Download - ET Intubation
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ALS Assist
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Introduction
You may need to be familiar with AEMT and
paramedic skills.
These include:
Advanced airway techniues
!ntravenous "!#$ therapy
%ardiac monitorin&
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Advanced Airway Techniques
Establishin& and maintainin& an airway is
the sin&le most important EMT skill.
Most conscious patients can maintain their own
airway. 'ther patients may reuire an oropharyn&eal or
nasopharyn&eal airway.
Advanced airway mana&ement provides better
airway protection and ventilation.
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Anatomy and Physiology of theAirway "( of )$
The respiratory system consists of all the
body structures used for breathin&.
*pper airway includes the nose+ mouth+ throat
"pharyn,$+ and laryn, "vocal cords$. -ower airway includes the trachea+ bronchi+ and
lun&s.
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Anatomy and Physiology of theAirway " of )$
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Anatomy and Physiology of theAirway "/ of )$
The respiratory system:
0elivers o,y&en to body
1emoves carbon dio,ide
This process takes place on two levels:
Alveolar2capillary e,chan&e
%apillary2cellular e,chan&e
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Anatomy and Physiology of theAirway "3 of )$
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Anatomy and Physiology of theAirway ") of )$
Each livin& cell of the body reuires a
re&ular supply of o,y&en.
4ome cells+ such as those in the heart+ brain+
and nervous system+ need a constant supply tosurvive.
'ther cells can tolerate short periods without
o,y&en.
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Basic Airway Management"( of $
Always assess the airway first in an in5ured
or ill patient.
'pen the airway.
*se the head tiltchin lift maneuver in a patient
with no suspected spinal in5ury.
*se the 5aw2thrust maneuver if there is a
possibility of spinal in5ury.
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Basic Airway Management" of $
Assess the airway and evaluate the need
for suctionin& to remove:
6orei&n bodies
-iuid
7lood
0etermine if the patient needs an airway
ad5unct.
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Endotracheal Intubation "( of $
!nsertion of a tube into the trachea to
maintain the airway
!f done throu&h the mouth+ it is called
orotracheal intubation. !f done throu&h the nose+ it is called
nasotracheal intubation.
Tube passes directly throu&h the laryn,
between the vocal cords and trachea.
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Endotracheal Intubation " of $
#ery effective method
!ndicated for:
8atients who cannot protect their own airway
8atients who need prolon&ed artificial
ventilation
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Equiment "( of 9$
Assemble all the euipment.
-aryn&oscope handle and blade
8roperly sied endotracheal "ET$ tube
4tylet
(;2m- syrin&e
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Equiment " of 9$
Assemble all the
euipment "cont=d$.
Ma&ill forceps
4tethoscope
%ommercial
securin& device
4econdaryconfirmation device
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Equiment "/ of 9$
-aryn&oscope
*sed to sweep the ton&ue out of the way and
ali&n the airway so the vocal cords can be
visualied Endotracheal tubes
8roper2sied tube for adults ran&es from >.; to
9.) mm
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Equiment "3 of 9$
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Equiment ") of 9$
Endotracheal tubes "cont=d$
*se the lar&est2diameter ET tube that will pass
easily throu&h the vocal cords.
6or children+ use a resuscitation tape device.
A standard ()?2mm adapter attaches to any
ventilation device.
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Equiment "> of 9$
4tylet
!nserted into the
ET tube to add
ri&idity and shapedurin& intubation
7end the tip to
form a &entle
curve. 0o not insert past
Murphy=s eye.
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Equiment "9 of 9$
4yrin&e
*se a (;2m- syrin&e to test for air leaks in the
ET tube before intubation.
'ther euipment
A suction unit may be needed to clear
secretions or blood.
A commercial securin& device ensures that thetube does not move.
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The Sellic! Maneuver
%an be used to intubate a patient who has
no cou&h and?or &a& refle,
elps reduce the chance of re&ur&itation
and aspiration of stomach contents
6ollow the steps in S!ill "rill #$%&.
7e sure to correctly identify anatomic
landmarks.
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The Intubation Procedure "( of >$
You may intubate only if authoried by off2
line or online medical control.
7e sure to use standard precautions.
An intubation attempt should not take more
than /; seconds.
7e&ins when ventilation stops and the
laryn&oscope blade is inserted Ends when ventilation be&ins a&ain
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The Intubation Procedure " of >$
!ntubation is a multiple2person task.
6irst EMT applies and uses the AE0.
4econd and third EMTs perform %81 at a ratio
of /; compressions to ventilations.
6ourth EMT prepares and intubates the patient.
6ollow the steps in S!ill "rill #$%'to
perform orotracheal intubation.
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The Intubation Procedure "/ of >$
You must use a secondary method of
confirmin& proper tube placement.
Esopha&eal detector devices
End2tidal carbon dio,ide detectors
%apno&raphy monitors
These devices are not (;;B &uaranteed.
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The Intubation Procedure "3 of >$
Source: The LIFEPAK 15 defibrillator monitor courtesy of Physio!ontrol" #sed $ith %ermission of Physio!ontrol& Inc"& and accordin' to the (aterial )elease
Form %ro*ided by Physio!ontrol"
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The Intubation Procedure ") of >$
8rimary confirmation is:
0irect visualiation of the tube passin& throu&h
the vocal cords
Auscultatin& &ood bilateral breath sounds
4eein& the patient=s chest rise and fall with each
ventilation
Cever let &o of the ET tube until it issecured.
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The Intubation Procedure "@ of >$
!ntubation complications
!ntubatin& the ri&ht main stem bronchus
!ntubatin& the esopha&us
A&&ravatin& spinal in5ury
!ncreased hypo,ia
8atient vomitin&
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The Intubation Procedure "> of >$
!ntubation complications "cont=d$
-aryn&ospasm
Trauma
Mechanical failure
8atient intolerant of the endotracheal tube
0ecrease in heart rate
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Multilumen Airways "( of 3$
Advanced airways
that do not reuire
visualiation of the
vocal cords forplacement
E,amples include
the %ombitube and
pharyn&eotracheallumen airway.
The Combitube
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Multilumen Airways " of 3$
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Multilumen Airways "3 of 3$
1emovin& the multilumen airway
!f the patient will no lon&er tolerate the airway+ it
should be removed.
1emember that the patient will likely vomit whenthe airway is removed+ so a suction unit must be
readily available.
4imply deflate both balloon cuffs and &ently
remove the tube.
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Single Lumen Airway "( of /$
in& -T airway
4in&le lumen airway that is blindly inserted into
the esopha&us
%onsists of a curved tube with ventilation portslocated between two inflatable cuffs
!ntended in patients who are taller than 3D
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Single Lumen Airway " of /$
Source: !ourtesy of Kin' Systems
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Single Lumen Airway "/ of /$
-aryn&eal mask
airway
%onsists of two
parts: the tube andthe mask or cuff
After blind insertion+
the device molds
and seals itself
around the laryn&ealopenin& by inflation
of the mask.
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(astric Tubes "( of $
4ometimes a patient may reuire
placement of a tube throu&h the nose or
mouth that e,tends into the stomach.
%ardiac arrest patients A nasal or oral &astric tube relieves &astric
distention.
May be used by E0 staff to lava&e the stomach
in cases of overdose
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(astric Tubes " of $
8roper placement can be confirmed by:
Aspiration of stomach contents with a syrin&e
-istenin& with a stethoscope as air is introduced
into the tube with a syrin&e 1adio&raph on arrival at the E0
) ti P iti Ai
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)ontinuous Positive AirwayPressure "( of /$
*sed in breathin& patients who are alert
and able to follow commands and have
reduced function of the alveoli due to:
%on&estive heart failure %hronic obstructive pulmonary disease
Asthma
) ti P iti Ai
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)ontinuous Positive AirwayPressure " of /$
A ti&ht2fittin& mask is placed over the mouth
and nose and connected to an o,y&en
source.
0elivers flow rates of at least ); -?min May be helpful in patients with severe
respiratory distress
) ti P iti Ai
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)ontinuous Positive AirwayPressure "/ of /$
!ourtesy of )es%ironics& Inc"& (urrays*ille& PA" All ri'hts reser*ed"
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Intravenous Theray
0evelop a routine to follow as you assemble
the appropriate euipment.
This will help you keep track of your euipment
and the steps necessary to complete successful!# administration.
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Indications
Many medications used by A-4 crews are
&iven by the !# route.
A fluid bolus may be indicated for patients
who: Are dehydrated because of vomitin& or
e,cessive diarrhea
ave e,perienced blood loss because of
hemorrha&e
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Assembling the Equiment
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)hoosing an I* Solution "( of /$
!n the prehospital settin&+ the choice of !#
solution is limited to:
!sotonic crystalloids
Cormal saline
-actated 1in&er=s solution
0)< is often reserved for administerin&
medication.
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)hoosing an I* Solution " of /$
Each !# solution ba&
is wrapped in a
protective sterile
plastic ba&.
Fuaranteed to
remain sterile until
the posted e,piration
date
'nce the wrap istorn+ the !# solution
has a shelf life of
3 hours.
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)hoosing an I* Solution "/ of /$
The bottom of each
ba& has two ports:
An in5ection port for
medication
An access port for
connectin& the
administration set
The more commonprehospital volumes
are (+;;; m- and
);; m-.
)hoosing an Administration
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)hoosing an AdministrationSet "( of /$
An administration
set moves fluid
from the !# ba&
into the patient=svascular system.
Each set has a
piercin& spike
protected by aplastic cover.
)hoosing an Administration
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)hoosing an AdministrationSet " of /$
0rip sets come in
two primary sies.
A microdrip set
allows @; &tt?m-. A macrodrip
set allows (; to
() &tt?m-.
)hoosing an Administration
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)hoosing an AdministrationSet "/ of /$
8reparin& an administration set
#erify the solution and check for clarity.
To spike the ba& with the administration set+
follow the steps in S!ill "rill #$%+. 4aline locks "buff caps$ are a way to maintain
an active !# site without runnin& fluids throu&h
the vein.
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)atheters
ollow+ laser2sharpened needle inside a
hollow plastic tube that is inserted into a
vein
4elect the catheter sie based on the: Ceed for the !#
%ondition of the patient=s veins
-ocation for the !#
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Starting an I* "( of $
Apply a tourniuet pro,imal to the site
where venipuncture is to be performed.
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Starting an I* " of $
*se tape or a commercially available device
to secure the catheter.
Always wear &loves durin& the procedure.
S!ill "rill #$%#covers how to start an !#.
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Securing the Line
Tape the area so that the catheter and
tubin& are securely anchored in case of a
sudden pull on the line.
Avoid circumferential tapin& around anye,tremity because it can act like a
constrictin& band and stop circulation.
Alternative I* Sites and
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Alternative I* Sites andTechniques "( of $
!ntraosseous "!'$
needles
*sed for emer&ency
venous access when
other !# access is
difficult or impossible
'ften patients are
e,periencin& a life2
threatenin& situation.
Fenerally inserted in
the pro,imal tibia
Alternative I* Sites and
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Alternative I* Sites andTechniques " of $
E,ternal 5u&ular !#
8rovides venous access throu&h the e,ternal
5u&ular veins in the neck
%atheter is inserted midway between the an&leof the 5aw and the midclavicular line.
8unctures can be difficult because these veins
are surrounded by a very tou&h+ fibrous sheath.
Possible )omlications of I*
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Possible )omlications of I*Theray
-ocal reactions include problems like
infiltration and phlebitis.
4ystemic complications include aller&ic
reactions and circulatory overload.
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Local I* Site ,eactions "( of 3$
!nfiltration
Escape of fluid into the surroundin& tissue when
the !# catheter is not in the vein
%an cause a localied are of edema or swellin& 4top the flow+ remove the catheter+ and reinsert
it at an alternative site.
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Local I* Site ,eactions "3 of 3$
ematoma
Accumulation of blood in the tissues
surroundin& an !# site
1esult from vein perforation or catheter removal !f a hematoma develops when !# catheter insert
is attempted+ the procedure should stop.
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Systemic )omlications "( of >$
A systemic complication can evolve from
reactions or complications associated with
!# insertion.
*sually involve other body systems and can belife threatenin&
Aller&ic reactions
True anaphyla,is is possible and must be
treated a&&ressively.
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Systemic )omlications " of >$
Aller&ic reactions "cont=d$
%an be related to a person=s une,pected
sensitivity to an !# fluid or medication
0iscontinue the !# fluid and remove thesolution+ maintain the airway+ and monitor A7%s
and vital si&ns.
S )
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Systemic )omlications "/ of >$
Air embolus
8atients who are already ill or in5ured can be
adversely affected if air is introduced into the
circulatory system.
8roperly flush the !# line.
Treat a patient by placin& him or her on the left
side with the head down.
S i ) li i
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Systemic )omlications "3 of >$
%irculatory overload
An unmonitored !# ba& can lead to circulatory
overload.
8roblems occur when the patient has cardiac+pulmonary+ or renal dysfunction.
The most common cause in the prehospital
settin& is failure to read5ust the drip rate after
flushin& an !# line.
S t i ) li ti
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Systemic )omlications ") of >$
%irculatory overload "cont=d$
To treat a patient:
4low the !# rate to keep the vein open.
1aise the patient=s head to ease respiratorydistress.
Administer hi&h2flow o,y&en.
Monitor vital si&ns and shortness of breath.
S t i ) li ti
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Systemic )omlications "@ of >$
#asova&al reactions
4ome patients have an,iety concernin& needles
or in response to the si&ht of blood.
8atients can present with an,iety+ diaphoresis+nausea+ or syncopal episodes.
-ower the head of the stretcher+ administer
o,y&en+ and monitor vital si&ns.
S t i ) li ti
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Systemic )omlications "> of >$
%atheter shear
8otential complication when startin& an !#
%ould have a devastatin& effect on your patient
May occur if you attempt to reinsert the needlethrou&h the catheter after the needle has been
partially withdrawn
T bl h ti
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Troubleshooting
4everal factors influence !# flow rate.
8erform the followin& checks after
completin& !# administration.
%heck your administration set.
%heck the hei&ht of the !# ba&.
%heck the type of catheter used.
%heck the tourniuet.
Age%Secific )onsiderations
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Age%Secific )onsiderations"( of $
!# therapy for pediatric patients
A child has smaller veins.
A small2&au&e catheter should be used
"2&au&e to 32&au&e$. #olume control is important.
*se a special type of microdrip set called a
#olutrol+ which fills the lar&e drip chamber with a
specific amount of fluid.
Age%Secific )onsiderations
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Age%Secific )onsiderations" of $
!# therapy for &eriatric patients
4maller catheters may be preferable.
The use of tape can lead to skin dama&e+ so be
careful when tapin& !# catheters and tubin&. 7e careful when usin& macrodrips because they
can allow infusion of fluids+ which may lead to
fluid overload.
) di M it i
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)ardiac Monitoring
(2lead E%F can help in the earlyidentification of an acute myocardial
infarction "AM!$.
The interpretation of cardiac rhythm may not bean EMT skill.
owever+ it is helpful to be able to place
electrodes and leads.
Electrical )onduction System
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Electrical )onduction System"( of $
Cetwork of specialied tissue capable ofconductin& electrical current throu&hout the
heart
%ontains: 4inoatrial "4A$ node
Three intermodal pathways
Atrioventricular "A#$ node 7undle of is
1i&ht and left bundle branches
Electrical )onduction System
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Electrical )onduction System" of $
El t d d -
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Electrodes and -aves
The E%F electrodes pick up the electricalactivity of the heart+ and the E%F machine
converts them to waves.
The way an E%F tracin& looks depends onwhere the lead is placed.
The E)( )omle
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The E)( )omle. "( of /$
'ne comple, represents one beat in theheart.
The comple, consists of several waves: the
8+ G14+ and T waves. A se&ment is a specific portion of the
comple,.
The E)( )omle. " f /$
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The E)( )omle. " of /$
The E)( )omle. "/ f /$
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The E)( )omle. "/ of /$
An interval is the distance+ measured intime+ occurrin& between two cardiac events.
The time between the be&innin& of the 8 wave
and the be&innin& of the G14 comple, is known
as the 821 interval.
E)( Paer
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E)( Paer
The paper on which an E%F is recordedcontains a &rid.
Each little bo, represents (?) of a second+ or
;.;3 second.
Each bi&&er bo, is composed of five smaller
bo,es+ or ;.; second.
6ive bi& bo,es eual ( second.
/ormal Sinus ,hythm "( f $
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/ormal Sinus ,hythm "( of $
4inus rhythm is a rhythm in which the 4Anode acts as the pacemaker.
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/ormal Sinus ,hythm " of $
The 0ormation of the E)( "( f /$
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The 0ormation of the E)( "( of /$
8roduction of the heart=s rhythm is acontinuous process+ with no actual period of
rest or inactivity.
!f the heart is functionin& normally+ theprocess will repeat over and over
continuously.
The 0ormation of the E)( " f /$
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The 0ormation of the E)( " of /$
The 0ormation of the E)( "/ f /$
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The 0ormation of the E)( "/ of /$
Arrhythmias "( of )$
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Arrhythmias "( of )$
Abnormal rhythm of the heart
4inus bradycardia
%onsistent 8 waves+ consistent 821 intervals+
re&ular heart rate less than @; beats?min
Source: FromArrhythmia Recognition: The Art of Interpretation, courtesy of Tomas +" ,arcia& (-"
Arrhythmias " of )$
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Arrhythmias " of )$
4inus tachycardia
%onsistent 8 waves+ consistent 821 intervals+
re&ular heart rate more than (;; beats?min
May cause a decrease in cardiac output
Source: FromArrhythmia Recognition: The Art of Interpretation&courtesy of Tomas +" ,arcia& (-"
Arrhythmias "/ of )$
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Arrhythmias "/ of )$
#entricular tachycardia
8resence of three or more abnormal ventricular
comple,es in a row with a rate of more than (;;
beats?min
#ery re&ular rhythm
Source: FromArrhythmia Recognition: The Art of Interpretation&courtesy of Tomas +" ,arcia& (-"
Arrhythmias "3 of )$
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Arrhythmias "3 of )$
#entricular fibrillation 1apid+ completely disor&anied ventricular rhythm with
chaotic characteristics
*ndulations of varyin& shapes and siesH no specific
patternH no discernable 8+ G14+ or T waves Co or&anied beatin& of the heart
Source: FromArrhythmia Recognition: The Art of Interpretation&courtesy of Tomas +" ,arcia& (-"
Arrhythmias ") of )$
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Arrhythmias ") of )$
Asystole
%omplete absence of any electrical cardiac
activity
8atient is clinically dead at this point.
Source: FromArrhythmia Recognition: The Art of Interpretation&courtesy of Tomas +" ,arcia& (-"
Assisting -ith )ardiac
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Monitoring
You may have a 32lead E%F or a (2leadE%F system.
Cew cardiac monitors include several new
features usin& modern technolo&y. They are compact+ li&ht+ and portable and
combine defibrillation and monitorin&
capabilities.
Lead Placement "( of )$
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Lead Placement "( of )$
A 32lead E%F uses four leads+ which areelectrodes attached to wires.
The four leads are called the limb leads.
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Lead Placement " of )$
!t does not matterwhere the leads
are placed on the
limbs+ as lon& as
all four are at least
(; cm from the
heart.
Lead Placement "/ of )$
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Lead Placement "/ of )$
6or the (2lead E%F+ electrodes are placedas a 32lead placement as well as in very
specific locations on the chest.
#(
and #.
on each side of the sternum #3at the midclavicular line
#/between #.and #3
#)at the anterior a,illary line+ and #@in the
mida,illary line
Lead Placement
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"3 of )$
Lead Placement ") of )$
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Lead Placement ") of )$
!t is very important to have direct skincontact when obtainin& an E%F.
!f the skin is wet or oily+ wipe and clean the skin
thorou&hly.
!f the skin is hairy+ use a raor.
Advanta&es of (2lead monitorin&
Early identification of acute ischemia
Accurate identification of arrhythmias
ST%Segment ElevationM di l I f i 1STEMI2
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Myocardial Infarction 1STEMI2
4pecific type of myocardial infarction inwhich the 4T se&ment of the cardiac cycle is
elevated
Treatable by techniues that rapidly restoreperfusion to the coronary arteries
ITime is muscle.J
SummarySummary "( of /$"( of /$
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SummarySummary "( of /$"( of /$
There may be cases in which an EMT mayfind it necessary to be familiar with skills
normally practiced at the AEMT and
paramedic level. These skills include
advanced airway techniues+ !# therapy+
and cardiac monitorin&.
SummarySummary " of /$" of /$
-
7/25/2019 ET Intubation
97/98
SummarySummary " of /$" of /$
An advanced airway techniue isendotracheal intubation+ the insertion of a
tube into the trachea to maintain the airway.
Additional advanced airway care devicesinclude the %ombitube+ pharyn&eotracheal
lumen airway+ the in& -T+ and the laryn&eal
mask airway.
SummarySummary "/ of /$"/ of /$
-
7/25/2019 ET Intubation
98/98
SummarySummary "/ of /$"/ of /$
!# therapy is used to replace fluids in apatient with shock or to administer
medications.
%ardiac monitorin& with an E%F is anadvanced skill that the EMT may provide in
assistance to the AEMT or paramedic.