma carefully and secure into place (if smaller size tracheostomy tube does not go in, skip to Step 4

 

2. If patient is still in distress, attempt suctioning to appropriate depth

 

3. c. If patient does not respond to suctioning after an appropriate amount of time or suction catheter does not reach correct depth go to Step 4

 

4. If the same size and smaller size tracheostomy tube does not insert into the stoma, does not allow appropriate suction depth to be achieved or relieve distress with good suctioning, or the tracheostomy tubes are not available, use an ET tube. For most adults, first attempt using a 6.0 ET tube. For pediatric patients, use an ET tube the same size diameter as the patient’s tracheostomy tube.

 

1. Advance the ET tube so that the balloon advances into the stoma and inflate the balloon, DO NOT force the ET tube

 

2. Utilize waveform capnography to confirm placement

 

3. Secure the ET tube in place and monitor for leaks

 

5. If these procedures fail consider intubation or ventilation via BVM covering the stoma

 

Ventilator Patients

 

1. Many tracheostomy patients will be on portable ventilator systems.

 

2. If the patient is NOT in cardiorespiratory arrest and the ventilator is determined to be functioning appropriately it may be in the best interest of the patient to be transported on their own ventilator.

 

1. Family members typically are well trained in the operation of portable ventilators and should be transported with the patient to operate the ventilator.

 

2. If a family member is not available to operate the ventilator and the EMS provider is not familiar with the ventilator the patient should be transported using BVM ventilation via their existing tracheostomy.

 

3. If there is a question regarding the appropriate functioning of the ventilator then patient should be removed from the ventilator and ventilated using BVM attached to the existing tracheostomy.

 

3. If a patient is removed from a portable ventilator the portable ventilator should be transported with the patient if at all possible.

 

4. Settings for the portable ventilator should be noted and relayed to the receiving hospital.

 

5. In-line capnography should be utilized if available and documented.