Emergency Medical Technician Basic Refresher Curriculum

1
Emergency Medical Technician Basic Refresher
Curriculum

• Module II Airway

2
Cognitive Objectives

• Perform techniques to assure a patent airway
• Describe the steps in performing the head-tilt
  chin-lift
  
• Describe the steps in performing the jaw thrust
• Describe the techniques of suctioning
• Describe how to measure and insert an
  oropharyngeal (oral) airway
  
• Describe how to measure and insert a
  nasopharyngeal (nasal) airway

3
Cognitive Objectives

• Provide ventilatory support for a patient
• Describe the steps in performing the skill of
  artificially ventilating a patient with a
  bag-valve-mask for one and two rescuers
  
• Describe the steps in performing the skill of
  artificially ventilating a patient with a flow
  restricted, oxygen-powered ventilation device

4
Cognitive Objectives

• Use oxygen delivery system components (nasal
  cannula, face mask, etc..)
  
• Identify a non-rebreather face mask and state the
  oxygen flow requirements needed for its use
  
• Identify a nasal cannula and state the flow
  requirements needed for its use

5
Affective Objectives

• Explain the rationale for basic life support
  artificial ventilation and airway protection
  skills taking priority over most other life
  support skills
• Explain the rationale for providing oxygenation
  through high inspired oxygen concentrations to
  patients who, in the past, may have received low
  concentrations

6
Psychomotor Objectives

• Demonstrate the steps in performing the skill of
  artificially ventilating a patient with a
  bag-valve-mask for one and two rescuers
  
• Demonstrate how to insert an oropharyngeal and
  nasopharyngeal airway
  
• Demonstrate the use of a non-rebreather face mask
  and a nasal cannula
  
• Demonstrate artificial ventilation of a patient
  with a flow restricted, oxygen powered
  ventilation device

7
Module II Airway

• Opening the Airway
• Head-tilt chin-lift when no neck injury
  suspected-review technique learned in BLS course
  
• Jaw thrust when the EMT-Basic suspects spinal
  injury - review technique learned in BLS course
  
• Assess need for suctioning

8
Techniques of Suctioning

• Suction device should be inspected on a regular
  basis before it is needed.
  
• A properly functioning unit with a gauge should
  generate 300 mm Hg vacuum.
  
• A battery operated unit should have a charged
  battery.

9
Techniques of Suctioning

• Turn on the suction unit
• Attach a catheter
• Use rigid catheter when suctioning mouth of an
  infant or child
  
• Often will need to suction nasal passages should
  use a bulb suction or French catheter with low to
  medium suction
  
• Insert the catheter into the oral cavity without
  suction, if possible. Insert only to the base of
  the tongue.

10
Techniques of Suctioning

• Apply suction
• Move the catheter tip side to side
• Suction for no more than 15 seconds at a time
• In infants and children, shorter time should be
  used
  
• If the patient has secretions or emesis that
  cannot be removed quickly and easily by
  suctioning, the patient should be logged rolled
  and the oropharynx should be cleared

11
Techniques of Suctioning

• Suction for no more than 15 seconds at a time
• If patient produces frothy secretions as rapidly
  as suctioning can remove, suction for 15 seconds,
  artificially ventilate for two minutes, then
  suction for 15 seconds, and continue in that
  matter. Consult medical direction for this
  situation
• If necessary, rinse the catheter and tubing with
  water to prevent obstruction of the tubing from
  dried material
  

12
Techniques of Artificial Ventilation

• In order of preference, the methods for
  ventilating a patient by the EMT-Basic are as
  follows
  
• Mouth-to-mask with supplemental oxygen
• Two person bag-valve-mask
• Flow restricted, oxygen powered ventilation
  device
  
• One person bag-valve-mask
• EMTs must be aware of the difficulty of a single
  rescuers maintaining an adequate mask-to-face
  seal and delivering an adequate inspiratory volume

13
Techniques of Artificial Ventilation

• Ensure BSI or body substance isolation
• Bag-valve-mask
• The bag-valve-mask consists of a self-inflating
  bag, one way valve, face mask, oxygen reservoir.
  
  
• The bag must be connected to oxygen to perform
  most effectively

14
Bag-Valve-Mask

• Volume of approximately 1600 mls
• Provides less volume than mouth-to-mask
• EMT-Basics working alone may have difficulty
  maintaining an airtight seal
  
• Two EMT-Basics using the device will be more
  effective

15
Bag-Valve-Mask

• Position self at top of patients head for
  optimal performance
  
• Adjunctive airways (oral or nasal) may be
  necessary in conjunction with bag-valve-mask
  

16
BVM Use Without Trauma

• After opening the airway, select correct mask
  size (adult, infant, or child).
  
• Position thumbs over top half of mask, index and
  middle fingers over the bottom half.
  
• Place apex of mask over bridge of nose, then
  lower mask over mouth and chin. If mask has
  large round cuff surrounding a ventilation port,
  center port over mouth.

17
BVM Use Without Trauma

• Use ring and little fingers to bring jaw up to
  mask
  
• Connect bag to mask if not already done
• Have assistant squeeze bag with two hands until
  chest rises
  
• If alone, form a C around the ventilation port
  with thumb and index finger, use middle, ring and
  little fingers under jaw to maintain chin lift
  and complete the seal

18
BVM Use Without Trauma

• Repeat a minimum of every 5 seconds for adults
  and every 3 seconds for children and infants
  
• If chest does not rise and fall, re-evaluate
• Reposition head if chest does not rise
• Reposition fingers and mask to get a good seal
• Check for obstruction
• Use alternative method (pocket mask) if still no
  chest rise

19
BVM Use Without Trauma

• If necessary, consider use of adjuncts
• Oral airway
• Nasal airway
• Dual lumen airway

20
BVM Use with Suspected Trauma

• Open airway, select correct mask size
• Immobilize head and neck
• Have assistant hold head or place head between
  knees
  
• Position thumbs over top half of mask, index and
  middle over bottom half
  
• Place apex of mask over bridge of nose, then
  lower mask over mouth and upper chin. If mask
  has large round cuff with ventilation port,
  center port over mouth.

21
BVM Use with Suspected Trauma

• Use ring and little fingers to bring jaw up to
  mask without tilting head or neck
  
• Connect bag to mask if not already done
• Have assistant squeeze bag with two hands until
  chest rises
  

22
BVM Use with Suspected Trauma

• Repeat every 5 seconds for adults and every 3 for
  children and infants, continuing to hold jaw up
  without moving head or neck
  

23
BVM Use with Suspected Trauma

• If chest does not rise, re-evaluate
• If abdomen rises, reposition jaw
• If air is escaping from under the mask,
  reposition fingers and mask
  
• Check for obstruction
• If chest still does not rise, use alternate
  method
  
• Consider use of adjuncts
• Oral or nasal airway

24
Flow Restricted, Oxygen-Powered Ventilation
Devices

• For adult use only and should provide
• A peak flow rate of 100 oxygen at up to 40 lpm
• An inspiratory pressure relief valve that opens
  at approximately 60 centimeters water and vents
  any remaining volume to the atmosphere or ceases
  gas flow

25
Flow Restricted, Oxygen-Powered Ventilation
Devices

• An audible alarm that sounds whenever the relief
  valve pressure is exceeded
  
• Satisfactory operation under ordinary
  environmental conditions and extremes of
  temperature
  
• A trigger positioned so that both hands of the
  EMT-Basic can remain on the mask to hold it in
  position

26
FROPVD Use Without Trauma

• After opening airway, insert correct size oral or
  nasal airway and attach adult mask
  
• Position thumbs over top half of mask, index and
  middle over bottom half
  
• Place apex of mask over bridge of nose, then
  lower mask over mouth and chin
  
• Use ring and little fingers to bring jaw up to
  mask

27
FROPVD Use Without Trauma

• Connect flow restricted, oxygen powered
  ventilation device to mask if not already done
  
• Trigger the FROPVD until chest rises
• Repeat every 5 seconds
• Consider use of adjuncts

28
FROPVD Use Without Trauma

• If chest does not rise, re-evaluate
• If abdomen rises, reposition head
• If air is escaping from under the mask,
  reposition fingers and mask
  
• Check for obstruction
• If chest still does not rise, use alternative
  method of artificial ventilation (e.g. pocket
  mask)

29
Use When Neck Injury is Suspected

• After opening airway, attach adult mask
• Immobilize head and neck
• Position thumbs over top half of mask, index and
  middle over bottom half
  
• Place apex of mask over bridge of nose, then
  lower mask over mouth and upper chin

30
Use When Neck Injury is Suspected

• Use ring and little fingers to bring jaw up to
  mask without tilting head or neck
  
• Connect flow restricted, oxygen powered
  ventilation device to mask
  
• Trigger the FROPVD until chest rises

31
Use When Neck Injury is Suspected

• Repeat every 5 seconds
• Consider use of adjuncts
• If chest does not rise and fall
• Reposition jaw and check seal
• Check for obstruction
• If chest still does not rise, use alternative
  method of artificial ventilation

32
Airway Adjuncts

• Oropharyngeal (oral) airways
• Oropharyngeal airways may be used to assist in
  maintaining and open airway on unresponsive
  patients without a gag reflex
  
• Select the proper size measure from the corner
  of the patients lips to the bottom of he earlobe
  or angle of jaw

33
Oropharyngeal Airways

• Insertion of oropharyngeal airway
• Open the patients mouth
• To avoid obstructing he airway with tongue,
  insert the airway upside down

34
Oropharyngeal Airways

• Advance the airway gently until resistance is
  encountered. Turn the airway 180 degrees so that
  it comes to rest with the flange on the patients
  teeth
• Another method is right side up, using a tongue
  depressor to press the tongue down and forward to
  avoid obstructing the airway. This is the
  preferred method for airway insertion in an
  infant or child.

35
Nasopharyngeal (Nasal) Airways

• Nasopharyngeal airways are less likely to
  stimulate vomiting and may be used on patients
  who are responsive but need assistance keeping
  the tongue from obstructing the airway
• Even though the tube is lubricated, this is a
  painful stimulus

36
Nasopharyngeal (Nasal) Airways

• Select the proper size, measure from the tip of
  the nose to the tip of the patients ear
  
• Consider diameter of the nare
• Lubricate the airway with a water soluble
  lubricant
  

37
Nasopharyngeal (Nasal) Airways

• Insert it posteriorly
• Bevel should be toward base of the nare or toward
  the septum
  
• If the airway cannot be inserted into one
  nostril, try the other nostril

38
Oxygen Equipment for Delivery

• Non-rebreather mask
• Preferred method of giving oxygen to prehospital
  patients
  
• Up to 90 oxygen can be delivered
• Non-rebreather bag must be full before mask is
  placed on patient
  
• Flow rate should be adjusted so that when patient
  inhales, bag does not collapse (15 lpm)

39
Oxygen Equipment for Delivery

• Patients who are cyanotic, cool, clammy, or short
  of breath need oxygen
  
• Patients with chronic obstructive pulmonary
  disease and infants and children who require
  oxygen should receive high concentration oxygen
  
• Be sure to select the correct mask size

40
Oxygen Equipment for Delivery

• Nasal Cannula
• Rarely the best method of delivering adequate
  oxygen to the pre-hospital patient
  
• Should only be used when patients will not
  tolerate a non-rebreather mask

41
Airway ManagementDual Lumen Airway
42
Cognitive Objectives

• Describe the equipment needed for inserting a
  dual lumen airway.
  
• Describe the indications for using a dual lumen
  airway.
  
• Explain the contraindications for using a dual
  lumen airway.
  
• Identify the advantages of a dual lumen airway.

43
Cognitive Objectives

• Identify the disadvantages of a dual lumen
  airway.
  
• Describe the complications associated with a dual
  lumen airway device.
  
• Describe the technique for inserting a dual lumen
  airway device.
  
• Describe the technique for removing a dual lumen
  airway device.

44
Affective Objectives

• Explain the rationale for basic life support
  artificial ventilation and airway protective
  skills taking priority over most other basic life
  support skills.
• Explain the rationale for inserting a dual lumen
  airway device over other basic airway skills.

45
Psychomotor Objectives

• Demonstrate how to insert a dual lumen airway
  device.
  
• Demonstrate how to remove a dual lumen airway
  device.

46
Dual Lumen Airway Devices

• The following are the two dual lumen airway
  devices approved for use by ADPH-EMS
  
• Pharyngeo-tracheal lumen airway (PTL)
• Combitube

47
Combitube
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49
Combitube

• Indications
• Use only in patients who are unresponsive and
  without protective reflexes gag reflex.
  
• For Paramedics use only in patients that you are
  unable to insert an endotracheal tube.
  
• Patients in cardiac or respiratory arrest.

50
Combitube

• Contraindications
• Less 16 years of age
• Under five feet in height
• Intact gag reflex
• Known esophageal disease
• Ingestion of a caustic substance

51
Combitube

• Insertion Technique
• Hyperventilate the patient at a rate of 24 times
  per minute for at least 2 minutes before
  attempting insertion, an oropharyngeal airway
  should be utilized in this time.
• Assemble equipment, ensure that cuffs are not
  leaking, and lubricate the distal end of the tube
  with water-soluble lubricant.
  

52
Combitube

• Insertion Technique
• Place the patients head in a neutral in-line
  position. If spinal injury is suspected maintain
  the head in a neutral in line position.
  
• Perform a tongue-jaw lift maneuver and insert the
  device until the teeth are between the two black
  rings.
  

53
Combitube

• Insertion Technique
• Use the large syringe to inflate the 1
  pharyngeal cuff with 100cc of air. The pharynx
  will be sealed once this cuff is inflated.
  
• Inflate the 2 distal cuff with 15cc of air.
  This will seal the esophagus or trachea depending
  on placement.
  

54
Combitube

• Insertion Technique
• Ventilate through the longer 1 ventilation tube.
  During ventilation, auscultate over the
  epigastrum and listen for gurgling sounds.
  
• If no sounds are heard, watch for chest rise and
  auscultate chest for breath sounds.
  

55
Combitube

• Insertion Technique
• If equal chest rise and breath sounds bilaterally
  are present, then continue to ventilate through
  the tube 1.
  
• If you hear gurgling sounds in the stomach then
  assume that you have inserted the device in the
  trachea and start to ventilate through the 2
  tube.

56
Combitube

• Insertion Technique
• Auscultate over the epigastrum, if gurgling is
  heard then remove the tube and ventilate patient
  with BVM.
  
• If no gurgling is heard then auscultate breath
  sounds, if the breath sounds are equal
  bilaterally then continue to ventilate through
  the 2 tube.

57
Combitube

• Insertion Technique
• Once placement is confirmed hyperventilate the
  patient for two minutes, then resume normal
  ventilation.
  
• Reassess the tube placement after each patient
  move, and periodically check the pilot balloons
  to ensure that the two cuffs are adequately
  inflated.

58
Combitube

• Removal Technique
• Have suction equipment ready for use.
• Deflate both cuffs and remove tube gently.
• Be alert for vomiting.