TRANSITION SERIES Topics for the Advanced EMT CHAPTER Advanced Skills for the AEMT 49

Objectives Address the clinical application, use, and interpretation of capnometry. Review the indications, site selection, and procedure for intraosseous cannulation in children. Learn the process of establishing a saline lock. Learn the six rights of medication administration.

Objectives (cont’d) Administration methods by container type: –Glass ampule –Single dose vial –Multi dose vial –Non-constituted drug vial –Prefilled syringe –IV piggyback

Introduction Given the provision of EMS in many states, it is now being recognized that the Advanced EMT can assist their paramedic partners with many advanced life support skills that are utilized during patient care and management.

Introduction (cont’d) No EMS provider can function without appropriate medical direction. –EMS system must have:  Medical control  Treatment protocols  Quality assurance

Capnometry End-tidal carbon dioxide (ETCO 2 ) monitoring is a noninvasive method of measuring the level of carbon dioxide (CO 2 ) in an exhaled breath.

Colorimetric end-tidal CO 2 detector. (Reprinted by permission of Nellcor Puritan Bennett LLC, Pleasanton, CA)

Capnometry (cont’d) Capnometry: measurement of expired CO 2 typically provides a numeric display of the partial pressure of CO 2 (in torr/mmHg) Capnography: graphic recording/display of the capnometry reading over time.

Capnometry (cont’d) Capnograph: device that measures expired CO 2 levels. Capnogram: visual representation of the expired CO 2 waveform.

Normal capnogram. AB = Phase I: late inspiration, early expiration (no CO 2 ). BC = Phase II: appearance of CO 2 in exhaled gas. CD = Phase III: plateau (constant CO 2 ). D = highest point (ETCO 2 ). DE = Phase IV: rapid descent during inspiration. EA = respiratory pause.

Capnometry (cont’d) Factors that influence carbon dioxide levels: –Changes in ventilation –Changes in perfusion –Changes in metabolic activity

Spontaneously breathing patient with a sampling line for CO 2 measurement.

Intraosseous Access Involves the insertion of a rigid needle into the medullary cavity of the bone. –Long bones –Sternum IO access is indicated in emergency situations in which an IV is required but not obtainable, or presumed difficult, such as cardiac arrest or trauma.

Intraosseous Access (IO) Advanced EMT may use intraosseous (IO) cannulation in children when appropriate

EZ-IO device with needles

Intraosseous Access (cont’d) Any solution or drug that can be given intravenously can be administered by the intraosseous route. Medications and fluids given IV or IO reach the central circulation in a similar concentration and in the same amount of time.

Intraosseous Access (cont’d) EZ-IO ® is a small battery-powered drill that places the needle into the bone.

Intraosseous Access (cont’d) Three needle sizes based on patient size –15mm pink hub –25mm blue hub –45mm yellow hub 5mm mark on the needle should be visible above the skin.

Selecting the appropriately sized EZ-IO needle.

Intraosseous Access (cont’d) Common sites for intraosseous insertion –Proximal tibia –Distal tibia –Proximal humerus

IO needle insertion sites depend on the device being used and include the proximal tibia.

IO needle insertion sites depend on the device being used and include the medial malleolus of the distal tibia.

IO needle insertion sites depend on the device being used and include the humeral head.

Intraosseous Access (cont’d) Determine the need for IO access and employ Standard Precautions. Assemble and check all equipment. Position the patient as appropriate for the intended insertion site. Locate the access site and indentify all the landmarks. Cleanse the site with alcohol or Betadine.

Intraosseous Access (cont’d) Perform the puncture using the device manufacturer’s instructions. Remove the trocar, attach the syringe, and attempt to aspirate bone marrow.

Intraosseous Access (cont’d) Attach IV administration and/or extension set if required and set fluid flow. Secure the needle at the insertion site with bulky dressings or commercial device.

Heparin/Saline Lock The Advanced EMT may wish to establish intravenous access but not administer fluids. Placement involves insertion of the IV catheter into a peripheral vein. A device with a short tube and clamp is flushed with heparin or saline and attached to the IV catheter then secured.

Heparin/Saline Lock (cont’d) IV catheter Heparin lock or saline lock Syringe with 3-5cc of sterile saline or commercial saline injection device Tape or commercial securing device

Heparin/Saline Lock (cont’d) Venous blood drawing equipment Tourniquet Antiseptic swab (alcohol, Betadine, etc.)

A heparin or saline lock regulates IV flow and decreases the risk of accidental fluid overload or electrolyte derangement.

Heparin/Saline Lock (cont’d) Use Standard Precautions. Prepare the heparin/saline lock. Select the venipuncture site. Place the tourniquet proximal to the site. Cleanse the site. Insert the catheter as described for a traditional IV.

Heparin/Saline Lock (cont’d) Slide the catheter into the vein. Carefully remove the metal stylet and dispose of it properly. Remove the tourniquet. Attach the lock device to the IV catheter. Inject 2-3 cc of sterile saline into the lock. Secure the device.

Preparation of Medications As an Advanced EMT, your EMS system may allow you to prepare medications for your paramedic partner for administration. Such situations include but are not limited to cardiac arrest, rapid sequence induction, and complicated myocardial infarction.

Preparation of Medications (cont’d) “Six rights” of drug administration –Right person –Right drug –Right dose –Right time –Right route –Right documentation

Preparation of Medications (cont’d) Medication label –Name of the medication –Expiration date –Total dose –Drug concentration

Preparation of Medications (cont’d) Ampule –Breakable glass container with a cone- shaped thin-neck top that is broken off to retrieve the medication. –Usually ranges from 1-5 cc of solution. –Solution is usually retrieved with a syringe and filter needle.

Glass ampules

Preparation of Medications (cont’d) Vials –Single or multi-dose. –Plastic or glass container. –Self-sealing hub at the top. –Medication is packaged in a vacuum. –Solution is retrieved with a syringe and needle.

Glass medication vials with self-sealing rubber tops

Preparation of Medications (cont’d) Nonconstituted vial –Used when a drug has a short shelf life or is unstable in a liquid form. –Packaged with powder drug vial and liquid mixing solution vial. –The dilution solution is injected into the powder medication with a syringe and needle. –Once dissolved the medication is withdrawn for administration.

The nonconstituted drug vial actually consists of two vials, one containing a powdered medication and one containing a liquid mixing solution.

Preparation of Medications (cont’d) Prefilled Syringe –Syringe of medication that does not need to be drawn from another source. –Two components  Drug cartridge (glass or plastic)  Plunger –Usually contains standard doses to prevent medication errors.

Preparation of Medications (cont’d) IV infusion/piggyback –Deliver a steady, continual dose of medication through an existing IV line. –Can be used for loading and maintenance doses. –Piggybacked into the primary IV line. –The Advanced EMT can prepare the IV infusion for delivery, however, the paramedic must establish the drip rate.

IV piggyback medication. (© Scott Metcalfe)

Preparation of Medications (cont’d) IV infusion/piggyback (continued) –When preparing an IV piggyback infusion, the Advanced EMT should ensure the medication is properly labeled.  Name of the medication (generic and trade names)  Total amount of the drug mixed in the bag

Preparation of Medications (cont’d) IV infusion/piggyback (continued) –When preparing an IV piggyback infusion, the Advanced EMT should ensure the medication is properly labeled  Concentration (amount of drug per mL)  Expiration date

Summary Assisting with medication administration is a fundamental skill and assisting your paramedic partner can save precious time. It is the Advanced EMT’s responsibility to be familiar with all equipment and techniques so they can be employed safely and efficiently.