CMC System CE EMS Equipment; EKG Rhythms; 12 Lead EKG’s

1. CMC System CEEMS Equipment;EKG Rhythms; 12 Lead EKG’s Condell Medical Center EMS System July 2008 Site code #10-7200E1208 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives • Upon successful completion of this module, the EMS provider should be able to: • maintain familiarity with equipment used in delivering patient care • C-collar, KED, HARE, IO, Quicktrach, ETT, ETCO2, and EDD • review a variety of EKG rhythms and treatment based on Region X SOP’s • review and participate in discussion of case presentations • successfully complete the quiz with a score of 80% or better

3. Immobilization With Cervical Collars • Indication • To be used when a spinal insult/injury has been suspected based on mechanism of injury, history, or signs and symptoms • Complaints of pain to the neck, numbness or tingling of any of the extremities or parts of the extremities no matter how small the area • Traumatic Injury above the level of the clavicles such as soft tissue damage to the head, face, or neck from trauma • Altered level of consciousness where injury or complaint cannot be ruled out

4. Region X SOPIn-Field Spinal Clearance A reliable patient without signs/symptoms of neck/spine injury and negative mechanism of injury does not require full spinal immobilization

5. WHEN IN DOUBT, FULLY IMMOBILIZE THE PATIENT

6. In-Field Spinal Clearance • Mechanism of injury • High velocity MVC > 40mph • Unrestrained occupant in MVC • Passenger compartment intrusion > 12 inches • Ejection from vehicle • Rollover MVC • Motorcycle collision >20 mph • Death in same vehicle • Pedestrian struck by vehicle • Falls > 2 times patient height • Diving injury

7. In-Field Spinal Clearance • Signs and symptoms • Pain in neck or spine • Tenderness / deformity of neck or spine upon palpation • Paralysis or abnormal motor exam • Paresthesia (tingling) in extremities • Abnormal response to painful stimuli

8. In-Field Spinal Clearance • Patient reliability • Signs of intoxication • Abnormal mental status • Communications difficulty • Abnormal stress reaction • Includes persons upset at scene of incident

9. IF YOU DO NOT HAVE THE PROPER SIZED COLLAR, IT IS BETER TO USE A TOWEL ROLL AND TAPE TO IMMOBILIZE THE PATIENT

10. Before application of the cervical collar, make sure the initial assessment has been completed and life-threatening problems have been addressed. • You may need to continue manual c-spine control for the unruly, uncooperative patient; document your additional efforts

11. Fit of the C-collar • The front height of the collar should fit between the point of the chin and the chest at the suprasternal notch (where the clavicles and sternum meet) • The collar should rest on the clavicles and support the lower jaw • The collar should not stretch the neck (too high), not support the chin (too short), and not constrict the neck (too tight)

12. Patient Positioning • Keep the patient’s head in the in-line anatomical position during manual stabilization and application of the collar • A neutral position with the head facing front, not tilted forward or back or turned to either side

13. Measuring For The C-Collar • The provider to place their fingers horizontal and measure from the top of the patient’s shoulder (at the crease of the neck) to a line visually drawn at the bottom of the patient’s chin • Keep your fingers horizontal, not angling downward with the patient’s neck • The collar will be one size too short if the fingers are slanted in measurement

14. Measuring for the C-Collar • Place your fingers along the plastic side of the c-collar to the closest hole opening • Adjust the collar into place and snap the locks into place • The collar is readjustable if the sizing is not correct • Hint: directions are printed on the side of the collar for quick reference

15. Measurement markings • Neck opening to grasp to secure Velcro strap

16. Applying the C-Collar Preform the collar by rolling the collar Position the chin into the collar bottom The 2nd rescuer applying the collar should stand at the side of the patient to wrap their fingers into the neck opening and firmly grasp the Velcro collar strap Avoid any torque movement and secure the strap into place with Velcro Visually inspect the placement of the collar for appropriateness of application Secure the patient to the backboard before stopping manual stabilization of the c-spine

17. A Perfect Fit • Consider the facts: • In a room of 12-15 EMS providers, on average, only 1 person would wear a no-neck sized collar • If the majority of your patients are being sized as a no-neck for the collar, then you are not measuring them correctly and you are not providing adequate care for your patient

18. Indications To allow immobilization of the patient when moving them from a sitting position to the long backboard and when there is time to apply the device Remember – it takes a lot of time to apply the KED device Do you have the time to do it right or do you need rapid extrication? KED Device

19. KED Device

20. KED Device • Manually secure the c-spine with the head in the neutral, in-line position • Assess the patient’s distal pulse, motor function, and sensation (PMS) • To be assessed before and after immobilization • Apply the appropriately sized cervical collar and continue to maintain manual immobilization

21. KED cont’d • Position device behind the patient • Secure the device to the patient’s torso • The top of the device should fit snuggly into the armpit • Pad behind the patient’s head as needed and secure the patient’s head to the KED • One Velcro strap to secure the forehead • One strap under the chin and attached to the KED – watch for pressure on the fleshy neck

22. KED cont’d • Evaluate and adjust all straps • Straps are to be tight enough to prevent up/down or lateral movement but not so tight to restrict breathing • Straps should not be pinching any flesh in the groin • Secure patient’s wrists and ankles as needed when moving the patient onto the backboard • Reassess distal PMS in extremities before and then again after moving patient

23. HARE Traction • Indications • To immobilize an injured leg when there is swelling, pain, and or deformity to the mid-thigh suggesting fracture of the femur in the absence of injury to the lower leg or of joint injury

24. HARE Traction • With a fractured femur, the powerful thigh muscles can go into spasm causing extreme pain for the patient • The traction reduces the incidence of thigh muscle spasms reducing the pain level for the patient and preventing further internal trauma from sharp, ragged bone ends

25. Pain Management SOP • Orthopedic injuries can be very painful. • When indicated and the patient condition is satisfied (ie: B/P remains > 100mmHg) • Morphine 2 mg IVP slowly over 2 minutes • May repeat 2 mg IVP every 2 minutes up to a max of 10mg • Observe & document the patient’s response to the intervention and monitor the blood pressure and for respiratory depression

26. HARE Traction Application • Manually stabilize the injured leg • Assess PMS - distal pulses, motor function (“can you wiggle your toes?”), and sensation (“can you feel me touching your toe? Which toe?”) • Apply and maintain manual traction • Usual amount of traction is when the patient reports relief of muscle spasms

27. HARE cont’d • Measure for the correct length of the splint • Place the splint alongside the non-injured leg • Make adjustments to the overall length • The ischial padded ring to fit from the ishial tuberosity (from the bottom of the buttocks) and extended past the foot with enough room to apply traction with the ankle strap • Set the device under the patient’s injured leg • Apply the ischial strap (proximal strap) • Apply the distal ankle hitch • Apply mechanical traction and let go of manual traction when the mechanical traction takes over

28. HARE cont’d • Position and secure the remaining straps • Avoid placing any straps over the injured area and the knee • Reassess distal PMS • Secure the patient to the backboard • Verify that enough of the backboard protrudes off the cot to be able to continue to support the distal end of the HARE traction

29. HARE Traction Secured In Place

30. FAQ’s - Intraosseous Needle • Does the IO replace the IV? • IO access is not a replacement for routine IV therapy; IO is an appropriate option when IV access is not possible and IV access is necessary • Is there any limitation to fluids or medications that can be infused via the IO? • Any fluid or medication that can be infused via IVP may be infused via IO

31. FAQ’s - Intraosseous Needle • What are the advantages to IO access over IV? • IO vessels don’t collapse in shock • IO access is quicker than IV in shock or trauma • IO requires minimal training and skill • IO access has a low complication rate (<1%) • Any medications that can be given IVP can be given via IO • Blood work can be drawn from the IO needle

32. FAQ’s - Intraosseous Needle • How long does it take the hole in the bone to heal after removal of the IO needle? • Complete healing can take up to several days. Sufficient healing where another IO needle can be placed is usually considered 24 hours but at 24 hours there is still risk of extravasation (leakage) of fluid from the 1st site (FYI: Region X SOP requests no repeat IO needle in the same site for 48 hours) • Is the bone weaker after being drilled? • No; the catheter size is 15 G (adult and pediatrics) and is considered a small hole in comparison to the bony framework

33. FAQ’s - Intraosseous Needle • What flow rates can I expect via the IO route? • The flow rates will vary patient to patient. Flow rates to date have varied from 20 ml/hour (rarely) to as high as 6000ml/hour. Flow rates depend on anatomical site used, adequacy of initial flushing, pressure used on infusion bag, and type of medication or fluid being infused.

34. FAQ’s - Intraosseous Needle • What are the requirements for optimal flow rates? • The IO space needs to be flushed under high pressure with a syringe (connected to the primed extension tubing). Thick marrow occupies medullary space and can inhibit free flowing fluids. • You need to have a pressure bag at a minimum of 300 mmHg (or B/P cuff (hand pressure in the absence of anything else but may not be enough pressure alone)) on the infusion bag for continuous flow. • Gravity alone will rarely generate adequate flow rates.

35. FAQ’s - Intraosseous Needle • Do I need to flush with saline after drugs are given? • Yes, to make sure all of the medication has entered the vascular space. There is approximately 1 ml of dead space in the IO site that needs to be flushed.

36. FAQ’s - Intraosseous Needle • When I push drugs via the IO, how fast does it take for the drug to reach the heart? • In cardiac arrest, drugs given via the tibial site will reach the heart within 51 seconds. In a normal circulating animal study, the drug reached the heart in 4 seconds.

37. FAQ’s - Intraosseous Needle • Do I need to clean the site differently for an IV versus an IO insertion? • No, the same skin preparation is sufficient for both devices and the usual aseptic technique is required for both.

38. FAQ’s - Intraosseous Needle • How much pain is there to place the IO needle? • IO insertion is no more painful than a large bore peripheral IV stick. Conscious patients report significant pain after infusion of fluids or medication have been started – this is from an extensive network of nerve fibers in the medullary cavity. • If the EMS patient is restless related to pain at the site, contact Medical Control

39. FAQ’s - Intraosseous Needle • Can I use the adult IO needle in the pediatric patient? • The adult EZ IO needle is to be used for all patients weighing more than 39 kg (88 pounds per Region X SOP). At times there may be a significant amount of tissue over the site that the longer adult needle may be required. • During insertion, when the tip of the needle is just touching the outer surface of the bone, you need to be able to observe the proximal hash mark on the needle shaft. Then you will know there is enough needle length to insert.

40. EZ IO Needle

41. FAQ’s - Intraosseous Needle • Can anyone insert an IO needle? • This device can only be used by the order of a licensed physician. Our protocols allow for the EMT-P to insert the device because they work under the license of the medical director. Our system requires the EMT-P to receive training on the use of the device and to return demonstrate insertion of the device before being allowed to use the device in the field.

42. FAQ’s - Intraosseous Needle • What are my resources if I need further information on the EZ IO device? • Contact your Medical Officer, a system EMS coordinator, the company 24/7 at toll free 1-800-680-4911 • The Vidacare company provides website training (www.vidacare.com “Training and Education”)

43. Quicktrach • Indications • To establish an airway when conventional methods to ventilate the patient have failed • Contraindications • Tracheal transection (trachea cut in half) • Children less than 3 years of age (per manufacturer) • When an alternative and less invasive maneuver allows ventilation

44. Quicktrach syringe hub of catheter neckstrap stopper

45. Quicktrach Packaging Box • Label the outside of your white packaging box – they look the same for the 2 mm size pediatric box and 4mm size adult box • The needles look very similar except for length

46. Quicktrach Procedure • Adults >100 pounds use the 4.0 mm ID and pediatrics <100 pounds use the 2.0 mm ID device • Place the patient supine with head slightly extended if no cervical spine trauma is suspected • Locate the cricothyroid membrane • Membrane is midline between the thyroid cartilage (Adam’s apple) and cricoid cartilage below the Adam’s apple • Cleanse the overlying skin

48. Quicktrach Procedure cont’d • Puncture the cricothyroid membrane at a 90 degree angle • Confirm entry of the needle in the trachea by aspirating air thru the syringe • Change the angle of insertion to 60 degrees • Slide the catheter sheath forward to the level of the stopper • Remove the stopper • Note: the stopper is a very tight fit and may need to be wiggled to be removed • Advance the plastic cannula as you remove the needle and syringe

49. Insertion of Quicktrach

50. Quicktrach Procedure cont’d • As soon as the needle and syringe are removed, begin to ventilate the patient • Then secure the catheter in place using the strap provided • Helpful to secure one side of the strap in place before beginning the procedure • Once secured, the hub of the catheter should be snug against the neck • Confirm placement • Auscultation, bilateral chest rise and fall