KANSAS BOARD OF EMERGENCY MEDICAL SERVICE

EMT-I Kansas Enrichment

KSE Module 1 Respiratory System

KSE Lesson 1.1 Overview of Human Systems

LESSON TERMINAL INSTRUCTIONAL OBJECTIVE

At the end of this lesson the EMT-Intermediate student will be able to apply the understanding of anatomy,  physiology and control mechanism of the respiratory system.

Cognitive Objectives

State the general function of the respiratory system.
Describe the structure and functions of the nose, nasal cavities, and pharynx.
Describe the structure of the larynx and explain the speaking mechanism.
Describe the structure and functions of the trachea and bronchial tree.
State the locations of the lungs and pleural membranes.
Describe the structure of the alveoli and pulmonary capillaries.
Describe normal inhalation and exhalation, and the changes in air pressures during the phases of breathing.
Explain the diffusion of gases in external respiration.
Describe how oxygen and carbon dioxide are transported in the blood.
Define and explain tidal volume, minute respiratory volume, inspiratory reserve, expiratory reserve, vital capacity and residual air.
Explain the nervous and chemical mechanisms that regulate respiration.
Explain how respiration affects the pH of body fluids.
Explain how the sympathetic division of the autonomic nervous system enables the body to adapt to a stress situation.
Explain how the parasympathetic division of the autonomic nervous system promotes normal body functioning in relaxed situations.
 

KSE Lesson 1.2 Airway Management and Ventilation

LESSON TERMINAL OBJECTIVE:

At the end of this lesson, the EMT-Intermediate will be able to utilize assessment findings to formulate a field impression and implement a management plan for the patient experiencing an airway or breathing emergency.

COGNITIVE OBJECTIVES:

Upon successful completion of this course, the EMT-Intermediate will be able to:

1. Review the anatomy of the upper and lower airways. (C1)
2. Review the functions of the upper and lower airways. (C1)
3. Explain the differences between the adult and pediatric airway anatomy. (C1)
4. Define gag reflex. (C1)
5. Explain the relationship between pulmonary circulation and respiration. (C3)
6. List the concentration of gases which comprise atmospheric air. (C1)
7. Describe the measurement of oxygen in the blood. (C1)
8. Describe the measurement of carbon dioxide in the blood. ( C1)
9. List factors which cause decreased oxygen concentrations in the blood. (C1)
10. Define atelectasis. (C1)
11. Define FiO2. (C1)
12. Define hypoxia. (C1)
13. Define hypoxemia. (C1)
14. List the factors which increase carbon dioxide production in the body. (C1)
15. List the factors which decrease carbon dioxide elimination in the body. (C1)
16. Describe the voluntary regulation of respiration. (C1)
17. Describe the involuntary regulation of respiration. (C1)
18. Describe the modified forms of respiration. (C1)
19. Define normal respiratory rates for the adult, child, and infant. (C1)
20. List the factors that affect respiratory rate. (C1)
21. List the factors that affect respiratory depth. (C1)
22. Define the normal tidal volumes for the adult, child, and infant. (C1)
23. Explain the risk of infection to EMS providers associated with ventilation. (C1,C3)
24. Define pulsus paradoxes. (C1)
25. Define partial airway obstruction. (C1)
26. Explain implications of partial airway obstruction with good air exchange. (C2)
27. Explain implications of partial airway obstruction with poor airway exchange. (C2)
28. Define complete airway obstruction. (C1)
29. Describe causes of upper airway obstruction, including:
a. the tongue;
b. foreign body aspiration;
c. laryngeal spasm;
d. laryngeal edema; and
e. trauma. (C1)
30. Describe causes of respiratory distress, including:
a. upper and lower airway obstruction;
b. inadequate ventilation;
c. impairment of the respiratory muscles; and
d. impairment of the nervous system. (C1)
31. Describe manual airway maneuvers, including:
a. opening the mouth;
b. head tilt/chin lift maneuver;
c. jaw-thrust maneuver; and
d. modified jaw-thrust maneuver. (C1)
32. Describe the Sellick's (cricoid pressure) maneuver. (C1)
33. Describe complete airway obstruction maneuvers, including:
a. the Heimlich maneuver;
b. finger sweep;
c. chest thrusts; and
d. removal with Magill forceps. (C1)
34. Describe the indications for suctioning the upper airway (C3)
35. Identify types of suction equipment, including:
a. hand-powered suction devices;
b. oxygen-powered portable suction devices;
c. battery-operated portable suction devices; and
d. mounted vacuum-powered suction devices. (C1)
36. Describe the indications for suctioning the upper airway. (C3)
37. Identify types of suction catheters, including:
a. hard or rigid catheters; and
b. soft catheters. (C1)
38. Identify techniques of suctioning the upper airway. (C1)
39. Identify special considerations of suctioning the upper airway. (C1)
40. Describe indications for tracheobronchial suctioning in the intubated patient. (C3)
41. Identify techniques of tracheobronchial suctioning in the intubated patient. (C1)
42. Identify special considerations of tracheobronchial suctioning in the intubated patient. (C1)
43. Describe indications and contraindications for inserting oropharyngeal airways. (C1)
44. List the steps to insert an oropharyngeal airway. (C1)
45. Describe indications and contraindications for inserting nasopharyngeal airways. (C1)
46. List the steps to insert a nasopharyngeal airway. (C1)
47. Describe methods to perform ventilation, including:
a. mouth-to-mouth;
b. mouth-to-mask;
c. 1 person bag-valve-mask;
d. 2 person bag-valve-mask; and mouth-to-nose
e. flow-restricted, oxygen-powered ventilation device (C1)
48. Describe complications of mouth-to-mask ventilation. (C1)
49. Explain the advantage of the 2 person method to perform ventilation with a bag-valve-mask. (C2)
50. Describe complications of ventilating with a bag-valve-mask. (C1)
51. Describe complications of ventilation with the flow- restricted, oxygen powered ventilation device. (C1)
52. Identify the automatic transport ventilator (ATV). (C1)
53. List the steps in performing ventilation with the ATV. (C1)
54. Describe complications of ventilating with the ATV. (C1)
55. Explain safety considerations of oxygen storage and delivery. (C2)
56. Identify types of oxygen cylinders. (C1)
57. Identify the types of oxygen pressure regulators, including:
a. high-pressure regulator; and
b. therapy regulator. (C1)
58. List the steps for delivering oxygen from a cylinder and a regulator. (C1)
59. Identify an oxygen humidifier. (C1)
60. Identify oxygen delivery equipment, liter flow range, and concentration of delivered oxygen, including:
a. nasal cannula;
b. simple face mask;
c. partial rebreather mask;
d. non-rebreather mask;
e. Venturi mask; and
f. small volume nebulizer. (C1)
61. Identify a stoma. (C1)
62. Define laryngectomy. (C1)
63. Identify a tracheostomy. (C1)
64. Identify a tracheostomy tube. (C1)
65. Describe mouth-to-stoma ventilation. (C1)
66. Describe bag-valve-mask-to-stoma ventilation. (C1)
67. Identify special considerations in airway management and ventilation for the pediatric patient. (C1)
68. Identify special considerations in airway management and ventilation for patients with facial injuries. (C1)
69. Identify equipment used to retrieve foreign bodies from the upper airway. (C1)
70. Describe laryngoscopy for foreign body airway obstruction. (C1)
71. Describe indications to perform advanced airway management. (C1)
72. Differentiate endotracheal intubation from other methods of airway management. (C3)
73. Describe equipment used for direct laryngoscopy. (C1)
74. Describe assembly of intubation equipment. (C1)
75. Describe visual landmarks for direct laryngoscopy. (C1)
76. Identify indications for endotracheal intubation. (C1)
77. Identify contraindications for endotracheal intubation. (C1)
78. Describe general precautions prior to endotracheal intubation. (C1)
79. Describe the use of cricoid pressure during intubation. (C1)
80. Describe complications of endotracheal intubation. (C1)
81. Describe the digital route for endotracheal intubation. (C1)
82. Describe methods of endotracheal intubation in the trauma patient. (C1)
83. Describe methods of endotracheal intubation in the pediatric patient. (C1)
84. Describe endotracheal intubation. (C1)
85. Describe uses and demonstrate the procedure of using an esophageal intubation detection device. (C1)
86. Undertand the dependency of the function of an esophageal intubation detection device on the difference between the structure of the trachea and the esophagus. (C2)
87. Describe dual lumen airway. (C1)
88. Describe indications for inserting the dual lumen airway. (C1)
89. Describe contraindications for inserting the dual lumen airway. (C1)
90. List the equipment used to perform the insertion of the dual lumen airway. (C1)
91. Describe complications of insertion of a dual lumen airway. (C1)
92. List the steps to insert the dual lumen airway. (C1)
93. Describe extubation. (C1)
94. Identify the indications for extubation. (C1)
95. Describe the complications of extubation. (C1)

AFFECTIVE OBJECTIVES:

Upon successful completion of this lesson, the EMT-Intermediate will be able to:

1. Explain the rationale for selection of each of the following basic approaches to airway management:
a. manual airway maneuvers;
b. oropharyngeal airway; and
c. nasopharyngeal airway. (A2)
2. Explain the rationale for selection of each of the following advanced approaches to airway management:
a. dual lumen airway; and
b. endotracheal intubation. (A2)
3. Defend the importance of using an esophageal intubation detection device to assure correct placement of an endotracheal tube. (A3)
4. Explain the rationale for selection of each of the following approaches to ventilation:
a. mouth-to-mask;
b. 1 person bag-valve-mask;
c. 2 person bag-valve-mask;
d. flow-restricted, oxygen-powered ventilation device; and
e. automatic transport ventilator. (A2)

PSYCHOMOTOR OBJECTIVES:

Upon successful completion of this lesson, the EMT-Intermediate will be able to:

1. Perform body substance isolation (BSI) procedures during basic airway management, advanced airway management, and ventilation. (P1,P2)
2. Perform pulse oximetry. (P1)
3. Perform manual airway maneuvers for adult patients, including:
a. opening the mouth;
b. head-tilt/chin-lift maneuver;
c. jaw-thrust maneuver: and
d. modified jaw-thrust maneuver. (P1,P2)
4. Perform manual airway maneuvers for pediatric patients, including:
a. opening the mouth;
b. head-tilt/chin-lift maneuver;
c. jaw-thrust maneuver: and
d. modified jaw-thrust maneuver. (P1,P2)
5. Perform the Sellick's maneuver. (P1,P2)
6. Perform complete airway obstruction maneuvers, including:
a. the Heimlich maneuver;
b. finger sweep;
c. chest thrusts; and
d. removal with Magill forceps. (P1,P2)
7. Perform suctioning of the upper airway, including:
a. selection of a suction device;
b. selection of a catheter; and
c. perform the proper suctioning technique. (C3,P2)
8. Perform tracheobronchial suctioning in the intubated patient, including:
a. selection of a suction device;
b. selection of a catheter; and
c. perform the proper suctioning technique. (C3,P2)
9. Perform insertion of an oropharyngeal airway. (P1,P2)
10. Perform insertion of a nasopharyngeal airway. (P1,P2)
11. Perform mouth-to-mask ventilation. (P1,P2)
12. Perform ventilation with a bag-valve-mask, including:
a. 1 person method; and
b. 2 person method. (P1,P2)
13. Perform ventilations with a bag-valve-mask with an in-line small-volume nebulizer. (P1,P2)
14. Perform ventilation with a bag-valve-mask resuscitator with an in-line metered-dose inhaler. (P1,P2)
15. Perform ventilation with the flow-restricted, oxygen-powered ventilation device. (P1,P2)
16. Perform oxygen delivery from a cylinder and regulator with an oxygen delivery device. (P1,P2)
17. Perform oxygen delivery with an oxygen humidifier. (P1,P2)
18. Perform oxygen delivery with oxygen delivery equipment, including:
a. the nasal cannula;
b. the simple face mask;
c. the partial rebreather mask;
d. the non-rebreather mask; and
e. the venturi mask. (P1,P2)
19. Perform administration of albuterol with a small volume nebulizer. (P1,P2)
20. Perform administration of albuterol with a metered-dose inhaler.
21. Perform mouth-to-stoma ventilation. (P1,P2)
22. Perform bag-valve-mask-to-stoma ventilation. (P1,P2)
23. Perform stoma suctioning. (P1,P2)
24. Perform retrieval of foreign bodies from the upper airway. (P1,P2)
25. Perform proper assembly of laryngoscope. (P1,P2)
26. Perform proper use of semi-rigid stylet. (P1,P2)
27. Perform cricoid pressure during endotracheal intubation. (P1,P2)
28. Perform orotracheal intubation. (P1,P2)
29. Perform endotracheal intubation in the trauma patient. (P1,P2)
30. Perform endotracheal intubation in the pediatric patient. (P1,P2)
31. Perform assessment to confirm correct placement of the endotracheal tube. (P1,P2)
32. Perform adequate securing of the endotracheal tube. (P1,P2)
33. Perform insertion of a dual lumen airway. (P1,P2)
34. Perform assessment to confirm correct placement of the dual lumen airway. (P1,P2)
35. Perform extubation. (P1,P2)2
 


Airway Management and Ventilation Lesson

Lesson Outline

Declarative:

I. Introduction

A. Need for oxygenation
1. Primary objective:
a. Insure optimal ventilation
(1) Delivery of oxygen
(2) Elimination of CO2
B. Major prehospital causes of death
1. Preventable with:
a. Early detection
b. Early intervention
c. Lay-person BLS education
C. Most neglected of prehospital skills
1. Basics taken for granted
2. Poor technique i.e.:
a. BVM seal
b. Improper positioning
c. Failure to reassess

II. Anatomy of upper airway

A. Function of the upper airway
1. Warms the air
2. Filters the air
3. Humidifies the air
B. Separated into:
1. Nasopharynx
2. Oropharynx
C. Nasopharynx
1. Formed by the union of facial bones.
2. Orientation of nasal floor is towards the ear, not the eye
3. Separated by the septum
4. Lined with:
A. Mucous membranes
b. Cilia
5. Has turbinates
a. Parallel to nasal floor
b. Provide increased surface area for air
(1) Filtration
(2) Humidifying
(3) Warming
6. Sinuses
a. Cavities formed by cranial bones
(1) Commonly become infected
2) Fracture of certain sinus bones may cause cerebrospinal fluid (CSF) leak
b. Appear to further trap bacteria and act as tributaries for fluid to and from eustachian tubes and tear ducts
7. Tissues extremely delicate and vascular
a. Improper or over aggressive placement of tubes or airways will cause significant bleeding which may not be controlled by direct pressure.
8. Oropharynx
a. Teeth
(1) 32 in adult
(2) Requires significant force to dislodge
(3) May fracture or avulse causing obstruction
b. Tongue
(1) Large muscle attached at the mandible and hyoid bone
(2) Most common airway obstruction
c. Palate
(1) Roof of mouth separates oro/nasopharynx
(a) Anterior is hard palate
b) Posterior (beyond the teeth) is soft palate
d. Adenoids
(1) Lymph tissue located in the mouth and nose that filters bacteria
(2) Frequently infect and swell
9. Hypopharynx
a. Posterior tongue
b. Epiglottis
c. Vallecula
(1) "Pocket" formed by the base of the tongue and the epiglottis
(2) Important landmark for endotracheal intubation
10. Larynx
a. Attached to hyoid bone
(1) "Horseshoe" shaped bone between the chin and the mandibular angle
(2) Supports trachea
b. Made of cartilage
(1) Thyroid cartilage
(a) First tracheal cartilage
i) "Shield" shaped
a) Cartilage anterior
b) Smooth muscle posterior
ii) Laryngeal prominence
a) "Adam's Apple" anterior prominence of thyroid cartilage
b) Glottic opening directly behind
(2) Glottic opening
(a) Narrowest part of adult trachea
(b) Patency heavily dependant on muscle tone
(c) Contain vocal bands
i) White bands of cartilage produce voice
ii) Arytenoid cartilage
a) Pyramid like posterior attachment of vocal bands
b) Important landmark for endotracheal intubation
iii) Pyriform fossae: Hollow pockets along the lateral borders of the larynx
(3) Cricoid ring
(a) First tracheal ring
(b) Completely cartilaginous
(c) Compression of, occludes esophagus
(4) Cricothyroid membrane
(a) Fibrous membrane between cricoid and thyroid cartilage
(b) Site for surgical and alternative airway placement
c. Associated structures
(1) Thyroid gland
(a) Located below cricoid cartilage
(b) Lies across trachea and up the sides
(2) Carotid arteries
(a) Branches cross and lie closely alongside trachea
(3) Jugular veins
(a) Branch across and lie close to trachea

III. Anatomy of lower airway

A. Function of the lower airway
1. Exchange of O2 and CO2
B. Location of the lower airway
1. From fourth cervical vertebrae to xiphoid process
2. From glottic opening to pulmonary capillary membrane
C. Structures of the lower airway
1. Trachea
a. Trachea bifurcates at carina into:
(1) Right and left mainstem bronchi
(2) Right mainstem has lesser angle and is frequently intubated
(3) Foreign bodies and ET tube commonly displace into right mainstem
(4) Lined with
(a) Mucous cells
(b) Beta 2 cells (dilate bronchioles)
b. Mainstem bronchi
(1) Enter lungs at "hilum"
(2) Branch into
a) Secondary and tertiary bronchi which branch into bronchioles which branch into alveolar ducts which end at alveolar sacs
(b) Branches narrow as they go
c. Alveoli
(1) "Balloon like" clusters
(2) Site of gas exchange
(3) Lined with surfactant
(a) Decreases surface tension of alveoli which facilitates ease of expansion
(b) Alveoli become thinner as they expand which make diffusion of O2/CO2 easier
(c) If surfactant is decreased or alveoli are not inflated, alveoli collapse (atelectasis)
2. Lungs
a. Right lung has 3 lobes
b. Left lung has 2 lobes
c. Lobes made of parenchymal tissue
d. Membranous outer lining called pleura
e. Lung capacity
(1) Total lung volume
(a) Adult male - 6 liters
(2) Not all inspired air enters alveoli
(3) Minor diffusion of CO2 takes place in alveolar ducts and terminal bronchioles
f. Tidal volume
(1) Volume of gas inhaled or exhaled during a single respiratory cycle
(a) 5-7 cc/kg (500 cc normally)
g. Dead space air
(1) air remaining in air passageways, unavailable for gas exchange (approximately 150 cc)
(a) Anatomic dead space
i) Trachea
ii) Bronchi
(b) Physiologic dead space
i) Formed by factors like disease or obstruction
a) COPD
b) Atelectasis
h. Minute volume
(1) Amount of gas moved in and out of the respiratory tract per minute
(2) Determined by: tidal volume - deadspace volume x respiratory rate
i. Functional reserve capacity
(1) After optimal inspiration: Optimum amount of air that can be forced from the lungs in a single forced exhalation
j. Residual volume
(1) Volume of air remaining in the lungs after maximum expiration
k. Alveolar air
(1) Air reaching the alveoli for gas exchange (alveolar volume)
(2) Approximately 350 cc
l. Inspiratory reserve
(1) Amount of gas that can be inspired in addition to tidal volume
m. Expiratory reserve
(1) Amount of air that can be expired after passive (relaxed) expiration
D. Differences in pediatric airway
1. Pharynx
a. Disproportionately large tongue;
b. Large floppy epiglottis; and
c. Absent or very delicate dentition
2. Trachea
a. Airway is smaller;
b. Trachea lies more superior;
c. Tracheal is "funnel shaped" due to narrow, undeveloped cricoid cartilage;
d. Narrowest point is at cricoid ring (before 10 years of age); and
e. Small change in airway size results in major increase in airway resistance
3. Chest wall
a. Ribs and cartilage are softer
(1) Cannot optimally contribute to lung expansion
(2) Infants and children tend to depend more heavily on the diaphragm for breathing

IV. Mechanics of respiration

1. Definitions
a. Respiration: An exchange of gases between a living organism and it's environment
b. Primary control is from the medulla and pons
c. External respiration: Exchange of gases between the lungs and the blood cells
d. Internal respiration: Exchange of gases between the blood cells and tissues
e. Pulmonary ventilation: Movement of air into and out of the lungs
2. Phases
a. Inspiratory
1. Stimulus to breathe from respiratory center
2. Impulse transmitted to diaphragm via the phrenic nerve
3. Diaphragm contracts ("flattens") causing intrapulmonic pressure to fall slightly below atmospheric pressure
4. Ribs elevate and expand
5. Air is drawn into the lungs like a vacuum
6. Alveoli inflate
7. O2/CO2 diffuse across the alveolar membrane
b. Expiratory
a. Stretch receptors in lungs signal the respiratory center via the vagus nerve to inhibit inspiration (Hering-Breuer reflex)
b. Natural elasticity (recoil) of the lungs passively expires air
3. Regulation of respiration
1. Control of respirations is from the medulla and the pons
2. Influenced by
a. Chemical stimuli
(1) Receptors of O2/CO2 balance
A) Cerebrospinal fluid pH
B) Carotid bodies (in the carotid sinus)
iii) Aortic arch
C) Hypoxic drive
i) Respiratory stimulus becomes dependent on O2 blood levels rather than CO2 blood levels as usual
(2) CNS regulation and nerve receptors
(a) Medulla
i) Primary involuntary respiratory center
a) Connected to respiratory muscles via the vagus nerve
(b) Pons
i) Apneustic center
a) Secondary control center if medulla fails to initiate respiration
ii) Pneumotaxic center
a) Controls expiration
(3) Muscle movement
(a) Connected to respiratory center via the vagus nerve
D. Types
1. Eupnea
2. Labored
3. Shallow
4. Absent
5. Agonal
6. Cheyne-Stokes
7. Kussmal
8. Biots
9. Central neurogenic hyperventilation

V. Measurement of gases

A. Total pressure
1. The combined pressure of all atmospheric gases
2. 100% or 760 TORR at sea level
B. Partial pressure
1. The pressure exerted by a specific atmospheric gas
C. Concentration of gases in the atmosphere
1. Nitrogen 597.0 TORR (74.9%)
2. Oxygen 159.0 TORR (20.84%)
3. CO2 0.3 TORR ((0.04%)
4. Water 3.7 TORR (0.50%)
D. Water vapor pressure
E. Alveolar gas concentration
1. Nitrogen 569.0 TORR (74.9%)
2. Oxygen 104.0 TORR (13.7%)
3. CO2 40.0 TORR (5.2%)
4. Water 47.0 TORR (6.2%)

VI. Exchange and transport of gases in the body

A. Diffusion
1. Is a passage of solution from area of higher concentration to an area of lower concentration
2. O2/CO2 dissolve in water and pass through alveolar membrane by diffusion
B. Oxygen content of blood
1. Dissolved O2 crosses pulmonary-capillary membrane and binds to hemoglobin (Hgb) of red blood cells
2. Oxygen is carried on Hgb molecule as well as dissolved in plasma
3. Approximately 97% of total O2 is bound to Hgb
4. O2 saturation
a. Compares available O2 (the O2 dissolved in plasma) to the O2 carrying capacity of blood
C. CO2 content of the blood
1. CO2 is a by-product of cellular work (cellular respiration)
2. CO2 is transported in the blood as Bicarbonate ion
a. About 33% is bound to Hgb
3. As O2 crosses into blood, CO2 diffuses into alveoli
D. Inadequate ventilation
1. Occurs when body cannot compensate for increased O2 demand or maintain O2/CO2 balance
2. Many causes
a. Infection
b. Trauma
c. Brainstem insult
d. Noxious or hypoxic atmosphere
e. Renal failure
3. Multiple symptoms
a. Altered response
b. Respiratory rate changes (up or down)
c. Respiratory pattern changes
(1) Cheyne-Stokes
(a) Gradual increasing rate and tidal volume followed by gradual decreasing
(b) Associated with brain stem insult
(2) Kussmal's
(a) Deep respirations
(b) Common in diabetic coma
(3) Biot's
(a) Irregular pattern of rate and volume with intermittent periods of apnea
(b) Increased intracranial pressure
(4) Central neurogenic hyperventilation
(a) Deep, rapid respirations similar to Kussmal's
(b) Increased intracranial pressure
4. Common endpoints
a. Tissue/brain ischemia, injury, and death
5. Agonal
a. Slow, shallow, gasping irregular respiration resulting from brain anoxia
E. Control of respiration by other factors
1. Body temperature
a. Respirations increase with fever
(1) Response to metabolic changes due to infection
b. Drug and medications
(1) May increase or decrease respirations depending on their physiologic action
c. Pain increases respirations
d. Emotion increases respirations
e. Hypoxia increases respirations
f. Acidosis increases respirations as compensatory response to increased CO2 production
g. Sleep decreases respirations
2. Modified forms of respiration
a. Protective reflexes
(1). Cough
(a) Forceful, spastic exhalation aids in clearing bronchi and bronchioles
(2) Sneeze - clears the nasopharynx
(3) Gag reflex
(a) Spastic pharyngeal and esophageal reflex from stimulus of the posterior pharynx
(4) Sighing
(a) Involuntary deep breath that increases opening of the alveoli
(b) Normally sigh about once per minute
(5) Hiccough
(a) An spastic closure of glottis

VII. Pathophysiology

A. Obstruction
1. Tongue
a. Most common airway obstruction
b. Snoring respirations
c. Corrected with positioning
2. Foreign body
a. May cause partial or full obstruction
b. Symptoms include
(1) Choking
(2) Gagging
(3) Stridor
(4) Dyspnea
(5) Aphonia (unable to speak)
(6) Dysphonia (difficulty speaking)
3. Laryngeal spasm
a. Spasmodic closure of vocal cords
b. Glottic opening become extremely narrow or totally obstructed
c. Most frequently caused by
(1) Bacterial infection of the epiglottis
(2) Severe allergic reactions
(3) Trauma during intubation
(4) Immediately upon extubation (especially if the person is semiconscious)
d. Relieve by
(1) Aggressive ventilation
(2) Forceful upward pull of the jaw
(3) Muscle relaxants (administered IV)
4. Fractured larynx
a. Airway patency dependent upon muscle tone
b. Fractured laryngeal tissue
(1) Increases airway resistance by decreasing airway size through
(a) Decreasing muscle tone
(b) Laryngeal edema
(c) Ventilatory effort
5. Aspiration
a. Significantly increases mortality
b. Obstructs airway
c. Destroys bronchial tissue
d. Induces pathogens
e. Decrease ability to ventilate
6. Reactive airway
a. Allergens
b. Stress induced asthma
7. Chronic diseases
a. Asthma
b. Emphysema
c. Chronic bronchitis

VIII. Airway evaluation

A. Essential parameters
1. Rate
a. Normal resting rate of adults is 12-24
2. Regularity
a. Steady pattern
(1) Irregular respiratory patterns are significant until proven otherwise
3. Effort
a. Breathing at rest should be effortless (eupnea)
b. Effort changes may be subtle in rate or regularity
c. Patients often compensate by preferential positioning
(1) Upright sniffing
(2) Semi-fowlers
(3) Frequently avoid supine
4. Tidal volume
a. Shallow respirations don't ventilate well
b. Rapid, shallow respirations may need assisted with mechanical devices
B. Recognition of airway problems
1. Difficulty in rate, regularity or effort (dyspnea)
2. Dyspnea may be a result of or result in hypoxia
a. Hypoxia is lack of O2
b. Hypoxemia is lack of O2 to tissues
c. Anoxia is the total absence of O2
3. Recognition and treatment of dyspnea is crucial to patient survival
a. Expert assessment and management is essential
(1) The brain can survive only a few minutes of anoxia
(2) All therapies fail if airway is inadequate
4. Visual signs and symptoms
a. Position (ie. tripod, upright with dangling feet
b. Anxiety
(1) Range from mild to extreme
c. Rise and fall of chest
(1) Normal, deep, shallow, or absent
d. Color of skin
e. Flaring of nares
f. Gasping
g. Pursed lips
h. Retractions: "Pulling in of skin" between thoracic skeleton during inspiration
(1) Intracostal
(2) Suprasternal notch
(3) Supraclavicular fossa
(4) Subcostral
i. Respiratory rate and pattern
5. Auscultation
a. Air movement at mouth and nose
b. Bilateral lung fields
(1) A silent chest in an asthmatic in distress indicates poor air movement (NOT GOOD)
(2) Lung sounds
6. Palpation
a. Air movement at mouth and nose
b. Chest wall
(1) Paradoxical motion
(2) Retractions
7. Bag-valve-mask
a. Resistance or changing compliance with bag- valve-mask ventilations
8. Pulsus paradoxus
a. Systolic blood pressure drops greater than 10 mmHg with inspiration
(1) Change in pulse quality may be detected
(2) Seen in COPD, pericardial tamponade
9. History
a. Evolution
(1) Sudden vs gradual over time
(2) Known cause or "trigger"
b. Duration
(1) Constant, recurring
c. Ease
(1) What makes it better
d. Exacerbate
(1) What makes it worse
e. Associate
(1) Other symptoms such as cough, chest pain, fever, etc.
f. Interventions
(1) Evaluations/admissions to hospital
(2) Meds (include compliance)
g. Ever intubated
10. Mechanical monitoring
a. Pulse oximetry
(1) Oxygen bound vs unbound Hgb in the red blood cells absorbs infrared light at different rates
(2) Pulse oximeters emit infrared beam that passes through the capillary bed. The absorption of infrared light by Hgb is measured in per cent as the infrared light passes from one end of the probe to the other
(3) Normal pulse ox values are between 94 to 100 per cent on room air. Values below 93% to 94% are abnormal and may suggest acute or chronic hypoxia (ie. COPD)
(4) Limitations
(a) A normal pulse ox does not mean that hypoxia is not present
(b) False positive readings are possible with
i) Patients who smoked prior to pulse ox
ii) COPD patients
iii) CO poisoning
b. End tidal CO2 monitoring
(1) Measures amount of CO2 of expired air
(2) CO2 is a by-product of cellular metabolism
(a) CO2 is carried to lungs and expired
(b) Pt's expired air passes through a measurement device such as a color graph or electronic probe
(3) Mainly used for confirming tube placement but other applications such as predicting cardiac arrest outcome as well as detecting improvement or deterioration during prehospital care has been suggested
(4) Limitations
(a) Does not conclusively confirm proper tube placement
i) Confirms tube is in an area that contains CO2 such as the pharynx
ii) Cannot detect mainstem placement or displacement

IX. Airway management

A. Noninvasive maneuvers
1. Opening the mouth
a. Head tilt/chin lift maneuver
(1) Most basic airway maneuver
(a) Tilt head back
(b) Lift chin forward
(c) Open mouth
(2) Indications
(a) Unresponsive patients who
i) Do not have a mechanism for C-Spine injury
ii) Unable to protect their own airway
(3) Contraindications
(a) Awake patients
(b) Possible C-Spine injury
(4) Advantages
(a) No equipment required
(b) Simple
(c) Safe
(d) Non-invasive
(5) Disadvantages
(a) Head-tilt hazardous to C-Spine injured patients
(b) Does not protect from aspirate
b. Jaw-thrust maneuver lift
(1) Head is maintained neutral
(a) Jaw is displaced forward
i) Lift by grasping under chin and behind teeth
(b) Mouth is opened
(2) Indications
(a) Patients who
i) Unresponsive
ii) Unable to protect their own airway
iii) May have C-Spine injury
(3) Contraindications
(a) Responsive patients
(b) Resistance to opening mouth
(4) Advantages
(a) May be used in C-Spine injury
(b) May be performed with cervical collar in place
(c) Does not require special equipment
(5) Disadvantages
(a) Can not maintain if patient becomes responsive or combative
(b) Difficult to maintain for extended period
(c) Very difficult to use in conduction with bag-valve-mask ventilation
(d) Thumb must remain in patients mouth in order to maintain displacement
(e) Second rescuer required to perform bag-valve-mask ventilation
(f) Does not protect against aspiration
c. Modified jaw-thrust maneuver
(1) Head maintained neutral
(a) Jaw is displaced forward at mandibular angle
(2) Indications
(a) Unresponsive
(b) Cervical spine injury
(c) Unable to protect own airway
(d) Resistance to opening mouth
(3) Contraindications
(a) Awake patients
(4) Advantages
(a) Non-invasive
(b) Requires no special equipment
(c) May be used with cervical collar in place
(5) Disadvantages
(a) Difficult to maintain
(b) Requires second rescuer for bag- valve-mask ventilation
(c) Does not protect against aspirate
(d) Cricoid pressure
d. Sellick's maneuver
(1) Pressure on cricoid ring
(a) Occludes the esophagus
(b) Helps to prevent passive emesis
(c) Can help minimized gastric distention during bag-valve-mask ventilation
(2) Indications
(a) Vomiting
(b) Patient can not protect own airway
(3) Contraindications
(a) Use with caution in cervical spine injury
(4) Advantages
(a) Non-invasive
(b) Easy to perform
(c) Protects from aspirate as long as pressure is maintained
(5) Disadvantages
(a) May have extreme emesis if pressure is removed
(b) Second rescuer required for bag- valve-mask ventilation
(c) May further compromise injured cervical spine
(6) Complications
(a) Laryngeal trauma with excessive force
(b) Esophageal rupture from unrelieved high gastric pressures
B. Suctioning
1. Types of suctioning equipment
a. Hand-powered suction devices
(1) Advantages
(2) Disadvantages
b. Oxygen-powered portable suction devices
c. Battery-operated portable suction devices
(1) Advantages
(a) Lightweight
(b) Portable
(c) Excellent suction power
(d) May "field strip" troubleshoot most components
(2) Disadvantages
(a) More complicated machines
(b) May lose battery integrity over time
(c) Some fluid contact components not disposable
d. Mounted vacuum-powered suction devices
(1) Advantages
(a) Extremely strong vacuum
(b) Adjustable vacuum power
(c) Fluid contact components disposable
(2) Disadvantages
(a) Non-portable
(b) Cannot "field service" or substitute a power source
2. Types of suction catheters
a. Hard or rigid catheters
(1) AKA "Yankauer" or "tonsil tip"
(2) Suction large volumes of fluid rapidly
(3) Standard size
b. Soft catheters
(1) Can be placed in oropharynx, nasopharynx, or down endotracheal tube
(2) Various sizes
(3) Smaller inside diameter than hard tipped catheters
3. Suctioning the upper airway
a. Prevention of aspirate critical
(1) Mortality increases significantly if aspiration occurs
(2) Preoxygenate if possible
(3) Hyperoxygenate after
b. Description
(1) Pre-lubricate soft tip catheter
(2) Place catheter
(3) Suction during extraction of catheter
(4) Do not exceed 15 seconds
(5) Hyperoxygenate
4. Tracheobronchial suctioning
a. Preoxygenation essential
b. Sterile technique important
c. Description
(1) Pre-lubricate soft tip catheter
(2) Hyperoxygenate
(a) May be necessary to inject 3 to 5 cc's of sterile water down the endotracheal tube to loosen secretions
(3) Gently insert catheter until resistance is felt
(4) Suction upon extraction of catheter
(5) Do not exceed 15 seconds
(6) Hyperoxygenate following suctioning
C. Gastric Distention
1. Air becomes trapped in the stomach
a. Very common when ventilating non-intubated patients
(1) Stomach diameter increases
(2) Pushes against diaphragm
(3) Interferes with lung expansion
(a) Abdomen becomes increasingly distended
(b) Resistance to bag-valve-mask ventilation
2. Management
a. May be reduced by increasing bag-valve-mask ventilation time
(1) Adults: 1.5-2 seconds
(2) Peds: 1-1.5 seconds
b. Prepare for large volume suction
c. Position patient left lateral
d. Slowly apply pressure to epigastric region
e. Suction as necessary
D. Basic airway management
1. Nasal airway
a. Soft rubber with beveled tip
(1) Distal tip rests in hypopharynx
(2) For adults, length measured from nostril to earlobe
(3) Diameter roughly equal to patient's little finger
b. Indications
(1) Unconscious patient
(2) Altered response patients with suppressed gag reflex
c. Contraindications
(1) Patient intolerance
(2) Caution in presence of facial fracture or skull fracture
d. Advantages
(1) Can be suctioned through
(2) Provides patent airway
(3) Can be tolerated by awake patients
(4) Can be safely placed "blindly"
(5) Does not require mouth to be open
e. Disadvantages
(1) Poor technique may result in severe bleeding
(a) Resulting epistaxis may be extremely difficult to control
(2) Does not protect from aspirate
f. Placement
(1) Determine correct length and diameter
(2) Lubricate nasal airway
(3) With bevel towards septum, insert gently along the nasal floor parallel to the mouth
(4) Do not force
(a) Measurement from corner of the mouth to the jaw angle rather than tip of the ear
i) Too long of an airway causes airway obstruction
2. Oral airway
a. Hard plastic airway designed to prevent the tongue from obstructing the glottis
(1) Indications
(a) Unconscious patients
(b) Absent gag reflex
(2) Contraindications
(a) Conscious patients
(3) Advantages
(a) Non-invasive
(b) Easily placed
(c) Prevents blockage of glottis by tongue
(4) Disadvantages
(a) Does not prevent aspiration
(b) Unexpected gag may produce vomiting
(5) Placement
(a) Open mouth
(b) Remove visible obstructions
(c) Place with distal tip towards glottis using tongue depressor as adjunct
(d) Alternate: Place airway with distal tip toward palate. Rotate into place
b. Special considerations
(1) Pediatrics
(a) Place with tongue depressor
(b) Place with tip toward cheek, not palate
E. Methods to perform ventilation
1. Mouth-to-mouth
a. Most basic form of ventilation
(1) Indications
(a) Apnea from any mechanism when other ventilation devices are not available
(2) Contraindications
(a) Awake patients
(b) Communicable disease risk limitations
(3) Advantages
(a) No special equipment required
(b) Delivers excellent tidal volume
(c) Delivers adequate oxygen
(4) Disadvantages
(a) Psychological barriers from:
i) Sanitary issues
ii) Communicable disease issues
a) Direct blood/body fluid contact
b) Unknown communicable disease risks at time of the event
iii) May be difficult to seal mouth
(5) Complications
(a) Hyperinflation of the patient's lungs
(b) Gastric distension
(c) Blood/body fluid manifestations
2. Mouth-to-nose
a. Ventilating through nose rather than mouth
(1) Indications
(a) Apnea from any mechanism
(2) Contraindications
(a) Awake patients
(3) Advantages
(a) No special equipment required
(b) May decrease blood/body fluid contact
(4) Disadvantages
(a) Direct blood/body fluid contact
(b) Psychological limitations of rescuer
(5) Complications
(a) Hyperinflation of patient's lungs
(b) Gastric distention
(c) Blood/body fluid manifestations
(d) Hyperventilation of rescuer
3. Mouth-to-mask
a. Adjunct to mouth-to-mouth ventilation
(1) Indications
(a) Apnea from any mechanism
(2) Contraindications
(a) Awake patients
(3) Advantages
(a) Physical barrier between rescuer's and patient's blood/body fluids
(b) One-way valve to prevent blood/body fluid splash to rescuer
(c) May be easier to obtain face seal
(4) Disadvantages
(a) Useful only if readily available
(5) Complications
(a) Hyperinflation of patient's lungs
(b) Hyperventilation of rescuer
(6) Method for use
(a) Position head by appropriate method
(b) Position and seal mask over mouth and nose
(c) Ventilate as appropriate
4. One person bag-valve-mask
a. Fixed volume self inflating bag can deliver adequate tidal volumes and O2 enrichment
(1) Indications
(a) Apnea from any mechanism
(b) Unsatisfactory respiratory effort
(2) Contraindications
(a) Awake, intolerant patients
(3) Advantages
(a) Excellent blood/body fluid barrier
(b) Good tidal volumes
(c) Oxygen enrichment
(d) Rescuer can ventilate for extended periods without fatigue
(4) Disadvantages
(a) Difficult skill to master
(b) Mask seal may be difficult to obtain and maintain
(c) Tidal volume delivered is dependent on mask seal integrity
(5) Complications
(a) Inadequate tidal volume delivery with:
i) Poor technique
ii) Poor mask seal
(6) Method for use
(a) Position appropriately
(b) Choose proper mask size
i) Seats from bridge of nose to chin
(c) Position, spread/mold/seal mask
(d) Hold mask in place
(e) Squeeze bag completely over 1.5-2.0 seconds for an adult
(f) Avoid overinflation
(g) Reinflate completely over several seconds
(7) Special considerations
(a) Medical
i) Observe for:
a) Gastric distension
b) Changes in compliance of bag with ventilation
c) Improvement or deterioration of ventilation status (ie. color change, responsiveness, air leak around mask)
(b) Trauma
i) very difficult to perform with cervical spine immobilization in place
(c) Pediatrics
i) Flat nasal bridge makes achieving mask seal more difficult
ii) Compressing mask against face to improve mask seal results in obstruction
iii) Mask seal best achieved with jaw displacement
5. Two person bag-valve-mask
a. Alternate bag-valve-mask ventilation method
b. Most efficient method
(1) Indications
(a) Bag-valve-mask ventilation on any patient
i) Especially useful for cervical spine immobilized patients
ii) Difficulty obtaining or maintaining adequate mask seal
(2) Contraindications
(a) Awake, intolerant patients
(3) Advantages
(a) Superior mask seal
(b) Superior volume delivery
(4) Disadvantages
(a) Requires additional personnel
(5) Complications
(a) Hyperinflation of patient's lungs
(c) Gastric distension
(6) Method for use
(a) First rescuer maintains mask seal by appropriate method
(b) Second rescuer squeezes bag
(7) Special considerations
(a) Observe chest movement
(b) Avoid overinflation
(c) Monitor lung compliance with ventilations
6. Flow-restricted, oxygen powered ventilation devices
a. Demand valve
(1) Trigger when patient inhales. Delivers O2 as long as inspiratory strength is enough to "hold the gate open"
7. Automatic transport ventilators
a. Volume/rate controlled
b. Indications
(1) Extended ventilation of intubated patients
c. Contraindications
(1) Awake patients
(2) Obstructed airway
(3) Increased airway resistance
(a) Pneumothorax
(b) Asthma
(c) Pulmonary edema
d. Advantages
(1) Lightweight
(2) Portable
(3) Durable
(4) Mechanically simple
(5) Adjustable tidal volume
(6) Adjustable rate
(7) Adapts to portable O2 tank
e. Disadvantages
(1) Cannot detect tube placement
(2) Does not detect increasing airway resistance
(3) Difficult to secure
(4) Dependent on O2 tank pressure
F. Oxygen delivery
1. Enriched O2 atmosphere increases oxygen to cells
a. Increasing available O2 increases patient's ability to compensate
2. O2 delivery method must be reassessed to determine adequacy and efficiency
3. Oxygen delivery equipment
a. Oxygen tank
(1) Sizes most common in pre-hospital environment
(a) "D" cylinder
(b) "E" cylinder
(c) "M" cylinder
(2) Tank volumes
(a) D: 400L
(b) E: 660L
(c) M: 3450L
(3) O2 delivery measured in Liters/minute
(4) Calculating tank life
(a) Tank pressure (psi) x 0.28 = Volume
(b) Volume/Lpm = tank life in minutes
b. Oxygen regulators
(1) Types of pressure regulators
(a) High pressure
i) Attached to cylinder stem delivers cylinder gas under high pressure
ii) Used to transfer cylinder gas from tank to tank
(b) Therapy regulators
i) Attached to cylinder stem
ii) 50 psi escape pressure is stepped down through regulator mechanism
iii) Subsequent delivery to patient is adjustable low pressure
c. Nasal cannula
(1) Nasally placed O2 catheter for oxygen enrichment
(a) Optimal delivery of 40% at 6L/min
(2) Indications
(a) Low to moderate O2 enrichment
(b) Long term O2 maintenance therapy
(3) Contraindications
(a) Poor respiratory effort
(b) Severe hypoxia
(c) Apnea
(d) Mouth breathing
(4) Advantages
(a) Well tolerated
(5) Disadvantages
(a) Does not deliver high volume/high concentration
d. Simple face mask
(1) Full airway enclosure with open side ports
(a) Room air is drawn through side ports on inspiration, diluting O2 concentrations
(2) Indications
(a) Delivery of moderate to high O2 concentrations
(b) Range: 40-60% at 10 L/min
(3) Advantages
(a) Higher O2 concentrations
(4) Disadvantages
(a) Delivery of volumes beyond 10 L/min does not enhance O2 concentration
(5) Special considerations
(a) Mask leak around face decreases O2 concentration
e. Partial rebreather
(1) Mask vent ports covered by one-way disc
(a) Expired air escapes through vents
(b) Residual expired air mixed in mask and rebreathed
(c) Room air not entrained with inspiration
(2) Indications
(a) Higher O2 concentration
(3) Contraindications
(a) Apnea
(b) Poor inspiratory effort
(4) Advantages
(a) Inspired gas not mixed with room air
(b) Higher O2 concentration attainable
(5) Disadvantages
(a) Delivery of volumes beyond 10L/min does not enhance O2 concentration
(6) Special considerations
(a) Mask leak around face decreases O2 concentration
f. Non-rebreather mask
(1) Mask side ports covered by one-way disc
(2) Reservoir bag attached
(3) Range: 80-95%+ at 15 L/min
(4) Indications
(a) Delivery of highest O2 concentration
(5) Contraindications
(a) Apnea
(b) Poor respiratory effort
(6) Advantages
(a) Highest O2 concentration
(b) Delivers high volume/high O2 enrichment
(c) Patient inhales enriched O2 from reservoir bag rather than residual air
(7) Disadvantages
(8) Complications
(9) Method for use
(10) Special considerations
i) Pediatrics
g. Venturi mask
(1) Mask with interchangeable adapters
(a) Adapters have port holes that entrain room air as 02 passes
(b) Patient receives a highly specific concentration of O2
(c) Air is entrained by venturi principle
h. Small volume nebulizer
(1) Delivers aerosolized medication
(2) O2 enters an aerosol chamber containing 3-5 cc's of fluid
(3) Presized O2 mists (aerosolizes) fluid
i. Oxygen humidifiers
(1) Sterile water reservoir for humidifying O2
(2) Good for long term oxygen administration
(3) Desirable for croup/eqiglottitis/bronchiolitis
G. Advanced airway management
1. Endotracheal intubation (ET)
a. Airway passed into trachea in order to provide externally controlled breathing through a BVM or ventilator
b. Indications
(1) Present or impending respiratory failure
(2) Apnea
(3) Failure to protect own airway
c. Contraindications
(1) Equipment to resolve complications is not available
d. Advantages
(1) Provides a secure airway
(2) Protects against aspiration
(3) Route for medication administration
e. Disadvantages
(1) Special equipment needed
(2) Bypasses physiologic function of upper airway
(a) Warming
(b) Filtering
(c) Humidifying
f. Complications
(1) Bleeding
(2) Laryngeal swelling
(3) Laryngospasm
(4) Anoxia
(5) Unrecognized misplacement
(6) Barotrauma
g. Special considerations
(1) Pediatrics
(a) Right mainstem displacement most common
(b) Tube depth determined by:
(i) Distal tube markings
(ii) cm markings
(iii)Tube depth calculation
a) 3 x (inside diameter)
h. Equipment
(1) Endotracheal tubes
(a) Size range
(i) 2.5-9.0mm inside diameter (id)
(ii) Length 12-32 cm
(b) Types
(i) Cuffed 5.0-9.0
a) Proximal end 15 mm adapter
b) Proximal end inflation port with pilot balloon
c) cm markings along length of tube
d) Distal end beveled tip
e) Distal end balloon cuff
(ii) Uncuffed 2.5-4.5
a) Proximal end 15mm adapter
b) Distal end beveled tip
c) Distal end depth markings
d) No balloon cuff or pilot balloon
(2) Laryngoscope
(a) Device used to visualize glottis during endotracheal intubation
(b) Battery pack/handle with interchangeable blades
(i) Blade types
a) Straight (Miller) - lifts epiglottis
b) Curved (Macintosh) - lifts epiglottis by fitting into vallecula
(3) Adjunct equipment
(a) 10 cc syringe
(i) To inflate/deflate balloon cuff
(b) Water soluble lubricant
(i) Lubricates endotracheal tube and promotes ease of passage and decreases trauma
(c) Stylet
(i) Semi-rigid wire for molding and maintaining tube shape
(d) esophageal intubation detection device
(e) Securing device
(i) Tape or commercially available endotracheal tube holder
(f) Suction
(4) Body substance precautions
(a) Gloves
(b) Mask
(c) Eyewear or face shield
(5) Pre-intubation precautions
(a) Essential prior to performing any intubation
(i) Positioning
a) Both patient and rescuer
(ii) Pre-oxygenation
(iii)Suction
(iv) Equipment preparation
2. Direct orotracheal intubation
a. Directly visualizing the passage of the endotracheal tube into the trachea
b. Indications
(1) Apnea
(2) Hypoxia
(3) Poor respiratory effort
(4) Unresponsive or absence of gag reflex
c. Contraindications
(1) Caution in unsupressed gag reflex
d. Advantages
(1) Direct visualization of anatomy and tube placement
(2) Ideal method for confirming placement
(3) May be performed in breathing and apneic patients
e. Disadvantages
(1) Requires special equipment
f. Complications
(1) Dental trauma
(2) Laryngeal trauma
(3) Misplacement
(a) Right mainstem bronchus
(b) Esophagus
g. Method
(1) Position when there is no potential pressure of c-spine injury
(a) Sniffing position
(i) Optimal hyperextension of head with elevation of occiput
a) Brings the axis of the mouth, pharynx and trachea into alignment
(2) Position if potential of c-spine injury exists
(a) Neutral
(i) Head is held firmly in neutral position during intubation
(3) Insure optimal oxygenation and ventilation with 100% oxygen
(4) Insure all equipment is prepared
(a) Lubricated tube with stylet in place
(i) Best position is "Hockey Stick" bend directly behind balloon cuff
(b) Working laryngoscope
(i) Blade locks securely in place
(ii) Light is bright and steady (unpleasant to look at)
(c) Syringe
(d) Securing device
(e) Suction
(f) Body substance isolation
(g) Stethoscope
(h) Ventilation device
(5) Ideally hyperoxygenate patient for 30 seconds to 1 minute
(6) Insert laryngoscope blade
(a) Gently insert to hypopharynx
b) Lift tongue and jaw with firm steady pressure
(c) Identify vocal cords
(d) Gently pass ET tube
(i) Observe passage of balloon cuff past vocal cords
(e) Remove stylet
(f) Inflate balloon cuff
(g) Ventilate patient
(h) Confirm placement using multiple methods
(i) Reconfirm placement following major patient movement or head movement
3. Confirming placement
a. Not confirming placement is the single greatest reason misplacement goes unrecognized
b. Methods
(1) Direct re-visualization
(a) Revisualize glottis
(b) Note tube depth
(i) Teeth and tube at 22 cm
(c) Note condensation in the tube
(2) Auscultation
(a) Epigastric area
(i) Air entering stomach indicates esophageal placement
(b) Bilateral bases of lung fields
(i) Equal volume and expansion
(c) Apices of lung fields
(i) Equal volume
(d) Unequal or absent breath sounds indicate
(i) Esophageal placement
(ii) Right mainstem placement
(iii)Pneumothorax
(iv) Bronchial obstruction
(3) Palpation of balloon cuff at sternal notch by compressing pilot balloon
(4) Esophageal detection devices
(a) Dependent on rigid cartilagenous structure of the trachea versus the easily collapsible fibroclastic tissue of the esophagus
(b) Bulb type
(i)Squeeze and hold the bulb before connecting it to the endotracheal tube
(ii)Connect the bulb to the 15 mm adapter on the end of the endotracheal tube
(iii)Release the bulb to allow it to refill
(iv)If the bulb refills swiftly, then this is a finding that would lead you to believe the endotracheal tube was correctly place in the trachea. This assessment should be used in conjunction with other assessment findings to assure proper tube placement
(v)If the bulb refills slowly or not at all, then this is a finding that would lead you to believe the tube is in the esophagus
(vi)If in doubt about proper tube placement then you should pull the tube and ventilate using other methods while preparing to attempt another endotracheal intubation
(4) Pulse oximetry
(a) In intubated patients with a pulse, oxygen saturation should increase rapidly
(5) Expired carbon dioxide (CO2)
(a) Measures presence of CO2 in expired air
(i) Colormetric
(ii) Digital
(iii)Digital/waveform
(6) Bag-valve-mask ventilation compliance
(a) Increased resistance to BVM compliance may indicate
(i) Gastric distention
(ii) Esophageal placement
(iii)Tension pneumothorax
c. Evidence of misplaced tube regardless of when it was last checked must be reconfirmed
d. Confirmation must be performed
(1) By multiple methods
(2) Immediately after tube placement
(3) After any major move
(4) After manipulation of neck
(a) Manipulation of neck may displace tube up to 5 cm
4. Securing tube
a. As critical as the intubation itself
b. Multiple methods and products available
c. Adjuncts include
(1) Securing to maxilla rather than mandible
(2) Tincture of benzoin to facilitate tape adhesion
H. Multi-lumen airways
1. Pharyngeo-tracheal lumen airway (PtL)
a. An endotracheal tube encased in a large pharyngeal tube
b. Designed to be passed blindly
c. Dual ventilation ports provide means to ventilate regardless of whether the tube is placed in the esophagus or the trachea
d. Indications
(1) Alternative airway control when conventional intubation procedures are not available or successful
e. Advantages
(1) Can ventilate with tracheal or esophageal placement
(2) No facemask to seal
(3) No special equipment
(4) Does not require sniffing position
f. Disadvantages
(1) Cannot be used in awake patients
(2) Adults only
(3) Unconscious only
(4) Pharyngeal balloon mitigates but does not eliminate aspiration risk
(5) Can only be passed orally
(6) Extremely difficult to intubate around
g. Method
(1) Head neutral
(2) Pre-intubation precautions
(3) Insert at the midline using jaw-lift
(4) Ventilate through pharyngeal tube (green) first
(a) Chest rise indicates tube is in the esophagus
(1) Inflate pharyngeal balloon and ventilate
(b) No chest rise indicates tube is in trachea
(1) Inflate ET tube balloon cuff
(2) Ventilate through ET tube
h. Complications
(1) Pharyngeal or esophageal trauma from poor technique
(2) Unrecognized displacement of ET tube into esophagus
(3) Displacement of pharyngeal balloon
2. Combitube
a. Pharyngeal tube and endotracheal tube molded into a single unit
b. Indications
(1) Alternative airway control when conventional intubation measures are unavailable or unsuccessful
c. Contraindications
(1) Children too small for the tube
(2) Esophageal trauma or disease
(3) Caustic ingestion
d. Advantages
(1) Rapid insertion
(2) No special equipment
(3) Does not require sniffing position
e. Disadvantages
(1) Impossible to suction trachea when tube is in esophagus
(2) Adults only
(3) Unconscious patients only
(4) Very difficult to intubate around
f. Method
(1) Head neutral
(2) Pre-intubation precautions
(3) Insert at midline with jaw-lift
(4) Inflate pharyngeal cuff with 10cc of air
(5) Inflate distal cuff with 10-15 cc of air
(6) Ventilate through longest tube first (pharyngeal)
(a) Chest rise indicates esophageal placement of distal tip
(b) No chest rise indicates tracheal placement
(i) Switch ports and ventilate
I. Special patient considerations
1. Patients with laryngectomies (stoma)
a. Laryngectomee patients have a permanent or semi-permanent surgical opening (stoma) below the glottis which acts as their primary airway
b. Airway is kept open by a short tube device that fits into the stoma
(1) Part or entire tube assembly may be removed for normal cleaning
c. Commonly produce moderately large amounts of mucous
(1) Protective function of upper airway is bypassed
d. Coughing is not as efficient or forceful
e. Most common laryngectomee problems
(1) Mucous plug
(a) Usually occurs while coughing
(b) Mucous builds up and cannot be forcefully expelled from bronchi or tube
(c) Treatment
(i) Suction trachea
a) Pre-oxygenate
b) Inject 1 to 3 cc sterile water into trachea to loosen secretions. Patient will cough
c) Gently insert flexible suction catheter into trachea
d) Suction on the way out. Encourage patient to cough
e) Oxygenate patient
f) Reassess
g) Repeat as necessary
(2) Stenosis
(a) Stoma narrows and patients cannot replace their tube
(b) Particularly dangerous in recent laryngectomee
(c) May require placement of smaller endotracheal tube into the stoma to prevent complete occlusion
(d) If tube placement is not immediately successful, rapid transport is necessary. Give 100% oxygen
f. Dental appliances
(1) Loose dentures, retainers, etc. should be removed when possible

KSE Module 2

KSE Lesson 2.1 Introduction of Microbiology and Human Disease

Explain how microorganisms are classified and named.
Describe the distribution of and benefits provided by normal flora.
Explain what is meant by an infectious disease, and describe the different types of infection.
Describe the ways in which infectious diseases may be spread.

KSE Lesson 2.2 Albuteral Pharmacology

LESSON TERMINAL INSTRUCTIONAL OBJECTIVE
At the end of this lesson the EMT-Intermediate student will be able to apply the understanding of albuterol
for the treatment of out of hospital respiratory emergencies.

COGNITIVE OBJECTIVES

REVIEW
Review the specific anatomy and physiology of the cardio-respiratory system pertinent to the administration of albuterol. (C-1)
Differentiate among the chemical, generic, non-proprietary, official, trade, and proprietary name of albuterol. (C-1)
Discuss pregnancy safety categories. (C-1)
Discuss the EMT-Intermediateís responsibilities and scope of management pertinent to the administration of albuterol. (C-1)
Describe mechanisms of drug action of albuterol.
Describe pharmacokinetics, including theories of drug action, drug-response relationship, factors altering drug responses, predictable drug responses, iatrogenic drug responses, and unpredictable adverse drug responses of albuterol. (C-1)
Differentiate among drug interactions. (C-3)
Discuss considerations for storing of albuterol.(C-1)
List and describe classifications of drugs. (C-1)
Practice use of terminology of pharmacology. (P-1, P-2)
Practice use of abbreviations of pharmacology. (P-1)

DECLARATIVE

I. Definitions
A. Drugs: chemical agents used in the diagnosis, treatment, or prevention of disease
B. Pharmacology: the study of drugs and their actions on the body
C. Chemical name: a precise description of the drugís chemical composition and molecular structure
D. Generic name or non-proprietary name; the name the manufacturer uses for a drug
E. Trade or proprietary name: the brand name registered to a specific manufacturer or owner
F. Official name: the name assigned by USP
II. Sources of Drugs
A. Plants
B. Animals and humans
C. Minerals or mineral products
D. Chemical substances made in the laboratory.
III. Drug Classification .
A. By body system
B. By class of agent
C. By mechanism of action
IV. Sources of Drug Information
A. AMA Drug Evaluation
B. Physicianís Desk Reference (PDR)
C. Hospital Formulary (HF)
D. Drug inserts
E. Other texts, sources
22. Special Considerations in Drug Therapy
A. Pregnant patients
1. Before using any drug during pregnancy, the expected benefits should be considered against the possible risks to the fetus.
2. The FDA has established a scale (Categories A,B,C,D, and X) to indicate drugs that may have documented problems in animals and/or humans during pregnancy.
3. Many drugs are unknown to cause problems in animals and/or humans during pregnancy.
4. Pregnancy causes a number of anatomical and physiological changes.
5. Drugs may cross the placenta or through lactation.
B. Pediatric patients
1. Based on the childís weight or body surface area.
2. Special concerns for neonates
3. Braslow Tape method
C. Geriatric patients
1. The physiological affects of aging can lead to altered pharmacodynamics and pharmacokinetics.
VI. The Scope of Management
A. EMT-Intermediates are held responsible for safe and therapeutically effective drug administration
B. EMT-Intermediates are personally responsible - legally, morally, and ethically - for each drug they administer
C. EMT-Intermediates:
1. Use correct precautions and techniques.
2. Observe and document the effects of drugs.
3. Keep their knowledge base current to changes and trends in pharmacology.
4. Establish and maintain professional relationships.
5. Understand pharmacology of albuterol.
6. Perform evaluation to identify drug indications and contraindications.
7. Seek drug reference literature
8. Take a drug history from their patients including;
a. Prescribed medications (name, strength, and daily dosage)
b. Over-the-counter medications
c. Vitamins
d. Drug reactions
9. Consult with medical direction.
10. Comply with medical direction.
VII. Overview of the Routes of Drug Administration
A. The mode of drug administration effects the rate at which onset of action occurs and may effect the therapeutic response that results
B. The choice of the route of administration is crucial in determining the suitability of a drug
C. Drugs are given for either their local or systemic effects
D. The routes of drug administration are categorized as:
1. Enteral (drugs administered along any portion of the gastrointestinal tract).
a. Sublingual
b. Buccal
c. Oral
d. Rectal
e. Nasogastric
2. Parenteral (any medication route other than through the alimentary canal)
a. Subcutaneous
b. Intramuscular
c. Intravenous
d. Intrathecal
e. Pulmonary
f. Intralingual
g. Intradermal
h. Transdermal
i. Umbilical
j. Intraosseous
VIII. Mechanisms of Drug Action
A. To produce optimal desired or therapeutic effects, a drug must reach appropriate concentrations at its site of action
B. Molecules of the chemical compound must proceed from point of entry into the body to the tissues with which they react
C. The magnitude of the response depends on the dosage and the time course of the drug in the body
D. Concentration of the drug at its site of action is influenced by various processes, which are divided into three phases of drug activity
1. Pharmaceutical
a. Disintegration of dosage form
b. Dissolution of drug
2. Pharmacokinetic
a. Absorption
b. Distribution
c. Metabolism
d. Excretion
3. Pharmacodynamics
a. Drug-receptor interaction
IX. Pharmacokinetics
A. Passive transport
B. Active transport
C. Absorption
1. Variables that affect drug absorption
A. Nature of the absorbing surface
B. Blood flow to the site of administration
C. Solubility of the drug
D. pH
E. Drug concentration
F. Dosage form
G. Routes of drug administration
H. Bioavailability
2. Mechanisms involved in absorption
A. Diffusion
B. Osmosis
C. Filtration
D. Distribution
1. Drug reservoirs
A. Plasma protein binding
B. Tissue binding
2. Barriers to drug distribution
A. Blood-brain barrier
B. Placental barrier
E. Biotransformation
1. Active metabolites
2. Inactive metabolites
F. Excretion
1. Organs of excretion
A. Kidneys
B. Intestine
C. Lungs
D. Sweat and salivary glands
E. Mammary glands
X. Pharmacodynamics
A. Theories of drug action - most drugs produce their effects by one of the following ways:
1. Drug-receptor interaction
A. Agonists
B. Antagonists
C. Affinity
D. Efficacy
E. Types of receptors (beta1, beta2, alpha1, alpha2, dopaminergic, etc.)
2. Drug-enzyme interaction
3. Nonspecific drug interaction
B. Drug-response relationship
1. Plasma level profile of a drug
2. Biologic half-life
3. Therapeutic threshold or minimum effective concentration
4. Therapeutic index
C. Factors altering drug responses
1. Age
2. Body mass
3. Sex
4. Environmental milieu
5. Time of administration
6. Pathologic state
7. Genetic factors
8. Psychologic factors
D. Predictable adverse responses
1. Desired action
E. Iatrogenic responses (adverse effects produced unintentionally)
F. Unpredictable adverse responses
1. Drug allergy
a. Medications frequently implicated in allergic reactions
2. Anaphylactic reaction
3. Delayed reaction ("serum sickness")
4. Hypersensitivity
5. Idiosyncracy
6. Tolerance
7. Cross tolerance
8. Tachyphylaxis
9. Cumulative effect
10. Drug dependence
11. Drug interaction
12. Drug antagonism
13. Summation (addition or additive effect)
14. Synergism
15. Potentiation
16. Additive
17. Interference
18. Vs. Side effects
XI. Drug Storage
A. Certain precepts should guide the manner in which drugs are secured, stored, distributed, and accounted for
B. Refer to local protocol
C. Drug potency can be affected by:
1. Temperature
2. Light
3. Moisture
4. Expiration date
D. Applies also to diluents
XII. Components of a Drug Profile
A. Drug names
B. Classification
C. Mechanisms of action
D. Indications
E. Side/adverse effects
F. Dosages
G. Contraindications
H. Considerations for pediatric patients, geriatric patients, pregnant patients, and other special groups
I. Other profile components
XIII. Albuterol
1. Classification
A. Pharmacologic
B. Therapeutic
2. Mechanisms of action
3. Indications
4. Pharmacokinetics
5. Side/adverse effects
6. Dosages
7. Contraindications
8. Special considerations
A. Pediatric patients
B. Geriatric patients
C. Pregnant patients

KSE Lesson 2.3 Albuterol Administration

LESSON TERMINAL INSTRUCTIONAL OBJECTIVE

At the end of this lesson, the EMT-Intermediate student will be able to safely and precisely perform administration of albuterol.

COGNITIVE OBJECTIVES

Review mathematical principles. (C-1)
Review mathematical equivalents. (C-1)
Define specific terminology of medication administration. (C-1)
Define specific abbreviations of medication administration (C-1)
Discuss formulas as a basis for performing drug calculations of albuterol. (C-1)
Discuss applying basic principles of mathematics to the calculation of problems associated with medication dosages. (C-1)
Describe how to perform conversion problems. (C-1)
Discuss legal aspects affecting medication administration. (C-1)
Describe on-line medical direction for medication administration. (C-1)
Describe off-line medical direction for medication administration. (C-1)
Discuss the "six rights" of drug administration and correlate these with the principles of medication administration. (C-1)
Discuss medical asepsis. (C-1)
Describe universal precautions and body substance isolation (BSI) procedures when administering albuterol.
Describe the equipment needed, techniques utilized, complications, and general principles for the preparation and administration of nebulized albuterol.

PSYCHOMOTOR OBJECTIVES
Perfect applying mathematical principles to calculation of problems associated with medication dosages. (P-3)
Perfect applying mathematical equivalents to calculation of problems associated with medication dosages. (P-3)
Perfect using formulas as a basis for performing drug calculations. (P-3)
Perform temperature readings between the centigrade and Fahrenheit scales. (P-1,P-2)
Perfect documentation of medication administration. (P-3)
Perform universal precautions and body substance isolation (BSI) procedures during medication administration. (P-1,P-2)
Perfect clean technique during medication administration. (P-3)
Demonstrate preparation and administration of nebulized albuterol. (P-1,P-2)
Perfect disposal of contaminated items and sharps. (P-3)

AFFECTIVE OBJECTIVES
Comply with EMT-Intermediate standards of medication administration. (A-1)
Comply with universal precautions and body substance isolation (BSI). (A-1)
Defend a pharmacologic management plan for medication administration. (A-3)
Serve as a model for medical asepsis. (A-3)
Serve as a model for advocacy while performing medication administration. (A-3)
Serve as a model for disposing contaminated items and sharps. (A-3)

INTEGRATION
Synthesize a pharmacologic management plan including administration of albuterol. (C-3)
Integrate pathophysiological principles of albuterol administration with patient management. (C-3)

DECLARATIVE

I. A Review of Mathematical Priniciples
A. Multiplication and division
B. Fractions
C. Decimal
D. Proportions
E. Percents
II. Mathematical Equivalents Used in Pharmacology
A. The apothecariesí system
B. The metric system
C. Household measures
D. Conversions between apothecariesí, metric, and household systems
E. Fahrenheit scale for temperature reading
F. Celsius (centigrade) scale for temperature reading
G. Converting between Fahrenheit and Celsius temperatures
III. Calculating Drug Dosages
A. Calculation methods
1. Fraction method
2. Ratio method
3. Desired over available method
B. Calculating dosages
1. Oral medications
2. Parenteral medications
3. Intravenous infusions
a. Flow rates
b. Flow rates for infants and children
c. Total infusion time
d. Other factors influencing flow rates
4. Calculating dosages for infants and children
IV. Medical Direction
A. Medication administration is bound by the EMT- Intermediateís on-line or off-line medical direction
B. Role of the medical director
C. Patient management protocols
1. Written standing orders
D. Legal considerations: policies and procedures which specify regulations of medication administration
V. Principles of Medication Administration
A. Local drug distribution system: policies which establish stocking and supply of drugs
B. EMT-Intermediateís responsibility associated with the drug order
1. Verification of the drug order
C. The "six rights" of medication administration
1. The right patient
2. The right drug
3. The right dose
4. The right route
5. The right time
6. The right documentation
VI. Medical Asepsis
A. Clean technique vs. sterile technique
VII. Universal Precautions and Body Substance Isolation (BSI) in Albuterol Administration
VIII. Administration of Albuterol
A. Percutaneous route: application of a medication for absorption through the mucous membranes or skin.
B. Factors which influence the amount of medication absorbed through the skin or mucous membranes.
C. Steps in preparing percutaneous administration of NTG.
D. Administering albuterol to mucous membranes.
1. Inhaled into the lungs
A. through an aerosol or nebulizer
B. Through positive pressure ventilation
2. Dosage forms
A. Drops
B. Metered-dose inhalers
3. Equipment needed for administration of albuterol and
4. Steps for the administration of the dosage form of albuterol
IX. Disposal of Contaminated Items and Sharps
A. Follow local protocol for disposition of contaminated items and sharps

KSE Module 3 Patient Assessment

KSE Lesson 3.1 Clinical Decision Making

LESSON TERMINAL OBJECTIVE
At the end of this lesson, the EMT-Intermediate student will be able to apply a process of clinical decision making to use the assessment findings to help form a field impression.

COGNITIVE OBJECTIVES

At the end of this lesson, the EMT-Intermediate student will be able to:
Compare the factors influencing medical care in the prehospital environment to other medical settings. (P)
Differentiate between critical life threatening, potential life threatening, and non-life threatening patient presentations.(P)
Evaluate the benefits and shortfalls of protocols, standing orders and patient care algorithms.(P)
Define the components, stages and sequences of the critical thinking process for EMT-Intermediates.(K)
Apply the fundamental elements of critical thinking process for EMT-Intermediates.(K)
Describe the effects of the "fight or flight" response and the positive and negative effects on a EMT-Intermediateís decision making.(K)
Summarize the "six Rs" of putting it all together: read the patient, read the scene, react, reevaluate, revise the management plan, review performance. (K)
Discuss obtaining a history by identifying classifications of drugs. (C-1)
Discuss considerations for administering albuterol when combined with a drug the patient may have taken. (C-1)
Perfect obtaining a history by identifying classifications of drugs. (P-3)
Serve as a model for obtaining a history by identifying classifications of drugs. (A-3)
Assess the pathophysiology of a patientís condition by identifying classifications of drugs. (A-3)
Defend the administration of albuterol by a EMT-Inter-mediate to effect positive therapeutic affect. (A-3)
Advocate drug education through identification of drug classifications. (A-3)
Integrate pathophysiological principles of albuterol with patient assessment. (C-3)
Synthesize patient history information and assessment findings to form a field impression. (C-3)
Synthesize a field impression to implement a pharmacologic management plan. (C-3)

AFFECTIVE OBJECTIVES
Defend the position that clinical decision making is the cornerstone of effective EMT-Intermediate practice (P)
Practice facilitating behaviors when thinking under pressure. (K)

DECLARATIVE

1. Critical thinking, decision making, and assessment based patient care
2. Introduction and key concepts
A. The cornerstones of effective EMT-Intermediate practice
1. Gathering, evaluating, and synthesizing information
2. Developing and implementing appropriate patient management plans
3. Apply judgment and exercise independent decision making
4. Thinking and working effectively under pressure
B. The prehospital environment
1. Unlike other environments where medical care is traditionally rendered
2. Unique, heavily influenced by factors that donít exist in other medical settings
C. The spectrum of patient care in prehospital care
1. Obvious, critical life threats
A. Major, multi-system trauma
B. Devastating single system trauma
C. End stage disease presentations
D. Acute presentations of chronic conditions
2. Potential life threats
A. Serious, multi-system trauma
B. Multiple disease etiologies
3. Non-life threatening presentations
D. Providing guidance and authority for EMT-Intermediate action and treatments
1. Protocols, standing orders, and patient care algorithms
A. Can clearly define and outline performance parameters
B. Promote a standardized approach
2. Limitations of protocols, standing orders & patient care algorithms
A. Only addresses "classic" patient presentations
1. Non-specific patient complaints donít follow model
2. Limited clarity of presenting patient problems
B. Donít speak to multiple disease etiologies
C. Donít speak to multiple treatment modalities
D. Promotes linear thinking, "cookbook medicine" providers
III. Components, stages, and sequence of critical thinking process for EMT-Intermediates
A. Concept formation
1. MOI/scene assessment
2. Initial assessment and physical examination
3. Chief complaint
4. Patient history
5. Patient affect
6. Diagnostic tests (PEAK flow, SaO2, Glucometers)
B. Data interpretation
1. Data gathered
2. EMT-Intermediate knowledge of A&P, and pathophysiology
3. EMT-Intermediate attitude
4. Previous experience base of EMT-Intermediate
C. Application of principle
1. Field impression/working diagnosis
2. Protocols/standing orders
3. Treatment/intervention
D. Evaluation
1. Reassessment of patient
2. Reflection in action
3. Revision of impression
4. Protocol/standing orders
5. Revision of treatment/intervention
E. Reflection on action
1. Run critique
2. Addition to/modification of experience base of EMT-Intermediate
IV. Fundamental elements of critical thinking for EMT-Intermediates
A. Adequate fund of knowledge
B. Ability to pay attention
C. Ability to gather and organize data and form concepts
D. Ability to identify and deal with medical ambiguity
E. Ability to differentiate between relevant and irrelevant data
F. Ability to analyze and compare similar situations
G. Ability to recall contrary situations
H. Ability to articulate decision making reasoning and construct arguments
22. Considerations with field application of assessment based patient management
A. The patient acuity spectrum
1. EMS is activated for countless reasons
2. Few prehospital calls constitute true life threatening emergencies
A. Minor medical and traumatic events require little critical thinking and have relatively easy decision making
B. Patientís with obvious life threats pose limited critical thinking challenges
C. Patientís who fall on the acuity spectrum between minor and life threatening pose the greatest critical thinking challenge
B. Thinking under pressure
1. Hormonal influence i.e. "Fight or flight" response impacts EMT-Intermediate decision making both positively and negatively
A. Enhanced visual and auditory acuity
B. Improved reflexes and muscle strength
C. Impaired critical thinking skills
D. Diminished concentration and assessment ability
2. Mental conditioning is the key to effective performance under pressure
A. Skills learned at a pseudo-instinctive performance level
B. Automatic response for technical treatment requirements
C. Mental checklist for thinking under pressure
1. Stop and think
2. Scan the situation
3. Decide and act
4. Maintain clear, concise control
5. Regularly and continually reevaluate the patient
D. Facilitating behaviors
1. Stay calm, don't panic
2. Assume and plan for the worst; err on the side of the patient
3. Maintain a systematic assessment pattern
4. Balance analysis, data processing and decision making styles
A. Situation analysis styles: reflective vs. impulsive
B. Data processing styles: divergent vs. convergent
C. Decision making styles: anticipatory vs. reactive
E. Situation awareness
1. Reading the scene
2. Reading the patient
F. Putting it all together - "The Six R's"
1. Read the patient
A. Observe the patient
1. Level of responsiveness/consciousness
2. Skin color
3. Position and location of patient - obvious deformity or asymmetry
B. Talk to the patient
1. Determine the chief complaint
2. New problem or worsening of preexisting condition?
C. Touch the patient
1. Skin temperature and moisture
2. Pulse rate, strength, and regularity
D. Auscultate the patient
1. Identify problems with the lower airway
E. Status of ABC's - identifying life threats
F. Complete and accurate set of vital signs
1. Use as triage tool to estimate severity
2. Can assist in identifying the majority of life threatening conditions
3. Influenced by patient age, underlying physical and medical conditions, and current medications
2. Read the scene
A. General environmental conditions
B. Evaluate immediate surroundings
C. Mechanism of injury
3. React
A. Address life threats in the order they are found
B. Determine the most common and statistically probable that fits the patient's initial presentation
C. Consider the most serious condition that fits the patient's initial presentation
D. If a clear medical problem is elusive, treat based on presenting signs and symptoms
4. Reevaluate
A. Focused and detailed assessment
B. Response to initial management/interventions
C. Discovery of less obvious problems
5. Revise management plan
6. Review performance at run critique

KSE Lesson 3.2 Documentation

OBJECTIVES
In order to properly document, the EMT-Intermediate shall:

COGNITIVE OBJECTIVES
General
Identify and use medical terminology correctly.
Recite appropriate and accurate medical abbreviations and acronyms.
Record all pertinent administrative information.
Describe the information pertinent to agency reimbursement.
Analyze the documentation for accuracy and completeness, including spelling.
Identify and eliminate extraneous or nonprofessional information.
Describe the differences between subjective and objective elements of documentation.
Evaluate a finished document for proper use and spelling of abbreviations and acronyms.
Advocate the confidential nature of an EMS report.
Describe the potential consequences of poor documentation.
Describe the special considerations concerning patient refusal of transport.
Describe the special considerations concerning mass casualty incident documentation.
Apply the principles of documentation to computer charting as this technology becomes available.

KSE Module 4 Clinical Rotations

The following goals must be successfully accomplished in the clinical environment, on actual patients. Clinical experiences should occur after the student has demonstrated competence in skills and knowledge in the didactic and laboratory components of the course.

PSYCHOMOTOR SKILLS

The student must demonstrate the ability to safely administer nebulized medications.
The student should safely, and while performing all steps of each procedure, properly administer nebulized albuterol to live patients.

The student must demonstrate the ability to safely perform endotracheal intubation.
The student should safely, and while performing all steps of each procedure, successfully intubate at least 10 live patients.

The student must demonstrate the ability to safely gain venous access.
The student should safely, and while performing all steps of each procedure, successfully access the venous circulation at least 20 times on live patients.

The student must demonstrate the ability to effectively ventilate a patient.
The student should effectively, and while performing all steps of each procedure, ventilate patients.

The student must demonstrate the ability to perform a comprehensive assessment on patients.
The student must demonstrate the ability to perform an advanced assessment, formulate and implement a treatment plan for patients with dyspnea/respiratory distress.

TEAM LEADER SKILLS

The student should demonstrate the ability to serve as a team leader in variety of prehospital emergency situations.