SOUTHWEST TENNESSEE COMMUNITY COLLEGE DEPARTMENT OF EMERGENCY MEDICAL SCIENCES

H. WAID RAY

SKILLS MANUAL 17th Edition

Preface Caring for the sick and injured has always been a demanding and oftentimes precarious profession. Early prehospital care in Tennessee usually consisted of funeral homes placing a sick or injured person in the back of a hearse and driving at a breakneck speed to the closest hospital. Fortunately, patients today receive far better professional care from highly-trained, highly-skilled providers. The goal of this manual is to provide you with the psychomotor skills and attendant facts necessary to save lives, reduce morbidity and give the “far better professional care” mentioned above. This manual is not a magic lantern illuminating the correct methodology for managing each and every illness or injury. Rather it is a suggested method of performing skills that, when mastered, provide the foundation for becoming a competent prehospital care provider. Always remember that the psychomotor skills described in this manual are useless without a sound and broad fund of basic knowledge from which to draw. Significant recognition must be given to the National Registry of Emergency Medical Technicians (NREMT) whose original skills sheets this manual is based upon. H. Waid Ray

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Oxygen............................................................................................................................1 Instructions to the Candidate: Oxygen Tank Set-Up and Administration .......................... 2 Oxygen Tank Set-Up and Administration......................................................................... 3 Instructions to the Candidate: Ventilation Skills – Pocket Mask ....................................... 4 Ventilation Skills – Pocket Mask ......................................................................................5 Instructions to the Candidate: Ventilation Skills – Bag-Valve-Mask (BVM) ...................... 6 Ventilation Skills – Bag-Valve-Mask (BVM) ..................................................................... 7 Instructions to the Candidate: Oro/Nasopharyngeal Airways and Suctioning ................... 8 Oro/Nasopharyngeal Airways and Suctioning................................................................ 10 Instructions to the Candidate: Pulse Oximetry ............................................................... 11 Pulse Oximetry .............................................................................................................. 12 Table of Autonomic Effects............................................................................................ 13 Bronchiodilator - Albuterol ............................................................................................. 14 Instructions to the Candidate: Inhaler: Assist with Patient’s Own Device ....................... 15 Inhaler: Assist with Patient’s Own Device ...................................................................... 16 Instructions to the Candidate: Nebulizer: Assist with Patient’s Own Device ................... 17 Nebulizer: Assist with Patient’s Own Device .................................................................. 18 Normal Vital Signs ......................................................................................................... 19 Vital Signs and Patient History ...................................................................................... 20 Patient Assessment Memory Prompts ........................................................................... 21 Instructions to the Candidate: Medical Assessment ...................................................... 22 Medical Assessment ..................................................................................................... 23 Instructions to the Candidate: Trauma Assessment ...................................................... 24 Trauma Assessment ..................................................................................................... 25 Instructions to the Candidate: Direct Pressure/Tourniquet ............................................. 26 Direct Pressure ............................................................................................................. 27 Tourniquet .....................................................................................................................28 Instructions to the Candidate: Amputation ..................................................................... 29 Amputation ....................................................................................................................30 Instructions to the Candidate: Eye Irrigation and Bandaging ......................................... 31 Eye Irrigation and Bandaging ........................................................................................ 32 Instructions to the Candidate: Head Bandage ............................................................... 33 Head Bandage ..............................................................................................................34 Instructions to the Candidate: Impaled Objects ............................................................. 35 Impaled Objects ............................................................................................................ 36 Instructions to the Candidate: Long Bone Injuries ......................................................... 37 Board Immobilization – Hip............................................................................................ 38 Board Immobilization – Radius/Ulna .............................................................................. 39 Board Immobilization – Tibia/Fibula ............................................................................... 40 Instructions to the Candidate: Flail Chest ...................................................................... 41 Flail Chest .....................................................................................................................42 Instructions to the Candidate: Foot/Ankle Injury ............................................................ 43 Foot/Ankle Injury ........................................................................................................... 44 Instructions to the Candidate: Joint Injury Management ................................................ 45 Joint Injury Management ............................................................................................... 46 PASG Fact Sheet .......................................................................................................... 47 Instructions to the Candidate: PASG – Splint ................................................................ 48 PASG – Splint ...............................................................................................................49 Instructions to the Candidate: Sling and Swathe ........................................................... 50 Sling and Swathe .......................................................................................................... 51 Instructions to the Candidate: Traction Splinting............................................................ 52

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Basic EMT Skills Manual H. Waid Ray, 17th Edition

Traction Splint ............................................................................................................... 53 The Maine Protocol ....................................................................................................... 54 The Maine Protocol - Flow Chart ................................................................................... 55 Instructions to the Candidate: Clam Shell Device .......................................................... 56 Clam Shell Device ......................................................................................................... 57 Instructions to the Candidate: Long Spine Board........................................................... 58 Long Spine Board ......................................................................................................... 59 Electrical Anatomy of the Heart ..................................................................................... 60 Instructions to the Candidate: Cardiac Arrest Management (CPR/AED) ........................ 61 Cardiac Arrest Management (CPR/AED)....................................................................... 62 Nitroglycerin (NTG) ....................................................................................................... 63 Nitroglycerin Spray ........................................................................................................ 64 Aspirin (ASA).................................................................................................................65 Instructions to the Candidate: Cardiac Pain Management (NTG/ASA) .......................... 66 Cardiac Pain Management (NTG/ASA) ......................................................................... 67 Oral Glucose .................................................................................................................68 Instructions to the Candidate: Hypoglycemia Management (Oral Glucose) ................... 69 Hypoglycemia Management (Oral Glucose) .................................................................. 70 Epinephrine 1:1,000 ...................................................................................................... 71 Instructions to the Candidate: Epinephrine Autoinjector ................................................ 72 Epinephrine Autoinjector ............................................................................................... 73

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Basic EMT Skills Manual H. Waid Ray, 17th Edition

Oxygen (O2) Description: • Oxygen is the most important emergency drug and is required by the body to facilitate the breakdown of glucose into usable forms of energy. Oxygen is odorless, colorless, and tasteless. Action: • Administration increases arterial oxygen tension which increases the oxygen saturation available for hemoglobin. Indications: • Respiratory emergencies. • Hypoxemia. • Chest Pain. • Cardiac arrest. • Trauma. Contraindications: • NONE in the emergency setting. Precautions: • Patients with COPD may experience apnea. These patient’s chemo-receptors no longer influence breathing as they have converted to an oxygen-based (hypoxic) drive to breathe. • Do not withhold oxygen from any patient who truly needs it. • Prolonged administration of high flow oxygen to newborn infants can result in eye damage. Dosage: • Cardiac Arrest – as close as possible to 100% FiO2 (BVM), NOT TO EXCEED 99% SaO2. • Hypoxia – as close as possible to 100% FiO2 (BVM or 15 LPM / NRB), NOT TO EXCEED 99% SaO2. • Chest Pain – as close as possible to 100 % FiO2 (15 LPM / NRB), NOT TO EXCEED 99% SaO2. • COPD 1. For severe respiratory distress, 100% FiO2 or as close as possible (15 LPM / NRB), NOT TO EXCEED 99% SaO2 while closely monitoring respiratory rate and depth. 2. For normal or minimal respiratory distress, 2-6 LPM via BNC IF patient cannot tolerate a NRB mask, NOT TO EXCEED 99% SaO2 while closely monitoring respiratory rate and depth. • In all instances, be prepared to ventilate and intubate with a double lumen airway.

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Basic EMT Skills Manual H. Waid Ray, 17th Edition

Instructions to the Candidate: Oxygen Tank Set-Up and Administration This station is designed to test your ability to correctly assemble the equipment needed to administer supplemental oxygen in the pre-hospital setting. This is an isolated skills test. You will be required to assemble an oxygen tank and a regulator and administer oxygen to a patient using a non-rebreather mask. At this point you will be instructed to discontinue oxygen administration by the non-rebreather mask and start oxygen administration using a nasal cannula because the patient cannot tolerate the mask. Once you have initiated oxygen administration using a nasal cannula, you will be instructed to discontinue oxygen administration completely. You may use only the equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions?

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Name: __________________________

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Date: ___________________________

Oxygen Tank Set-Up and Administration Points Possible Take or verbalize standard precautions 1 Assemble the regulator to the tank 1 Open the tank 1 Check for leaks 1 Check tank pressure 1 Attach non-rebreather mask to oxygen 1 Prefill reservoir 1 Adjust liter flow to 12 liters per minute or greater 1 Apply and adjust the mask to the patient's face 1 Note: The medical director now orders you to apply a nasal cannula to the patient Attach nasal cannula to oxygen 1 Adjust liter flow to six (6) liters per minute or less 1 Apply nasal cannula to the patient 1 Note: The medical director now orders you to discontinue oxygen therapy Remove the nasal cannula from the patient 1 Shut off the regulator 1 Relieve the pressure within the regulator 1 Total: 15

Points Awarded

Critical Criteria    

Did not take, or verbalize, standard precautions Did not assemble the tank and regulator without leaks Did not prefill the reservoir bag Did not adjust the device to the correct liter flow for the non-rebreather mask (12 liters per minute or greater)  Did not adjust the device to the correct liter flow for the nasal cannula (6 liters per minute or less)  Any other action or inaction causing patient harm or unnecessary pain

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Basic EMT Skills Manual H. Waid Ray, 17th Edition

Instructions to the Candidate: Ventilation Skills – Pocket Mask This station is designed to test your ability to ventilate a patient with supplemental oxygen using a mouth-to-mask technique. This is an isolated skills test. You may assume that mouth-to-barrier device ventilation is in progress and that the patient has a central pulse. The only patient management required is ventilator support using a mouth-to-mask technique with supplemental oxygen. You must ventilate the patient for at least 30 seconds. You will be evaluated on the appropriateness of ventilatory volumes. You may use any equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions?

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Name: __________________________

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Date: ___________________________

Ventilation Skills – Pocket Mask

Take or verbalize standard precautions Connect one-way valve to mask Open patient's airway or confirm patient's airway is open (manually or with adjunct) Establishes and maintains a proper mask to face seal Ventilate the patient at the proper volume and rate (800-1200 ml per breath/10-20 breaths per minute) Connect the mask to high concentration of oxygen Adjust flow rate to at least 15 liters per minute Continue ventilation of the patient at the proper volume and rate (800-1200 ml per breath/10-20 breaths per minute) Note: The examiner must witness ventilations for at least 30 seconds Total: Critical Criteria  Did not take, or verbalize, standard precautions  Did not adjust liter flow to at least 15 liters per minute  Did not provide proper volume per breath (more than 2 ventilations per minute were below 800 ml)  Did not ventilate the patient at a rate a 10-20 breaths per minute  Did not allow for complete exhalation  Any other action or inaction causing patient harm or unnecessary pain

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Points Possible 1 1 1 1 1 1 1 1 8

Points Awarded

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Instructions to the Candidate: Ventilation Skills – BagValve-Mask (BVM) This station is designed to test your ability to ventilate a patient using a bag-valve-mask. As you enter the station you will find an apneic patient with a palpable central pulse. There are no bystanders and artificial ventilation has not been initiated. The only patient management required is airway management and ventilatory support. You must initially ventilate the patient for a minimum of 30 seconds. You will be evaluated on the appropriateness of ventilator volumes. I will then inform you that a second rescuer has arrived and will instruct you that you must control the airway and the mask seal while the second rescuer provides ventilation. You may use only the equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions? General Considerations: • Gastric distention - Increase inspiratory times to deliver the necessary tidal volume at low peak inspiratory pressures. If possible, apply cricoid pressure or the Sellick Maneuver (requires additional rescuer) to reduce air inflow to the stomach. • Low ventilatory volume - Squeeze the bag with your free hand against your leg or side to expel additional volume. With two rescuers, use two hands to seal the mask to the patient’s face and a second rescuer to squeeze the bag with both hands. The two-rescuer technique is preferred. If available, incorporate the use of an automatic transport ventilator to provide adequate tidal volume while sealing mask with both hands. If difficulty exists in providing a leak proof seal to the face, resort to using the mouth-to-mask method. • Observe for vomitus and be prepared to suction. • ALWAYS reassess the patient’s ABC’s, skin color, LOC and record.

Page 6 of 73

Name: __________________________

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Date: ___________________________

Ventilation Skills – Bag-Valve-Mask (BVM)

Take or verbalize standard precautions Verbalize opening the airway Verbalize inserting an oral airway Select appropriately sized mask Create a proper mask-to-face seal Ventilate patient at no less than 800 ml volume (The examiner must witness for at least 30 seconds) Connect reservoir and oxygen Adjust liter flow to 15 liters/minute or greater Note:A second EMT arrives to ventilate the patient while you control the mask and the airway Verbalize re-opening the airway Creates a proper mask-to-face seal Instruct assistant to resume ventilation at proper volume per breath (The examiner must witness for at least 30 seconds) Total: Critical Criteria     

Did not take, or verbalize, standard precautions Did not immediately ventilate the patient Interrupted ventilations for more than 20 seconds Did not provide high concentration of oxygen Did not provide, or direct assistant to provide, proper volume/breath (more than two (2) ventilations per minute are below 800 ml)  Did not allow adequate exhalation  Any other action or inaction causing patient harm or unnecessary pain

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Points Possible 1 1 1 1 1 1 1 1

1 1 1 11

Points Awarded

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Instructions to the Candidate: Oro/Nasopharyngeal Airways and Suctioning This station is designed to test your ability to properly measure, insert and remove oropharyngeal and nasopharyngeal airway adjuncts as well as suction a patient’s upper airway. This is an isolated skills test comprised of three separate skills. You may use any equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions? OROPHARYNGEAL (ORAL) AIRWAY Indications: • An inadequate airway, or • Patient with loss of consciousness, without a gag reflex, or not breathing, and • Need for prolonged artificial ventilation. Contraindications: • Conscious or semiconscious patient with an intact gag reflex (the adjunct could cause vomiting or spasm of the vocal cords). • Inability to introduce the adjunct into the oropharynx secondary to massive trauma. Risk & Complications: • Stimulation of gag reflex may increase risk of vomiting, aspiration, or laryngospasm. Be prepared to suction. • If the chosen adjunct is TOO SHORT, the tip may displace the tongue into oropharynx obstructing the airway or the adjunct will not advance far enough to lift tongue. • If the chosen adjunct is TOO LONG, the tip may push the epiglottis over the glottic opening or induce laryngospasm. • If the only choice is between an adjunct that is too long and an adjunct that is too short, choose the adjunct that is TOO LONG. Measure from the corner of the patient’s lips to the bottom of the patient’s ear lobe or angle of jaw and mark the adjunct. Follow proper insertion techniques to the mark and secure the adjunct to prevent it from advancing further. NASOPHARYNGEAL (NASAL) AIRWAY Indications: • A conscious patient with an intact gag reflex. • An inadequate airway due to a relaxed tongue. • A patient with decreased level of consciousness who cannot tolerate the oropharyngeal adjunct. • Trismus, preventing oropharyngeal adjunct insertion. • Massive trauma to lower jaw, preventing insertion of an oropharyngeal adjunct. Contraindications: • Nasopharyngeal adjuncts should not be used in suspected basilar skull fractures or severe nasal injuries.

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Basic EMT Skills Manual H. Waid Ray, 17th Edition

Risk & Complications: • Inserting a nasopharyngeal adjunct too far or using a nasopharyngeal adjunct that is too long may stimulate the gag reflex and may cause vomiting and aspiration or laryngospasm. • Always have suction prepared prior to insertion. • If the chosen nasopharyngeal adjunct is TOO SHORT, it may not advance far enough to create an adequate airway. • If the chosen nasopharyngeal adjunct is TOO LONG, the tip may push the epiglottis over the glottic opening or induce laryngospasm • If the only choice is between a nasopharyngeal adjunct that is too long and a nasopharyngeal adjunct that is too short, choose the adjunct that is TOO LONG. Measure from the tip of the earlobe to the tip of the nostril and mark the adjunct. Follow proper insertion techniques to the mark and secure the adjunct to prevent the adjunct from advancing further. • Even if the adjunct is generously lubricated, the nasal passages may still suffer trauma secondary to insertion. Be prepared for epistaxis (nose bleed).

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Name: __________________________

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Date: ___________________________

Oro/Nasopharyngeal Airways and Suctioning Points Points Possible Awarded OROPHARYNGEAL AIRWAY Take or verbalize standard precautions Select appropriately sized airway Measure airway Insert airway without pushing the tongue posteriorly Note: The patient is gagging and becoming conscious Remove the oropharyngeal airway SUCTIONING Note: The patient requires suctioning Turn on/prepare suction device Assure presence of mechanical suction Insert the suction tip without suction Apply suction to the oropharynx/nasopharynx NASOPHARYNGEAL AIRWAY Note: The patient now requires a nasopharyngeal airway Select appropriately sized airway Measure airway Verbalize lubrication of the nasal airway Fully inserts the airway with the bevel facing toward the septum

1 1 1 1 1

1 1 1 1

Total: Critical Criteria     

Did not take, or verbalize, standard precautions Did not obtain a patent airway with the oropharyngeal airway Did not obtain a patent airway with the nasopharyngeal airway Did not demonstrate an acceptable suction technique Any other action or inaction causing patient harm or unnecessary pain

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1 1 1 1 13

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Instructions to the Candidate: Pulse Oximetry This station is designed to test your ability to correctly apply, monitor and interpret pulse oximetry. This is an isolated skills test. You will be required to correctly apply a pulse oximeter and then verbalize its monitoring and how to interpret the data it provides. You may use only the equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions?

Page 11 of 73

Name: __________________________

Basic EMT Skills Manual H. Waid Ray, 17th Edition

Date: ___________________________

Pulse Oximetry

Take or verbalize standard precautions Retrieve pulse oximeter and check batteries Assess patient’s fingernails for polish or false nails and remove if necessary Document SaO2 Verbalize normal values (96 – 100%) and describe treatment: Non rebreather mask at 12-15 LPM or nasal cannula at 4 – 6 LPM if patient cannot tolerate a mask and based on patient’s chief complaint Verbalize mild hypoxia values (91 – 95%) and describe treatment: Immediate need to increase the FiO2; Non rebreather mask at 12 – 15 LPM; consider use of CPAP if available Verbalize moderate hypoxia values (86 – 90%) and describe treatment: Immediate need to increase the FiO2; consider possible loss of airway patency; Non rebreather mask at 12 – 15 LPM; consider airway adjunct and bag-valvemask at 15 LPM; consider use of CPAP if available Verbalize severe hypoxia values (