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:

C   Cervical-spine control, where indicated
O   Oral airway in place
P   Proper head and neck positioning
E   Elevate the jaw
S   Seal the mask (two hands)

S   Steady, slow, single-hand, 1 second squeeze followed by quick release on the bag
O   Oxygen supply sufficient and functioning properly
S   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

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:

Proper assessment and documentation of endotracheal intubation requires the medic to:

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
  OR
• Any age patient with ACS signs & symptoms AND a history of:
  
  
• Hypertension (HTN)
• Cardiac disease
• Smoking
• 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.

Intranasal Administration

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.

IV Therapy

Cardiac Arrest

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 defibrillation shocks.

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 and children)).

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

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