Als Assist c40

Chapter 40
ALS Assist
Introduction
You may need to be familiar with AEMT and paramedic skills. These include:
Advanced airway techniques
Intravenous (IV) therapy

Cardiac monitoring
Advanced Airway Techniques

Establishing and maintaining an airway is the single most important EMT skill.
Most conscious patients can maintain their own airway.
Other patients may require an oropharyngeal or nasopharyngeal airway.

Advanced airway management provides better airway protection and ventilation.
Anatomy and Physiology of the Airway (1 of 5)

The respiratory system consists of all the body structures used for breathing.
Upper airway includes the nose, mouth, throat (pharynx), and larynx (vocal cords).
Lower airway includes the trachea, bronchi, and lungs.

The respiratory system:
Delivers oxygen to body
Removes carbon dioxide
This process takes place on two levels:

Alveolar-capillary exchange Capillary-cellular exchange

Each living cell of the body requires a regular supply of oxygen.
Some cells, such as those in the heart, brain, and nervous system, need a constant supply to survive. Other cells can tolerate short periods without oxygen.
Basic Airway Management

(1 of 2) Always assess the airway first in an injured or ill patient. Open the airway.
Use the head tiltchin lift maneuver in a patient with no suspected spinal injury. Use the jaw-thrust maneuver if there is a possibility of spinal injury.
Basic Airway Management

(2 of 2) Assess the airway and evaluate the need for suctioning to remove:
Foreign bodies Liquid
Blood
Determine if the patient needs an airway adjunct.
Endotracheal Intubation (1 of 2)
Insertion of a tube into the trachea to maintain the airway
If done through the mouth, it is called orotracheal intubation.
If done through the nose, it is called nasotracheal intubation.

Tube passes directly through the larynx between the vocal cords and trachea.
Endotracheal Intubation (2 of 2)
Very effective method
Indicated for:
Patients who cannot protect their own airway Patients who need prolonged artificial ventilation
Equipment (1 of 8)
Assemble all the equipment.
Laryngoscope handle and blade
Properly sized endotracheal (ET) tube Stylet
10-mL syringe
Water-soluble lubricant for the ET tube Suction unit with rigid and soft-tip catheters
Equipment (2 of 8)
Assemble all the equipment (contd).
Magill forceps Stethoscope
Commercial securing device

Secondary confirmation device
Equipment (3 of 8)
Laryngoscope
Used to sweep the tongue out of the way and align the airway so the vocal cords can be visualized
Endotracheal tubes
Proper-sized tube for adults ranges from 7.0 to 8.5 mm
Equipment (4 of 8)
Equipment (5 of 8)
Endotracheal tubes (contd)
Use the largest-diameter ET tube that will pass easily through the vocal cords.
For children, use a resuscitation tape device.
A standard 15/22-mm adapter attaches to any ventilation device.
Equipment (6 of 8)
Equipment (7 of 8)
Stylet
Inserted into the ET tube to add rigidity and shape during intubation
Bend the tip to form a gentle curve.
Do not insert past Murphys eye.
Equipment (8 of 8)
Syringe
Use a 10-mL syringe to test for air leaks in the ET tube before intubation.
Other equipment
A suction unit may be needed to clear secretions or blood.
A commercial securing device ensures that the tube does not move.
The Sellick Maneuver

Can be used to intubate a patient who has no cough and/or gag reflex Helps reduce the chance of regurgitation and aspiration of stomach contents
Follow the steps in Skill Drill 40-1.

Be sure to correctly identify anatomic landmarks.
The Intubation Procedure (1 of 7)

You may intubate only if authorized by offline or online medical control. Be sure to use standard precautions. An intubation attempt should not take more than 30 seconds.
Begins when ventilation stops and the laryngoscope blade is inserted
Ends when ventilation begins again

Intubation is a multiple-person task.
First EMT applies and uses the AED.
Second and third EMTs perform CPR at a ratio of 30 compressions to 2 ventilations.
Fourth EMT prepares and intubates the patient.
Follow the steps in Skill Drill 40-2 to perform orotracheal intubation.

You must use a secondary method of confirming proper tube placement.
Esophageal detector devices End-tidal carbon dioxide detectors
Capnography monitors
These devices are not 100% guaranteed.
Source: The LIFEPAK 15 defibrillator monitor courtesy of Physio-Control. Used with permission of Physio-Control, Inc., and according to the Material Release Form provided by Physio-Control.

Primary confirmation is:
Direct visualization of the tube passing through the vocal cords
Auscultating good bilateral breath sounds
Seeing the patients chest rise and fall with each ventilation
Never let go of the ET tube until it is secured.

Intubation complications
Intubating the right main stem bronchus
Intubating the esophagus Aggravating spinal injury
Increased hypoxia
Patient vomiting

Intubation complications (contd)
Laryngospasm
Trauma Mechanical failure
Patient intolerant of the endotracheal tube

Decrease in heart rate
Multilumen Airways (1 of 4)
Advanced airways that do not require visualization of the vocal cords for placement
The Combitube Examples include the Combitube and pharyngeotracheal lumen airway.
Contraindications
Conscious or semiconscious patients with a gag reflex
Children younger than 14 years
Adults shorter than 5

Patients who have ingested a caustic substance Patients who have an esophageal disease
Removing the multilumen airway
If the patient will no longer tolerate the airway, it should be removed.
Remember that the patient will likely vomit when the airway is removed, so a suction unit must be readily available. Simply deflate both balloon cuffs and gently remove the tube.
Single Lumen Airway (1 of 3)

King LT airway
Single lumen airway that is blindly inserted into the esophagus
Consists of a curved tube with ventilation ports located between two inflatable cuffs Intended in patients who are taller than 4
Source: Courtesy of King Systems

Laryngeal mask airway
Consists of two parts: the tube and the mask or cuff After blind insertion, the device molds and seals itself around the laryngeal opening by inflation of the mask.
Gastric Tubes (1 of 2)
Sometimes a patient may require placement of a tube through the nose or mouth that extends into the stomach.
Cardiac arrest patients
A nasal or oral gastric tube relieves gastric distention.

May be used by ED staff to lavage the stomach in cases of overdose
Gastric Tubes (2 of 2)
Proper placement can be confirmed by:
Aspiration of stomach contents with a syringe
Listening with a stethoscope as air is introduced into the tube with a syringe
Radiograph on arrival at the ED
Continuous Positive Airway Pressure (1 of 3)

Used in breathing patients who are alert and able to follow commands and have reduced function of the alveoli due to:
Congestive heart failure
Chronic obstructive pulmonary disease

Asthma

A tight-fitting mask is placed over the mouth and nose and connected to an oxygen source.
Delivers flow rates of at least 50 L/min
May be helpful in patients with severe respiratory distress
Courtesy of Respironics, Inc., Murraysville, PA. All rights reserved.
Intravenous Therapy
Develop a routine to follow as you assemble the appropriate equipment.
This will help you keep track of your equipment and the steps necessary to complete successful IV administration.
Indications
Many medications used by ALS crews are given by the IV route. A fluid bolus may be indicated for patients who:
Are dehydrated because of vomiting or excessive diarrhea
Have experienced blood loss because of hemorrhage
Assembling the Equipment
Choosing an IV Solution (1 of 3)
In the prehospital setting, the choice of IV solution is limited to:
Isotonic crystalloids Normal saline
Lactated Ringers solution
D5W is often reserved for administering medication.
Each IV solution bag is wrapped in a protective sterile plastic bag.
Guaranteed to remain sterile until the posted expiration date Once the wrap is torn, the IV solution has a shelf life of 24 hours.
The bottom of each bag has two ports: An injection port for medication An access port for connecting the administration set The more common prehospital volumes are 1,000 mL and 500 mL.
Choosing an Administration Set (1 of 3)

An administration set moves fluid from the IV bag into the patients vascular system.
Each set has a piercing spike protected by a plastic cover.

Drip sets come in two primary sizes.
A microdrip set allows 60 gtt/mL.
A macrodrip set allows 10 to 15 gtt/mL.

Preparing an administration set
Verify the solution and check for clarity.
To spike the bag with the administration set, follow the steps in Skill Drill 40-3.
Saline locks (buff caps) are a way to maintain an active IV site without running fluids through the vein.
Catheters
Hollow, laser-sharpened needle inside a hollow plastic tube that is inserted into a vein Select the catheter size based on the:
Need for the IV
Condition of the patients veins Location for the IV
Starting an IV (1 of 2)
Apply a tourniquet proximal to the site where venipuncture is to be performed. When a suitable vein is identified, the area should be cleaned.
The needle/catheter is introduced into the vein, the needle withdrawn and disposed of properly, and IV tubing or lock placed.
Starting an IV (2 of 2)
Use tape or a commercially available device to secure the catheter. Always wear gloves during the procedure. Skill Drill 40-4 covers how to start an IV.
Securing the Line

Tape the area so that the catheter and tubing are securely anchored in case of a sudden pull on the line. Avoid circumferential taping around any extremity because it can act like a constricting band and stop circulation.
Alternative IV Sites and Techniques (1 of 2)

Intraosseous (IO) needles
Used for emergency venous access when other IV access is difficult or impossible Often patients are experiencing a lifethreatening situation. Generally inserted in the proximal tibia
Alternative IV Sites and Techniques (2 of 2)

External jugular IV
Provides venous access through the external jugular veins in the neck
Catheter is inserted midway between the angle of the jaw and the midclavicular line. Punctures can be difficult because these veins are surrounded by a very tough, fibrous sheath.
Possible Complications of IV Therapy

Local reactions include problems like infiltration and phlebitis. Systemic complications include allergic reactions and circulatory overload.
Local IV Site Reactions (1 of 4)

Infiltration
Escape of fluid into the surrounding tissue when the IV catheter is not in the vein
Can cause a localized are of edema or swelling
Stop the flow, remove the catheter, and reinsert it at an alternative site.

Phlebitis
Inflammation of the vein
Not usually seen in emergency prehospital patients
Associated with fever, tenderness, and red streaking along the vein

Occlusion
Physical blockage of a vein or catheter
Vein irritation
More common with IV medication administration and very uncommon with administration of pure IV fluids Patients often complain immediately that the IV is bothering them.

Hematoma
Accumulation of blood in the tissues surrounding an IV site
Result from vein perforation or catheter removal
If a hematoma develops when IV catheter insert is attempted, the procedure should stop.
Systemic Complications (1 of 7)
A systemic complication can evolve from reactions or complications associated with IV insertion.
Usually involve other body systems and can be life threatening
Allergic reactions
True anaphylaxis is possible and must be treated aggressively.
Allergic reactions (contd)
Can be related to a persons unexpected sensitivity to an IV fluid or medication
Discontinue the IV fluid and remove the solution, maintain the airway, and monitor ABCs and vital signs.
Air embolus
Patients who are already ill or injured can be adversely affected if air is introduced into the circulatory system.
Properly flush the IV line. Treat a patient by placing him or her on the left side with the head down.
Circulatory overload
An unmonitored IV bag can lead to circulatory overload.
Problems occur when the patient has cardiac, pulmonary, or renal dysfunction. The most common cause in the prehospital setting is failure to readjust the drip rate after flushing an IV line.
Circulatory overload (contd)
To treat a patient: Slow the IV rate to keep the vein open. Raise the patients head to ease respiratory distress. Administer high-flow oxygen. Monitor vital signs and shortness of breath.
Vasovagal reactions
Some patients have anxiety concerning needles or in response to the sight of blood.
Patients can present with anxiety, diaphoresis, nausea, or syncopal episodes. Lower the head of the stretcher, administer oxygen, and monitor vital signs.
Catheter shear
Potential complication when starting an IV
Could have a devastating effect on your patient May occur if you attempt to reinsert the needle through the catheter after the needle has been partially withdrawn
Troubleshooting
Several factors influence IV flow rate.
Perform the following checks after completing IV administration.

Check your administration set.
Check the height of the IV bag.

Check the type of catheter used. Check the tourniquet.
Age-Specific Considerations
(1 of 2) IV therapy for pediatric patients
A child has smaller veins.
A small-gauge catheter should be used (22-gauge to 24-gauge).
Volume control is important.

Use a special type of microdrip set called a Volutrol, which fills the large drip chamber with a specific amount of fluid.
Age-Specific Considerations
(2 of 2) IV therapy for geriatric patients
Smaller catheters may be preferable.
The use of tape can lead to skin damage, so be careful when taping IV catheters and tubing.
Be careful when using macrodrips because they can allow infusion of fluids, which may lead to fluid overload.
Cardiac Monitoring
12-lead ECG can help in the early identification of an acute myocardial infarction (AMI).
The interpretation of cardiac rhythm may not be an EMT skill. However, it is helpful to be able to place electrodes and leads.
Electrical Conduction System

(1 of 2) Network of specialized tissue capable of conducting electrical current throughout the heart Contains:
Sinoatrial (SA) node
Three intermodal pathways Atrioventricular (AV) node
Bundle of His
Right and left bundle branches
Electrical Conduction System

(2 of 2)
Electrodes and Waves

The ECG electrodes pick up the electrical activity of the heart, and the ECG machine converts them to waves. The way an ECG tracing looks depends on where the lead is placed.
The ECG Complex (1 of 3)

One complex represents one beat in the heart. The complex consists of several waves: the P, QRS, and T waves.
A segment is a specific portion of the complex.

An interval is the distance, measured in time, occurring between two cardiac events.
The time between the beginning of the P wave and the beginning of the QRS complex is known as the P-R interval.
ECG Paper
The paper on which an ECG is recorded contains a grid.
Each little box represents 1/25 of a second, or 0.04 second.
Each bigger box is composed of five smaller boxes, or 0.20 second.

Five big boxes equal 1 second.
Normal Sinus Rhythm (1 of 2)

Sinus rhythm is a rhythm in which the SA node acts as the pacemaker. With normal sinus rhythm:
All of the P waves should be the same.
The heart rate should be between 60 and 100 beats/min.
Normal Sinus Rhythm (2 of 2)
The Formation of the ECG (1 of 3)

Production of the hearts rhythm is a continuous process, with no actual period of rest or inactivity. If the heart is functioning normally, the process will repeat over and over continuously.
Arrhythmias (1 of 5)
Abnormal rhythm of the heart
Sinus bradycardia
Consistent P waves, consistent P-R intervals, regular heart rate less than 60 beats/min
Source: From Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD.
Sinus tachycardia
Consistent P waves, consistent P-R intervals, regular heart rate more than 100 beats/min
May cause a decrease in cardiac output
Ventricular tachycardia
Presence of three or more abnormal ventricular complexes in a row with a rate of more than 100 beats/min
Very regular rhythm
Ventricular fibrillation
Rapid, completely disorganized ventricular rhythm with chaotic characteristics Undulations of varying shapes and sizes; no specific pattern; no discernable P, QRS, or T waves No organized beating of the heart
Asystole
Complete absence of any electrical cardiac activity
Patient is clinically dead at this point.
Assisting With Cardiac Monitoring

You may have a 4-lead ECG or a 12-lead ECG system. New cardiac monitors include several new features using modern technology.
They are compact, light, and portable and combine defibrillation and monitoring capabilities.
Lead Placement (1 of 5)
A 4-lead ECG uses four leads, which are electrodes attached to wires. The four leads are called the limb leads.
White lead on the right shoulder or arm
Black lead on the left shoulder or arm

Green lead on the right low abdomen/leg Red lead on the left low abdomen/leg
It does not matter where the leads are placed on the limbs, as long as all four are at least 10 cm from the heart.
For the 12-lead ECG, electrodes are placed as a 4-lead placement as well as in very specific locations on the chest.
V1 and V2 on each side of the sternum
V4 at the midclavicular line

V3 between V2 and V4 V5 at the anterior axillary line, and V6 in the midaxillary line
Lead Placement
(4 of 5)
It is very important to have direct skin contact when obtaining an ECG.
If the skin is wet or oily, wipe and clean the skin thoroughly.
If the skin is hairy, use a razor.
Advantages of 12-lead monitoring

Early identification of acute ischemia
Accurate identification of arrhythmias
ST-Segment Elevation Myocardial Infarction (STEMI)

Specific type of myocardial infarction in which the ST segment of the cardiac cycle is elevated Treatable by techniques that rapidly restore perfusion to the coronary arteries
Time is muscle.
Summary (1 of 3)
There may be cases in which an EMT may find it necessary to be familiar with skills normally practiced at the AEMT and paramedic level. These skills include advanced airway techniques, IV therapy, and cardiac monitoring.
Summary (2 of 3)
An advanced airway technique is endotracheal intubation, the insertion of a tube into the trachea to maintain the airway. Additional advanced airway care devices include the Combitube, pharyngeotracheal lumen airway, the King LT, and the laryngeal mask airway.
Summary (3 of 3)
IV therapy is used to replace fluids in a patient with shock or to administer medications. Cardiac monitoring with an ECG is an advanced skill that the EMT may provide in assistance to the AEMT or paramedic.
Review
1. You are called for a male patient complaining of respiratory distress. When you arrive, you assess the patient and find that he is unconscious and apneic, but has a pulse. You should: A. perform immediate endotracheal intubation. B. attach an AED and analyze the patients rhythm. C. ensure a patent airway and effective ventilation. D. administer 100% oxygen via a nonrebreathing mask.
Review
Answer: C
Rationale: Before performing advanced airway procedures (eg, endotracheal intubation), you must first ensure that the patients airway is patent. Open the airway, ensure that it is clear of secretions, insert a basic airway adjunct, and ventilate with a bagmask device.
Review (1 of 2)
1. You are called for a male patient complaining of respiratory distress. When you arrive, you assess the patient and find that he is unconscious and apneic, but has a pulse. You should: A. perform immediate endotracheal intubation. Rationale: Perform BLS airway management before performing any advanced airway management. B. attach an AED and analyze the patients rhythm. Rationale: The patient has a pulse, so immediate airway intervention is necessary.
Review (2 of 2)
1. You are called for a male patient complaining of respiratory distress. When you arrive, you assess the patient and find that he is unconscious and apneic, but has a pulse. You should: C. ensure a patent airway and effective ventilation. Rationale: Correct answer D. administer 100% oxygen via a nonrebreathing mask. Rationale: The patient is apneic. You must initiate rescue breathing via a bag-mask device.
Review
2. You are assisting your paramedic partner while she intubates a 50-year-old man who is in cardiac arrest. You should anticipate that she will ask you for a ____ ET tube.
A. 6.0-mm
B. 6.5-mm C. 7.5-mm
D. 9.0-mm
Review
Answer: C
Rationale: The proper-sized ET tube ranges from 7.0 to 8.5 mm. A good rule of thumb is to have a 7.5 mm ET tube on hand; this size tube will fit most adults. Of course, a variety of tube sizes should always be available.
Review (1 of 2)
A. 6.0-mm Rationale: This sized tube would be used in a very small individual.
B. 6.5-mm Rationale: This sized tube would be used in a small individual.
Review (2 of 2)
C. 7.5-mm Rationale: Correct answer
D. 9.0-mm Rationale: This sized tube would be used in large adults.
Review
3. A single intubation attempt in an adult should not exceed:
A. 10 seconds. B. 20 seconds.
C. 30 seconds.
D. 40 seconds.
Review
Answer: C
Rationale: An intubation attempt should not exceed 30 seconds. During the period of time that you are intubating, the patient is not breathing. Prolonged intubation attempts increase the risk of severe hypoxia and must be avoided.
Review (1 of 2)
A. 10 seconds. Rationale: The maximum time should not exceed 30 seconds. B. 20 seconds. Rationale: The maximum time should not exceed 30 seconds.
Review (2 of 2)
C. 30 seconds. Rationale: Correct answer
D. 40 seconds. Rationale: The maximum time should not exceed 30 seconds.
Review
4. Which of the following is clearly a lethal complication of endotracheal intubation?
A. Unrecognized esophageal intubation B. Chipping two of the patients front teeth
C. Slightly extending the neck of a trauma patient

D. Ventilating the patient without supplemental oxygen
Review
Answer: A
Rationale: While all of the choices in this question will cause some degree of harm to the patient, unrecognized esophageal intubation is, without a doubt, the most lethal. If you intubate the esophagus, and do not recognize and immediately correct it, the patient will dieperiod!
Review (1 of 2)
A. Unrecognized esophageal intubation Rationale: Correct answer
B. Chipping two of the patients front teeth Rationale: This is a complication of intubation, but it is typically not lethal.
Review (2 of 2)
C. Slightly extending the neck of a trauma patient Rationale: This is something that needs to be avoided. Paralysisnot deathis usually the end result of this mistake. D. Ventilating the patient without supplemental oxygen Rationale: 100% oxygen must be delivered to a patient using a bag-mask. It is not a lethal error to deliver less.
Review
5. In which of the following patients would you NOT use a multilumen airway device?
A. 40-year-old man in cardiac arrest who has esophageal cancer
B. 17-year-old patient in cardiac arrest secondary to electrocution

C. 23-year-old man who is unconscious, apneic, and has a weak pulse D. 56 female who is unconscious and apneic after overdosing on heroin
Review
Answer: A
Rationale: Multilumen airway devices are contraindicated in conscious or semiconscious patients who have a gag reflex, patients younger than 16 years of age, adults shorter than 5 tall, patients who have ingested a corrosive substance, and patients with an esophageal disease (ie, cancer, varices).
Review (1 of 2)
A. 40-year-old man in cardiac arrest who has esophageal cancer Rationale: Correct answer B. 17-year-old patient in cardiac arrest secondary to electrocution Rationale: This device is not used in patients younger than 16 years.
Review (2 of 2)
C. 23-year-old man who is unconscious, apneic, and has a weak pulse Rationale: There is not a contraindication, unless the patient has a gag reflex. D. 56 female who is unconscious and apneic after overdosing on heroin Rationale: The minimum height for using this device is 5.
Review
6. Your paramedic partner is preparing to start an IV and asks you to set up the equipment using a 500-mL bag of normal saline and a microdrip administration set. You should recall that a microdrip set delivers ____ mL of volume for every ____ drop(s). A. 1, 60 B. 60, 1
C. 1, 10
D. 10, 1
Review
Answer: A
Rationale: A microdrip administration set which allows for more precise fluid administration than a macrodripdelivers 1 mL of volume for every 60 drops (gtts). Although several types of macrodrip administration sets exist, the most common type delivers 1 mL of volume for every 10 gtts.
Review (1 of 2)
6. Your paramedic partner is preparing to start an IV and asks you to set up the equipment using a 500-mL bag of normal saline and a microdrip administration set. You should recall that a microdrip set delivers ____ mL of volume for every ____ drop(s). A. 1, 60 Rationale: Correct answer B. 60, 1 Rationale: 60 mL would be a total of 3600 drops.
Review (2 of 2)
6. Your paramedic partner is preparing to start an IV and asks you to set up the equipment using a 500-mL bag of normal saline and a microdrip administration set. You should recall that a microdrip set delivers ____ mL of volume for every ____ drop(s). C. 1, 10 Rationale: This is a macrodrip, delivering 1 mL for every 10 drops (gtts). D. 10, 1 Rationale: 10 mL would be a total of 600 drops.
Review
7. After inserting the piercing spike of the administration set into a bag of IV fluid, you should next:
A. write the time, date, and your initials on the IV bag. B. remove air bubbles from the tubing by flushing the line. C. squeeze the drip chamber until it is approximately 50% full. D. attach the line to the catheter that has been inserted into the vein.
Review
Answer: C
Rationale: After inserting the piercing spike into a bag of IV fluid (spiking the bag), you should squeeze the drip chamber until it is approximately 50% full. Next, open the roller clamp on the tubing and allow fluid to run through it (priming the tubing); this will fill the line with fluid and remove any air bubbles. After these steps are completed, the IV line is ready to be attached to the catheter inside the patients vein.
Review (1 of 3)
A. write the time, date, and your initials on the IV bag. Rationale: This process is usually not done unless the IV bag has been filled with a specific medication in addition to the normal IV solutions.
Review (2 of 3)
B. remove air bubbles from the tubing by flushing the line. Rationale: This is done after the drip chamber has been partially filled. C. squeeze the drip chamber until it is approximately 50% full. Rationale: Correct answer
Review (3 of 3)
D. attach the line to the catheter that has been inserted into the vein. Rationale: The line must be flushed before being attached to an IV site; otherwise air will be infused into the patient.
Review
8. All of the following are local IV reactions, EXCEPT:
A. hematoma. B. infiltration.
C. vein irritation.
D. catheter shear.
Review
Answer: D
Rationale: If the IV needle is reinserted back into the catheter, it may shear a portion of the catheter off, resulting in a free-floating catheter fragment that could travel throughout the body and lodge in a major artery (catheter shear). This is a systemic complication. Hematoma, infiltration, and vein irritation are examples of local IV reactions.
Review (1 of 2)
A. hematoma. Rationale: A hematoma is an example of a local IV reaction. B. infiltration. Rationale: Infiltration is an example of a local IV reaction.
Review (2 of 2)
C. vein irritation. Rationale: Vein irritation is an example of a local IV reaction. D. catheter shear. Rationale: Correct answer
Review
9. In the adult, the sinoatrial (SA) node normally paces the heart at a rate of:
A. 40 to 60 beats/min. B. 60 to 100 beats/min.
C. 80 to 110 beats/min.
D. 100 to 120 beats/min.
Review
Answer: B
Rationale: For the heart to pump, one of the parts of the electrical conduction system must act as the pacemakerthe area that generates an electrical impulse. In a normally functioning heart, the sinoatrial (SA) node performs this function. In the adult, the SA node paces at a rate of 60 to 100 beats/min, hence the normal adult heart rate of 60 to 100 beats/min.
Review
9. In the adult, the sinoatrial (SA) node normally paces the heart at a rate of:
A. 40 to 60 beats/min. Rationale: This would be bradycardia. B. 60 to 100 beats/min. Rationale: Correct answer C. 80 to 110 beats/min. Rationale: The normal rate is 60 to 100 beats/min. D. 100 to 120 beats/min. Rationale: This would be tachycardia.
Review
10. The red lead should be placed on the patients:
A. left leg. B. left arm.
C. right leg.
D. right arm.
Review
Answer: A
Rationale: Correct lead placement is important in order to obtain an accurate ECG tracing. When using a 4-lead configuration, the white lead is placed on the right arm, the black lead is placed on the left arm, the red lead is placed on the left leg, and the green lead is placed on the right leg.
Review (1 of 2)
10. The positive (red) lead should be placed on the patients:
A. left leg. Rationale: Correct answer
B. left arm. Rationale: The black lead goes on the left arm.
Review (2 of 2)
10. The positive (red) lead should be placed on the patients:
C. right leg. Rationale: The green lead goes on the right leg. D. right arm. Rationale: The white lead goes on the right arm.
Credits
Background slide image (ambulance): Galina Barskaya/ShutterStock, Inc. Background slide images (non-ambulance): Jones & Bartlett Learning. Courtesy of MIEMSS.

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Chapter 40

Intravenous (IV) therapy

Advanced Airway Techniques

Other patients may require an oropharyngeal or nasopharyngeal airway.

Anatomy and Physiology of the Airway (1 of 5)

Lower airway includes the trachea, bronchi, and lungs.

Anatomy and Physiology of the Airway (2 of 5)

Anatomy and Physiology of the Airway (3 of 5)

This process takes place on two levels:

Anatomy and Physiology of the Airway (4 of 5)

Anatomy and Physiology of the Airway (5 of 5)

Basic Airway Management

Basic Airway Management

Determine if the patient needs an airway adjunct.

If done through the nose, it is called nasotracheal intubation.

Commercial securing device

A standard 15/22-mm adapter attaches to any ventilation device.

Do not insert past Murphys eye.

The Sellick Maneuver

Follow the steps in Skill Drill 40-1.

The Intubation Procedure (1 of 7)

Ends when ventilation begins again

The Intubation Procedure (2 of 7)

Fourth EMT prepares and intubates the patient.

Follow the steps in Skill Drill 40-2 to perform orotracheal intubation.

The Intubation Procedure (3 of 7)

The Intubation Procedure (4 of 7)

The Intubation Procedure (5 of 7)

Never let go of the ET tube until it is secured.

The Intubation Procedure (6 of 7)

The Intubation Procedure (7 of 7)

Patient intolerant of the endotracheal tube

Adults shorter than 5

Single Lumen Airway (1 of 3)

Single Lumen Airway (2 of 3)

Source: Courtesy of King Systems

Single Lumen Airway (3 of 3)

A nasal or oral gastric tube relieves gastric distention.

Radiograph on arrival at the ED

Continuous Positive Airway Pressure (1 of 3)

Chronic obstructive pulmonary disease

Continuous Positive Airway Pressure (2 of 3)

May be helpful in patients with severe respiratory distress

Continuous Positive Airway Pressure (3 of 3)

Courtesy of Respironics, Inc., Murraysville, PA. All rights reserved.

Assembling the Equipment

Lactated Ringers solution

D5W is often reserved for administering medication.

Choosing an Administration Set (1 of 3)

Choosing an Administration Set (2 of 3)

A macrodrip set allows 10 to 15 gtt/mL.

Choosing an Administration Set (3 of 3)

Securing the Line

Alternative IV Sites and Techniques (1 of 2)

Alternative IV Sites and Techniques (2 of 2)

Possible Complications of IV Therapy

Local IV Site Reactions (1 of 4)

Local IV Site Reactions (2 of 4)

Local IV Site Reactions (3 of 4)

Local IV Site Reactions (4 of 4)

Perform the following checks after completing IV administration.

Check the height of the IV bag.

Volume control is important.