Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

114

CHAPTER 7 Assisting the ALS Provider KEY TERMS ALS provider:

A paramedic, nurse, or physician who performs advanced level skills.

114 115

Capnometry:
A device that displays the proportion of carbon dioxide in exhaled air.

Cardiac monitoring:
The evaluation of the electrical activity of the heart.

Direct laryngoscopy:
The use of a laryngoscope to view the larynx.

Endotracheal intubation:
The placement of a tube orally or nasally into the trachea.

End-tidal CO2 detector:

Detects the presence of carbon dioxide in exhaled air.

Intravenous:
Access to the circulatory system through a vein; within the vein.

Macrodrip:
Intravenous fluid administration set producing large drops and used for large amounts of fluid infusion (approximately 10-15 gtts = 1 cc fluid).

Microdrip:
Intravenous fluid administration set producing small drops and used for small amounts of fluid infusion (approximately 60 gtts = 1 cc fluid).

Preoxygenate:
A 2-minute period of ventilatory assistance before procedures such as intubation and suctioning.

CHAPTER 7 Assisting the ALS Provider

Page 1 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition Pulse oximetry:

The process of measuring the amount of oxygen carried in the blood.

CHAPTER 7 Assisting the ALS Provider

Page 2 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

115

CHAPTER 7 Assisting the ALS Provider

Page 3 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition IN THE FIELD

At 2130 hours EMTs Gray and Williams have arrived at the residence of Mr. Smith, a 45-year-old male patient who was complaining of chest pain. As the crew enters the home, family members inform them that Mr. Smith has a past medical history of several heart attacks and takes numerous medications. The initial assessment reveals Mr. Smith is unresponsive and has snoring respirations with slow, shallow breathing and a weak, irregular carotid pulse. Immediately EMT Gray begins to support Mr. Smith with basic airway maneuvers and bag-valve-mask ventilation while EMT Williams completes a rapid assessment and obtains additional patient history from the family. At 2133 hours, Paramedic Jones arrives on location and receives a quick report from the BLS crew. At 2134 hours EMT Williams applies the electrodes and turns on the cardiac monitor and begins to assemble the equipment necessary for an intravenous infusion. Paramedic Jones quickly interprets the cardiac rhythm while assembling the necessary equipment for endotracheal intubation. The patient is pre-oxygenated and with the assistance of EMT Gray, a successful intubation is performed by paramedic Jones and secured following confirmation of tube placement at 2138. At 2139 hours paramedic Jones establishes intravenous access with the intravenous administration set and equipment prepared by EMT Williams. Mr. Smith receives several intravenous medications and fluid at 2142 hours, and the crew quickly packages the patient for transport, departing the residence at 2145 hours. This chapter will provide the EMT with an orientation for assisting the advanced life support (ALS) provider with several ALS skills performed in the out-of-hospital setting. The EMT's knowledge of the procedures and equipment related to cardiac monitoring, intravenous therapy, and endotracheal intubation will greatly increase the functioning of the EMS team.

115 116

THE TEAM CONCEPT

Care in the out-of-hospital setting may involve lay persons, police, fire, EMS, and other healthcare providers who strive to provide appropriate care to the sick and injured. This goal can best be achieved by working together as a team. Regardless of the certification or licensure level of the healthcare provider, failure to adequately assess and intervene in the management of the airway, breathing, and circulation of a patient in distress will often result in an undesired patient outcome. The EMT's ability to quickly and efficiently assess these areas is the foundation of effective care. Following basic interventions, providers of advanced level care may elect to further evaluate and initiate additional interventions. This may include cardiac monitoring, intravenous therapy, and endotracheal intubation. The EMT who is able to anticipate the need or is requested to assist the ALS provider with such skills and procedures will greatly enhance the functioning of the team.

ALS PROCEDURES AND EQUIPMENT ELECTROCARDiOGRAM MONITORING Rationale

In many instances, ALS providers use cardiac monitoring to increase their ability to assess the patient condition (Box 7-1).

CHAPTER 7 Assisting the ALS Provider

Page 4 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition BOX 7-1 Examples of Patient Complaints and Conditions Where Cardiac Monitoring May Occur (Noninclusive) Patient Complaints and Conditions
Altered mental status Unresponsive patient Cardiac arrest Chest pain Respiratory distress Abdominal pain or discomfort Traumatic injuries to the chest Hypotension Diabetes
116

Assessing the electrical activity of the heart determines what interventions are appropriate for the presenting patient condition. Assisting with the application of the cardiac monitor will expedite the assessment and any electrical and pharmacological interventions necessary.

117

Monitors and Patient Preparation

There are several common types of cardiac monitors used by ALS providers in the out-of-hospital setting. The EMT should become familiar with the type, application, and start-up features of the monitor used by the ALS services with whom they frequently interact. Many cardiac monitors offer multiple electronic features including electrocardiogram (ECG, EKG) monitoring, defibrillation, synchronized cardioversion, and transcutaneous pacing. Other features may include automatic noninvasive blood pressure, pulse oximetry, and capnometry/CO2 monitoring. Through in-service and orientation opportunities, the EMT is capable of assisting with the application of these monitoring devices. When questions or expectations of assistance with the application of the monitoring devices exist, the EMT should ask the ALS provider for clarification or further instructions. The application and use of the automatic external defibrillator (AED) is discussed in Chapter 19.

Electrode Placement
Cardiac monitoring involves the application of electrodes to the patient's skin and connection of the electrical cables to the cardiac monitor. The number of electrodes used and their placement on the patient will be based on the number of monitor cables. The most common electrode placements used to view the electrical activity of the heart are three-, five-, or twelve-lead systems. Figure 7-1 indicates the proper electrode placement for the three-cable lead system. Following placement of the electrode on the patient's skin, the electrical cables are connected to the appropriate electrodes. Each

CHAPTER 7 Assisting the ALS Provider

Page 5 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

connector may be identified based on color and letter indications on each snap connector. On three-cable systems, the identifiers include right arm (RA) and is white in color; left arm (LA) is black in color; and left leg (LL) is red in color. The addition of the right leg (RL) which is brown in color and a central ground (G) is green in color are added for five-monitor cable systems. Twelve-lead systems have ten cable-electrode connections. Placement of electrodes on the chest, abdomen, or arms and legs is often based on practicality and accessibility. Placement on the upper extremities is often a challenge due to clothing, and artifact may be increased on the monitor due to extremity movement.

Fig. 7-1 Electrode placement for four leads.

With three- and five-lead systems, frequently the upper right and left chest just below the lateral clavicular area is used for the arm leads, and the left and right lateral abdominal area for the left leg placement. With twelve-lead systems, ten electrodes are placed on the patient. The four limb leads are placed distally on the extremities, and the remaining six electrodes are placed across the anterior to the left lateral chest wall.

117 118

Fig. 7-2 Standard equipment for establishing intravenous access.

CHAPTER 7 Assisting the ALS Provider

Page 6 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition BOX 7-2 Electrode Application
Identify the need for cardiac monitoring. Identify electrode placement based on monitor cable system. Expose the patient's skin in the area of electrode placement to ensure it is dry and free of excess hair. Remove the protective cover from the electrode and apply it to the patient's skin. Connect the electrical cables to the electrodes. Turn the monitor to the on position and ensure that the appropriate monitoring view is selected.

BOX 7-3 List of Standard Intravenous Access Equipment

Sharps container Tourniquet 2 2 or 4 4 dressing Alcohol prep Intravenous catheter Heparin port or saline lock Administration set Intravenous fluid Tape Biooclusive dressing Gloves The electrode must be firmly secured to the patient's skin to obtain an adequate view of the electrical activity of the heart. Preparation of the skin includes removal of any moisture. The removal of excess hair may be necessary to allow the adhesive portion of the electrode to completely adhere to the surface of the skin. Excess hair is removed gently with a disposable razor immediately over the area where the electrode is to be placed on the skin. When indicated, the electrical activity of the heart may be monitored through the application of defibrillator/pacer pads and is used in the hands-free operations of the monitor/defibrillator. These pads are positioned as AED pads are positioned. For placement of the pads, refer to Chapter 19. Box 7-2 summarizes the steps for electrode application.

CHAPTER 7 Assisting the ALS Provider

Page 7 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition INTRAVENOUS THERAPY Rationale
The capacity to administer medications and fluids to patients may improve their condition and outcome. Intravenous access is obtained by placement of a small catheter in a vein. The needle is removed, and the catheter is left in place as the access port to the circulatory system. This port may also be used to obtain blood samples for glucose checks and laboratory studies.
118 119

Fig. 7-3 Components of an intravenous administration set.

Preparation
Before assembling the intravenous (IV) administration set, a number of things must be considered. The most important factor is ensuring that all of the necessary equipment is present and in working order. Figure 7-2 and Box 7-3 provide examples of the standard equipment that will be needed. The ALS provider will decide what type of fluid will be administered to the patient, if any. The establishment of intravenous access without fluid administration is a common practice. The end of the catheter is capped with a heparin port or saline lock. Medications may be introduced through this port without connecting the catheter to a fluid administration set. If the ALS provider decides to administer fluid, the EMT must always check that the appropriate fluid is prepared, as well as the expiration date and clarity of the fluid. If the fluid is discolored, expired, or the bag is leaking, another bag must be used. The expiration date can be found on the front of the fluid bag inside the plastic protective cover. To open the fluid bag, tear or carefully cut the protective covering and remove the fluid bag. Fluid bags may have multiple ports located on the inferior end. One port is used for connecting the administration set; the other permits medication to be added to the fluid. After the type of fluid has been identified, an administration set must be attached. This tubing transports the fluid to the intravenous catheter placed in the patient's circulatory system. Two common types of administration sets are available as intravenous tubing. The type of administration set used depends on how much fluid needs to be infused to the patient. The rate and amount of fluid delivered is based on the size of the fluid drops created by the administration set. A macrodrip administration set produces large drops of fluid (10 to 15 drops per 1 cc) and facilitates the rapid infusion of fluid. A microdrip administration produces small drops of fluid (60 drops per 1 cc) and

CHAPTER 7 Assisting the ALS Provider

Page 8 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

restricts the amount of fluid being administered. The components of an administration set are outlined in Figure 7-3.

Assembly of equipment.
To connect the administration set tubing to the bag of fluid, remove the cap protecting the drip chamber and the plastic tab protecting the bag of fluid. Take care to maintain the sterility of both sites so that the risk of infection to the patient does not increase. Remove the appropriate drip set from the packaging and if present, the paper strap retainer around the tubing. Take care not to tangle the tubing. Unwrap the tubing and close the regulating clamp. Remove the cap protecting the drip chamber and the tab protecting the bag of fluid. Take care not to contaminate either end. Insert the spiked drip chamber end into the appropriate port on the fluid bag far enough to puncture the internal plastic membrane. A straight-line insertion must be performed to avoid puncturing the side of the fluid bag port. With the fluid bag in the upright position and the administration tubing below the bag, squeeze the drip chamber to fill approximately one half of the drip chamber. Place the distal end of the administration tubing in the plastic protective cover from the fluid bag. This will collect any excess fluid that may drain out of the tubing. Unclamp the tubing using the regulating clamp and allow the fluid to fill the entire tubing. To initiate the flow of fluid, the EMT may need to remove the protective cap at the distal end of the administration tubing. Be careful not to contaminate the end of the tubing. After the fluid has filled the tubing, recap the distal end and close the regulating clamp on the tubing. The EMT should inspect for any trapped air in the tubing. This will be noted by the presence of air bubbles seen inside the tubing. If air is present, move the regulating clamp to the full open position and allow fluid to flow. The EMT may need to tap the tubing to facilitate the removal of air. Close the tubing with the roller clamp after all the air has been removed. The intravenous fluid and administration set is now ready to be connected to the intravenous catheter. Technique 7-1 outlines the assembly of the intravenous administration set and fluid.

119 120

TECHNIQUE 7-1 Assembly of Intravenous Administration Set and Fluid

CHAPTER 7 Assisting the ALS Provider

Page 9 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

1. Identify the desired type of fluid and administration set. Confirm the fluid for expiration date, clarity, and no leaks. Open the fluid bag and administration set. Close the administration set using the regulating clamp on the tubing.

2. Ensuring sterility is maintained, remove the protective covers from the fluid bag and the administration chamber side of the tubing. Insert the administration set into the fluid bag.

CHAPTER 7 Assisting the ALS Provider

Page 10 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

3. Squeeze the administration set chamber to fill approximately one half. Open the regulating clamp on the tubing to fill it with fluid. Ensuring sterility is maintained, remove the distal tubing protective cap if needed. Close the regulating clamp on the tubing when the tubing is filled. Ensure all air is removed from tubing. Replace the distal tubing protective cap if removed.

Patient preparation.
The ALS provider will most likely be the individual preparing the patient and intravenous insertion site for the procedure. If requested, the area where the intravenous catheter will be introduced

CHAPTER 7 Assisting the ALS Provider

Page 11 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

through the skin is prepared by swabbing the alcohol prep over the area in a circular motion, beginning at the center of the area and moving outward. The area cleansed should be approximately 3 3 inches.

Securing and Monitoring

The risk of the EMT being exposed to blood and bodily fluids increases during the connection of the administration tubing to the intravenous catheter. To minimize the chance of exposure, the EMT must have the appropriate body substance isolation precautions in place.

BOX 7-4 Signs and Symptoms of Fluid Infiltration at an Intravenous Catheter Site
Increased pain in the area of the catheter Swelling Discoloration Intravenous fluid infuses slowly or not at all When the intravenous administration set is prepared for connecting to the intravenous catheter, the ALS provider will remove the needle and insert the distal tubing end into the catheter. The needle should immediately be placed in a sharps container. The restrictive venous tourniquet placed proximal to the catheter site should be released, and any excess fluid or blood should be removed from the catheter area. The regulating clamp is moved to the open position, and the site is observed for infiltration of the fluid. Box 7-4 lists some common signs and symptoms of intravenous infiltration. If signs of infiltration are noted, immediately close the regulation clamp. The ALS provider will remove the catheter from the skin, and gentle pressure with a dressing is applied to the insertion area.

120 121

Fig. 7-4 Application of a biooclusive dressing.

CHAPTER 7 Assisting the ALS Provider

Page 12 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

When access to the circulatory system is obtained, the catheter is secured to the skin with a biooclusive dressing and/or tape. Before applying any products containing these materials, the EMT should ask the patient about any latex allergies. ALS providers often have their own preferences on how they secure the catheter to the patient's skin. The EMT should follow the instructions given by the ALS provider when assisting with this procedure. The biooclusive dressing or tape should be applied carefully over the intravenous catheter and injection site and should not occlude the administration set connection point (Fig. 7-4). After the catheter is secured, a small loop is placed in the administration set tubing and secured to the patient's skin (Fig. 7-5). This loop will help prevent dislodgment of the catheter from the insertion site. In areas where the insertion site is over a joint, placement of a splint to stabilize the extremity may be necessary to maintain infusion continuity. To promote continuous monitoring of the insertion site, a standard board-type splint may be used in this situation, taking care not to cover the insertion site with the bandage material. After securing the catheter and administration tubing to the patient's skin, the site should be rechecked for signs of infiltration, and the rate of fluid infusion should be confirmed by the ALS provider. Frequent reassessment of the infusion site should occur during all aspects of patient contact. The position of an extremity, kinking of the administration tubing, or a change in the position of the regulating clamp will affect the rate of fluid infusion.

Fig. 7-5 Securing the intravenous administration tubing to the patient.

CHAPTER 7 Assisting the ALS Provider

Page 13 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition ENDOTRACHEAL INTUBATION Rationale
Management of a patient's airway is initiated from a basic perspective and proceeds to advanced airway management as necessary. When endotracheal intubation is indicated, it will be beneficial for the EMT to assist the ALS provider in performing this skill. Endotracheal intubation is a procedure that is performed when a patient is unable to maintain a patent or secure airway without assistance. This may occur with individuals who have experienced traumatic events or medical emergencies such as those outlined in Box 7-5. This list does not include all conditions; it is up to the ALS provider to judge whether a patient warrants advanced airway management. The three primary methods of intubation in the out-of-hospital setting include direct laryngoscopy, nasotracheal, and digital. Direct laryngoscopy is the most common intubation method and will be discussed in this chapter.

Equipment and Patient Preparation BOX 7-5 Conditions Potentially Requiring Endotracheal Intubation
Altered mental status/unresponsive Respiratory distress/arrest Cardiopulmonary arrest Traumatic injuries disrupting the airway Status epilepticus Two of the three prominent areas in which the EMT can assist the ALS provider with advanced airway management are equipment and patient preparation. Depending on the ALS provider, the EMT may be instructed to manage the airway while preparations are made for intubation, or the EMT may be instructed to set up the equipment and prepare the patient for the procedure. If the EMT is instructed to manage the airway, all aspects of basic airway management must be implemented. The EMT must preoxygenate the patient before the procedure. A normal respiration rate and tidal volume for the patient should be provided for a minimum of 2 minutes before beginning endotracheal intubation. When the ALS provider is ready to perform endotracheal intubation, the EMT will be requested to stop assisting with ventilations, remove the oropharyngeal airway, and perform any oral suctioning that may be required. When the EMT is requested to set up the equipment and prepare the patient for the procedure, all necessary items must be gathered and assembled. Figure 7-6 and Box 7-6 provide examples of the standard equipment needed to perform the endotracheal intubation procedure. With body substance isolation precautions in place, the EMT will begin by assembling the laryngoscope handle with the desired blade. The two standard laryngoscope blade styles are straight

121 122

CHAPTER 7 Assisting the ALS Provider

Page 14 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

(e.g., Miller) or curved (e.g., MacIntosh), and each style comes in various sizes. Depending on patient size, access to the oral cavity, and provider preference, the EMT will need to determine which style and size of blade the ALS provider wants to use for the procedure. The blade is attached to the laryngoscope by placing the blade into the top of the handle in an unopened position and securing it to the pin with a downward motion. A click may be heard when using metal equipment. When using blades that are non-fiberoptic, the EMT must ensure the bulb at the distal end of the blade is tight by attempting to turn the bulb in a clockwise manner. If secure, the bulb will not move. Figure 7-7 demonstrates this procedure.

Fig. 7-6 Standard endotracheal intubation equipment.

BOX 7-6 List of Standard Endotracheal Intubation Equipment

Hard and soft suction catheters Laryngoscope handle with various sizes of blades Magill forceps Oropharyngeal airway and tongue depressor Endotracheal tubes and stylet 10-cc syringe Commercial endotracheal tube holder Tape

CHAPTER 7 Assisting the ALS Provider

Page 15 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

End-tidal CO2 and esophageal bulb detectors Gloves and eye protection Next the EMT will move the blade into the open position on the laryngoscope handle. This is accomplished by moving the distal end of the blade away from the handle in an outward motion. The blade will pivot on the top of the handle and lock into position. At this time the bulb on the blade should be brightly illuminated. After confirming bulb illumination, close the blade by depressing the distal end of the blade back into the unlocked position. Leave the blade attached to the laryngoscope handle. Figure 7-8 is an example of a laryngoscope blade attached to the handle with illumination. If the intubation is being accomplished by nasotracheal or digital procedures, assembly of the laryngoscope blade and handle is not necessary. It is recommended, however, to proceed with assembly in the event the ALS provider may change methods for the advanced airway skill. Next the EMT will be directed or should inquire as to what size endotracheal tube the ALS provider wishes to use. Standard adult sizes range from 6.0 to 9.0, with half sizes available (e.g., 6.5, 7.5). Following size selection of the endotracheal tube, remove the tube from the packaging and attach a 10-cc syringe without a needle to the cuff connection port near the top of the tube. The top of the endotracheal tube may be identified by the 15-mm adapter attachment for the bag-valve device. Inflate the distal cuff using no more than 10 cc of air and disconnect the syringe. Check to make sure the distal endotracheal cuff remains inflated. Figure 7-9 provides an example of checking an inflated endotracheal tube cuff.

122 123

Fig. 7-7 Confirm the bulb on the laryngoscope blade is tightly secured in place.

CHAPTER 7 Assisting the ALS Provider

Page 16 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition Fig. 7-8 Laryngoscope handle with blade attached and illuminated.

Fig. 7-9 The endotracheal cuff should be checked for air leaks.

CHAPTER 7 Assisting the ALS Provider

Page 17 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

Reattach the 10-cc syringe to the cuff connection port and withdraw all the air in the cuff. Any air remaining in the cuff may cause complications during the endotracheal intubation procedure. Some ALS providers choose to use a stylet during the procedure. This thin, fairly rigid device helps maintain the desired shape of the endotracheal tube during the intubation procedure. If instructed, place the stylet into the top of the endotracheal tube and advance it until the end is just proximal to the Murphy hole or eye on the side of the distal end of the endotracheal tube. Bend the stylet over the top of the endotracheal tube and reconfirm the distal end of the stylet is not beyond the landmark identified. The ALS provider will shape the endotracheal tube according to preference. The EMT may also be instructed to apply a lubricant to the distal end of the endotracheal tube. Following stylet and lubrication as directed, place the endotracheal tube back into the packaging and keep the 10-cc syringe with the tube. The esophageal detection, end-tidal CO2, and commercial tube securing devices along with the prepared endotracheal tube, laryngoscope handle and blade, and suction unit should be placed within reach of the ALS provider performing the endotracheal procedure.

Assisting with the Procedure

Performing endotracheal intubation can be very stressful for the ALS provider. This is the third area in which the EMT can be an invaluable resource to the ALS provider during the procedure. The application of cricoid pressure, also referred to as the Sellick's maneuver, decreases the risk of aspiration by occluding the esophagus. This procedure is described in detail in Chapter 37. During spinal restrictive maneuvers for suspected neck injuries, the EMT will often take a position above the head of the patient and hold spinal restrictive measures from this position. When endotracheal intubation by direct laryngoscopy is performed, the ALS provider may desire to occupy this position. Therefore, the EMT should hold the head in a neutral position from the chest upward toward the head. While stabilizing the head, opening the anterior section of the cervical collar allows for greater displacement of the mandible. This may increase visualization of the glottic opening and vocal cords during direct laryngoscopy. During the intubation procedure, the EMT may also be requested to ensure that the lips of the patient are not between the teeth and the laryngoscope blade. If this is the case, reposition the lips to be free from the blade. Additionally, the right corner of the mouth may be gently displaced towards the right ear or laterally to provide better visualization for the ALS provider during the intubation procedure. Following placement of the endotracheal tube into the patient, the ALS provider should not release the tube until it has been appropriately secured in place. To do so may increase the chance of the endotracheal tube being displaced from the trachea. The EMT may be requested to hand the ALS provider suction or airway equipment that has been prepared.
123 124

Confirmation of Endotracheal Tube Placement

Confirming the placement of an endotracheal tube into the trachea with subsequent adequate ventilation of oxygen is a critical step in the airway management procedure. Failure to ensure

CHAPTER 7 Assisting the ALS Provider

Page 18 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

appropriate placement of an endotracheal tube will often result in the decompensation and ultimately the death of the patient. Verifying placement of an endotracheal tube can be performed with several methods. Following the procedure, the EMT may be requested to confirm the endotracheal tube placement by auscultation of breath sounds or placement of the esophageal and/or end-tidal CO2 detectors. The esophageal detector is operated by squeezing the device to remove the air and attaching it to the 15-mm connection at the top of the endotracheal tube. After it is attached to the tube, release the detector. It should reinflate at this time. The absence of inflation may indicate esophageal placement of the endotracheal tube. Commercially available end-tidal CO2 detectors are used to detect the presence of carbon dioxide during the expiration phase of respiration/ventilation. After attaching the device directly to the 15-mm connector on the endotracheal tube and providing four to five ventilations, a color change indicates the presence of carbon dioxide. Commonly used devices change from purple to yellow in the presence of carbon dioxide, but not all devices use this color scheme. Become familiar with the equipment used by ALS providers in your area.

BOX 7-7 Assessment of the Patient Following Endotracheal Intubation

Symmetrical chest rise and fall Absence of epigastric sounds Presence of bilateral breath sounds Color of patient skin Reinflation of the esophageal detector Color change from purple to yellow on the CO2 detector Endotracheal tube is free of large amounts of secretions, blood, and vomit The physical assessment of ventilations (Box 7-7) in addition to the use of the devices described above helps the EMT and ALS provider confirm the appropriate placement of the endotracheal tube following intubation.

Securing and Ventilating

After the correct placement of the endotracheal tube has been confirmed and the patient is receiving adequate ventilations, securing the tube is the next priority. Assist the ALS provider in applying a commercially available endotracheal tube holder or by using a preferred taping method. Make a mental note of the depth of the endotracheal tube in reference to the patient's lips or teeth. This is a quick way to see if the tube has moved from the originally secured position. Figure 7-10 shows an endotracheal tube secured by a commercially available device. If the anterior portion of the cervical collar was opened during the intubation procedure, it should be re-secured in place on the patient. To restrict movement of the head and decrease the risk of

CHAPTER 7 Assisting the ALS Provider

Page 19 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

inadvertent endotracheal tube displacement, the EMT may consider placing intubated, nontraumatic patients on a long back board with a cervical immobilization device. Following appropriate securing of the endotracheal tube, the EMT may be requested to ventilate the patient with the bag-valve device. After attaching the bag-valve device to the 15-mm endotracheal tube, the EMT performs ventilations as directed or described in Chapter 8. In addition to monitoring vital signs, frequent reassessment of the patient's airway and ability to ventilate is necessary. Any change in the ability to ventilate, rise and fall of the chest, skin color (cyanosis), change in breath sounds, or rapid distention of the abdomen requires immediate reassessment of the airway and confirmation of correct endotracheal tube placement.
124 125

REVIEW QUESTIONS ALS PROCEDURES AND EQUIPMENT

1. How is the skin prepared for electrode placement? 2. Which IV administration set delivers larger drops, providing faster fluid flow? 3. List several reasons to immediately reconfirm endotracheal tube placement.

Fig. 7-10 Endotracheal tube secured by a commercial device.

CHAPTER 7 Assisting the ALS Provider

Page 20 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

Suctioning the airway will be required when secretions are present in the endotracheal tube. Refer to Chapter 8 and Chapter 37 for various methods of suctioning. When available, the application of pulse oximetry and capnometry (measurement of continuous end-tidal CO2 monitoring) devices will enhance monitoring the patient's clinical condition.

CHAPTER SUMMARY THE TEAM CONCEPT

The EMT must always remember to initiate basic medical practices first. When interfacing with ALS providers, the opportunity to expand the procedures and skills performed on a patient becomes available. The EMT who is familiar with the equipment and able to assist with ALS procedures will increase the overall functionality of the team.

ALS PROCEDURES AND EQUIPMENT

The ECG monitor may be used on medical and trauma patients. Determine the electrode placement for the type of view desired and prepare the patient and equipment. Intravenous access is common when interfacing with ALS providers. Assembling the required equipment and checking the fluid for expiration date and clarity will decrease the time for IV initiation. Endotracheal intubation can be difficult and may create anxiety. Patient and equipment preparation combined with good basic airway management skills will increase the opportunity for successful patient care.

Objectives
Check your knowledge. Can you meet these objectives?

125 126

Cognitive
1. At the completion of this lesson, the EMT-Basic student will be able to: 2. Identify the equipment necessary for assisting with electrocardiography monitoring. 3. Identify the proper electrode placement for various cardiac monitoring leads. 4. Describe how to properly apply electrodes to a patient. 5. Identify the equipment necessary for assisting with intravenous therapy. 6. Identify the intravenous solutions commonly used. 7. Describe the appropriate checks performed on intravenous fluid. 8. Describe the difference between microdrip and macrodrip intravenous administration sets. 9. Define the signs and symptoms related to an infiltrated intravenous line. 10. Identify the equipment necessary for assisting with endotracheal intubation.

CHAPTER 7 Assisting the ALS Provider

Page 21 of 22

Mosby's EMT-Basic Textbook - Revised Reprint, 2nd Edition

11. Identify the difference between straight and curved laryngoscope blades. 12. Describe the method to attach a laryngoscope blade to the handle. 13. Describe the method of inserting a stylet into an endotracheal tube. 14. Identify the necessity of securing an endotracheal tube. 15. Define the signs and symptoms related to incorrect endotracheal tube placement.

Affective
1. At the completion of this lesson, the EMT-Basic student will be able to: 2. Explain the necessity in functioning as a team. 3. Explain the importance of performing the airway, breathing, and circulation assessment on all patients. 4. Explain the importance of basic airway management skills to maintain a patient's airway. 5. Explain how advanced life support procedures of electrocardiography, intravenous therapy, and endotracheal intubation benefit in patient care.

Psychomotor
1. At the completion of this lesson, the EMT-Basic student will be able to: 2. Demonstrate the proper application of electrodes. 3. Demonstrate the proper set up of intravenous fluid to an administration set. 4. Demonstrate the appropriate attachment of a laryngoscope blade to the handle. 5. Demonstrate the insertion of a stylet into the endotracheal tube. 6. Demonstrate bag-valve-mask and bag-valve endotracheal tube ventilation.
126 127

Review Questions Answer Key ALS PROCEDURES AND EQUIPMENT

1. Removal of moisture and excess hair. 2. The macrodrip administration set delivers larger drops for fast fluid flow. 3. Change in ability to ventilate the patient, inadequate rise and fall of the chest, cyanosis noted, distended abdomen, change in tube depth.

CHAPTER 7 Assisting the ALS Provider

Page 22 of 22