Brady Skills

Brady Skills Series—EMT-B

EDUCATIONAL CONSULTANTSBaxter Larmon, PhD, MICP

Heather Davis, MS, NREMT-P

Video Leader’s Guide

AUTHORSBob Elling, MPA, REMT-P

Kirsten Elling, BS, REMT-P

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Table of Contents

Introduction 3Teaching Tips 4Correlation with Content in Brady Textbooks 5Credits 8Tape 1: Patient Assessment 10Tape 2: Patient Assessment 19Tape 1: Airway Management 30Tape 2: Airway Management 41Tape 1: Medical Emergencies 53Tape 2: Medical Emergencies 64Tape 1: Trauma Emergencies 71Tape 2: Trauma Emergencies 80

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IntroductionWelcome to the Brady Skills Series Video Leader’s Guide! This guide has been prepared as aresource for you, the EMS educator, who has chosen to use the Brady Skills Series as part ofyour training program. This guide begins with a correlation showing where in each of Brady’s topEMT-B texts each of these skills is covered. Next, each of the skills has a complete leader’sguide to help you incorporate this valuable content into your lessons.

We have designed the guide so that each skill includes the following teaching elements:the program segment name; the time codes that show where on the tape the segment begins andends (don’t forget to set your time code at the beginning of the tape); the objectives of thesegment; and an overview to the segment, which includes the necessary equipment,assessment, skill close-up, and ongoing assessment. We’ve also listed and defined a few keyterms that are used in the segment. Finally, we’ve provided questions to ask your students tostimulate discussion during your lessons.

The tapes have been extensively reviewed and carefully prepared to be an adjunct toyour EMS instruction, as well as a means of demonstrating to your students a uniform manner inwhich the skills of the EMT-B should be performed. We hope you will find the Brady Skills Serieshelpful in your EMT-B classroom as well as useful for in-service continuing education. Mostimportant, we hope the series will help your students grow to become excellent EMS providersand help improve the quality of care they deliver to their patients. After all, isn’t that what it’s allabout!

See you in the streets!

The Brady Skills Series Development Team

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Teaching TipsVideo is not intended to replace the teacher. However, if used correctly, video can enhance theteacher’s effectiveness in many of the following ways:

• Portray re-enactments so students can visualize “model” behaviors.• Display actual emergency scenes and critical injuries or medical conditions that cannot

be easily simulated or role-played in the classroom. This is important to providing asense of realism to training.

• Provide a concise, to-the-point message that is consistent and high quality.• Introduce environments that would be too difficult or expensive for the class to explore.• Reduce the time it takes to demonstrate skills.• Scenes can be replayed to reinforce key points.• Standardize training techniques and ensure coverage of key points.

So how can you best utilize video in your classroom? First, select a video that meets yourlesson’s objectives, and always preview the video. Many available videos have errors or adhereto old training standards. You need to decide whether the detriment of showing the outdatedtechnique (and correcting it) outweighs the benefits to showing the specific video in the first place.Videos with live footage may provide a sense of realism but often do not display “model”behaviors to which you would like your students exposed.

Always introduce the video you are about to show. Engage the students by asking somequestions that directly relate to the topic on the video. Explain why you chose this video, and tryto focus their attention to some key points or what you are looking for them to get out of the video.Make sure your projection equipment is the right size and in proper working order for the size ofthe classroom you are using. Adjust the sound volume and cue up the video before your classbegins. Finally, stay there and watch the video with your students so your wrap-up discussion ofthe key points or student impressions of the video can begin promptly.

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Correlation with Content in Brady Textbooks

• Limmer/Emergency Care, 9th Edition• Limmer/Essentials of Emergency Care, 3rd Edition• Mistovich/Prehospital Emergency Care, 6th Edition

Tape 1Patient Assessment andPreparatory

EmergencyCare

Essentials ofEmergency Care

PrehospitalEmergency Care

Body Substance Isolation(BSI)

Chapter 2Page 16-17

Chapter 2Page 21-22

Chapter 2Page 20-23

Lifting and MovingPatients

Chapter 5Page 85-91

Chapter 5Page 59-73

Chapter 6Page 84-87

Introduction to PatientAssessment

Chapter 8Page 163

Chapter 6Page 104

Chapter 9Page 147-149

Initial Assessment andScene Size-up

Chapter 7Page 106



Vital Signs Chapter 9Page 180-188


Chapter 5Page 72-79

Tape 2Patient Assessment andPreparatory

EmergencyCare



Trauma Patient with aSignificant MOI




Trauma Patient with NoSignificant MOI

Chapter 10Page 226



Medical PatientResponsive




Medical PatientUnresponsive



Chapter 9Page192-194

Detailed Physical Exam Chapter 10Page 219



Ongoing Assessment Chapter 12Page 247-251

Chapter 9Page 150


Tape 1Airway Management

EmergencyCare



Head-Tilt, Chin-Lift Maneuver Chapter 6Page 110

Chapter 6Page 80-81

Chapter 7Page 99

Jaw Thrust Maneuver Chapter 6Page 111

Chapter 6Page 81-82

Chapter 7Page 100

Pocket Mask Chapter 6Page 113

Chapter 6Page 85-86

Chapter 7Page 110

BVM Two Person Chapter 6Page 114

Chapter 6Page 87-89


Insertion of OPA Chapter 6Page 117-118

Chapter 6Page 91

Chapter 7Page 105

Insertion of NPA Chapter 6Page 121

Chapter 6Page 91

Chapter 7Page 105

Oral Suction Chapter 6Page 122-125

Chapter 6Page 82-85

Chapter 7Page 102

Suctioning through andEndotracheal Tube

Chapter 35Page 785

Chapter 29Page 501

Chapter 44Page 903

Tape 2 Emergency Essentials of Prehospital

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Airway Management Care Emergency Care Emergency CareOxygen Tank Assembly Chapter 6

Page 133-135Not Available Chapter 7

Page 117-119Administering OxygenNon-Rebreather Mask


Chapter 6Page 96


Administering OxygenNasal Cannula

Chapter 6Page 138

Chapter 6Page 96-97


Nasogastric (NG) Tube Chapter 35Page 783-784



Sellick’s Maneuver Chapter 35Page 778

Chapter 6Page 98


Ventilatory ManagementAssist with EndotrachealIntubation

Chapter 35Page 795



Ventilatory ManagementCombitube

Chapter 35Page 789

Chapter 29Page 503


Ventilatory ManagementStoma Patient


Chapter 6Page 89


Using a Pulse Oximeter Chapter 9Page 190

Not Available Not Available

Tape 1Medical Emergencies

EmergencyCare



Administration of ActivatedCharcoal

Chapter 16Page 309

Chapter 12Page 180


Administration of Glucose Chapter 19Page 374-377

Chapter 15Page 225


Metered Dose Inhaler Chapter 17Page 329-331

Chapter 13Page 195


Nitroglycerin Chapter 16Page 311



Epinephrine Auto Injector Chapter 20Page 393-397



Nebulizer Not Available Chapter 13Page 193

Not Available

Tape 2Medical Emergencies

EmergencyCare



Automated ExternalDefibrillator




Soft Restraints Chapter 23Page 456-457

Chapter 19Page 279


Assisting with Childbirth Chapter 24Page 471



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Tape 1Trauma Emergencies

EmergencyCare



Bleeding and Shock Chapter 26Page 503-519

Chapter 21Page 305


Dressing and Bandaging Chapter 26Page 506-507

Chapter 21Page 308


Long Bone Splinting Chapter 28Page 577-578



Joint Splinting Chapter 28Page 579



Hare Traction Splint Chapter 29Page 595-598



Sager Traction Splint Chapter 28Page 599

Chapter 23Page 363

Chapter 32Page 628

Sling and Swathe Chapter 28Page 588-589


Chapter 32Page 622, 629

Tape 2Trauma Emergencies

EmergencyCare



Cervical Collar Chapter 10Page 201-206



Kendrick ExtricationDevice (KED)




Immobilizing a SupinePatient




Immobilizing a StandingPatient




Helmet Removal Chapter 29Page 638-644



Rapid Extrication Chapter 29Page 631-632



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Credits

Educational Consultants• Baxter Larmon, PhD, MICP

Professor, UCLA School of MedicineDirector, UCLA Center for Prehospital Care

• Heather Davis, MS, NREMT-PClinical Instructor, UCLA School of MedicineClinical Coordinator, UCLA Center for Prehospital Care

Brady Medical Review Panel• D.A. Hnatow, MD

Assistant Professor and ChiefDivision of Emergency Medicine, Department of SurgeryThe University of Texas Health Science Center at San Antonio

• Bob Elling, MPA, REMT-PSenior AssociateHigh Quality Endeavors, Ltd.

US Army Medical Review Panel• LTC Michael Huott, Medical Corps

US Army Medical Department Center & School, Department of Combat Medical Training• Major Allen Whitford Medical Corps

US Army Medical Department Center & School, Department of Combat Medical TrainingExecutive Producers

• Greg Vis, Visible Productions• LTC Patrick Wilson, Department of the Army, Office of the Surgeon General

Producer• Linda Stone, Stone Productions

Video Editing• NonLinear Creative, Detroit, MI• 3 Point Productions, Novi, MI

Cameras• Eric Smith• Bill DeWeese

Script Adaptation• Deb Parks

Brady Publishing• Publisher: Julie Levin Alexander• Executive Editor: Marlene McHugh Pratt• Assistant Editor: Monica Silva• Managing Editor: Lois Berlowitz• Senior Media Editor: John J. Jordan• Senior Marketing Manager: Katrin Beacom• Production Editor: Jeanne Molenaar• Manufacturing Buyer: Pat Brown• Design Director: Cheryl Asherman• Software Testing: Steve Hartner• Secondary Videography: Hector Grillone

Visible Productions• CEO: Paul Baker• COO: Lewis Sadler• Executive VP: John Sundquist• Video Technician: Sean McCracken• Interface Design: Joshua Sadler• Programmer: James Douglas

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Leader’s Guide Authors• Bob Elling, MPA, REMT-P• Kirsten Elling, BS, REMT-P

Special Thanks –Locations and Equipment

• Los Angeles County Fire Department–Ed Martinez• UCLA Department of Emergency Medicine• Laerdal Medical Corporation• Microflex Gloves

Narrator• Bruce Freestone

Brady Actors• SSG Victor Anda, US Army• Dave Carlson, Visible Productions• Sgt Diane Colligan, US Army• Jim Farley, EMT-P• SSG Michael LaClair, US Army• K.C. Kainsinger, UCLA• Steven Leapley, EMT-P• Carlos Lopez, Los Angeles County Fire Department• Sgt Jonathan Paradis, US Army• Lindsey Simpson, EMT-P• Jade Swendseid, Los Angeles County Fire Department• Gina-Raye Swensson• Todd Swensson, EMT-B

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Tape 1 Patient Assessment

Segment Name: Body Substance Isolation (BSI)Time Codes: Begin: 1:01:00 End: 1:07:10Objectives

• List the various types of Body Substance Isolations (BSI) equipment and when it shouldbe worn.

• List 8 questions to consider when determining what type of BSI precautions to take.• Describe the most effective means of preventing contamination.• Describe what to do when you have been exposed.• Describe your company’s policy exposure control plan.

Overview I. Wear the following BSI equipment:

• Gloves – when hands may contact body fluids.• Eye protection – when body fluids may contact eyes or when airborne particles

are present.• Mask – when body fluids may enter the mouth or when airborne particles are

present.• Gowns – when significant amount of body fluid is present or patient may have a

communicable disease. II. Equipment

• Gloves, latex or vinyl• Eye protection• Mask, appropriate particulate protection• Gowns• Hand-washing solution

III. Assessment• Ask yourself the following questions when determining which BSI precautions to

take:• Is there any blood or body fluid present or is there any risk of

exposure to blood or body fluid that is currently not present?• Is there any risk of the patient spitting or vomiting?• Is the patient coughing?• Is there urine or feces present?• Is there the possibility that the patient could be suctioned?• Is there the possibility of placing your fingers in the patient’s

mouth?• Are there objects at the scene that may have to be touched that

could have blood or body fluids on them?• At the end of the call is there the risk of contaminated material at

the scene that needs to be cleaned up or is there equipment thatneeds to be cleaned?

IV. Skill Close-up• Explain to the patient the reasons for taking BSI precautions.• Apply gloves.• Apply eye protection or face shield.• Apply mask, if appropriate.• Provide appropriate assessment and treatment.• Remove personal protection, once exposure is not an issue.• Dispose of all contaminated material from the scene, and place in an appropriate

disposal bag or container.• Wash hands as soon as possible with any approved infection control soap or solution.

V. Ongoing Assessment• Assess BSI frequently and replace as needed.

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Key TermsBody Substance Isolation (BSI) precautions – a form of infection control based on thepresumption that all body fluids are infectious. BSI calls for always using appropriate barriers toinfection at the emergency scene, such as gloves, masks, gowns, and protective eyewear.Exposure control plan – standards (Title 29 CFR 1910.1030) developed by Occupational Safetyand Health Administration (OSHA) for EMS-Bs to use when dealing with bloodborne pathogens.An EMS service or employer establishes an exposure control plan and provides annual refreshertraining.Teaching ActivitiesQuestions to ask before or after viewing tape:

• How does your service clean up a blood spill?• When is it appropriate to suspect the patient may have TB?

Additional activities associated with the tape:• Allow adequate time to practice the skill of hand washing and BSI application.

Other ideas:• Teach the students the proper technique for hand washing.

Segment Name: Lifting and MovingTime Codes: Begin: 1:07:18 End: 1:15:53Objectives

• List four things to consider prior to lifting or moving any object.• List four rules related to body mechanics.• List four things you can do to prevent injury while lifting.• List six points to remember when pushing or pulling.• Describe the power lift and power grip.• Describe the three types of moves and provide an example of each.• List six types of lifts and moves.

Overview I. Prior to lifting any object consider the following:

• The patient’s weight• Will additional assistance be required?• What are the physical lifting abilities of you and your partner?• Plan how you will accomplish the lift and communicate it.

II. Another important aspect of body mechanics involves following a few simple ruleswhen lifting:

• Position your feet on a firm surface and shoulder width apart.• Use your legs, not your back, to lift.• Do not lean over and compensate when lifting with only one hand.• Keep the weight as close to your body as possible.

III. To prevent injury when reaching you should:• Keep your back in a locked-in position.• Avoid twisting while reaching.• Avoid reaching more than 20 inches in front of you.• Avoid a prolonged reach when a strenuous effort is necessary.

IV. When pushing or pulling you should try to:• Push, rather than pull, when practical.• Keep your back in a locked-in position.• Keep the line of the pull through the center of your body by bending your knees.• Keep the weight close to your body.• Avoid pushing or pulling overhead.• Keep your elbows bent and close to your sides.

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V. To prevent injury, use the power lift or the power grip.• The power lift involves squatting rather than bending at the waist and keeping the

weight as close to you as possible.• The power grip involves using as much of the surface area of your hands and

palms as possible. VI. There are three classifications of moves:

• Emergency moves• Urgent moves• Non-urgent moves

VII. Skill Close-up• One-rescuer assist• Two-rescuer assist• Direct ground lift• Firefighter’s drag• Blanket drag• Firefighter’s carry

Key TermsBody mechanics – the proper use of the body to facilitate lifting and moving and prevent injury.Emergency moves – moves, which must be made immediately, but only when definite lifethreats exist.Non-urgent move – moves that are performed when no harm will come to the patient due to thedelay or to the external environment. The patient will generally receive complete emergencymedical care prior to being moved in a non-urgent manner.Power grip – gripping with as much hand surface as possible in contact with object being lifted,all fingers bent at the same angle, hands at least 10 inches apart.Power lift – also called the squat lift position. It is a lift from a squatting position with weight to belifted close to the body, feet apart and flat on the ground, body weight on or just behind balls offeet, back locked in. The upper body is raised before the hips.Urgent move – moves that are used when the patient must be moved quickly but withprecautions for spinal injury.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Describe an example of a situation where an emergency move would be appropriate.• Describe an example of a situation where an urgent move would be appropriate.

Additional activities associated with the tape:• Allow adequate time to practice the use of the stair chair, wheeled ambulance cot, and

lifts.Other ideas:

• Arrange for an ambulance to be at the class and have students practice using thestretcher and loading it into the ambulance.

• It is also a good idea to let each student ride the stretcher to gain an appreciation forwhat it feels like as a patient.

Segment Name: Patient AssessmentTime Codes: Begin: 1:15:58 End: 1:27:25Objectives

• List in order the assessment steps in the patient assessment algorithm.• List two primary components of the scene size-up.• List the four primary components of the initial assessment.• List the equipment needed to conduct an initial assessment.• Explain how AVPU is used to rapidly determine a patient’s mental status.• Provide five examples of high priority patients.• List a number of problems associated with the initial assessment and describe how to

correct them.

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Overview I. The EMT-B will perform the following assessment steps on each call:

• Scene size-up• Initial assessment• Make a decision: Is this trauma or medical?• For trauma patients, determine if the mechanism of injury (MOI) was significant

or non-significant and follow the algorithm based on the determination.• For medical patients, determine if the patient is responsive or non-responsive

and follow the algorithm based on your determination.• Ongoing assessment

II. Scene Size-up• Determine if the scene is safe.• Assess the need for additional resources.

III. Initial Assessment• Form a general impression of the patient.• Assess the ABCs.• Correct any life-threats as they are discovered.• Make a priority transport decision.

IV. Equipment• BSI equipment• Stethoscope• Oxygen delivery devices• Airway management equipment• Jump kit containing emergency supplies such a bandages, dressing, etc.

V. Skill overview• Verbalize your general impression of the patient, noting obvious observations

such as level of distress, positioning of the patient, and surroundings.• Determine the patient’s mental status using AVPU.• Assure a patient airway.• Once you’ve assured an open airway, assess the rate and quality of breathing.

• If breathing is inadequate assist ventilations.• Ensure that lung sounds are present and equal.• Apply oxygen as needed.• Assess the circulation.

• Check central and peripheral pulses for rate, strength, and regularity.• If circulation is absent begin CPR.• Assess skin color, temperature, and condition.• Control any external bleeding with direct pressure.

• Decide the patient’s priority in terms of immediate transport vs. further on-sceneassessment and care.

VI. Skill Close-up• Form a general impression of the patient and verbalize it.• Determine mental status using AVPU.

• Determine whether the patient is Alert.• Responsive to Verbal stimuli• Responsive to Painful stimuli• Unresponsive to any stimuli

• Assess ABCs.• Treat life-threats as they are discovered.• Make a priority transport decision.• Examples of high-priority conditions include:

• Difficulty breathing• Shock (hypoperfusion)• Complicated childbirth• Chest pain with systolic blood pressure less than 100• Severe pain anywhere

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VII. Ongoing Assessment• If the patient’s condition deteriorates, reevaluate the ABCs.• Reassess vital signs.

VIII. Problem Solving• Failure to treat life-threatening conditions

• Manage life-threats as soon as you recognize them.Key TermsAVPU – a memory aid for alert, verbal response, painful response, unresponsive as aclassification of a patient’s level of responsiveness.Patient assessment algorithm – a flow diagram of the key steps in the patient assessmentprocess.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What are examples of high priority patients?• What are examples of low priority patients?

Additional activities associated with the tape:• Allow adequate time to practice patient assessment.

Other ideas:• Once students have mastered the skills of assessment, give them realistic scenarios

involving a moulaged patient found at the bottom of a stairway to assess and manage asa team.

Segment Name: Vital SignsTime Codes: Begin: 1:27:27 End: 1:45:33Objectives

• Explain what baseline vital signs are and how they differ from serial vital signs.• Describe when first to obtain a full set of vital signs.• List the equipment needed to obtain a set of vital signs.• List the terms for abnormal respiratory rates that are too fast and too slow.• Describe the locations to palpate a distal pulse.• Explain when a pulse rate should be counted for a full minute.• List seven respiratory rhythms and patterns.• List the four categories of quality of respiration.• Describe three types of abnormal breath sounds.• Describe three signs of abnormal breathing.• Explain what the systolic and diastolic fractions of a blood pressure reading are.• Describe how to take a blood pressure by auscultation and by palpation.• List the features of the skin that are assessed by the EMT-B.• Describe normal and abnormal findings of the pupils.• List the vital signs findings that should be documented on a prehospital care report

(PCR).Overview

I. Vital signs are measurable objective assessment findings and include:• Pulse• Respiration• Blood pressure• Skin: color, temperature, and condition• Pupils

II. Baseline and Serial vital signs• Baseline vital signs are a complete set of vital signs taken after the initial

assessment is performed.• Serial vital signs allow for trending of a patient’s condition.

III. Equipment• BSI equipment

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• Documentation form (PCR or assessment card)• Pen• Stethoscope• Blood pressure cuff• Watch with second hand or digital readout• Penlight

IV. Assessment• Vital sign assessment should be completed after the initial assessment and

repeated every 5 minutes on an unstable patient and every 15 minutes on astable patient.

V. Skill Close-up: Pulse• Evaluate pulse – rate, rhythm, and strength.• Normal adult rate is between 60 – 100 bpm.• Abnormal adult pulse rates:

1. Any pulse rate above 100 bpm is rapid. A rapid pulse rate iscalled tachycardia.

2. Any pulse rate below 60 bpm is slow. A slow pulse rate is calledbradycardia.

• Pulse rhythm reflects regularity.• Strength may be described as strong, thready, or weak.• Locate the radial pulse on the lateral part of the patient’s wrist.• You might also use the carotid, brachial, femoral, and dorsalis pedal pulses.• Assess the heart rate by counting the number of pulses you feel in one minute.• Note any irregularity in rhythm.• Note the quality of the pulse. It should be strong and easily palpated.

1. Any pulse that is thready, or hard to feel, can be an indication ofshock or other medical problems.

• Document the rate and quality of the pulse, as well as the time of assessment, onthe prehospital care report.

• When counting the pulse and the pulse is irregular or the rate is very slow, youwill need to count for one full minute in order to be accurate.

• Avoid pressing too hard on the pulse point during assessment. VI. Skill Close-up: Respiration

• Evaluate respiration – rate, depth, rhythm, pattern, and quality.• Normal adult respiration rate for an adult at rest is between 12 – 20 bpm.• Depth is described as normal, shallow, or deep.• Rhythm and pattern are described as:

• Healthy – exhalations are twice as long as inhalations• Irregular• Hypoventilation – slow and shallow respiration• Hyperventilation – sustained increased rate and depth of

respiration• Sigh – deep inhalation followed by a slow audible exhalation• Apnea – temporary absence of breathing• Tachypnea – increased respiration rate, usually 24 or more

breaths per minute in adults• The quality of a patient’s breathing may fall into any of four categories:

• Normal – effortless, automatic, regular rate, even depth,noiseless, and free of discomfort

• Dyspnea – difficult or labored breathing• Wheezing or whistling sound• Rattling or bubbling

• The steps for evaluating breathing:• Look for the presence of breathing by watching for chest rise and

fall.

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• In the absence of chest rise and fall or if breathing is inadequate,begin ventilations.

• Observe the patient’s position. Most patients in respiratorydistress prefer to be seated upright or standing.

• Hunching forward with elbows outward is called tripodpositioning and indicates severe respiratory distress.

• Abnormal noises during breathing include:• A high-pitched noise like stridor can indicate upper airway

obstruction.• Whistling or wheezing sounds may indicate lower airway

obstruction.• Bubbling (rhonchi), wet, or crackling (rales) can indicate fluid in

the airway.• Signs of labored breathing include:

• Use of accessory muscles• Nasal flaring• Retractions above the collarbones or between the ribs

(intercostal)• Respirations that are very fast, very deep, or interrupted (apnea) can be signs of

serious medical conditions.• Determine the respiratory rate by counting the number of times the patient

breathes in one minute.• Document the respiratory rate, quality, and any rhythms that you might observe

as well as the time, on the prehospital care report. VII. Skill Close-up: Auscultated Blood Pressure

• The top or first number reported is the systolic blood pressure. This is thepressure created when the heart contracts and forces blood into the arteries.

• The bottom or second number is the diastolic blood pressure. It measures thepressure remaining in the arteries when the left ventricle relaxes and refills, orthe residual pressure in the system.

• Auscultated blood pressures are more accurate than palpated blood pressures.• Procedure:

• Remove or roll clothing to expose bare skin on the upper arm.• Select the appropriate size BP cuff.• The cuff should measure two-thirds of the length of the upper

arm, from elbow to shoulder.• Place the cuff on the bare arm, following the instructions on the

cuff for putting it over the artery.• With your fingertips, locate the brachial pulse on the medial

upper arm near the antecubital fossa, or the crease of the elbow.• Place the diaphragm of the stethoscope over this pulse point.• With the bulb valve closed, inflate the cuff until the pulse is no

longer heard or felt.• Listen for the sound of the pulse returning as the pressure in the

cuff is slowly released.• Note the number on the cuff’s gauge as soon as you hear the

first pulse beat. This is the systolic pressure – the top number ofthe BP fraction.

• Continue to deflate the cuff, this time listening for the point atwhich the beats fade. This is the diastolic blood pressure – theBP fraction’s bottom number.

• Record the measurements (in even numbers) and time. VIII. Skill Close-up: Palpated Blood Pressure

• An estimated blood pressure can be obtained by palpation.• Less reliable and usually lower than obtained by auscultation• No diastolic pressure is obtained with this method.

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• Procedure:• Inflate the cuff until the radial pulse disappears.• Slowly release the pressure in the cuff until the pulse reappears.• Check the gauge for systolic blood pressure.• Report your findings as blood pressure over palpation, as well as

the time of the reading. IX. Skill Close-up: Skin

• In assessing the skin, you should check color, temperature, condition, and inchildren under 6 years, capillary refill time.

• The best place to assess skin color in adults:• Nail beds• Inside the cheek• Inside the lower eyelid

• The best place to assess skin color in infants and children:• Palms of the hands• Soles of the feet

• Variations in color may suggest poor circulation or other problems:• Pale skin may be a sign of blood loss, shock, heart attack, fright,

anemia, hypotension, or emotional distress.• Cyanotic skin points to inadequate oxygenation and perfusion,

inadequate respirations, heart attack or poisoning.• Both the temperature and condition of the skin can vary as well:

• Cool, clammy skin is a sign of shock or anxiety.• Cold, moist skin means that the body is losing heat.• Cold, dry skin results from an exposure to cold.• Hot, dry skin or hot, moist skin indicates a high fever or heat

exposure.• “Goose bumps” accompanied by shivering, chattering teeth, blue

lips, and pale skin can result from chills, cold exposure, pain,fear, or a communicable disease.

• Evaluate the color of the patient’s skin by observing the overall complexion plusthe inside of the lower eyelid, the nail beds, or the inside of the cheek.

• If the skin feels cool, check a more central body temperature by placing yourhand on the abdomen beneath the clothing.

• Assess the condition of the skin for moisture.• Document skin color, temperature, and condition on the prehospital care report.

X. Skill Close-up: Pupils• Pupils should normally be round and reactive to light.• Note the pupil size before you shine any light into them.• Shine a penlight into the eye.• The pupil should constrict when the light is shining into it and enlarge when you

remove the light.• Repeat with the other eye.• Pupils that are dilated, constricted to pinpoint size, unequal in size or reactivity,

or nonreactive may indicate a variety of conditions including drugs, head injury,or eye injury.

• Any deviations from normal should be reported and documented.

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Key TermsAccessory muscles – muscles used in respiration during respiratory distress, disease, trauma orduring strenuous exercise.Apnea – absence of breathing.Bradycardia – heart rate less than 60 beats per minute.Cyanosis – a blue or gray color resulting from lack of oxygen in the body.Diastolic pressure – the pressure remaining in the arteries when the heart is relaxed andrefilling.Hyperventilation – increase of air in the lungs above the normal amount.Hypoventilation – decrease of air in the lungs below the normal amount.Intercostal – situated or extending between the ribs.Nasal flaring – an abnormal widening of the openings of the nose; an indication of respiratorydistress.Rales – abnormal rattling or crackling sound in the lungs.Rhonchi – coarse snoring sound in the upper airways.Systolic pressure – the pressure created when the heart contracts and forces blood out into thearteries.Tachycardia – a rapid heart rate; any pulse rate above 100 beats per minute.Tachypnea – abnormally fast breathing.Teaching ActivitiesQuestions to ask before or after viewing tape:

• When is it most appropriate to use palpation to take a blood pressure?• Why is capillary refill not a routine assessment in an adult?

Additional activities associated with the tape:• Allow adequate time to practice taking a full set of vital signs.

Other ideas:• Consider having each student in the class obtain a complete set of vital signs on the rest

of the class and logging them for an assignment.

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Tape 2 Patient Assessment

Segment Name: Assessment of the Trauma Patient with a Non-SignificantMechanism of InjuryTime Codes: Begin: 1:00:54 End: 1:06:31Objectives

• Describe when the EMT-B makes the determination that the MOI is significant or non-significant.

• List the equipment utilized to perform an assessment on a trauma patient.• Describe the steps of the focused trauma assessment.

Overview I. All trauma patients should be evaluated for spinal precautions, life threats, and rapid

transport decision.• Rapid trauma examination vs. focused trauma assessment• Life-threatening injuries are treated as they are discovered

II. Equipment• BSI equipment• Long spine board• Cervical collar• Head blocks or towel rolls• 2” or 3” tape• Backboard straps• Blood pressure cuff and stethoscope• Pen light• Scissors• Bandaging supplies• Portable suction unit and rigid Yankauer® tip• Oropharyngeal airways (OPAs) and/or nasopharyngeal airways (NPAs)• Oxygen and appropriate tubing• BVM and reservoir and tubing• Non-rebreather mask

III. Skill Close-up• Scene size-up; consider the mechanism of injury (MOI).

• Significant or non-significant MOI• Perform an initial assessment and obtain the chief complaint, assess for:

• Mental status• Airway and breathing• Circulation• Determine patient’s treatment priority and make a transport

decision.• Reconsider the MOI.• Perform a focused trauma assessment based on chief complaint and MOI.• You should look and feel for the familiar DCAP-BTLS signs:

• Deformities• Contusions• Abrasions• Punctures/penetrations• Burns• Tenderness• Lacerations• Swelling

• Obtain baseline vital signs.• Obtain a focused history.

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Key TermsDCAP-BTLS – a memory aid to remember deformities, contusions, abrasions,punctures/penetrations, burns, tenderness, lacerations, and swelling; signs and symptoms ofinjury found by inspection or palpation during patient assessment.Focused trauma assessment – the step of patient assessment that follows the initialassessment and concentrates on a specific body area based on the chief complaint and MOI.Mechanism of injury (MOI) – a force or forces that may have caused an injury.Oropharyngeal airways (OPAs) – a curved device inserted through the patient’s mouth, into thepharynx, to help maintain an open airway.Nasopharyngeal airways (NPAs) – a flexible breathing tube inserted through the patient’s nose,into the pharynx, to help maintain an open airway.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What are two examples of patients who have a non-significant MOI?• Why is it unnecessary to do a detailed physical exam on a trauma with non-significant

MOI?Additional activities associated with the tape:

• Allow adequate time to practice the focused physical exam of a patient with a cut hand ora twisted ankle and no significant MOI.

Other ideas:• Consider practicing scenarios in realistic settings such as at the bottom of the stairs

(significant MOI) and at the curb after stepping in a pothole (non-significant).

Segment Name: Assessment of the Trauma Patient with a SignificantMechanism of Injury (MOI)Time Codes: Begin: 1:06:35 End: 1:15:34Objectives

• Describe when the EMT-B makes the determination that the MOI is significant or non-significant.

• List nine examples of significant mechanisms of injury (MOI).• List three additional significant MOIs for children.• List the equipment utilized to perform an assessment on a trauma patient.• Describe the steps of the rapid trauma assessment.

Overview I. All trauma patients should be evaluated for spinal precautions, life-threats, and rapid

transport decision.• Rapid trauma examination vs. focused trauma assessment• Life-threatening injuries are treated as they are discovered.

II. Rapid trauma assessment• Reconsider the mechanism of injury (MOI).

III. Significant mechanisms of injury (MOI) include:• Ejection from a vehicle• Death in the same passenger compartment• Falls of more than 15 feet or 3 times the patient’s height• Rollover of a vehicle• High-speed vehicle collision• Vehicle-pedestrian collision• Motorcycle crash• Unresponsive or altered mental status• Penetrations of the head, chest, or abdomen

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IV. Additional significant MOIs for children include:• Falls from more than 10 feet• Bicycle collision• Vehicles in medium-speed collision

V. Equipment• BSI equipment• Long spine board• Cervical collar• Head blocks or towel rolls• 2” or 3” tape• Backboard straps• Blood pressure cuff and stethoscope• Pen light• Scissors• Bandaging supplies• Portable suction unit and rigid Yankauer® tip• Oropharyngeal airways (OPAs) and/or nasopharyngeal airways (NPAs)• Oxygen and appropriate tubing• BVM and reservoir and tubing• Non-rebreather mask

VI. Skill Close-up: Rapid Trauma Assessment• Reconsider the MOI.• Approach the patient from his or her front; introduce yourself and instruct the

patient not to move.• Perform initial assessment.

• Verbalize a general impression based on assessment of theenvironment and patient’s chief compliant and appearance.

• Determine the need for stabilization of the spine.• Provide manual stabilization on the first contact with any patient

you suspect may have an injury to the spine.• Assess the mental status.• Assess airway and breathing.• Assess circulation.• Determine patient’s treatment priority and make a transport

decision.• Focused history and physical exam of the trauma patient with significant MOI:

• Reconsider the MOI.• Continue manual stabilization of the head and neck.• After assessing head and neck, apply a cervical collar and

continue to maintain manual stabilization.• Consider requesting ALS personnel.• Reconsider transportation decision.• Reassess the mental status.• Perform a rapid trauma assessment.

• You should look and feel for the familiar DCAP-BTLS signs:• Deformities• Contusions• Abrasions• Punctures/penetrations• Burns• Tenderness• Lacerations• Swelling

• Begin at the head.• Check the neck for DCAP-BTLS, plus jugular vein distention and

crepitation of bones in the cervical spine.

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• Assess the chest for DCAP-BTLS, plus crepitation, paradoxical motion andbreath sounds.

• Assess the abdomen for DCAP-BTLS, plus firmness, softness, and distention.• Assess the pelvis for DCAP-BTLS by observing and by applying gentle

downward pressure on the pelvic bone.• Do not rock the pelvis girdle as it may cause spinal injury.

• Assess all four extremities for DCAP-BTLS, plus distal pulse, motor function, andsensation (PMS).

• If possible, roll the patient to his or her side and assess the posterior andbuttocks for DCAP-BTLS, then carefully roll the patient onto a long board.

• Obtain baseline vital signs.• Obtain a SAMPLE history.

Key TermsCrepitation – the grating sound or feeling of broken bones rubbing together; also called crepitus.Paradoxical motion – movement of a part of the chest in the opposite direction to the rest of thechest during injury.Rapid trauma assessment (RTA)– a rapid assessment of the head, neck, chest, abdomen,pelvis, extremities, and posterior of the body to detect signs and symptoms of injury.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What are two examples of patients who have a significant MOI?• Why should the detailed physical exam be done enroute to the hospital on most patients

with significant MOI?Additional activities associated with the tape:

• Allow adequate time to practice the RTA of a patient whose scenario involves significantMOI.

Other ideas:• This is the time to consider the use of a moulage kit to add realism to scenarios.

Segment Name: Detailed Physical ExamTime Codes: Begin: 1:15:40 End: 1:24:13Objectives

• Describe when the detailed physical exam (DPE) is performed on most patients.• List the equipment needed to conduct a DPE.• List the steps of the DPE.

Overview I. The detailed physical exam (DPE) is most commonly performed on trauma patients

with a significant mechanism of injury (MOI) enroute to the hospital. II. Equipment

• BSI equipment• Long spine board• Cervical collar• Head blocks or towel rolls• 2” or 3” tape• Backboard straps• Blood pressure cuff and stethoscope• Pen light• Scissors• Bandaging supplies• Splinting devices

III. Assessment• During the DPE you will inspect and palpate each part of the body for DCAP-BTLS:

• Deformities• Contusions

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• Abrasions• Punctures/penetrations• Burns• Tenderness• Lacerations• Swelling

IV. Skill Overview• Assure proper BSI.• Expose the patient.• Conduct a systematic examination of the patient beginning with the head.

• Inspect the scalp, cranium, and face for DCAP-BTLS, pluscrepitation.

• Check the ears and nose for DCAP-BTLS, plus bleeding ordrainage of clear fluid.

• Inspect the mouth for DCAP-BTLS, plus loose or broken teeth,foreign objects, swelling or lacerations of the tongue, andunusual odors on the breath.

• Check the eyes for DCAP-BTLS, plus unequal pupil size,reactivity, discoloration, foreign bodies, and blood in the anteriorchamber.

• Check the neck for DCAP-BTLS, plus jugular vein distention andcrepitation of bones in the cervical spine.

• Assess the chest for DCAP-BTLS, plus crepitation, paradoxical motion, andbreath sounds.

• Assess the abdomen for DCAP-BTLS, plus firmness, softness, and distention.• Assess the pelvis for DCAP-BTLS by observing and by applying gentle

downward pressure on the pelvic bone.• Note any pain, tenderness, lack of motion, or crepitation.• Do not rock the pelvis girdle as it may cause spinal injury.

• Assess all four extremities for DCAP-BTLS, plus distal pulse, motor function, andsensation (PMS).

• If possible, roll the patient to his or her side and assess the posterior andbuttocks for DCAP-BTLS, then carefully roll the patient onto a long board.

• Treat any injuries not attended to during the rapid trauma assessment.• Transport the patient if you have not already done so.

V. Skill Close-up• Assure BSI.• Expose the patient.• Conduct a systematic examination of the patient beginning with the head.• Treat any injuries not attended to during the rapid trauma assessment.• Transport the patient if you have not already begun to do so.

VI. Problem Solving• If the patient’s condition worsens during the exam, repeat the initial assessment,

reassess the ABCs and treat life-threatening injuries.• Disorganization leads to missed steps.

VII. Ongoing Assessment• Repeat assessment.• If at any point the patient’s condition worsens, repeat the initial assessment.

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Key TermsDetailed physical exam (DPE) – an assessment of the head, neck, chest, abdomen, pelvis,extremities, and posterior of the body to detect signs and symptoms of injury. The examination ofthe head includes detailed examination of the face, ears, eyes, nose, and mouth. It is usuallydone enroute to the hospital after earlier on-scene assessments and interventions are completed.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why should the DPE be done enroute to the hospital?• When would be an example of a patient with significant MOI where the EMT-B may not

have ample time to do the DPE?Additional activities associated with the tape:

• Allow adequate time to practice the DPE.Other ideas:

• Consider having your mock patient wear scrubs with Velcro seams and apply moulage ormake-up for bruises that fit the story of the scenario.

Segment Name: Assessment of the Medical Patient - ResponsiveTime Codes: Begin: 1:24:17 End: 1:34:10Objectives

• Explain when the EMT-B should obtain information about the nature of illness (NOI).• Describe how to obtain a focused history from the responsive patient.• List the assessment steps in order for the responsive medical patient.• List the equipment needed to perform an assessment on a medical patient.• List the two main techniques used to complete a focused physical exam.• Explain why good communication skills are a key component in assessment of the

medical patient.• Describe some common problems associated with the patient interview.

Overview I. In contrast to the trauma patient assessment, the medical patient assessment

requires thorough history taking:• Obtain information from the responsive patient prior to a physical exam.• For the unresponsive patient obtain information from family, bystanders, and

observations at the scene. II. For the responsive medical patient perform the steps in this order:

• History of present illness (HPI)• SAMPLE history• Focused physical assessment (exam based on chief complaint and observed

signs and symptoms)• Baseline vital signs

III. Assessment• Scene size-up• Perform initial assessment.• Determine the nature of illness (NOI).

IV. Equipment• Blood pressure cuff• Stethoscope• Pen light• Scissors

V. Skill Close-up• Take BSI precautions.• Perform a scene size-up as you approach or come on scene.

• Determine that the scene is safe and free of hazards.• Determine the NOI (i.e.: an overdose, vomiting, or shortness of breath).

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• Verbalize your general impression of the patient regarding his/her level ofdistress and other obvious findings such as positioning and surroundings.

• Determine level of consciousness of the patient using the AVPU scale.• If the patient can communicate, ask for his/her chief complaint.• Ensure airway patency.• Assess the rate and quality of breathing.

• Apply high-flow oxygen as appropriate.• Check central and peripheral pulses for rate, strength, and regularity.• Assess the skin: color, temperature, and condition (CTC).

• Control external bleeding with direct pressure.• Initiate shock management as indicated.

• Determine the priority of the patient and make a transport decision.• Patients with life-threats to the ABCs should be prepared for

immediate transport.• Stable patients can be treated on the scene and transported with

less urgency. VI. Focused History and Physical Exam

• Gather history of the present illness using OPQRST:• Onset – What were you doing when the pain started?• Provocation – Does anything make it better or worse?• Quality – Describe the pain. What does it feel like?• Radiation – Does the pain move anywhere? Does it stay in one

place?• Severity – How bad is the pain? On a scale of 1-10, one being

very little and 10 being very severe.• Time – When did the pain start? How long have you had the

pain?• Gather a past medical history, commonly known as SAMPLE history:

• Signs and symptoms• Allergies• Medications• Pertinent past history• Last oral intake• Events leading up to the call

VII. Complete a focused physical exam using two main techniques.• Inspection• Palpation

• Assess the patient’s baseline vital signs:• Respiration• Pulse• Blood pressure• Skin CTC

• Examine the appropriate body system(s) based on the chief complaint andobservation findings discovered during the initial assessment.

• Determine the appropriate treatment plan.• Utilize on-line medical control when appropriate.

• Perform interventions and reassess.• Reevaluate the transport decision.• Perform the ongoing assessment.

VIII. Problem Solving• Good communication skills are key.• The patient interview is an excellent means to reduce patient fear and promote

cooperation.• Create an environment conducive to conversation.• Be respectful to the patient by asking questions of the patient first.

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• Language barrier may require finding an interpreter or alternate means ofcommunication.

• Phrase open-ended questions and follow up questions for clarification.• Use closed-ended questions when the patient has difficulty

breathing or trouble speaking.Key TermsFocused physical assessment – examination based on chief complaint and observed signs andsymptoms.OPQRST – a memory aid for the questions asked to get a description of the present illness orelaborate on the chief complaint: Onset, Provocation, Quality, Radiation, Severity, and Time. Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is the most common type of responsive medical complaint in your district?• Why are the OPQRST questions sometimes subtly different for different chief

complaints?Additional activities associated with the tape:

• Allow adequate time to practice assessment of a responsive medical patient.Other ideas:

• Consider using props for simulations such as medication canisters, poison containers,beer bottles, or other devices that add to the story.

Segment Name: Assessment of the Medical Patient - UnresponsiveTime Codes: Begin: 1:34:14 End: 1:43:03Objectives

• Explain how the EMT-B obtains information about the nature of illness (NOI) in anunresponsive patient.

• Describe how to obtain a focused history about a patient who is unresponsive.• List the sequence of assessment steps in order for the unresponsive medical patient.• List the equipment needed to perform an assessment on a medical patient.• List the two main techniques used to complete a focused physical exam.• Explain why good communication skills are a key component in assessment of the

medical patient.Overview

I. Assessment of the medical patient is highly dependent on the focused history.• For the unconscious medical patient the history will need to be pieced together

from the family, bystanders, and findings at the scene. II. For the unresponsive medical patient perform the steps in this order:

• Rapid medical assessment (head-to-toe exam)• Baseline vital signs• Possible request for ALS support (if not yet done in the initial assessment)• History of present illness (HPI), or the SAMPLE history, if possible

III. Assessment• Scene size-up• Perform initial assessment• Determine nature of illness (NOI) if possible

IV. Equipment• Blood pressure cuff• Stethoscope• Pen light• Scissors

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V. Skill Close-up• Take BSI precautions.• Perform a scene size-up as you approach or come on the scene.

• Determine that the scene is safe and free of hazards.• Determine the NOI such as an overdose, vomiting, or shortness of breath.

• If the patient appears unconscious and is on the ground or couldhave otherwise suffered trauma, direct manual stabilization ofthe cervical spine.

• Verbalize your general impression of the patient regarding his/her level ofdistress and other obvious findings such as positioning and surroundings.

• Determine level of consciousness of the patient using the AVPU scale.• If the patient can communicate, ask for his/her chief complaint.• Ensure airway patency.

• If the airway is not open, do so using the head-tilt/chin liftmaneuver as long as no trauma is present.

• Insert an airway adjunct to assure patency.• Assess the rate and quality of breathing.

• Assure lung sounds are present and equal bilaterally.• Apply high-flow oxygen as appropriate.• Suction as necessary.

• Check central and peripheral pulses for rate, strength, and regularity.• Assess skin: color, temperature, and condition (CTC).

• Control external bleeding with direct pressure.• Initiate shock management as indicated.

• Determine the priority of the patient and make a transport decision.• Patients with life-threats to the ABCs should be prepared for

immediate transport.• Stable patients can be treated on scene and transported with

less urgency. VI. The rapid physical exam is the first major step in the assessment of the unresponsive

medical patient.• Assess head, neck, chest, abdomen, pelvis, extremities, and posterior.• In addition to inspecting and palpating each of these areas for DCSP-BTLS,

other things to look for in a medical patient include:• Neck – jugular vein distension or medical identification devices• Chest – presence and quality of breath sounds• Abdomen – distension, firmness or rigidity• Pelvis – incontinence of urine or feces• Extremities – distal PMS and medical identification devices

• Assess vital signs• Pulse• Respirations• Blood pressure• Skin signs and pupils

• Take a history of the present illness and a SAMPLE history by interviewingbystanders and relatives:

• Signs and symptoms• Allergies• Medications• Pertinent past history• Last oral intake• Events leading up to the call

• The physical exam and history should reveal enough information to determinethe patient’s presenting problem and formulate a treatment plan.

• Perform any interventions as necessary and transport to an appropriatetreatment facility.

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Key TermsRapid physical exam – a rapid assessment of the head, neck, chest, abdomen, pelvis,extremities, and posterior of the body to detect signs and symptoms of the NOI or injury.Teaching ActivitiesQuestions to ask before or after viewing tape:

• If an unknown medication is prescribed to the patient, what are the ways the EMT-B canquickly learn about the med?

• What is the value of having a first responder check the patient’s refrigerator?Additional activities associated with the tape:

• Allow adequate time to practice the assessment of a medical patient who is notresponsive.

Other ideas:• This is a good time to show samples of the Medic Alert® devices that are commonly

used. Many times these companies will provide samples to instructors for EMSeducation.

Segment Name: Ongoing AssessmentTime Codes: Begin: 1:43:05 End: 1:49:11Objectives

• List two reasons for performing the ongoing assessment.• State when the ongoing assessment is completed in the patient assessment process.• List the equipment needed to complete the ongoing assessment.• State how often the ongoing assessment should be repeated for both stable and unstable

patients.Overview

I. The Ongoing Assessment (OA) is the opportunity to:• Reassess a patient’s signs and symptoms.• Evaluate the effectiveness of any treatment.

II. The ongoing assessment is completed prior to arrival at the receiving facility. III. The management of life-threatening conditions takes priority over performing an

ongoing assessment. IV. Equipment

• Blood pressure cuff• Pen light• Stethoscope

V. Assessment• Begin by repeating the initial assessment and managing any life-threats to the

ABCs.• Reassess vital signs, noting any changes.• Repeat the focused physical exam.

VI. Skill Overview• Take BSI precautions.• Repeat the initial assessment to detect any life-threatening problems. This

assessment includes:• Reassessment of the patient’s mental status• Maintain an open airway.• Monitor the breathing rate and quality.• Reassess pulse rate and quality.• Monitor the skin: color, temperature, and condition.• Reestablish, as necessary, priorities in patient treatment and/or

transport.• Repeat the focused assessment as it relates to the chief complaint.• Evaluate the effectiveness of any interventions.

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VII. Skill Close-up• Assure BSI.• Reassess mental status using AVPU.

• Changes in mental status can indicate an improvement ordeterioration in the patient’s neurological function and should bereported to medical direction.

• Reassess the ABCs and support as needed.• Reassess patient priority and transport decision.• Obtain vital signs and identify any trending or changes over time.• Repeat the focused physical exam.• Evaluate the effectiveness of any intervention.

VIII. Problem Solving• Repeat the ongoing assessment every 5 minutes for unstable patients and every

15 minutes for stable patients.• If the patient’s condition worsens at any time reassess the initial assessment.• Reevaluate interventions as to do no harm.• Transport the patient to the appropriate treatment facility.

Key TermsOngoing Assessment (OA) – a procedure for detecting changes in a patient’s condition. Itinvolves: repeating the initial assessment, reestablishing patient priority, repeating and recordingvital signs, repeating the focused assessment, and checking interventions.Trending – the inclination to proceed in a certain direction or rate; used to describe the prognosisor course of a symptom or disease.Teaching ActivitiesQuestions to ask before or after viewing tape:

• If a splint was applied to the patient, what ways can this intervention be reevaluated?• If a bronchodilator were administered by the EMT-B with permission from medical control,

how would the intervention be reevaluated?Additional activities associated with the tape:

• Allow adequate time to practice the ongoing assessment.Other ideas:

• When having students practice the ongoing assessment, provide portable radios so theycan also practice giving an ambulance-to-hospital radio report.

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Tape 1 Airway Management

Segment Name: Head-tilt, Chin-Lift maneuverTime Codes: Begin: 1:00:54 End: 1:04:32Objectives

• Describe the type of patient the EMT-B should consider for the head-tilt, chin-liftmaneuver.

• List the equipment needed to perform the head-tilt, chin-lift maneuver.• Describe some of the potential problems associated with performing the head-tilt, chin-lift

maneuver.Overview

I. The head-tilt, chin-lift maneuver is used on patients with a loss of muscle tone in theairway having no actual or suspected cervical spine injury.

II. The head-tilt, chin-lift maneuver opens the airway by tilting the head back and liftingthe chin forward, which helps lift the tongue away from the back of the throat.• This technique should not be used in a patient with a suspected cervical spine

injury. III. Equipment

• BSI – gloves, goggles, mask or face shield IV. Assessment

• The patient should be unresponsive, having an altered mental status.• The patient may be in respiratory arrest or cardiac arrest.• The patient should not have actual or suspected trauma to the head, neck, or

spine. These patients should have their airway opened using the jaw thrustmaneuver.

V. Skill Close-up• Apply BSI.• Place the patient in the supine position.• Place one hand on the patient’s forehead and press down while you place your

other hand under the jaw bone and lift up.• Assess for breathing and ventilate as needed.

VI. Ongoing Assessment• Continuously monitor the patient.• If no gag reflex is present insert an oropharyngeal airway (OPA).

VII. Problem Solving• Only use the bony part of the jaw under the chin during this maneuver. If you

use the soft tissue under the chin an obstruction could occur during thismaneuver.

• Do not place your finger into the patient’s mouth during this maneuver, you maybe bitten.

• Try not to completely close the mouth during this maneuver.• Note that on a small child the airway does not need to be hyperextended, just

extended.• Be careful not to push on the tongue when grasping the jaw.

Key TermsHead-tilt, chin-lift maneuver – a means of correcting blockage of the airway by the tongue bytilting the head back and lifting the chin. Used when no trauma or injury to the head or neck issuspected.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What precautions should be made when doing a head-tilt, chin-lift on an infant?• Why would this technique be inappropriate for a victim of trauma?

Additional activities associated with the tape:• Allow adequate time to practice the head-tilt, chin-lift maneuver.

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Other ideas:• When practicing this technique, have the student use both a mannequin and each other.

Be sure to emphasize the use of BSI.

Segment Name: Jaw Thrust ManeuverTime Codes: Begin: 1:04:36 End: 1:07:48Objectives

• Describe the type of patient the jaw thrust maneuver is used on.• List the equipment needed to perform the jaw thrust maneuver.• Describe the steps to perform a jaw thrust maneuver.• List the possible problems associated with performing a jaw thrust maneuver.

Overview I. An open airway is essential in those who cannot do so for themselves. II. The jaw thrust maneuver is the only technique for the patient who is unconscious or

unresponsive with an actual or suspected spinal cord injury.• Opens the airway with little or no movement to the head or neck

III. Equipment• BSI – mask, glove, goggles or eye shield

IV. Assessment• The patient should be unresponsive and suspected to have head, neck, or

cervical spinal injury.• The patient may also have an altered mental status.• The patient may be suffering from respiratory or cardiac arrest.

V. Skill Close-up• Apply BSI.• Patient supine. If not, keep neutrally aligned, then roll as a unit to supine.• Position yourself at the top of the patient’s head if possible.• Without moving the head or neck, place your hands on either side of the patient’s

head near the orbits, using your fingers place them at the angle of the jaw, usingyour index and middle fingers gently jut the jaw forward.

• Do not rotate the head.• Assess for ventilation as needed.

VI. Ongoing Assessment• Continuously monitor airway.• If no gag reflex, insert OPA.

VII. Problem Solving• Only the jaw thrust maneuver should be considered in a patient with suspected

head or a spine-injured patient that needs an open airway.• Do not place your finger into patient’s mouth during this maneuver.• Try not to close the mouth during maneuver.

Key TermsJaw thrust maneuver – a means of correcting blockage of the airway by moving the jaw forwardwithout tilting the head or neck. Used when trauma or injury is suspected to open the airwaywithout causing further injury to the cervical spine.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it essential to jut the jaw for the jaw thrust maneuver?• What should the EMT-B do to maintain a jaw thrust if the patient with a cervical collar

applied becomes difficult?Additional activities associated with the tape:

• Allow adequate time to practice the jaw thrust maneuver.Other ideas:

• In addition to practicing on a mannequin, make sure all students practice on each other toassure they are competent at the skill.

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Segment Name: Pocket MaskTime Codes: Begin: 1:07:54 End: 1:13:10Objectives

• Describe some of the advantages of using a pocket mask to assist with ventilations.• List the equipment needed to perform ventilations using the pocket mask.• Describe how to place a pocket mask on a patient.• Describe the differences between ventilating adults, children, and infants.• Describe some of the potential problems associated with the use of a pocket mask.

Overview I. Mouth-to-mask is an option for ventilating patients.

• Small and compact• Clear face mask

II. Equipment• BSI equipment• Pocket mask with one-way valve and oxygen inlet• Suction if available• Oxygen tank and regulator

III. Assessment• Check the patient’s mental status.• Check his/her airway.• Check breathing rate, volume, and quality.• Check circulation.• Check skin signs.

IV. Skill Close-up• Take BSI precautions.• Place yourself at the patient’s head if possible.• Open the airway using the head-tilt, chin-lift maneuver, or the jaw thrust

maneuver if there is any indication of trauma or cervical spine injury.• Suction as necessary.• Insert oropharyngeal or nasopharyngeal airway if possible.• Connect oxygen tubing to pocket mask oxygen inlet.• Turn oxygen regulator liter flow gauge to 15 liters per minute.• Center the pocket mask on the patient’s face.• Place your thumbs over the top of the mask and place your little, ring, middle,

and index fingers on the patient’s mandible near the angle of the jaw.• Pull the jaw up to the mask.• Take a deep breath and exhale into the one-way valve at the top of the mask.• Adult ventilation should be delivered over a 1- to 2-second period and the rate is

1 every 5 seconds.• Children and infants’ ventilations should be delivered over 1 to 11/2 seconds and

the rate is 1 every 3 seconds.• Remove your mouth from the one-way valve during each exhalation.• If the patient does not have a pulse and both ventilations and compression are

necessary, perform CPR. V. Ongoing Assessment

• Continuously monitor patient during ventilation for chest rise and lungcompliance.

VI. Problem Solving• There is a high risk of contamination with this procedure.• Consider the use of a BVM (especially if you have a second rescuer to assist).• When secretions or vomit is present in the mask, immediately clear and suction

the patient.• Conserve energy while using a pocket mask.

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Key TermsPocket mask – a device, usually with a one-way valve, to aid in artificial ventilation. A rescuerbreathes through the valve when the mask is placed over the patient’s face. Also acts as barrierto prevent direct contact with the patient’s face. Can be used with supplemental oxygen whenfitted with an oxygen inlet.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it important not to push the mask onto the face?• What is the advantage of having two hands to seal the mask?

Additional activities associated with the tape:• Allow adequate time to practice the use of the pocket mask.

Other ideas:• If students do not have their own personal pocket mask, it is essential to properly

disinfect the masks prior to different students using the mask.

Segment Name: Bag-Valve Mask (BVM) Ventilation, Two-Person TechniqueTime Codes: Begin: 1:13:15 End: 1:22:50Objectives

• Explain why the bag-valve mask (BVM) is the preferred method of ventilation over mouth-to-mouth, mouth-to-mask, and flow-restricted devices.

• Describe how to ventilate an adult, child, and infant.• Discuss the problems associated with ventilating with a BVM.

Overview I. The BVM is the preferred method of ventilation over mouth-to-mouth, mouth-to-mask,

and flow-restricted devices. II. The BVM consists of the following components:

• A self-inflating bag with a one-way non-rebreathing valve• A clear face mask with an inflatable air cushion• Attached oxygen supplemental reservoir bag or tube attached to the BVM

III. The American Heart Association has issued the following guidelines on ventilationsby a BVM:• If supplemental oxygen is available, administer 6 to 7 mL/kg, which would be

approximately 400 to 600 ml, over 1 to 2 seconds for an adult.• If supplemental oxygen is unavailable, deliver 10 mL/kg, which would be

approximately 700 to 1,000 ml, over 1 to 2 seconds for an adult.• BVM systems without a reservoir supply approximately 50% oxygen. Systems

with an oxygen reservoir provide nearly 100% oxygen. IV. Assessment

• BSI precautions• Establish a patent airway.

V. Equipment• BSI equipment• Oral or nasal airways in various sizes• Suction unit• Bag-valve mask with attached oxygen reservoir• Full oxygen tank and regulatory

VI. Skill Overview• Take BSI precautions.• Ensure that the equipment is operational.• The patient should be in the supine position.• Position yourself at the head of the patient.• Use a manual maneuver to open the airway.• Insert an oral or nasal airway, if available.

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• The first EMT-B centers the mask on the patient’s face, to make a good maskseal.

• The second EMT-B begins squeezing the bag slowly.• Ventilate once every 5 seconds in an adult, once every 3 seconds in children and

infants.• Each ventilation should be delivered over 2 seconds in adults and 1 to 1_

seconds for children and infants.• The BVM should be attached to oxygen cylinder.• Visualize the chest for chest rise on each ventilation.• Feel the compliance (ease of ventilation of the bag on each ventilation).• If no chest rise during ventilation, consider an airway obstruction.• Document use and proper ventilations.

VII. Ongoing Assessment• Continuously monitor ventilations, chest rise and fall, and lung compliance.• If the patient regains spontaneous respirations, assess the respirations for

adequacy. VIII. Problem Solving

• The mask used with the BVM must be clear to note any vomiting or secretions.• Stop and suction immediately when vomitus or secretions are

present.• When increased compliance is detected consider an obstruction or increased

pressure in the chest cavity.Key TermsBag-valve mask device – a hand-held device with a face mask and self-refilling bag that can besqueezed to provide artificial ventilations to a patient. Can deliver air from the atmosphere oroxygen from a supplemental oxygen supply system.Compliance - ease of ventilation of the bag on each ventilation.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What are examples of patients who may have increased lung compliance?• When ventilating with a BVM, if air is leaking around the mask what should the EMT-B

do?Additional activities associated with the tape:

• Allow adequate time to practice the skill of BVM ventilations.Other ideas:

• Make sure to emphasize that this skill is best done with two rescuers. It is possible to dothis technique properly with one rescuer, however it is much less effective. Be sure topractice BVM ventilation on a regular basis to maintain proficiency.

Segment Name: Insertion of the Oropharyngeal AirwayTime Codes: Begin: 1:22:52 End: 1:31:37Objectives

• Explain when the EMT-B would use an oropharyngeal airway (OPA).• List the equipment needed to aid in the insertion of an OPA.• Describe the steps to insert an OPA in an adult, child, and infant.• Describe the potential problems associated with the use of an OPA.

Overview I. The oropharyngeal airway (OPA) is an airway adjunct.

• Must be used in conjunction with manual airway maneuvers• Comes in many sizes for adults, children, and infants• Oral airways should be considered in any patient who is not breathing or who is

unresponsive without a gag reflex.• Insertion of an oral airway in a patient with a gag reflex can cause him to vomit.• Can also trigger spasms in the upper airway

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II. Equipment• BSI equipment• Full set of OPAs• Suction unit with a rigid tip Yankauer®

III. Assessment• Use a painful stimulus to assess for unresponsiveness.• Examine the patient for the proper size.

• Measure the airway (center of the mouth to angle of jaw, orcorner of mouth to tip of the ear lobe).

• Improper size can cause an airway obstruction.• If the patient gags during insertion, immediately remove the OPA.

IV. Skill Overview• Take BSI precautions.• Place the patient in a supine position.• Use the head-tilt, chin-lift maneuver or the jaw thrust maneuver if a cervical

spinal injury is known or suspected.• Select the proper size oral airway.• Measure the airway.• Open the patient’s mouth using the cross-finger technique.• Insert the airway with the tip pointing to the top of the mouth (in adults only) and

slide it along the roof of the mouth.• Gently rotate the airway 180 degrees to flip it over the tongue.• Continue to insert the OPA until it lies flat on the top of the tongue and the

phalange rests on the lips.• If the OPA is too large or too small remove it and select the

proper size.• Place the mask you will use for ventilation over the airway adjunct you have

inserted.• If the patient begins to gag at any point in this procedure, remove the airway at

once following the anatomical curvature.• Reassess the patient’s breathing and begin ventilations as necessary.• Document insertion of an OPA and changes in patient’s condition.

V. Ongoing Assessment• Continuously monitor the patient’s airway patency. If a gag reflex returns,

immediately remove the OPA. VI. Problem Solving

• Improper size can cause an obstruction.• Insertion of an OPA can help you determine if the patient has a gag reflex.• Be prepared for vomiting; have suction ready.

• Suction may be difficult to perform with the airway in place.• Remove the OPA to suction, then reinsert.

• If you are aggressive during insertion of an OPA, you can cause trauma, spasms,and swelling in the upper airways.

• An OPA might be used as a bite block in suspected seizure patients or a biteblock with endotracheal intubation.

• The insertion technique for a child or infant is to use a tongue depressor to holdthe tongue, then to slide straight in without flipping it over the tongue.

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Key TermsGag reflex – vomiting or retching that results when something is placed in the back of the pharynx. Thisis tied to the swallow reflex, which is designed to cap the glottic opening with epiglottis.Oropharyngeal airway (OPA) – a curved device inserted through the patient’s mouth into thepharynx to help assist maintaining an open airway.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why do some patients, particularly children, develop bradycardia when the back of thethroat is stimulated?

• If the patient has clenched teeth from a seizure, should an OPA be used?Additional activities associated with the tape:

• Allow adequate time to practice the skill of OPA insertion.Other ideas:

• Emphasize that there are different types of OPAs (e.g.: Berman type and Cathguidestyle). Make sure the students understand that the diameter of a suction catheter thatwould fit through a Cathguide is too small to effectively suction the patient. It is best toremove the OPA when suctioning the patient.

Segment Name: Insertion of the Nasopharyngeal AirwayTime Codes: Begin: 1:31:40 End: 1:38:22Objectives

• Explain when the EMT-B would use a nasopharyngeal airway (NPA).• List the equipment needed to aid in the insertion of an NPA.• Describe the steps to insert an NPA.• Describe the potential problems associated with the use of an NPA.

Overview I. The nasopharyngeal airway (NPA) is an airway adjunct.

• A disposable, uncuffed, plastic or soft rubber tube• Sizes vary from 17 to 20 cm in length and diameter ranges from 20 to 36 French.• When in place, the NPA rests between the tongue and the posterior pharyngeal wall.• The NPA does not stimulate a gag reflex.

II. Equipment• BSI equipment• NPAs of various sizes• Water-soluble lubricant (e.g.: KY® jelly, Lubifax®, Surgilube®)• Suction equipment

III. Assessment• Use caution in a patient with suspected facial trauma.• Select the proper length.

• Measure from the end tip of the nose to the ear lobe.• Incorrect size may cause an obstruction or improper ventilation.

IV. Skill Close-up• Take BSI precautions.• Place the patient preferably in a supine position with the head in a neutral

position.• Assess the mental status.• Select proper size NPA.• Apply a water-soluble lubricant to the NPA before inserting.• Insert the airway with the bevel pointing toward the base of the nostril or toward

the septum.• Slowly push the airway into the nostril.

• Never force the NPA.• If resistance is felt, remove the NPA, apply more lubricant and

reinsert.

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• Continue to insert the airway into the nostril, advancing until the proximal flangerests against the nostril.

• Assess the patient’s breathing.• Document insertion of the NPA.

V. Ongoing Assessment• Continuously monitor patient respirations.• Monitor for gag reflex. If gag reflex becomes present, immediately remove the

NPA.• Improper insertion can cause bleeding in the nostrils.• Be prepared for vomiting by having suction ready.

• Examine the posterior pharynx for any bleeding that may haveoccurred and suction if necessary.

VI. Problem Solving• If the patient’s mental status improves and a gag reflex returns, immediately

remove the NPA.• Keep suction ready during removal of NPA.

• Improper size can cause an obstruction.• Lubrication is essential prior to insertion.• Aggressive insertion may cause trauma, spasms, swelling, and bleeding.• Be prepared for vomiting; have suction ready.

• Suction may be difficult to perform with the airway in place.• Remove the NPA to suction, then reinsert.

Key TermsNasopharyngeal airway (NPA) – a flexible breathing tube inserted through the patient’s noseinto the pharynx to help maintain an open airway.Nasal septum – the wall that separates the nostrils.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What type of lubricant can be used on an NPA?• Why doesn’t an NPA stimulate a gag reflex in the patient?

Additional activities associated with the tape:• Allow adequate time to practice NPA insertion on a mannequin.

Other ideas:• When a patient has clenched teeth and lots of secretions, insert an NPA and you can

suction with a catheter down the tube.

Segment Name: Oral SuctioningTime Codes: Begin: 1:38:27 End: 1:45:12Objectives

• Explain why clearing a patient’s airway of secretions and/or vomitus is such a high priorityin patient care.

• List the three types of power sources for suction units.• List the equipment needed to perform oral suctioning.• Explain why BSI precautions are strongly urged when performing suctioning.• Describe the potential problems associated with suctioning.

Overview I. Clearing a patient’s airway is the highest priority.

• Immediate removal of any aspirated materials and/or fluids is essential. II. Many types of suction units are available; each unit consists of the following:

• A suction source• A collection container• Thick-wall, non-kinking, wide-bore tubing• Rigid (hard) suction tips or flexible (soft) catheters

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III. Suction units can be either mounted or portable.• May be powered manually, by oxygen source or electricity

IV. Improper suctioning can cause trauma, swelling, spasms, hypoxia, and aspiration. V. Equipment

• BSI equipment• Suction units• Suction tubing• Suction catheters and/or rigid suction tips• Collection container• Sterile water or irrigation solution

VI. Assessment• Full BSI precautions are essential for this skill.• Be prepared well in advance for the potential use of suction.

VII. Skill Close-up• Apply BSI precautions.• Assemble suctioning equipment; check that suction is working.• Place yourself at the patient’s head.• Turn on the suction unit.• Place patient on his or her side, or turn head to the side if possible.• Open the patient’s mouth using a cross-finger technique; remove any airway that

may be in place.• Slowly insert the catheter into the mouth with the curve or distal part of the

catheter pointing towards the jaw.• Place the Yankauer® so that the convex, or bulging-out side is against the roof of

the mouth. Insert the tip to the base of the tongue.• Insert no further than the base of the tongue.• If a gag reflex begins, pull back slightly.• Begin suctioning by placing your finger over the hole in the catheter tube.• Move the suction catheter from side to side in the oral cavity.• Never suction for more than 15 seconds at a time in adults; no more than 5

seconds in children and infants.• If the catheter or tubing becomes clogged with materials, use sterile water or

irrigation solution to clean or clear the catheter and/or tubing.• Allow a few seconds between suctions, giving the patient time to relax.• Ventilate between suctioning attempts.• Document your suction procedure.

VIII. Ongoing Assessment• Constantly monitor for materials and/or fluids that may need to be removed:

• Monitor for signs of hypoxia during suction.• Be especially aware of vagal stimuli in infants/children, which

causes bradycardia. IX. Problem Solving

• Deep insertion of a catheter can stimulate a gag reflex.• When tubing becomes clogged, use sterile water or irrigation solution to clear the

tube, or replace the tubing and catheter.• Exposure while cleaning suction equipment is a high risk.

Key TermsVagal stimuli – actions that stimulate the tenth cranial nerve causing bradycardia, such astouching the back of the throat when suctioning.Yankauer® – a disposable commercial rigid tip suction catheter.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it important to carry a portable suction unit to the patient’s side?• Why is it important to test the suction unit on each shift?

Additional activities associated with the tape:

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• Allow adequate time to practice suctioning a mannequin.Other ideas:

• Try challenging your students with chunky soup in the appropriate mannequin in asimulation needing suctioning.

Segment Name: Suctioning through an Endotracheal TubeTime Codes: Begin: 1:45:14 End: 1:53:06Objectives

• List the indications for suctioning through an endotracheal tube.• List the equipment needed to perform endotracheal suctioning.• Describe the steps to perform endotracheal suctioning.• Discuss some of the common problems associated with endotracheal suctioning.

Overview I. The goal of this skill is to clear the airway of unwanted debris and/or fluids.

• This skill should be done under the direction of an advanced provider.• To reduce risk of infection in the patient’s lung, this skill is performed with sterile

technique. II. Equipment

• BSI equipment• Suction unit• Soft suction catheters• Sterile water

III. Assessment• Visible secretions in the endotracheal tube• Gurgling sounds• Resistance in ventilations (increased compliance)

IV. Skill Close-up• Observe BSI precautions.• Explain the procedure to the conscious patient.• Check and assemble the equipment.• Pre-oxygenate the patient.• In the case of pulmonary edema, your partner should hyperventilate the patient

prior to suctioning.• Approximate the length of the catheter.

• Keep the catheter sterile during measurement.• Place the soft catheter into the ET tube without applying suction.• Place your non-dominant thumb over the hard plastic hole at the proximal end of

the catheter and apply suction.• Slowly withdraw the suction catheter with a twisting motion.• Clean the catheter in sterile water.• When setting down the catheter, make sure you put it in a sterile environment if it

is to be used again.• Hyperventilate and repeat the procedure if necessary.

V. Ongoing Assessment• Assess the patient immediately after suctioning for signs of hypoxia (e.g.:

bradycardia).

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VI. Problem Solving• The risk of exposure during this procedure is high, so always utilize full BSI

precautions.• Hypoxia can result by taking too long to perform the suction procedure.

• Pre-oxygenate the patient well before suctioning.• Never suction, or interrupt ventilation, for more than 15 seconds.

• If you do not measure the catheter you can cause the following complications:• A coughing reflex• Bronchospasms• Dysrhythmias• Injury to the mucosa of the lower airways• Employing suction pressure that is too high can cause these

same complications.• If the tip of the catheter becomes clogged, place the tip of the catheter into sterile

water and draw water through the catheter.Key TermsBronchospasms –constriction of the air passages of the lung by spasmodic contraction of thebronchial muscles.Hyperventilate – to provide ventilations at a higher rate than normal.Pulmonary edema – accumulation of fluid in the lungs.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it important to keep the catheter sterile when deep suctioning?• Why is it imperative that a mask and eye shield be used when deep suctioning?

Additional activities associated with the tape:• Allow adequate time to practice endotracheal suctioning.

Other ideas:

• Since this skill may be one of the optional EMT-B skills, check with your medical directorto be sure it is acceptable practice.

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Tape 2 Airway Management

Segment Name: Oxygen Tank AssemblyTime Codes: Begin: 1:00:55 End: 1:09:39Objectives

• List the various sizes of oxygen cylinders and the amounts of oxygen they contain.• List the equipment needed to assemble an oxygen delivery system.• Describe the steps for an oxygen cylinder assembly.

Overview I. Most oxygen tanks and regulators have standard fittings that only work one way. II. Portable cylinders for the field include:

• D cylinders which contain about 350 liters of oxygen• E cylinders which contain about 625 liters of oxygen

III. Onboard tanks found in the ambulance (fixed systems) include:• M cylinders which contain about 3,000 liters of oxygen• G cylinders which contain about 5,300 liters of oxygen• H cylinders which contain about 6,900 liters of oxygen

IV. Equipment• Oxygen cylinder with yoke• Oxygen regulator

• On E size cylinders, or smaller, the pressure regulator is securedto the cylinder valve assembly by a yoke assembly.

• Cylinders larger than E size have a valve assembly with athreaded outlet.

• Flowmeter – 3 types• Bourdon Gauge Flowmeter (useful for most portable units)• Constant Flow Selector Valve (useful with any size oxygen

cylinder)• Pressure-Compensated Flowmeter (useful for fixed delivery

systems)• Oxygen key

V. Assessment• Inspect equipment for damage prior to assembly.• Oxygen tanks are usually green or have a green strip and are labeled “oxygen.”• Make sure the regulator has an O-ring or washer.• Oxygen should be stored at room temperature.

VI. Skill Overview• Place the cylinder in a secure, upright position.• Remove the seal or cap protecting the cylinder outlet or valve.• Open the valve. This will remove any dust or debris from the valve assembly.• Select the correct pressure regulator and flowmeter.• Align the pins and hand tighten the “T” screw or tighten a threaded connection

with a non-ferrous wrench.• Place the oxygen key on the tank valve screw.• Slowly open the valve to charge the oxygen regulator.• Check the pressure gauge to see that an adequate amount of oxygen is present

in the tank.• Attach tubing and the oxygen device of choice.• Open the main valve and adjust the flowmeter.• Document the oxygen flow rate delivered to the patient.

VII. Ongoing Assessment• Continuously monitor the pressure in the oxygen cylinder and be prepared to

change an empty cylinder.• When transporting a patient with an oxygen cylinder secure the cylinder.

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VIII. Problem Solving• Regularly check hydrostatic expiration dates.• Do not use damaged tanks or regulator gauges.• If you open a cylinder and hear a leak, turn off the pressure and check the O-

ring; replace as needed.Key TermsFlowmeter – also called a regulator; a valve that indicates the flow of oxygen in liters per minute.O-ring – a plastic washer that fits between the flowmeter and oxygen cylinder to prevent gas fromleaking out when the tank is turned on.Oxygen cylinder – a steel or aluminum cylinder filled with oxygen under pressure.Teaching ActivitiesQuestions to ask before or after viewing tape:

• How can you find out if an oxygen tank has been hydrostat-tested recently?• What are five safety rules to consider when using oxygen tanks?

Additional activities associated with the tape:• Allow adequate time to practice the skill of exchanging oxygen tanks and regulators.

Other ideas:• Discuss how your service receives oxygen when the tanks are empty. If a cascade

system is used, discuss the policy and procedure for filling tanks.

Segment Name: Administering Oxygen by a Non-Rebreather MaskTime Codes: Begin: 1:09:39 End: 1:13:44Objectives

• List the indications for the use of a non-rebreather mask (NRB) on a patient.• List the oxygen concentration ranges an NRB is able to deliver.• Describe the steps to place an NRB on a patient.• Describe the ongoing assessment of a patient wearing an NRB.

Overview I. Non-rebreather mask (NRB) device delivers the highest concentration of oxygen in

the prehospital setting.• Delivers oxygen concentrations ranging from 80 to 100%.

II. Indications for utilizing an NRB include:• Cyanosis• Cool, clammy skin• Shortness of breath• Chest pain• Severe injuries• Altered mental status

III. NRBs can be used in combination with oropharyngeal airways (OPAs) andnasopharyngeal airways (NPAs).

IV. Equipment• Full oxygen tank and regulator• NRB

V. Assessment• The patient should be breathing.• Select the appropriate size NRB.

VI. Skill Close-up• Take BSI precautions.• Introduce yourself to the patient and explain the need for an NRB.• Make sure that the oxygen tank is full and that the pressure is within accepted

limits.• Attach the NRB to the nipple on the oxygen regulator.• Set the flowmeter at 12-15 liters per minute or at the rate specified by medical

direction.

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• Allow the reservoir bag to fill completely.• Position the NRB over the patient’s nose and mouth and instruct the patient to

breathe normally while the mask is in place.• Slip the elastic strap over the patient’s head so that it rests above the patient’s

ear and tighten the strap as needed.• Document the use of an NRB and the rate of oxygen delivery.

VII. Ongoing assessment• Check to see that oxygen is turned on and flowing; continuously monitor the

pressure.• Remind the patient to breathe normally.• Check the position of the mask for comfort and effectiveness.

VIII. Problem Solving• Reassure the patient to avoid the fears associated with claustrophobia.

Key TermsNon-rebreather mask (NRB) – a face mask with a reservoir bag device designed to deliver highconcentrations of oxygen. The patient’s exhaled air escapes through a valve so it is not mixedwith the gas inhaled from the reservoir.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Should airway adjuncts be used together with a non-rebreather mask?• Why shouldn’t you use an adult-sized NRB on a child?

Additional activities associated with the tape:• Allow adequate time to practice applying an NRB.

Other ideas:• Emphasize that the mask should be monitored to assure the bag does not remain empty

or that sheets or clothing do not block the valves on the mask.

Segment Name: Administering Oxygen by a Nasal CannulaTime Codes: Begin: 1:13:47 End: 1:18:14Objectives

• List the indications for the use of a nasal cannula on a patient.• List the oxygen concentration ranges a nasal cannula is able to deliver.• Describe the steps to place a nasal cannula on a patient.• Describe the ongoing assessment of a patient wearing a nasal cannula.

Overview I. Nasal cannulas provide low-concentration oxygen ranging from 24-44%. II. The main indication for the use of a nasal cannula is the patient who feels suffocated

by an NRB.• May be indicated for COPD patients with minimal respiratory distress• May be indicated for the patient who is nauseous or vomiting

III. Contraindicated in the patient with a nasal obstruction• Should not be utilized on patients requiring high-flow oxygen

IV. Equipment• Full oxygen tank and regulator• Nasal cannula of various sizes

V. Assessment• Patient must have adequate respirations and the ability to breathe through the

nose.• Patient requires low to moderate concentration of oxygen.

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VI. Skill Close-up• Explain the need for oxygen administration to the patient. Then go over the

procedure you intend to follow.• Attach the nasal cannula tubing to the oxygen regulator.• Set the liter flow between 1 and 6 liters per minute.• Insert the two prongs into the patient’s nostrils.• Position the tubing of the cannula over the patient’s ear.• Bring the remainder of the tubing under the patient’s chin, and secure the slip

loop by gently sliding the plastic adjust in place.• Document the use of a nasal cannula and the liter flow.

VII. Ongoing Assessment• Check position of cannula.• Check the regulator for continuous flow.

VIII. Problem Solving• If the patient is unable to breathe through his/her nose initially, placing a nasal

cannula into the nostrils will be ineffective. Consider an oxygen mask in thiscase.

• Remind the patient to breathe normally.• Rescuers may wear a nasal cannula while providing mouth-to-mouth or mouth-

to-mask ventilations to increase oxygen concentration delivery with ventilations.Key TermsCOPD – an acronym for chronic obstructive pulmonary disease (e.g.: chronic bronchitis,emphysema, or black lung).Nasal cannula – a disposable device that delivers low concentrations of oxygen through twoprongs that rest in a patient’s nostrils.Teaching ActivitiesQuestions to ask before or after viewing tape:

• If a COPD patient is in respiratory failure should a nasal cannula be used?• If a COPD patient is always on home oxygen by nasal cannula and called EMS for a

sprained ankle, with no increase in respiratory distress, should a nasal cannula be usedand if so, what liter flow?

Additional activities associated with the tape:• Allow adequate time to practice the skill of using a nasal cannula.

Other ideas:• Review your local protocols for oxygen administration.

Segment Name: Nasogastric (NG Tube) IntubationTime Codes: Begin: 1:18:18 End: 1:22:51Objectives

• List the indications for the use of a nasogastric tube (NG tube).• List the equipment needed for the intubation of an NG tube.• Describe the steps on the insertion of an NG tube.• Describe the possible complications associated with NG tube intubation.

Overview I. Nasogastric (NG tube) intubation is the insertion of a tube into the stomach through

the nasal passage.• NG tube can be attached to suction to remove stomach contents including air,

blood, or vomit.• Pediatric indications are for gastric distention in the unresponsive patient or when

gastric distention interferes with ventilation.• In the hospital, NG tubes may be used to deliver medications or nutritional

substances. II. NG tube insertion is contraindicated where nasal bleeding, facial trauma, or basilar

skull fractures are present.

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III. Assessment• Assess the unresponsive patient or patient who is being ventilated for increased

gastric distention. IV. Equipment

• BSI precaution• Various sizes of NG tubes• Emesis basin• Water-soluble lubricant• Tape• 20cc syringe• Suction equipment• Stethoscope

V. Skill Close-up• Take BSI precautions.• Prepare all equipment.• Maintain adequate oxygenation of patient.• Measure tube length before insertion – nose to ear to xiphoid process. This

predicts how far the tube will be inserted.• Lubricate the tube and gently insert the tube through one nostril. Motion should

be downward along the nasal floor.• Insert the tube to pre-determined, measured location.• Confirm placement of the tube in the stomach.

• Listen over epigastrium as air is injected through tube withsyringe (10-20cc).

• A bubbling sound or rush of air should be heard by auscultation.• Apply suction to the syringe. Gastric contents should be aspirated in the tube.• Secure NG tube with tape.• Attach NG tube to suction device to decrease gastric distention.

VI. Ongoing Assessment• Assess NG tube for proper placement and dislodgement.• Patient may need to be restrained to prevent self-removal of NG tube.

VII. Problem Solving• Trauma or vomiting may occur during insertion.• During insertion the tubing may coil in the back of the throat; partially remove the

tubing, then reinsert.• When securing the tube avoid sharply bending and occluding the tube at the

nostril.• Tubing may clog with stomach contents; flush tubing with normal saline (5-10cc).

Key TermsNasogastric tube (NG tube) – a tube designed to be passed through the nose, nasopharynx,and esophagus. In the prehospital setting it is used to relieve distention of the stomach,especially in children and infants.Xiphoid process – the inferior portion of the sternum.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is the problem with gastric distention in the field?• Why do children tend to be affected by gastric distention more frequently than adults?

Additional activities associated with the tape:• Allow adequate time to practice the skill of NG tube placement.

Other ideas:• Not all EMT-Bs are trained to utilize this skill. Check with your Medical Director to see

what the local protocol is.Segment Name: Sellick’s ManeuverTime Codes: Begin: 1:22:55 End: 1:27:42

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Objectives• Describe some of the potential scenarios for the use of Sellick’s maneuver.• Describe two of the potential problems associated with the use of the Sellick’s maneuver.

Overview I. Sellick’s maneuver is also referred to as cricoid pressure.

• Allows for improved ventilation while helping to prevent gastric regurgitation• Used to assist in the placement of an endotracheal tube

II. Equipment• BSI equipment

III. Assessment• Unresponsive patient with no gag reflex

IV. Skill close-up• Apply firm but gentle posterior pressure. Using the thumb and index finger of

one hand, apply pressure to the anterior and lateral aspects of the cricoidcartilage, just next to the midline.

• Document that the maneuver was done. V. Ongoing Assessment

• Assess the neck for swelling or signs of trauma after the maneuver is performed. VI. Problem Solving

• Be prepared for vomiting after releasing cricoid pressure.Key TermsCricoid cartilage – the ring-shaped structure that circles the trachea at the lower edge of thelarynx.Sellick’s maneuver – also called cricoid pressure; pressure applied to the cricoid cartilage tosuppress vomiting and bring the vocal cords into view.Thyroid cartilage – also known as the Adam’s apple; the largest cartilage in the larynx.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why should the Sellick’s maneuver be utilized?• How does the Sellick’s maneuver work?

Additional activities associated with the tape:• Allow adequate time to practice the skill of Sellick’s maneuver.

Other ideas:• Explain how this may be helpful to prevent regurgitation during intubation attempts, as

well as bring the cords into view.

Segment Name: Ventilatory Assist with Endotracheal IntubationTime Codes: Begin: 1:27:46 End: 1:32:32Objectives

• Explain the EMT-B’s role in assisting with endotracheal intubation.• List the equipment needed for endotracheal intubation.• Describe the steps to assist ventilations of a patient who is intubated.• List the most common problem associated with endotracheal intubation.

Overview I. The gold standard for airway management is the endotracheal tube (ET tube).

• Provides direct control of the airway II. In some areas of the country EMT-Bs are permitted to perform endotracheal

intubation.• EMT-Bs may assist with endotracheal intubation.• EMT-Bs may ventilate an intubated patient.

III. Equipment• BSI equipment• BVM, with reservoir attachment• Oxygen cylinder

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• Suction unit and catheter• ET tube (proper size)• Stylet• Laryngoscope• Laryngoscope blades (straight, curved)• Water-soluble lubricant• 10cc syringe• Towel• Esophageal intubation detector device or end tidal CO2 monitor• Commercial tube restraints• Oral airway• ET tube securing device, commonly tape• Stethoscope

IV. Assessment• Ventilation by endotracheal intubation should only be done with the direction of

an advanced life support provider. V. Skill Close-up

• Take BSI precautions.• Position yourself at the patient’s head.• With a BVM attached to oxygen, ventilate at a rate of 12 times a minute.• Slowly squeeze the bag over 2 seconds for each ventilation.• Notify the ALS provider immediately of any complications.

VI. Ongoing Assessment• Continuously monitor chest rise during each ventilation.

VII. Problem Solving• ET tubes can be displaced with movement or during various procedures.

• Advise the advanced provider immediately if you suspect tubedisplacement.

Key TermsEndotracheal tube – a tube designed to be inserted into the trachea. Oxygen, medication, or asuction catheter can be directed into the trachea through an endotracheal tube.Laryngoscope – an illuminating instrument that is inserted into the pharynx to permitvisualization of the larynx and vocal cords.Stylet – a long, thin, flexible metal probe used to provide shape to a flexible tube.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is your agency’s policy on EMT-Bs ventilating a patient with an ET tube?• Why is it so important that the ET CO2 be checked after any movement of the patient?

Additional activities associated with the tape:• Allow adequate time to practice assisting ventilating an intubated mannequin.

Other ideas:• EMT-Bs should work together with ALS personnel in scenarios where the patient needs

to be ventilated prior to intubation, then assist after intubations.

Segment Name: Insertion of Esophageal Tracheal Combitube® (ETC Airway)Time Codes: Begin: 1:32:37 End: 1:44:50Objectives

• List the major advantages of the esophageal tracheal Combitube® as an airway device.• List the equipment needed for the use of a Combitube®.• List the indications and contraindications for the use of a Combitube®.• Describe the steps for placing a Combitube® and how the EMT-B verifies tube

placement.• List the problems associated with the use of the Combitube® and how to correct them.

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Overview I. The esophageal tracheal Combitube® is a double lumen airway device.

• In some areas of the country EMT-Bs are permitted to utilize the Combitube®.• Combitube® comes in two sizes.• This device does not require visualization of the trachea.

II. Combitube® is a back-up airway device which offers several major advantages:• It is a “blind technique” that does not require visualization of the trachea.• The Combitube® may prevent vomit from entering the trachea, thus protecting

the airway.• The Combitube® allows for rapid intubation of the patient independent of the

patient’s position. III. Equipment

• BSI equipment• Oxygen cylinder• BVM and reservoir• Suction equipment• Combitube® (appropriate size for patient)• Water-soluble lubricant (KY® jelly, Lubifax®, or Surgilube®)• Large 100cc syringe• Small 20cc syringe• Stethoscope

IV. Assessment• The Combitube® is indicated when:

• Patients are unconscious and lack a gag reflex• Endotracheal intubation is not allowed or cannot immediately be

performed, even though strongly indicated• Endotracheal intubation is unsuccessful after two attempts• In-line immobilization of the patient prevents endotracheal

intubation• Bleeding, vomiting, or a patient’s anatomy obstructs the direct

visualization required for endotracheal intubation• The Combitube® is contraindicated when:

1. Patients are less than 16 years of age2. Patients are less than 5 feet tall3. Esophageal disease is present4. Patients are conscious with a gag reflex5. Patients have swallowed a caustic substance

V. Skill Overview• Take BSI precautions.• Position yourself at the patient’s head.• Prior to insertion of the Combitube®, the airway should be cleared of any

materials or fluids that might cause an obstruction.• Assist ventilations as needed.• Assess the patient for contraindications (e.g.: age and size).• Assemble and check equipment.• Lubricate the distal end of the tube.• Keep the patient supine with the head in a neutral position.• Consider hyperventilation prior to performing insertion of the airway.• Perform a jaw-lift maneuver and place the tube into the mouth and gently insert

into the airway.• Insert the Combitube® until the airway’s black rings meet the level of the

patient’s teeth.• Using the large syringe, inflate the pharyngeal cuff with 100cc of air.• Using the small syringe, inflate the distal cuff with 10 to 15cc of air.• Attach the BVM to tube #1, and slowly begin ventilations.

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• Place the stethoscope over the patient’s stomach and auscultate for gurglingsounds.

• If no gurgling sounds, auscultate the lungs and watch for chestrise; continue ventilations.

• If gurgling sounds are heard, stop ventilations on tube #1 andmove BVM to tube #2, begin ventilations again.

• Auscultate the stomach and lungs again; if no gurgling is heardand chest rise and breath sounds are heard, continue ventilatingon tube #2.

• Consider hyperventilation for 2 minutes after insertion, then resume normalventilation rate.

VI. Ongoing Assessment• Continuously monitor chest rise and stomach distension.• Monitor the pilot balloons to ensure the cuffs are inflated.• Reevaluate lung sounds after every movement of the patient.• Visualize the airway for materials and/or fluids.

VII. Problem Solving• If you meet resistance while inserting the tube, do not force the tube.• If you are unsure of tube placement, remove the tube and reinsert.

• Be prepared for vomiting when removing the tube.• Use caution in patients with facial trauma.• If you suspect cervical spine injury, do not hyperextend the head or neck.• Do not take a long time to insert the tube; stop and ventilate if tube insertion is

prolonged.• Prior to tube insertion, suction the airway when any fluids or materials are

present.• Air pressure must be maintained in cuffs; remove the syringes after inflations and

monitor pilot balloons; keep the syringes nearby in case they are needed.• To remove the Combitube® take these steps:

• Have suction ready.• Place the patient on his or her side.• Deflate the pharynx cuff.• Deflate the distal cuff.• Remove tube gently.• Reassess the patient.

Key TermsCombitube® – The esophageal tracheal Combitube® is a double lumen airway device designedto be placed in either the esophagus or the trachea to assist in ventilation of a patient.Teaching ActivitiesQuestions to ask before or after viewing tape:

• How should the Combitube® be stored in your EMS unit?• What is the proper procedure for disinfecting a Combitube®?

Additional activities associated with the tape:• Allow adequate time to practice the skill of Combitube® insertion into an airway

mannequin.Other ideas:

• Not all agencies use this device, nor are all EMT-Bs trained in its insertion. Review yourMedical Director’s policy on the use of the Combitube®.

Segment Name: Ventilatory Management Stoma PatientTime Codes: Begin: 1:44:53 End: 1:48:59Objectives

• List the information the EMT-B should obtain about a patient with a stoma.• Describe the steps to ventilate a patient with a full and partial laryngectomy.• Describe how to assess for effectiveness of ventilations through a stoma.

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• Explain the possible complications associated with ventilating a stoma and how to correctthem.

Overview I. Stomas are surgical openings in the neck that are used to breathe.

• When a patient presents with respiratory distress or arrest you may ventilatethrough the stoma.

• Mucous plugs often obstruct a stoma causing respiratory distress; attempt toclear the obstruction from the stoma using a suction catheter.

II. Assessment• Assess the stoma for obstruction first.• Attempt to ascertain information about the stoma:

• Reason it was placed• When it was placed• Whether the patient relies entirely on the “neck breather”; some

patients have a partial laryngectomy and are able to breathethrough their mouth and nose

III. Skill Close-up• Take BSI precautions.• Remove any items of clothing, such as scarves or ties, from the area of the stoma.• Clear the stoma of obvious mucous plugs or secretions.• Leave the patient’s head in a neutral position.• Select a mask, most often a pediatric mask, that fits securely over the stoma and

can be sealed against the neck.• Hold the mask seal with your hand, and ventilate the patient at the appropriate

rate for his or her age.• Assess for effectiveness of ventilations.

• Watch for chest rise and fall.• If unable to ventilate, suspect a partial laryngectomy and seal the

nose and mouth with one hand by placing the palm over the lipsand pinching the nose between the third and fourth fingers.Reattempt your ventilations.

• If you are unable to ventilate through the stoma, consider sealingthe stoma and ventilate through the mouth and nose.

IV. Ongoing Assessment• Continuously monitor the stoma for secretions. Suction may be required multiple

times before the airway is patent.• Assess the effectiveness of ventilations:

• Good mask seal• Chest rise and fall• Lung sounds• Skin color• Pulse oximetry

V. Problem Solving• If mucous is too thick to suction, and the materials are available to you, consider

injecting 3-5ccs of normal saline through the stoma to break up the plug and aidin its removal.

• If you are unable to ventilate through the stoma, a small endotracheal tube canbe inserted through the stoma into the trachea. Follow local protocols inperforming this procedure.

Key TermsStoma – a permanent surgical opening in the neck through which the patient breathes.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is the difference between a partial and complete laryngectomy?• How is it possible for a patient with a stoma to talk?

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Additional activities associated with the tape:• Allow adequate time to practice the skill of ventilating a stoma.

Other ideas:• Review where your agency carries the needed equipment to ventilate a stoma, and

discuss how to suction the stoma.

Segment Name: Using a Pulse OximeterTime Codes: Begin: 1:49:00 End: 1:55:38Objectives

• List the indications for the use of the pulse oximeter.• List the two readings the pulse oximeter provides.• Describe the various places to apply a pulse oximeter probe.• Explain why the pulse oximeter does not provide an accurate reading for every patient.• Describe the possible problems associated with the use of a pulse oximeter and how to

correct them.Overview

I. A pulse oximeter is a photoelectric device which measures hemoglobin that issaturated with oxygen.• Consists of a portable monitor and a sensor probe• Clips onto a finger, toe, or ear lobe• Records the reading as oxygen saturation percentage or SpO2

• Non-invasive device II. Normally, SpO2 is around 95% to 99%. Saturation below 95% may represent varying

levels of hypoxia. Be aware, however, that some patients may present normally withan SpO2 of less than 95%. A good example would be a COPD patient who normallyretains high levels of CO2.

III. Equipment• Pulse oximeter• Various sizes of probes (adult, child, infant)• Extra batteries• Acetone wipe (to remove fingernail polish)

IV. Assessment• Do not delay assessment or oxygen administration to apply the pulse oximeter.• A pulse oximeter is most useful in two situations:

• Evaluating the effectiveness of any interventions you mayperform, such as artificial respirations, oxygen therapy,bronchodilator therapy, or BVM ventilations

• Alerting you to a deterioration of the patient’s oxygen saturation• When using a pulse oximeter, keep in mind that readings will not be accurate in

all patients. For example:• Carbon monoxide (CO) poisoning• Chronic cigarette smokers• Anemic patients• Certain poisons• Hypoperfused or hypothermic patients

V. Skill Overview• Take BSI precautions.• Select appropriate size sensor.• Connect the sensor lead to the monitor and clip the sensor probe to the patient’s

fingertip, or other suitable location.• Attach the sensor cable to the pulse oximeter and turn it on.• Observe SpO2 and heart rate. Ensure screen heart rate matches patient’s pulse

rate.• Some pulse oximeters may display a pulsatile waveform, which

should correspond with the patient’s pulse rate.

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• Once you get an accurate reading check the oximeter reading every 5 minutes.A convenient time to do this is when you check the patient’s vital signs.

• Document the SpO2, and the amount of oxygen being delivered to the patient. VI. Ongoing Assessment

• Check to see that the probe is still attached to the patient as they can be easilydislodged; some models have an alarm to alert you when the probe is off.

• Some models turn themselves off after a certain amount of inactivity. VII. Problem Solving

• If you are having difficulty keeping a probe in place, consider taping it on.• If you are having difficulty getting a reading, consider using an alternate location

(e.g.: ear lobe).• Nail polish can interfere with a reading; use an acetone wipe to remove polish.

Key TermsAnemia – a condition in which there is a lack of blood.Pulse oximeter – is a photoelectric device, which measures the level of oxygen circulationthrough a patient’s blood vessels.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why would a firefighter who has smoke inhalation have a false SpO2 reading?• Why might the SpO2 be inaccurate on a patient who is in shock?

Additional activities associated with the tape:• Allow adequate time to practice the skill of SpO2 detection.

Other ideas:• Demonstrate the use of the earlobe sensor to the group.

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Tape 1 Medical Emergencies

Segment Name: Administration of Activated CharcoalTime Codes: Begin: 1:00:53 End: 1:06:50ObjectivesAfter viewing this segment, the student should be able to:

• Describe when to consider the administration of activated charcoal to a patient.• List the contraindications for the administration of activated charcoal.• List the potential side effects of activated charcoal.• List the equipment needed to administer activated charcoal.• Describe the assessment of a patient who has swallowed a poison or taken an overdose,

including the ongoing assessment.• Explain the five rights of medication administration.• Describe how to administer activated charcoal.• Discuss the problems associated with administration of activated charcoal.

Overview I. Activated charcoal is used to treat patients who have swallowed a poison or taken an

overdose.• Antidote• Binds to poison to minimize absorption

II. Contraindications for activated charcoal include:• Inability to swallow• Altered mental status (AMS)• Ingested acids or alkalis• Poisoning by cyanide, organic solvents, iron, ethanol and methanol

III. Side effects• Vomiting and/or nausea• Abdominal cramping• Constipation• Black stool

IV. Equipment• Activated charcoal• Covered container with lid• Straw• Suction unit• Emesis basin

V. Assessment• Determine the patient’s mental status.• Perform initial assessment and focused history and physical exam.• Determine substance ingested.• Identify possible contraindications.• Determine when taken.

VI. Obtain medical consent to administer medication.• Report information to medical control.• Request and confirm order to administer medication.

VII. Confirm the five rights of medication administration:• Right patient• Right drug• Right dose• Right route of administration• Right time

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VIII. Administration of activated charcoal• Measure and mix the preparation.• Adult dose is 25-50 grams / pediatric dose is 12.5-25 grams (confirm with local

protocols)• Explain the procedure to the patient.• Instruct the patient to drink the mixture through the straw.• Prepare for vomiting.• If the patient vomits or spits up the dose, consider a second dose (obtain medical

consent for second dose).• Document

IX. Ongoing assessment• Monitor and reassess.• Be prepared for vomiting.

X. Problem Solving• Never force a patient to swallow medication.• Notify medical control.• Use an opaque cup to mask the medication’s appearance.

Key TermsActivated charcoal – a powder, usually pre-mixed with water, that will absorb some poisons andhelp prevent them from being absorbed by the body.Adverse reaction – any reaction to a procedure or drug administration other than the desiredaction.Contraindications – specific signs or circumstances under which it is not appropriate and maybe harmful to administer a particular drug to a patient.Indications – specific signs or circumstances under which it is appropriate to administer a drug toa patient.Side effect – any action of a drug other than the desired action.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is your state, regional, or local treatment protocol for poisoning?• Why is activated charcoal inappropriate to administer to a patient with an altered mental

status?Additional activities associated with the tape:

• Allow adequate time to practice the skill of activated charcoal administration.Other ideas:

• In this instance it may be appropriate to substitute a milkshake as a reward for thestudent’s attention to details.

• List a number of substances that would be appropriate use for activated charcoal.• Discuss your Medical Director’s and the regional Poison Control’s view on activated

charcoal as well as use of Ipecac.

Segment Name: Administration of GlucoseTime Codes: Begin: 1:06:55 End: 1:12:10ObjectivesAfter viewing this segment, the student should be able to:

• Describe when to consider the administration of oral glucose to a patient.• List the contraindications for administering oral glucose.• Describe the assessment of a patient experiencing a hypoglycemic episode, including the

ongoing assessment.• List the equipment needed to administer oral glucose.• Explain the five rights of medication administration.• Describe how to administer oral glucose.• Discuss the special considerations associated with administration of oral glucose.

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Overview I. Oral glucose is used to treat patients with a history of diabetes exhibiting an altered

mental status (AMS) and the ability to swallow.• Oral glucose is a form of glucose.• Can reverse a diabetic’s hypoglycemic condition.• Time of administration can make a critical difference.• Preparation comes in a tube.

II. Assessment• Determine the patient’s mental status.• Perform initial assessment and focused history and physical exam.• Determine if the patient takes insulin or an oral hypoglycemic agent, as well as

when these medications were taken last.• Determine when the patient had eaten last.• Determine if the patient has had overexertion or recent illness.• Determine is there has been vomiting.• Determine if the onset of AMS was rapid or slow.• Determine if the patient is able to swallow and has a gag reflex.

III. Equipment• BSI• Oral glucose tube• Tongue depressor• Suction

IV. Skill Close-up• Obtain medical consent.• Consult with medical control for medication administration instructions.• Review protocols or standing orders.• Reassess patient’s ability to swallow.• Explain the procedure to the patient.• Confirm the five rights of medication administration:

• Right patient• Right drug• Right dose• Right route of administration• Right time

• Patient may self administer• Document

V. Ongoing Assessment• Monitor patient for subtle mental status changes.• Monitor airway.• Monitor vital signs.

VI. Problem solving• Patient may have a glucose monitor that may be used by the EMT-B if approved

by local protocol.• Do not give anything orally to a patient with the inability to swallow or intact gag

reflex.• Utilize ALS for patients with the inability to swallow or intact gag reflex.

Key TermsDiabetes mellitus – also called “sugar diabetes” or just “diabetes,” the condition brought aboutby decreased insulin production. The person with this condition is a diabetic.Hypoglycemia – low blood sugar.Insulin – a hormone produced by the pancreas or taken as a medication by many diabetics.Oral glucose – a form of glucose given by mouth to treat an awake patient with an altered mentalstatus and a history of diabetes.

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Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is the role of insulin in the diabetic patient?• Why is the field treatment of low blood sugar more urgent than high blood sugar?

Additional activities associated with the tape:• Allow adequate time to practice administering oral glucose to a simulated hypoglycemic

patient. You may want to substitute cake frosting for the classroom setting to be realistic.Other ideas:

• If the Medical Director or ALS instructor is available it would be helpful to review how aglucometer works since many patients will have these devices in their home.

Segment Name: Metered Dose InhalerTime Codes: Begin: 1:12:15 End: 1:20:35ObjectivesAfter viewing this segment, the student should be able to:

• Describe when to consider the administration of a metered dose inhaler (MDI) to apatient.

• List the contraindications for an MDI.• Explain what a bronchodilator is and list the most common bronchodilator medications.• Describe the assessment of a patient experiencing respiratory distress, including the

ongoing assessment.• List the equipment needed to administer an MDI.• Explain the five rights of medication administration.• Describe how to assist a patient with an MDI.• Discuss the special considerations associated with administration of an MDI.

Overview I. Metered dose inhalers (MDIs) administer a prescribed dose of medication

• Usually to patients with a history of chronic pulmonary disease• The most common medication found in MDIs are bronchodilators

II. Bronchodilators are drugs that dilate, or enlarge the air passages, making breathingeasier.• Bronchodilators begin to work immediately.• Effects last for hours.• The device administers a specific measured (metered) dose of medication.• A spacer can be utilized to help administer the medication.

III. The most common bronchodilators include:• Albuterol (Proventil, Ventolin®)• Metaproterenol (Metaprel®, Alupent®)• Isoetharine (Bronchosol®, Bronkometer®)

IV. MDIs are usually self-administered by the patient.• EMT-Bs may assist the patient when they are unable to self-administer.• EMT-Bs must consult with medical control or local protocol on the appropriate

dose, as well as guidelines on multiple dosing. V. Use of an MDI is indicated when:

• A patient is short of breath and/or has signs and symptoms of difficulty breathing.• The MDI has been prescribed to a patient by a physician.• Local protocols or medical direction has approved the use of the device.

VI. Use of an MDI is contraindicated when:• The patient is unable to use the device (i.e. unresponsive).• The patient has already taken the maximum number of doses prior to the arrival

of EMT-Bs.• Permission has not been given by local protocols or medical direction.

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VII. Assessment• Determine the patient’s mental status.• Perform initial assessment and focused history and physical exam.• Determine if the patient has taken the MDI prior to your arrival and if so, how

many times. VIII. Equipment

• BSI• MDI• Stethoscope• Oxygen

IX. Skill overview• BSI• Confirm the five rights of medication administration:


• Check expiration date and that this medication is prescribed to this patient.• Shake MDI before use.• Best used at room temperature.• Explain the procedure to the patient and obtain consent.• Assist the patient with the MDI.• Place oxygen on the patient.• Document.

X. Ongoing Assessment• Reassess vital signs, pulse oximetry and other pertinent physical findings.• Continuously monitor the patient for drug effects, including adverse reactions.• Document any changes.

XI. Problem Solving• Timing and coordination is key in MDI administration.• Consider the use of a spacer.• Wait at least two minutes prior to administering additional doses.

Key TermsAsthma – a condition triggered by an allergen, exercise, or emotional stress. Asthma affectsyoung and old patients with episodic attacks that occur at irregular intervals. The patient is free ofsymptoms between attacks. During an attack, bronchioles in the lungs constrict and mucus isproduced. This causes wheezing and severe difficulty breathing.Bronchodilator – a drug designed to dilate the constricted bronchial tubes in order to makebreathing easier.Metered dose inhaler (MDI) – a patient self-administered prescribed inhaler, usually abronchodilator.Spacer – a “spacer” device between an inhaler and the patient allows more effective use ofmedication. If the patient has a spacer, it should be attached to the inhaler before use.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Can the use of an MDI hurt a patient? If so, give examples of someone it could hurt.• Why are spacers often used for children who use an MDI?

Additional activities associated with the tape:• Allow adequate time to practice administration of an MDI with a simulated medication and

patient.Other ideas:

• Sometimes the manufacturers produce MDIs that can be used for training, which do notactually contain medication.

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Segment Name: NitroglycerinTime Codes: Begin: 1:20:38 End: 1:27:40ObjectivesAfter viewing this segment, the student should be able to:

• Describe when to consider the administration of nitroglycerin (nitro) to a patient.• Describe what type of medication nitro is and how it works.• List the indications for the administration of nitro.• List the contraindications for the administration of nitro.• List the possible side effects of nitro.• Describe the assessment of a patient experiencing chest pain, including the ongoing assessment.• List the equipment needed to administer nitro.• Explain the five rights of medication administration.• Describe how to assist a patient with nitro.• Discuss the special considerations associated with administration of nitro.

Overview I. Nitroglycerin (nitro) is a potent vasodilator which helps to dilate the coronary arteries

that supply the heart with blood.• Relieves the chest pain associated with angina.• Patients that are prescribed nitro are instructed to take the medication when they

experience chest pain and may have taken it before the EMT-B arrives on scene.• Assisting a patient with nitroglycerin may help to reduce myocardial damage.• Absorption rate is 1 to 2 minutes with a duration of 30 minutes.

II. To assist a patient with nitro, all of the following indications must be met:• The patient complained of chest pain.• The patient has a history of cardiac problems.• The patient’s physician has prescribed nitro.• The patient has the medication and it is prescribed to them.• The patient’s systolic blood pressure is greater than 100.• Medical direction, a medical standing order, or local protocol allows you to assist

with nitro. III. Contraindications for administering nitro include:

• The patient’s systolic blood pressure is less than 100.• The patient has already taken the maximum prescribed doses.• The patient is unable to open his or her mouth.• The patient has taken Viagra® within the last six hours.• The patient has a head injury.• The patient is an infant, child, or falls below an age limit set by local protocols.• Presence of significant trauma

IV. Possible side effects include:• Hypotension• Headache• Changes in pulse rate

V. Equipment• Blood pressure cuff• Patient’s nitro tablets or spray• Stethoscope

VI. Assessment• Complete an initial assessment of the patient.• Administer high concentration oxygen.• Complete a focused history and physical exam.• Make sure the patient meets the indications for using nitro.• Make sure the patient exhibits none of the contraindications.• Take full set of vital signs including blood pressure prior to administration.

VII. Skill Overview• BSI

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• Consult with medical direction and/or review any standing medical orders orprotocols.

• Confirm the five rights of medication administration:• Right patient• Right drug• Right dose• Right route of administration• Right time

• Check expiration date.• Ask the patient when the nitro container was opened and how it was stored.• Nitro is sensitive to light, heat, and age.• Ask when the patient last took nitro and what the reaction was.• Have the patient take a comfortable position that will allow for ability to lay supine

if necessary.• Remove the oxygen mask and administer the medication.• Assist the patient with the nitro.• Replace the oxygen mask.• Reassess blood pressure within two minutes.• Document.

VIII. Ongoing Assessment• Monitor the patient’s vital signs every 5 minutes.• Ask the patient about response or relief.• Continuously monitor the patient for drug effects, including adverse reactions.• Document any changes.

IX. Problem Solving• The most common and significant problem with nitro is a hypotensive response.• First time users of nitro or patients who drank alcohol or who are taking

antihypertensive medications can have more prominent hypotensive effects.• Place the patient in a supine position and elevate the legs.• Wear PPE to prevent absorption of the medication into your own system.• Headaches are a common side effect of the medication.• If the patient does not have nitro with them provide immediate transport and

request ALS back up.Key TermsNitroglycerin – a medication that dilates the blood vessels.Vasodilator – a drug, which acts to widen or dilate the blood vessels.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is the significance of finding a patient who has a nitro patch or paste applied to hischest wall?

• Why does fresh nitro produce a headache for the patient?Additional activities associated with the tape:

• Allow adequate time to practice the skill of nitro administration with mint TicTacs®(candy) in a simulated patient. Binoca® breath spray is another option.

Other ideas:• Discuss the value of nitrates in the management of other cardiac patients.

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Segment Name: Epinephrine Auto InjectorTime Codes: Begin: 1:27:46 End: 1:32:25ObjectivesAfter viewing this segment, the student should be able to:

• Describe when to consider the administration of an epinephrine auto injector (Epi pen) toa patient.

• List the contraindications for an auto injector.• Describe the assessment of a patient experiencing allergic reaction, including the

ongoing assessment.• List the equipment needed to administer an auto injector.• Explain the five rights of medication administration.• Describe how to assist a patient with an auto injector.• Discuss the special considerations associated with administration of an auto injector.

Overview I. Epinephrine auto-injector (Epi pen)

• A life-saving self-administered medication• Prescribed by a physician to a specific patient• EMT-Bs may assist administration (depending on State, Regional or local

protocols)• Disposable prepackaged single dose• Usually administered in the thigh

II. Equipment• BSI• Patient’s auto-injector• Sharps or biohazard container• Oxygen equipment

III. Assessment• Complete an initial assessment on the patient.• Administer high concentration oxygen to the patient.• Complete a focused history and physical exam.• Assess for signs of allergic reaction, which may include:

• Altered level of consciousness• Rash• Hives• Edema• Shortness of breath• Signs of hypotension or shock• Pale, cool, moist skin• Rapid pulse• Thirst• Hypotension

IV. Skill Overview• BSI• Obtain the patient’s auto-injector.• Make sure the medication is visible and is not cloudy or discolored.• Consult with medical direction and/or review any standing medical orders or

protocols.• Confirm the five rights of medication administration:


• Check expiration date.• Explain the procedure to the patient and obtain consent.

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• Expose the thigh area.• Place the auto-injector device on the lateral thigh midway between the knee and

the waist.• Administer the medication.• Dispose of the injector in a sharps or biohazard container.• Document.

V. Ongoing Assessment• Reassess vital signs and patient condition.• Consider the need for a second dose if the patient’s condition deteriorates and

medical control approves.• Assess blood pressure, pulse, respirations, skin signs, and other earlier positive

physical findings.• Continuously monitor the patient for drug effects, including adverse reactions.• Document any changes.

VI. Problem Solving• The spring-loaded device needs firm pressure against the thigh.• Make sure that you are pressing hard enough.• Needle stick injuries are possible; if one occurs consult local protocols and

implement needle stick procedures immediately.• Immediately consult with medical control if the patient experiences any adverse

effects from the medication.Key TermsAnaphylaxis – a severe or life-threatening allergic reaction in which the blood vessels dilate,causing a drop in blood pressure, and the tissues lining the respiratory system swell, interferingwith the airway. Also called anaphylactic shock.Epinephrine auto injector – a syringe with a spring-loaded needle that will release and injectepinephrine into the muscle when the auto-injector is pushed against the thigh.Urticaria – a skin reaction in which there is intense itchiness near pale, irregular raised patchesof skin. Also called a “nettle rash.”Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it important to determine if the patient has a second epi auto-injector and to bringit along to the hospital?

• What are examples of allergies patients may have?Additional activities associated with the tape:

• Allow adequate time to practice this skill with an auto-injector trainer and a simulatedpatient.

Other ideas:• The manufacturer of the medication can provide an auto-injector trainer to use in training

students in this technique.

Segment Name: Administration of Nebulized MedicationTime Codes: Begin: 1:32:30 End: 1:37:40ObjectivesAfter viewing this segment, the student should be able to:

• Describe when to consider the administration of a nebulized medication to a patient.• List the medications that might be used in a nebulizer.• List the contraindications for the use of a nebulizer.• Describe the assessment of a patient experiencing respiratory distress, including the

ongoing assessment.• List the equipment needed to administer a nebulized medication.• Explain the five rights of medication administration.• Describe how to assemble the nebulizer.• Describe how to assist a patient with a nebulizer.

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• Discuss the special considerations associated with administration of a nebulizedtreatment.

Overview I. A nebulizer is a device which aerosolizes medications into a mist for delivery directly

into the lungs.• A fast, non-invasive way to administer medication.• Requires an air compressor or oxygen delivery system.• The patient has to be alert enough to assist in the delivery process.

II. Equipment• BSI• Medication• Hand-held nebulizer

• Connection tube• Nebulizer chamber• T-tube• 6-inch flex• Mouthpiece

• Oxygen tank and regulator III. Assessment

• Complete initial assessment.• Administer high-concentration oxygen.• Complete a focused history and physical exam.• Determine if the patient has the ability to use the hand-held nebulizer.• Determine the drug to be administered (albuterol, Atrovent).

IV. Skill Overview• BSI• Consult with medical direction and/or review any standing medical orders or

protocols.• Confirm the five rights of medication administration:


• Check expiration date and that the medication is prescribed to this patient.• Explain the procedure to the patient and obtain consent.• Add the medication to the nebulizer chamber attach lid.• Connect the mouthpiece to one end of the T-tube and the flex tube to the other

end.• Attach oxygen-connecting tube from nebulizer to the oxygen source.• Adjust oxygen to 6 liters per minute.• Ask the patient to sit upright and hold the nebulizer.• Ask the patient to place the mouthpiece in his/her mouth tightly and breathe

deeply and slowly through the mouth until the medication is gone.• Document.

V. Ongoing Assessment• Reassess vital signs and patient condition.• Consider the need for a second dose if the patient’s condition deteriorates and

medical control approves.• Assess blood pressure, pulse, respirations, skin signs, and other earlier positive

physical findings.• Continuously monitor the patient for drug effects, including adverse reactions.• Document any changes.

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VI. Problem Solving• For the procedure to be effective, the patient has to be alert and have a fair

respiratory volume.• Contact medical control for options if treatment is not effective or patient

deteriorates.Key TermsChronic obstructive pulmonary disease (COPD) – an irreversible disease in which there is anobstruction in the lungs causing respiratory difficulty.Nebulizer – a device, which causes a gas such as oxygen to flow through a liquid medication,turning it into a vapor that can be continuously inhaled.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What are examples of patients who may need a nebulizer treatment?• What is a wheeze?

Additional activities associated with the tape:• Allow adequate time to practice administering a nebulizer treatment using sterile water

(instead of actual medication) on a simulated patient.Other ideas:

• To simulate the sensation of difficulty breathing that a patient with reactive airwaydisease may have, ask the students to imagine breathing through a cocktail straw whilesomeone is sitting on their chest!

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Tape 2 Medical Emergencies

Segment Name: Automated External DefibrillatorTime Codes: Begin: 1:00:53 End: 1:13:45ObjectivesAfter viewing this segment, the student should be able to:

• Explain the need for an automated external defibrillator (AED) and its role in the chain ofsurvival.

• List the equipment needed to administer shocks to a patient using an AED.• List the indications for the use of an AED.• Describe the procedure to use an AED.• Explain what to do when an AED specifies “no shock indicated.”• Explain the steps to take when pulses return after shock(s) have been administered.• Describe the steps to take in the ongoing assessment.• Discuss the special considerations associated with the use of an AED.

Overview I. Automated External Defibrillator (AED)

• One of the most important links in the chain of survival.• A device that delivers an electrical shock through the chest wall to the heart

which is fibrillating or is in ventricular tachycardia.• The goal is to stop the heart from fibrillation so the normal pacemaker can take

over.• Simple to operate allowing for many potential users.• Two types of AED – monophasic and biphasic (user will not know the difference).

II. Equipment• BSI• AED• Defibrillator pads• Razor• Oxygen• Ventilator• Bag-valve mask• Suction equipment

III. Assessment• Patient must be unconscious, non-breathing, and without a pulse (signs of

circulation).• If CPR is in progress have the responder stop CPR to verify pulselessness and

breathing status. Look for external blood loss. IV. Skill close-up

• Upon arrival, briefly question those on the scene about the arrest events.• If someone is performing CPR direct them to stop momentarily for assessment.• Take BSI precautions.• Lay the patient supine on a dry, non-metallic surface.• If a pulse or signs of circulation are absent perform or resume CPR.• One EMT-B performs CPR while another sets up the AED.• Determine whether the patient is a candidate for the AED.

• If the patient is at least 8 years old and has not sustainedtrauma, proceed with the AED.

• If the patient is younger than 8 years old or has sustained traumado not attach the AED unless instructed to do so by medicaldirection. Continue CPR and transport.

• Turn on AED, attach defibrillator pads to the patient’s chest, and followinstructions provided by the AED.

• If the device detects a shockable rhythm, prepare to shock.

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• If the device does not detect a shockable rhythm, check the patient’s pulse. Ifno pulse, resume CPR for one minute then reanalyze.

• Even if a pulse returns, in most cases the patient will require ventilatoryassistance.

1. If breathing is adequate, apply high-concentration oxygen bynon-rebreather mask.

2. If breathing is not adequate, ventilate the patient with high-concentration oxygen.

V. Ongoing Assessment• If pulses have returned, check the blood pressure and respirations.• If no pulse returns, continue CPR and reanalyze with the AED as directed by

medical control or local protocol.• Continue on with the reassessment of the initial assessment.

VI. Problem Solving• Safety for the patient and the responders is essential during defibrillation.• Move the patient to a safe area when necessary.• Remove any nitro patches from the patient.• Do not allow anyone to touch the patient during the AED’s assessment and

defibrillation.• The AED will not function properly if there is any patient movement (i.e.: CPR or

ventilations) or the defibrillation pads are not placed securely on the patient.• Hypothermic patient – consult your local treatment protocols.• Batteries VII. Transport the patient as soon as one of the following occurs:• You have administered six shocks.• You have received three consecutive “no shock indicated” readings (separated

by one minute of CPR).• The patient regains pulses.

Key TermsAutomated External Defibrillator (AED) – an automated defibrillator with a microprocessor thatinterprets the rhythm and determines whether or not it is appropriate to deliver a shock.Biphasic – a newer method in which a defibrillator delivers a shock. The energy goes in onedirection, then reverses itself and moves in the opposite direction between the two electrodes.Defibrillator pads – self-adhesive pads (patches) that attach to the patient and plug into the AEDfor the purpose of monitoring and defibrillation.Monophasic – is one method in which a defibrillator delivers a shock. The traditional directcurrent shock goes from one electrode to the other.Teaching ActivitiesQuestions to ask before or after viewing tape:

• How should the electrodes be placed if you feel a pacemaker battery under the skin?• Why is it so important that AEDs be available in places of mass public occupancy?

Additional activities associated with the tape:• Allow adequate time to practice the use of an AED.

Other ideas:Note: become familiar with the AED protocols and Public Access Defibrillation (PAD) projects.Some states allow defibrillation of children less than 8 years old with the appropriate AED, as wellas require these devices in the schools.

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Segment Name: Application of Soft RestraintsTime Codes: Begin: 1:13:49 End: 1:19:10ObjectivesAfter viewing this segment, the student should be able to:

• Describe when it is appropriate to consider the use of reasonable force and softrestraints.

• Explain the goal of the use of soft restraints.• Describe the assessment and ongoing assessment of a patient who is, or may be, a

danger to himself or others.• List the equipment needed to apply soft restraints.• Explain the approach to take with the patient that needs to be restrained.• Explain the possible dangers to the patient, as well as the rescuers when soft restraints

are used.

• Discuss the special considerations associated with the use of soft restraints.Overview

I. When it has been determined that the patient is a danger to himself or others,reasonable force and restraint may be used.• The goal is to restrain the patient and not harm him or her.

II. Assessment• Always consider physiologic causes for the patient’s behavior.• Make sure the patient is not carrying a weapon.• You can perform a “pat-down” during the patient assessment.• Attempt to determine what triggered the patient’s unruly behavior.• Quickly perform a scene assessment.• Make sure the scene is safe. Law enforcement should be required to intervene if

the patient is extremely combative or wielding a weapon.• Always have an exit plan and stay at least an arm’s distance from the patient.

III. Equipment• Soft restraints• Sufficient personnel, one person per extremity at a minimum• Surgical mask or oxygen mask• BSI• Wipe tape, sheets

IV. Skill Close-up• BSI• Plan your actions ahead of time.• Assign one person to each limb.• Rescuers should act all at once to overwhelm the patient.• Attempt to grab clothing or large joints, avoid placing pressure on the neck or

chest.• Avoid the mouth as some patients may try to bite.• An EMT-B should be assigned to reassure the patient throughout the procedure.• Secure all limbs with restraints approved by local protocol.• The patient should be secured on the ambulance stretcher in a supine or lateral

position.• If the patient is spitting at rescuers, a surgical mask or oxygen mask (connected

to oxygen) can be placed over the patient’s face.• Continually monitor distal circulation in restrained extremities.• Once restrained do not leave the patient at any time.• Consider having extra personnel in the ambulance’s patient compartment during

transport.• Monitor ABCs.• Do not remove restraints unless sufficient personnel are available to restrain the

patient.• Document how and why the patient was restrained.

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V. Ongoing Assessment• Constantly reassess restrained extremities during transport.• Monitor ABCs.• Reassess vital signs.

VI. Problem Solving• Be familiar with the type of restraints carried in your ambulance.• Practice using them before you need them.• Consider ALS resources for chemical restraint.

Key TermsChemical restraints – drugs, which may be used to sedate or calm a patient who may beharmful to himself or others.Reasonable force – to place whatever reasonable restraints are required on the patient asquickly as possible, and with the least amount of discomfort to the patient, and with the leastamount of force.Soft restraints – humane restraints such as wide roller gauze or commercial restraints designedfor the purpose of humane restraint.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it dangerous and no longer allowed, to restrain a patient in the prone position?• Why is it dangerous to “hog tie” a patient?

Additional activities associated with the tape:• Allow adequate time to practice patient restraint in a room that has mats and no furniture.

Other ideas:• Consider reviewing a copy of the Position Paper of the National Association of EMS

Physicians on patient restraint in Emergency Medical Services with the students.• If there is any danger to EMS personnel it is strongly advised that the police be contacted

prior to restraint of the patient.

Segment Name: ChildbirthTime Codes: Begin: 1:19:14 End: 1:29:15ObjectivesAfter viewing this segment, the student should be able to:

• Describe the stages of labor.• List the indications of imminent delivery.• Review the questions to ask in the focused history of a pregnant patient.• List the equipment needed to assist a patient with childbirth.• Describe the assessment of a patient experiencing labor.• Describe how the EMT-B can best prepare the patient and assist the patient with delivery

of the baby.• Describe how to clamp and cut the umbilical cord.• Describe the steps in delivery of the placenta.• List the steps in the ongoing assessment of infant and mother.• Describe the possible complications of childbirth.• Explain the steps to take when vaginal bleeding becomes excessive after delivery.

Overview I. Childbirth is a natural process, the EMT-B may assist.

• Pregnancy is divided into 9 months or 3 trimesters.• Labor is divided into the following three stages:

1. The first stage begins when contractions start and cervixbecomes fully dilated.

2. The second stage ends when the baby is delivered.3. The third stage ends with the delivery of the placenta.

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• When contractions begin, they usually last for 30 seconds to 1 minute and occurat 2- to 3- minute intervals. Contractions less than 2 minutes apart are a signof delivery.

• A transport decision will need to be made based on the indications of imminentdelivery.

II. Assessment• Begin to evaluate the mother by asking the following questions:

• What is the due date?• What prenatal care have you received?• Have you had any complications in your pregnancy?• Is this your first pregnancy?• Describe your contractions, how long and how far apart are

they?• Have you had any vaginal discharge; if so, what color and how

much?• Has your water broken?• Do you have the urge to urinate or defecate?• Do you have the urge to push?

• Obtain a SAMPLE history and baseline vital signs.• Be observant for hypertension.• Examine for crowning (the baby’s head visible through the vaginal opening).• Be reassuring and respectful of the patient’s privacy.

III. Equipment• BSI• Obstetric kit which contains the following:

• Sterile gloves• Plastic bag to store placenta• Umbilical cord clamp or ties• Umbilical cord scissors• Towels or sheets to keep delivery area as sterile as possible• Bulb syringe (to suction baby)• Sanitary pad (to help control bleeding)• Gauze sponges or towels (to dry baby)• Baby blanket

IV. Skill Close-up• BSI• Remove clothing that obstructs the vaginal area.• If possible, clean vaginal area with antiseptic towelettes.• Using sheets, drape the patient leaving vaginal area exposed.• As the baby’s head presents, support the head and apply slight counter-

pressure.• Spread your fingers across the head avoiding the fontanelles.• If the amniotic sac has not ruptured, gently tear it open.• Once the head has delivered, quickly suction the baby’s mouth, then nose.• If the umbilical cord is wrapped around the baby’s neck, gently remove it.

• If you cannot remove the cord, clamp the cord in two places andcut.

• After the head, the anterior shoulder will deliver first. As the anterior shoulderdelivers, apply gentle downward pressure.

• After the anterior shoulder, the posterior shoulder will deliver. As the posteriorshoulder delivers, apply gentle upward pressure.

• Support the trunk and feet as the rest of the baby delivers.• After delivery, dry off the baby and continue to monitor the airway, suctioning as

needed.• Wrap the baby in blankets to conserve warmth.

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• Keep the baby at the same level as the vaginal opening until the umbilical cordstops pulsating.

• To cut the cord, place one clamp 7 inches from the baby and a second clamp 10inches from the baby and cut between the clamps.

• Note the time of birth.• Placental delivery usually begins within 10-15 minutes after the baby has

delivered.• Never pull on the placenta.• Save the placenta for examination in the ED.

• Monitor the mother and baby during transport to the hospital. V. Ongoing Assessment

• For the baby:• Immediately assess baby after birth and 5 minutes later.• Monitor breathing, heart rate, crying, movement, and skin color.• Maintain warmth.

• If the baby is not breathing after 30 seconds of stimulation, resuscitation will benecessary. The EMT-B should focus on these measures:

1. Drying2. Warming3. Positioning4. Suctioning5. Tactile stimulation6. Oxygen7. Bag mask ventilation8. Chest compression

• For the mother:1. Placenta usually delivers several minutes after childbirth.2. Keep all afterbirth tissue. The receiving physician will examine it

for abnormality.3. The mother may continue to bleed vaginally but usually no more

than 500cc.4. If excessive bleeding occurs, sanitary pads may be placed over

(not into) the vagina to help control bleeding.5. Massage the uterus through the abdomen, stimulating uterine

contractions, which stop bleeding.6. Nursing the baby also promotes the release of oxytocin, a

hormone that causes uterine contractions.7. Monitor for signs and symptoms of hypovolemic shock.8. Transport in position of comfort.

VI. Problem Solving• Breech presentation (buttocks or feet first)• Prolapsed cord (umbilical cord presents first)• Limb presentation (arm or leg presentation)

• MeconiumKey TermsBreech presentation – when the baby appears buttocks or both legs first during birth.Limb presentation – when a baby’s limb protrudes from the vagina before the appearance ofany other body part.Meconium staining – amniotic fluid that is greenish or brownish-yellow rather than clear as aresult of fetal defecation; an indication of possible maternal or fetal distress during labor.Obstetric Kit – a childbirth delivery kit.Prolapsed umbilical cord – when the umbilical cord presents first and is squeezed between thevaginal wall and the baby’s head.

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• Why is good prenatal care so important?• What are the effects of delivering an infant to a mother who is addicted to narcotics?

Additional activities associated with the tape:• Allow adequate time to practice skill of childbirth with a mannequin.

Other ideas:• Review newborn resuscitation and the inverted triangle.

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Tape 1 Trauma Emergencies

Segment Name: Bleeding Control / Shock ManagementTime Codes: Begin: 1:00:55 End: 1:19:04ObjectivesAfter viewing this segment, the student should be able to:

• List the signs and symptoms of shock.• Describe the three types of external bleeding.• Describe the primary methods for controlling external bleeding.• List the equipment needed for controlling bleeding.• Describe how to assess the patient with external bleeding.• Describe how to bandage and dress a bleeding injury.• Explain how to treat a patient who is in shock.• Explain the special considerations associated with the use of occlusive dressings, air

splints, PASG, and tourniquets.• Describe the special techniques used for managing impaled objects, avulsions,

amputations, and open neck and chest wounds.Overview

I. Signs of shock include:• Pale, cool, clammy skin• Nausea and vomiting• Thirst, dilated pupils, cyanosis• Vital sign changes to include:

� Increased pulse, followed by decreased pulse� Increased respirations, labored, shallow, irregular� Decreased blood pressure

II. Types of external bleeding• Arterial• Venous• Capillary

III. Methods for controlling bleeding• Direct pressure• Elevation• Pressure points

IV. Equipment needed for controlling bleeding includes:• Gloves, goggles, mask, and/or gown• Absorbent materials• Bandaging materials• Pressure dressing• Occlusive dressing• Tape

V. Assessment• BSI• Estimate amount of blood loss.• Expose.• Recognize signs of shock.• Manage life-threatening bleeding.

VI. Treatment• BSI• Expose.• Apply direct pressure.• Elevate.• If bleeding persists, apply more pressure, bandages and elevate.• Locate arterial pulse proximal to the injury site and apply pressure.

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• Bandage dressing in place.• Assess distal circulation.• Position the patient and transport.• Reassess.

VII. Treatment for shock• Position the patient.• Maintain airway and apply oxygen.• Explain procedure to patient and obtain consent.• Elevate legs.• Prevent heat loss.• Monitor patient.• Reassess.

VIII. Problem Solving• Occlusive dressings• Air splints /PASG• Tourniquets

IX. Dressing and Bandaging• Prevents further bleeding• Prevents further contamination• Once in place do not remove bandage.

X. Special Techniques• Impaled objects• Avulsions• Amputations• Open chest wounds

Key TermsAmputation – the surgical removal or traumatic severing of a body part, usually an extremity.Arterial bleeding – is characterized by bright red, spurting blood, which indicates that an arteryhas been damaged or severed.Avulsion – the tearing away or tearing off of a piece or flap of skin or other soft tissue. This termalso may be used for an eye pulled from its socket or a tooth dislodged from its socket.Capillary bleeding – is characterized by dark red blood oozing slowly from a wound.Occlusive dressing – any dressing that forms an airtight seal.PASG – pneumatic anti shock garment. A large air splint used for the treatment of shock, pelvicinjuries or instability accompanied by shock, and to control bleeding in massive soft-tissue injuriesto the lower extremities.Tourniquet – a device used for bleeding control that constricts all blood flow to and from anextremity.Venous bleeding – is characterized by a dark red, steady flow of blood, which indicates a vein issevered or damaged.Teaching ActivitiesQuestions to ask before or after viewing tape:

• How do the types of bleeding differ?• What is a pressure point and what are two examples of one?

Additional activities associated with the tape:• Allow adequate time to practice bleeding control.

Other ideas:• Demonstrate how to immobilize a pencil in the eye or a sheet of glass in a patient’s back.

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Segment Name: Immobilizing a Long BoneTime Codes: Begin: 1:19:10 End: 1:26:50ObjectivesAfter viewing this segment, the student should be able to:

• List the signs of a dislocated or fractured long bone.• Describe the types of splints used to immobilize a fracture.• List additional equipment used to splint a fracture.• Describe the assessment of a patient with a possible fracture including ongoing

assessment.• Explain the procedure for splinting a long bone.• Describe the hazards of incorrect splinting.

OverviewI. Signs and symptoms

• Exposed bone ends• Joints locked in position• Pain, paralysis, paresthesia• Pallor of the injury site

II. Types of splints• Rigid• Formable• Traction

III. Equipment needed to splint a long bone• Rigid or formable splint• Cravats, Kling bandage, or tape• Padding

IV. Assessment• Safety /BSI• Manage ABCs.• Rapid Trauma Assessment (RTA) / Focused Physical Exam (FPE).• Recognize signs of shock.• Assess for pain, pallor, paresthesia, pulses, and paralysis on injured extremity.

V. Skill overview• BSI• Stabilize the injury.• Expose the injury.• Select appropriate splint.• Explain procedure to the patient and obtain consent.• Assess distal pulses, motor function and sensation (PMS).• Apply splint.• Reassess PMS.• Document.

VI. Ongoing assessment• Reassess distal PMS.• Reevaluate splint.

VII. Hazards of incorrect splinting include:• Loss of pulses distal to the injury• Most rigid splints require padding.• Splint is too loose.• Splint is too tight.• Open fractures with protruding bone ends

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Key TermsClosed fracture – an internal injury with no open pathway from the outside.Crepitus – the grating sound or feeling of broken bone rubbing together.Open fracture – an injury in which the skin has been broken or torn through from the inside by aninjured bone or from the outside by something that has caused a penetrating wound withassociated injury to the bone.Paralysis – loss of muscle function caused by injuries or disease of the nerves, brain, or spinalcord.Paresthesia – an abnormal sensation such as numbness or tingling.Traction splint – a special splint that applies constant pull along the length of a lower extremityto help stabilize the fractured bone and to reduce muscle spasms. Traction splints are usedprimarily on femoral shaft fractures.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is a long bone?• Give four examples of long bones.

Additional activities associated with the tape:• Allow adequate time to practice long-bone splinting.

Other ideas:• Demonstrate how traction could be applied to a long bone when no traction splint is

available.

Segment Name: Joint ImmobilizationTime Codes: Begin: 1:27:00 End: 1:36:04ObjectivesAfter viewing this segment, the student should be able to:

• List the signs and symptoms of a dislocated joint.• List the equipment needed to splint a joint injury.• Describe assessment of a joint injury including ongoing assessment.• Describe the procedure for splinting a joint injury.• Explain the special considerations associated with open fractures.• Explain the special techniques used to immobilize an ankle, knee, wrist, elbow, and

fingers.Overview

I. Signs and symptoms of a dislocated joint• Pain, tenderness and/ or bruising• Deformity and swelling• Grating or crepitus• Severe weakness or loss of function• Locked joint

II. Equipment• Rigid splint• Formable splint• Cravat, Kling, Ace bandage, or tape• Padding• Cold pack

III. Assessment• Assess for pain, pallor, paresthesia, pulses, and paralysis on injured extremity.

IV. Skill overview• BSI• Stabilize the injury.• Expose the injury.• Select appropriate splint.• Explain procedure to the patient and obtain consent.

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• Assess distal pulses, motor response, and sensation (PMS).• Apply splint.• Reassess PMS.• Apply cold pack.• Document.

V. Ongoing assessment• Reassess distal PMS.

VI. Problem solving• Splint in position found, in most cases.• Open fractures / exposed bone ends• Rigid splints often require padding.• Using a cold pack to reduce swelling

VII. Special techniques• Ankle• Knee• Wrist• Elbow• Fingers

Key TermsDislocation – the disruption or “coming apart” of a joint.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why shouldn’t an injured elbow or knee be straightened before splinting?Additional activities associated with the tape:

• Allow adequate time to practice splinting joints.Other ideas:

• Demonstrate how to immobilize a bent, injured knee by using 2 board splints and cravatsto triangulate.

Segment Name: Applying a Hare Traction SplintTime Codes: Begin: 1:36:07 End: 1:44:15ObjectivesAfter viewing this segment, the student should be able to:

• List the signs and symptoms of a mid-shaft femur fracture.• List the equipment needed to splint a mid-shaft femur fracture.• Explain the potential for the development of shock due to a femur fracture.• Describe the assessment of a patient with a suspected femur fracture, including ongoing

assessment.• Describe the procedure for applying a Hare traction splint.• Explain the special considerations associated with compound and open fractures.

Overview I. Signs and symptoms

• Pain and tenderness• Deformity and swelling• Grating or crepitus• Severe weakness or loss of function

II. Equipment to apply a Hare traction splint includes:• Hare traction splint• Ankle hitch• Splint straps or cravats• Long spine board

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III. Assessment• Manage ABCs.• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).• Recognize potential for shock due to significant blood loss.• Assess for pain, pallor, paresthesia, pulses, and paralysis on injured extremity.

IV. Skill overview• Traction splint is contraindicated for knee, ankle, or hip dislocation/ fracture.• BSI• Stabilize the injury.• Expose the injury.• Explain procedure to the patient and obtain consent.• Assess distal pulses, motor response, and sensation (PMS).• Measure and apply splint.• Reassess PMS.• Move patient onto long spine board and reassess.• Apply cold pack.• Document.

V. Ongoing assessment• Reassess distal PMS.• Reevaluate the splint.

VI. Problem solving• Hemorrhage from femoral artery• Compound fractures• Open fractures• Using a cold pack to reduce swelling

Key TermsAnkle hitch - a strap used with a traction splint or with a single-padded board splint toimmobilize injured knees or legs.HARE traction splint - a bipolar commercial traction splint.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why does a femur fracture need traction?• Why don’t we use a traction splint on a hip fracture?

Additional activities associated with the tape:• Allow adequate time to practice traction splinting.

Other ideas:• Demonstrate alternative methods of tying an ankle hitch with a cravat when the

commercial Hare traction ankle hitch is not available.

Segment Name: Applying a Sager SplintTime Codes: Begin: 1:44:22 End: 1:53:25ObjectivesAfter viewing this segment, the student should be able to:

• List the signs and symptoms of a mid-shaft femur fracture.• List the equipment needed to splint a mid-shaft femur fracture.• Explain the potential for the development of shock due to a femur fracture.• Describe the assessment of a patient with a suspected femur fracture, including ongoing

assessment.• Describe the procedure for applying a Sager traction splint.• Explain the special considerations associated with compound and open fractures.

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Overview I. Signs and symptoms

• Pain and tenderness• Deformity and swelling• Grating or crepitus• Severe weakness or loss of function

II. Equipment• Sager traction splint• Sager ankle hitch• Straps or cravats• Long spine board

III. Assessment• Manage ABCs.• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).• Recognize potential for shock due to significant blood loss.• Assess for pain, pallor, paresthesia, pulses, and paralysis on injured extremity.

IV. Skill overview• Traction splint is contraindicated for knee, ankle, or hip dislocation/ fracture.• BSI• Stabilize the injury.• Expose the injury.• Explain procedure to the patient.• Assess distal pulses, motor response, and sensation (PMS).• Measure and apply splint.• Reassess PMS.• Move patient onto long spine board and reassess.• Apply cold pack.• Document.

V. Ongoing assessment• Reassess distal PMS.• Reevaluate the splint’s effectiveness.

VI. Problem solving• Hemorrhage from femoral artery• Compound /open fractures• Using a cold pack to reduce swelling

Key TermsSager splint - a unipolar commercial traction splint.Teaching ActivitiesQuestions to ask before or after viewing tape:

• What is the difference between a simple and compound femur fracture?• Why is it necessary to use traction when splinting a fractured femur?

Additional activities associated with the tape:• Allow adequate time to practice Sager® traction splinting.

Other ideas:• Demonstrate alternative methods of tying an ankle hitch with a cravat when the

commercial Sager traction hitch is not available.

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Segment Name: Sling and Swathe Immobilization of a Shoulder GirdleTime Codes: Begin: 1:53:30 End: 2:01:39ObjectivesAfter viewing this segment, the student should be able to:

• List the signs and symptoms of a dislocated /fractured shoulder.• List the equipment needed to splint a shoulder injury.• Describe assessment of a patient with a shoulder injury including ongoing assessment.• Describe the procedure for splinting a shoulder injury using a sling and swathe.• Explain the special considerations associated with open and compound fractures/

dislocations.• Describe the special considerations of an associated Spinal Cord Injury (SCI).

Overview I. Signs and symptoms of a fracture/ dislocation of the shoulder girdle (humerus,

clavicle or scapula)• Pain and tenderness• Deformity and swelling• Dropped shoulder• Grating or crepitus• Severe weakness or loss of function

II. Equipment• Triangle bandages or cravats• Safety pin• Padding/ pillow

III. Assessment• Manage ABCs.• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).• Assess for pain, pallor, paresthesia, pulses, and paralysis on injured extremity.

IV. Skill overview• BSI• Stabilize the injury.• Expose the injury.• Explain procedure to the patient and obtain consent.• Assess distal pulses, motor response, and sensation (PMS).• Apply sling and secure with swathe.• Reassess distal PMS.• Apply cold pack.• Document.

V. Ongoing assessment• Reassess distal PMS.• Reevaluate the splint’s effectiveness.

VI. Problem solving• Open fractures/ dislocation• Compound fractures/ dislocation• Using a cold pack to reduce swelling• Associated Spinal Cord Injury (SCI)• Knots impeding on soft tissue or spine

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Key TermsSling – a triangle bandage used to support the shoulder and arm.Swathe – a triangle bandage tied around the chest and injured arm, over the sling.Teaching ActivitiesQuestions to ask before or after viewing tape:

• If the shoulder is dislocated with the arm upright, how can the injury be splinted?• Why is it not standard practice to just pop a shoulder dislocation back into place?

Additional activities associated with the tape:• Allow adequate time to practice sling and swathe application.

Other ideas:• Demonstrate alternative methods of tying a sling and swathe to immobilize a shoulder

injury.

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Tape 2 Trauma Emergencies

Segment Name: Application of a Cervical CollarTime Codes: Begin: 1:00:55 End: 1:08:30ObjectivesAfter viewing this segment, the student should be able to:

• List the indications for the need of a cervical collar.• Describe the procedure for measuring a cervical collar.• Explain the steps in applying a cervical collar.• Describe some of the special considerations for applying a cervical collar.

Overview I. Spinal immobilization should be considered:

• With significant MOI• Complaint of head, neck, or back pain• Soft-tissue damage to the head, face, or neck from trauma• Altered mental status (AMS)• Reports or shows signs of any blow above the clavicle

II. Equipment• Cervical collar (adjustable or full set)

III. Assessment• Manage ABCs.• Instruct patient not to move.• Manually stabilize the patient’s head.• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).• Assess for pain, pallor, paresthesia, pulses, and paralysis in all extremities.

IV. Skill overview• BSI• Instruct patient not to move.• Maintain manual stabilization of the head and neck.• Explain procedure to the patient and obtain consent.• Assess pulse, motor, and sensory function (PMS) in all extremities.• Measure and apply cervical collar.• Reassess PMS in all extremities.

V. Do not hyperextend the neck or restrict the airway. VI. Ongoing Assessment

• Reassess distal PMS in all extremities.• Note changes in mental status.

VII. Problem Solving• AMS• Intoxication• Remove earrings, clothing• Hair

Key TermsCervical collar – a rigid collar applied to neck to protect the cervical spine.Significant MOI – certain mechanisms of injury, which carry with them a greater risk of serious orlife-threatening injury.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why are soft collars inappropriate for field use?• If you are having difficulty maintaining a jaw thrust maneuver on a trauma patient with a

difficult airway, is it acceptable to remove the cervical collar?Additional activities associated with the tape:

• Allow adequate time to practice applying rigid cervical collars.

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Other ideas:• Demonstrate applying a cervical collar on supine patients found in difficult positions (e.g.:

on a stair case, under a car).

Segment Name: Kendrick Extrication Device (KED)Time Codes: Begin: 1:08:35 End: 1:18:20ObjectivesAfter viewing this segment, the student should be able to:

• Describe when to apply a KED to a patient.• List the equipment needed to apply a KED.• Describe the assessment of the patient requiring the need for a KED, including the

ongoing assessment.• List the steps in applying a KED.• Explain the special considerations associated with the use of a KED.

Overview I. KED is used to immobilize a seated patient with a potential spinal injury. II. Equipment

• KED• Long spine board• Cervical collars• Head blocks, towels, blankets, or other padding• Tape• Backboard straps

III. Assessment• Manage ABCs.• Instruct patient not to move.• Manually stabilize the patient’s head.• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).• Assess for pain, pallor, paresthesia, pulses, and paralysis in all extremities.

IV. Skill Overview• BSI• Approach from the front.• Instruct patient not to move.• Manually stabilize the patient’s head.• Explain the need for spinal immobilization and the procedure and obtain consent.• Assess distal pulse, motor, and sensory function (PMS) in all extremities.• Measure and apply cervical collar.• Apply KED.• Move patient to long board and secure to the board.• Reassess distal PMS in all extremities.• Document.

V. Ongoing Assessment• Reassess distal PMS in all extremities.• Note changes in mental status.• Be alert for vomiting.

VI. Problem Solving• Secure torso to the board before the head.• Pad voids as needed.

Key TermsKendrick Extrication Device (KED) – a commercial vest-style extrication device used toimmobilize seated patients.

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• When is it appropriate to use a KED as opposed to the rapid extrication technique?• Why is it important that the device be secured tightly under the armpits?

Additional activities associated with the tape:• Allow adequate time to practice application of the KED.

Other ideas:Demonstrate how a KED can be used to immobilize a small child as well as how it can be used toimmobilize a fractured hip in an adult.

Segment Name: Immobilizing a Supine PatientTime Codes: Begin: 1:18:25 End: 1:28:35ObjectivesAfter viewing this segment, the student should be able to:

• List the indications for immobilizing a supine patient to a long spine board.• List the equipment used to immobilize a supine patient.• Describe the assessment of the patient with a potential spinal injury, including the

ongoing assessment.• List the steps taken to immobilize a supine patient to a long spine board.• List the special considerations taken with a patient immobilized to a long spine board.

Overview I. Supine spinal immobilization should be considered:

• With significant MOI• With complaint of head, neck, or back pain• When the patient has sustained penetrating injury, laceration, or contusion to the

head or scalp• Patient is unconscious for unknown reason

II. Equipment• Long spine board• Cervical collars• Head blocks, towels, blankets, or other padding• Tape• Back board straps

III. Assessment• Manually stabilize the patient’s head.• Conduct an initial assessment evaluating the MS-ABCs and prioritize the patient.• Instruct patient not to move.• Explain the need and procedure for spinal immobilization and obtain consent.• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).• Assess for pain, pallor, paresthesia, pulses, and paralysis.

IV. Skill Overview• BSI• Instruct patient not to move.• Manually stabilize the patient’s head.• Maintain the patient in a neutral position.• Explain the need for spinal immobilization, explain the procedure and obtain consent.• Assess PMS in all extremities.• Inspect and palpate cervical vertebrae.• Measure and apply cervical collar.• Roll the patient on the side and inspect the back.• Move the patient to long board and secure to the board.• Pad voids as necessary.• Reassess PMS in all extremities.• Document.

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V. Ongoing Assessment• Reassess distal PMS in all extremities.• Monitor the patient’s mental status.• Be alert for vomiting.

VI. Problem Solving• Move the patient as a unit to prevent manipulation of the spine.• Secure the patient’s torso to the board first and the head last.• Strap the bony prominences of the body (hips, upper chest, legs) to the board.• Be alert for vomiting.

Key TermsCervical vertebrae – seven cervical vertebrae (stacked bones) are found in the neck.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it necessary to pay close attention to the means of egress when planning toimmobilize a supine patient on a long spine board?

• If it will be necessary to carry a patient who is immobilized on a long spine board over amile out of the woods, what else should be considered to make it possible?

Additional activities associated with the tape:• Allow adequate time to practice skill of supine immobilization.

Other ideas:Once the students are able to do this skill in the classroom setting, consider giving them asituation in the stairwell or in a tight bathroom.

Segment Name: Immobilizing a Standing PatientTime Codes: Begin: 1:28:40 End: 1:36:06ObjectivesAfter viewing this segment, the student should be able to:

• Explain when it would be appropriate to immobilize a standing patient.• List the equipment needed to perform a rapid takedown.• Describe the assessment of a patient requiring a rapid takedown, including ongoing

assessment.• Describe the steps to immobilize a standing patient.• Discuss the problems associated with immobilizing a standing patient.

Overview I. A rapid takedown with spinal immobilization should be considered:

• A standing or ambulatory patient that sustained a significant MOI• Chronic back pain patients found in a standing position

II. Equipment• Long spine board• Cervical collar• Head block, towels, blankets, or other padding• Tape• Back board straps

III. Assessment• Manually stabilize the patient’s head.• Conduct an initial assessment evaluating MS-ABCs and prioritize the patient.• Instruct patient not to move.• Explain the need and procedure for spinal immobilization and obtain consent.• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).• Assess for pain, pallor, paresthesia, pulses, and paralysis.

IV. Skill Overview• BSI• Approach the patient from the front.• Instruct patient not to move.

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• Manually stabilize the patient’s head from behind.• Maintain the patient in a neutral position.• Explain the need for spinal immobilization, explain the procedure and obtain

consent.• Assess PMS in all extremities.• Inspect and palpate cervical vertebrae.• Measure and apply cervical collar.• Place a long spine board against the patient’s back.• Grasp the board and while supporting the patient, lower the board down to the

ground.• Secure the patient to the board.• Pad voids as needed.• Reassess PMS in all extremities.• Document.

V. Ongoing Assessment• Reassess distal PMS in all extremities.• Monitor the patient’s mental status.• Be alert for vomiting.

VI. Problem Solving• Move the patient as a unit to prevent manipulation of the spine.• Secure the patient’s torso to the board first and then the head last.• Strap the bony prominences of the body (hips, chest, legs) to the board.

Key TermsRapid takedown – also known as Standing Takedown, allows immobilization of the patient in theposition found.Teaching ActivitiesQuestions to ask before or after viewing tape:

• If you and your partner need to utilize the assistance of an untrained helper, why is it soimportant to place the helper in front of the board as opposed to the position behind theboard?

• Why is it important to remember, “as the shoulders lean back and touch the backboard soshould the back of the head” and at that point, the head should never again lose contactwith the board?

Additional activities associated with the tape:• Allow adequate time to practice the standing takedown.

Other ideas:• This is not a 2-person technique. There is a minimum of 3 people needed to properly do

the technique. Practice with one of the helpers in front of the board being untrained,being careful to go slow and instruct as you go.

• Practice this technique with a 4th rescuer, supporting the board from behind, for thesituation of an obese patient.

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Segment Name: Helmet RemovalTime Codes: Begin: 1:36:16 End: 1:42:35ObjectivesAfter viewing this segment, the student should be able to:

• List the indication for removing a helmet from a patient.• List the indications for keeping the helmet in place.• List the equipment needed for a helmet removal from a patient.• Describe the steps in the procedure of removing a helmet from a patient.• Describe the common problems associated with removing a helmet from a patient.• Explain why it is necessary to examine the helmet for cracks or other damage.

Overview I. Finding a patient with a helmet may be common in sports and cycling. II. Indications for removing the helmet include:

• Helmet interferes with assessment and management of the airway.• Helmet interferes with immobilization.• The helmet is too loose and allows for movement of the head or neck.• The patient exhibits signs of respiratory or cardiac arrest.

III. Indications for keeping the helmet in place include:• No immediate airway or breathing problems• No reason to ventilate with a BVM• Helmet does not interfere with assessment of the airway and breathing• The helmet does not impede proper spinal immobilization• Removal of the helmet may cause further injury

IV. Equipment• Cervical collar• Towel rolls

V. Assessment• Manually stabilize the patient’s head.• Conduct an initial assessment evaluating MS-ABCs and prioritize the patient.• Instruct the patient not to move.• Explain the procedure and obtain consent.• Assess for pain, pallor, paresthesia, pulses, and paralysis.

VI. Skill Overview• BSI• Approach the patient from the front.• Instruct patient not to move.• Manually stabilize the patient’s head from behind.• Maintain the patient in a neutral position.• Explain the need for spinal immobilization and the procedure and obtain consent.• Assess distal pulse, motor, and sensory function (PMS) in all extremities.• Open, remove, or cut chin strap.• Hold the occipital area of the head and stabilize the mandible.• Support and hold the head while the helmet is removed.• Remove the helmet, maintaining the head in a neutral position.• Measure and apply cervical collar.• Move patient to a long spine board.• Reassess distal PMS in all extremities.• Document.

VII. Ongoing Assessment• Reassess distal PMS is all extremities.• Monitor the patient’s mental status.• Be alert for vomiting.

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VIII. Problem Solving• Shoulder pads may require removal or padding behind the head.• Large earrings may catch on your fingers or the helmet, be careful or remove as

necessary.• Eye glasses will need to be removed before the helmet, if possible.• Examine helmet for cracks indicating significant MOI.

Key TermsOccipital skull – the back region of the skull.Priaprism – persistent erection of the penis that may result from spinal injury and some medicalproblems.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why will it be difficult to assess the airway of a motorcyclist who is found unconsciouswith a full-face helmet in place?

• When would it be appropriate to consider removing earrings from the biker prior toactually removing a helmet?

Additional activities associated with the tape:• Allow adequate time to practice helmet removal using football and motorcycle helmets.

Other ideas:• Obtain a set of shoulder pads and practice the helmet-removal procedure on a victim who

is lying on grass to simulate an actual incident.• It is helpful to meet with the athletic trainer for the teams your unit may respond to ahead

of time to work out procedures and protocols for dealing with injured athletes.

Segment Name: Rapid ExtricationTime Codes: Begin: 1:42:40 End: 1:49:00ObjectivesAfter viewing this segment, the student should be able to:

• Describe the indications for performing a rapid extrication.• List the equipment needed to perform a rapid extrication.• Explain the steps of a rapid extrication.• Explain the components of the ongoing assessment for the patient who has been rapidly

extricated.• List common problems associated with rapid extrication.

Overview I. Rapid extrication is indicated for the critical or unstable (high priority) patient.

• Actual or impending cardiac arrest• Respiratory failure• Decompensated shock• Rising intracranial pressure• Severe upper airway difficulties• Cardiorespiratory instability• Uncontrollable external bleeding• Chest pain with a BP less than 100 systolic• Unresponsive patient• Responsive but confused and not following commands• Penetrating injuries to the head, neck, chest, abdomen, or pelvis• A patient in an unsafe situation requiring an urgent move

II. Equipment• Cervical collar• Long spine board• Straps• Head blocks• Tape

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III. Assessment• Instruct the patient not to move.• Manually stabilize the patient’s head.• Conduct an initial assessment evaluating MS-ABCs and prioritize the patient.• Explain the procedure and obtain consent.• Assess for pain, pallor, paresthesia, pulses, and paralysis.

IV. Skill Overview• BSI• Approach the patient from the front.• Instruct patient not to move.• Manually stabilize the patient’s head from behind.• Maintain the patient in a neutral position.• Confirm the patient is in a critical or unstable (high priority) condition.• Explain the need for spinal immobilization, the procedure, and obtain consent.• Assess distal pulses, motor, and sensory function (PMS) in all extremities.• Inspect and palpate cervical vertebrae.• Measure and apply cervical collar.• Place a long spine board under the patient’s buttocks.• Rotate the patient into a parallel position with the board.• Lay the patient supine.• Secure the patient to the board.• Reassess distal PMS in all extremities.• Document.

V. Ongoing Assessment• Reassess every 5 minutes.• Monitor the patient’s mental status.• Be alert for vomiting.

VI. Problem Solving• Excessive movement• Length time for extrication• Patient is extremely tall or obese

Key TermsRapid extrication – an urgent move from a motor vehicle, which takes into consideration theneed for spinal precautions.Critical status – the highest priority patient transport rating.Unstable status – the second highest priority transport rating.Teaching ActivitiesQuestions to ask before or after viewing tape:

• Why is it imperative that the hands holding the head/neck and chest not be moved untilthey are first taken over by another rescuer when switching positions?

• If there are only 3 rescuers, how can a stretcher be utilized to act as the 4th rescuer?Additional activities associated with the tape:

• Allow adequate time to practice rapid extrication.Other ideas:

• This skill should be practiced as a team in actual vehicles so it can be accomplishedsafely in 3 minutes.

• Practice in small cars with consoles, as well as a pickup truck, where there is no room toplace a rescuer behind the patient.

Documents

Brady Skills