Basic Airway Management

EMS personnel often use bag-valve-mask (BVM) devices prior to or in conjunction with advanced airway placement.  Ideally, ventilation with a BVM is a two- or three-person procedure.  Proper BVM ventilation should follow this mnemonic:


Cervical-spine control, where indicated


Oral airway in place


Proper head and neck positioning


Elevate the jaw


Seal the mask (two hands)




Steady, slow, single-hand, 1- to 1.5-second squeeze, followed by quick release of the bag


Oxygen supply sufficient and functioning properly


Sellick's maneuver (cricoid pressure) (NOTE: No longer routinely recommended; may be helpful in some cases.)

Advanced Airway Management

Any approved supraglottic airway is a suitable alternative to endotracheal intubation for most adult patients.  EMT-Basics may insert an approved supraglottic airway provided that:

Paramedics may attempt endotracheal intubation if it is impossible to ventilate or oxygenate the patient with less invasive methods, AND the patient’s clinical condition is deteriorating.  In situations that warrant endotracheal intubation but the patient’s level of consciousness precludes ET tube insertion, contact BioTel for authorization to sedate the patient. (Refer to the PHARMACOLOGICALLY-ASSISTED INTUBATION Policy.)

EMS personnel must use assessment adjuncts to guide intubation decisions and to confirm advanced airway placement, with the following caveats:

Proper assessment and documentation of endotracheal intubation (for both the adult and the pediatric patient) requires the paramedic to:


Do not assume that an endotracheal tube is in either the correct or the incorrect position based on any one of these steps in isolation.  Continue to re-evaluate every few minutes and particularly after patient movement.

If there is ANY doubt as to the appropriate placement of an endotracheal tube, REMOVE the tube and ventilate the patient using a BVM.  Paramedics may make only one endotracheal intubation attempt per patient.  If the single attempt is unsuccessful, paramedics should insert an approved supraglottic airway (SGA) or provide effective ventilation with a BVM.  The Medical Direction Team defines an endotracheal intubation attempt as the passage of an endotracheal tube past the teeth. 

Assisted Ventilation, ETCO2, and Advanced Airways

The use of ETCO2 monitoring with waveform analysis is helpful in titrating the rate and volume of assisted ventilation in critically ill patients, both intubated and non-intubated.

Excessive rates of assisted ventilation may be harmful, as overzealous positive pressure ventilation can impair venous return, cardiac output and cerebral perfusion in certain patients. Examples include: patients with hypovolemia, acute exacerbations of COPD or asthma, and other conditions that might already impair circulation (e.g. cardiac tamponade, tension pneumothorax, or severe hemorrhage).  After endotracheal intubation, use a tidal volume equal to a gentle, one-hand squeeze of the BVM sufficient only to create visible chest rise.

Begin assisted ventilation at a rate of no more than 8 to 10 breaths per minute and judiciously adjust ventilation rates in an effort to keep capnography levels within normal limits.  However, do not adjust ventilation rates during or after cardiac arrest and CPR.  In cases of suspected hypovolemia, post-traumatic circulatory arrest, or severe pulmonary expiratory obstruction (e.g. asthma, COPD), reduce the rates to approximately 6 breaths per minute.  In all of these situations, over-ventilation can be harmful and dangerous.

If assisted ventilation is still required after return of spontaneous circulation (ROSC) following cardiac arrest, ventilation rates should not exceed 10 to 12 breaths per minute.  A transiently high ETCO2 level during ROSC is to be expected.  Do NOT over-treat this by attempting to reduce levels rapidly to within normal limits.

Electrocardiogram (ECG) Acquisition

Paramedics MUST acquire a 12-lead ECG for any patient who meets EITHER of these criteria:


When in doubt, obtain & transmit a 12-lead ECG.

NOTE: Continuous, 3-lead, ECG monitoring is NEITHER the same as NOR a substitute for the acquisition and transmission of a 12-lead ECG.

Endotracheal Tube Medication Administration

Because of the lack of demonstrated benefit, endotracheal medication administration is no longer performed in the UTSW/BioTel EMS system.

Intranasal (IN) Medication Administration

The use of generic mucosal atomizer devices (MAD) allows paramedics to administer certain medications into the nose (IN).  The device creates a medication mist that is deposited onto the mucosal surfaces. The drug is then rapidly absorbed into the bloodstream.  Within the BioTel system, only the following medications may be administered intranasal (IN):

Medications administered via the IN route require a higher concentration of drug in a smaller volume of fluid than is typically used IV/IO.  In general, do not administer more than 1 mL of volume during a single IN dose.  Do not administer medications IN if the patient’s nose is bleeding, or if nasal congestion or nasal discharge is present.  Nasal administration does not always work for every patient and is less likely to be effective if the patient has been abusing inhaled vasoconstrictors such as cocaine.

IV/IO Therapy

Normal Saline will be the only IV/IO fluid routinely used in the BioTel system.

Document in the patient care record the amount of fluid administered in the prehospital setting.

Antecubital veins and external jugular veins are the access sites of choice for adults in cardiac arrest.  Paramedics may access pre-existing central venous lines in critical cases, if the individual paramedic has the specialized knowledge and equipment to do so.  Intraosseous (IO) access may be performed on critically ill or injured patients when fluids and/or medications are necessary.  Do not establish IO access to replace routine IV access that is unsuccessful or difficult to establish.

Cardiac Arrest

Metronomes: Chest compressions performed at a rate of 100-120 compressions per minute are associated with the best survival and recovery outcomes.  Use of a metronome (built-in or standalone) throughout the resuscitation is critical to maintain the optimal rate of chest compressions.

First responders using an automated external defibrillator (AED) should power on the device first and then place the hands-free defibrillation pads on the patient’s bare chest as early as possible.  Do not interrupt CPR while applying the pads.  The CARDIAC ARREST Guidelines provide direction for determining the proper timing for delivering defibrillation shocks. In general, following all AED visual and voice prompts ensures optimal care.

When using a manual defibrillator, place the device in the PADDLES lead, not in Lead II upon first patient contact.  Continue to use the PADDLES lead throughout the resuscitation attempt.  Use the manual defibrillator in MANUAL mode throughout the resuscitation attempt, unless medical direction and the agency MOP specifically permit otherwise.  If the patient appears to be in asystole, quickly check for loose or disconnected leads, check the power, and check the gain (signal strength).  The American Heart Association (AHA) and the Medical Direction Team no longer recommend interrupting CPR to check multiple leads to confirm asystole.

During cardiac arrest, perfusion of the heart muscle itself falls dramatically once chest compressions have stopped.  Perform compressions with minimal interruptions in order to ensure maximum myocardial perfusion.  Keep pauses in chest compression to less than 10 seconds (less than 5 seconds for shocks).  Only pause for rhythm analysis, shock delivery, and ventilations prior to advanced airway insertion (when performing standard 30:2 CPR (adults) or 15:2 CPR (infants and children)).  Proper compression depth for adults and children at least 8 years of age is at least 2 inches (5 cm), ensuring that the chest is allowed to fully recoil between compressions (recoil/release is the phase of the compressions duty cycle that “primes the pump”).

Compression-to-Ventilation Ratio


No Advanced Airway

Advanced Airway in place

Adult with BVM ventilation


100-120 continuous chest compressions per minute and 8 to 10 ventilations per minute delivered asynchronously, without pausing chest compressions
(6 ventilations per minute for traumatic cardiac arrest)

Child with BVM ventilation


Infant with BVM ventilation


Perform therapy for medical CPR cases on-scene where you find the patient.  Do not attempt to move the patient to the ambulance for at least 10 minutes, assuming there is no risk of harm to the patient or EMS personnel by remaining at that location.  Moving medical CPR patients early in the resuscitation phase interrupts CPR and diminishes the chances of recovery.

Researchers have not clearly established a link between long-term outcome and advanced skills, such as medication administration and tracheal intubation.  Studies demonstrate that tracheal tube insertion in the field produces unacceptably high misplacement or unrecognized esophageal placement rates in many systems.  Other studies demonstrate that tracheal tube insertion may produce excessive interruptions in chest compressions, which decreases the likelihood of a successful outcome.  For all of these reasons, proper ventilation with a BVM (with a naso- or oropharyngeal airway) is the ventilation method of choice during the first six minutes of CPR (3 cycles of 2 minutes each).  Paramedics should not make any attempt at advanced airway insertion (endotracheal or supraglottic) until after performing at least 6 minutes of CPR, unless the patient actively regurgitates.  If this occurs, make every effort to continue uninterrupted chest compressions during suctioning and advanced airway placement.

During defibrillation attempts, all rescue personnel EXCEPT for the chest compressor should clear the patient while charging the AED or manual defibrillator.  The chest compressor should continue chest compressions during charging.  When the AED or defibrillator is ready, the chest compressor should very briefly pause compressions for shock delivery.  As soon as the shock has been delivered, the chest compressor will immediately resume compressions within 5 seconds or less.  This is the ideal point to rotate chest compressors.

During transport, two rescuers must be present in the back of the ambulance regardless of whether or not the patient has regained spontaneous circulation or not.


Contact BioTel as early as possible to insure adequate notification and preparation of the receiving facilities.