Adult Treatment Guidelines
Basic Airway Management
EMS personnel often use bag-valve-mask (BVM) devices prior to or in conjunction with advanced airway insertion. Ideally, usage of a BVM is a two (2) or three (3) person procedure. Proper BVM usage should follow this mnemonic scheme:
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 second squeeze followed by quick release on the bag
Oxygen supply sufficient and functioning properly
Sellick's maneuver (cricoid pressure)
Advanced Airway Management
Any approved supraglottic airway is a suitable alternative to endotracheal intubation for most patients. EMT-Basics may insert an approved supraglottic airway provided
- The Medical Direction Team approves their agency for this procedure
- Every EMT-Basic within the agency attends an approved training course.
- The EMT can only insert the supraglottic airway under the watchful eye of an agency paramedic.
Paramedics may attempt endotracheal intubation if there is a failure of ventilation or oxygenation when less invasive methods have been exhausted or cannot be utilized AND a deteriorating clinical course is occurring. In situations that warrant endotracheal intubation but the patient’s level of consciousness precludes tube insertion, contact BioTel for authorization to sedate the patient with an approved sedative.
EMS personnel must use assessment adjuncts to aid in intubation decisions and for confirmation of advanced airway placement, with the following caveats:
- Pulse oximetry - a valuable tool to detect occult hypoxia; a normal reading does not rule out respiratory distress or the need for airway management. Has no role in confirming ET tube placement.
- End-tidal CO2 detectors (EtCO2) - The use of capnography with waveform analysis is mandatory for verifying initial advanced airway placement and for ongoing tube surveillance. Be aware that certain conditions (e.g., prolonged cardiac arrest, massive pulmonary embolus, and poor chest compressions) may not produce detectible quantities of carbon dioxide.
Proper assessment and documentation of endotracheal intubation requires the medic to:
- Visualize the tube passing between the vocal cords (for oral intubation)
- Ensure no sounds are heard over the stomach when ventilating the patient through the ET tube
- Ensure good bilateral breath sounds when ventilating the patient through the ET tube
- Observe the chest rising and falling with each ventilation
- Confirm placement with waveform capnography (less sensitive in certain cardiac arrest situations)
Do not assume either a tube is in 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.
Medics may make only one endotracheal intubation attempt per patient. If the single attempt is unsuccessful, medics should insert an approved supraglottic airway or provide effective ventilation with a BVM. An endotracheal intubation attempt is defined 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 breaths can impair
venous return and cardiac output in certain patients, particularly those with hypovolemia, acute exacerbations of
COPD or asthma, and other conditions that might already impair circulation (e.g., tamponade, tension
pneumothorax, or severe hemorrhage). After endotracheal intubation, medics should use a tidal volume equal to
a one-hand squeeze of the BVM (produce enough ventilation for visible chest rise).
Begin assisted ventilation at a rate of no more than 8 to 10 breaths per minute and 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.
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. Medics should expect transiently high ETCO2
levels during ROSC and should not over-treat 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:
- A patient greater than 20 years old experiencing any acute coronary syndrome (ACS) signs & symptoms
- Any age patient with ACS signs & symptoms AND a history of:
- Hypertension (HTN)
- Cardiac disease
- Diabetes mellitus
- Severe obesity
- High cholesterol
- Recent recreational drug use
When in Doubt, obtain a 12-lead ECG.
Endotracheal Tube Drug Administration
Because of the lack of demonstrated benefit, paramedics within the BioTel system will no longer administer medications via the endotracheal route.
he use of generic mucosal atomizer devices (MAD) allows medics to administer certain IV medications into the nose. The device creates a medication mist, which lands on the mucosal surfaces and is absorbed directly into the bloodstream. Within the BioTel system, medics will limit intranasal (IN) medications to
Medications administered via the IN route require a higher concentration of drug in a smaller volume of fluid than typically used in the IV route. In general, medics should administer no more than 1 ml of volume during a single administration event. Do not administer medications via the IN route if the patient’s nose is bleeding or if nasal congestion or nasal discharge is present. Bear in mind that nasal administration does not always work for every patient. Nasal administration is less likely to be effective if the patient has been abusing inhaled vasoconstrictors such as cocaine.
Normal saline will be the only IV fluid routinely used in the BioTel system.
Antecubital veins and external jugular veins are the access sites of choice for adults in cardiac arrest. Medics may access pre-existing central venous lines in critical cases, if the individual medic has the knowledge and equipment to do so. Medics may attempt intraosseous access 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.
- Medics should record in the patient care record the amount of fluid administered in the prehospital setting.
- For routine IV placement, infuse the fluid at a TKO rate. Medics may substitute a saline lock for IV TKO.
- Certain hypotensive trauma patients, such as those suffering traumatic cardiac arrest may respond to fluid run wide open (WO).
- Others requiring volume resuscitation are best treated using 250 mL boluses up to 1,000 mL and frequent reevaluation.
- For shock patients with uncontrolled internal or external bleeding, administer only enough fluid to maintain a radial pulse.
First responders using an automated external defibrillator (AED) should 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
Treatment Guidelines and AED device settings provide direction for determining the proper timing for delivering
Medics using a manual defibrillator should place the device in the PADDLES lead, not in Lead II when first making
patient contact and continue to use the PADDLES lead throughout the resuscitation attempt. Medics should use
the manual defibrillator in MANUAL mode throughout the resuscitation attempt, unless medical direction and
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 Medical Direction Team no
longer recommends checking 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 perfusion of the heart.
Keep pauses in chest compression to less than 10 seconds. 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
||No Advanced Airway
||Advanced Airway in place
Adult with BVM ventilation
||100 continuous chest compressions and 8 to 10 ventilations delivered asynchronously each minute (6 ventilations each 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 and 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
produce 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). Medics should not make any attempt at advanced airway insertion until after
performing at least 6 minutes of CPR, unless the patient actively regurgitates. If this happens, 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 will briefly pause compressions for
shock delivery. As soon as the medic delivers the shock, the chest compressor will immediately resume
compressions within 10 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 the patient
has regained spontaneous circulation or not.
MASS CASUALTY INCIDENTS
Contact BioTel as early as possible to insure adequate notification and preparation of the receiving facilities.