7mosby's emt-basic textbook - revised reprint, 2nd edition

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

CHAPTER 7 Assisting the ALS Provider

KEY TERMS

ALS provider:

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

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.

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CHAPTER 7 Assisting the ALS Provider of 22


Pulse oximetry:

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



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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.

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).

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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

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.

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

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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.

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

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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.



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.

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

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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.

TECHNIQUE 7-1 Assembly of Intravenous Administration Set and Fluid

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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.



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



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.

Fig. 7-4 Application of a biooclusive dressing.

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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.



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

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(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



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.

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

in place.

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Fig. 7-8 Laryngoscope handle with blade attached and illuminated.

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



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.

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

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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



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.

REVIEW QUESTIONS


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.

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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.


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?

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.

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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


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


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.

Review Questions Answer Key


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.

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7mosby's emt-basic textbook - revised reprint, 2nd edition

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