Lisbon Fire Department Standard Operating Guidelines and Policies

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To increase the partial pressure of oxygen in the lungs increasing diffusion across the alveolar and capillary membranes into the blood, providing additional oxygen to the tissues of the body

Oxygen source with connecting tubing

Nasal cannula (25-40%)

Non-rebreathing face mask (90+%)

Bag-valve-mask device with reservoir bag (100%)

Personal protective equipment to prevent exposure to blood/body fluids

1. Assure scene safety and observe universal precautions (see guideline #107).

2. Assemble regulatory/flow meter and oxygen source:

a. Remove protective cap or tape.

b. Open and close cylinder valve to crack

c. Attach regulator and flowmeter with leak-proof seal

d. Turn on tank; check that pressure gauge registered in the safe (green) range.

3. Select administration device which will meet patient’s needs:

a. Nasal cannula delivers 25-40% oxygen content at 1-6 L/min flow from the source (4%

increase for each one liter flow rate)

b. Non-rebreather face mask delivers 90+% at 12-15L/min flow rate

c. Bag-valve device delivers nearly 100% oxygen content when used with the oxygen

reservoir attachment and maximum (15+ L/min) flow rate from the source

d. Nebulizer chamber for aerosol medications is run at 6-8 L/min flow rate.

4. Attach delivery device to oxygen source.

5. Monitor and evaluate patient’s response to oxygen therapy.

6. Document procedure and results, including any unusual circumstances and/or difficulties

encountered.

1. Remove the device from the patient.

2. Shut off the cylinder.

3. Bleed the regulator.

4. Return the flow meter control to the “off” position

• 
  Increasing the partial pressure of oxygen in the blood stream increases the availability of oxygen to the tissue, minimizing the effects of hypoxia and anaerobic metabolism on the cells.
  

• 
  Oxygen is stored under pressure. Damage to the tank or valve can turn the cylinder into a projectile.
  
• 
  Oxygen supports combustion. There is an increased fire risk when oxygen is in use.
  

• 
  Oxygen can suppress the respiratory drive of a patient with chronic obstructive pulmonary disease.
  
• 
  Prolonged administration of high pressures of oxygen can cause lung damage in susceptible individuals. (Oxygen toxicity)
  
• 
  Prolonged administration of high pressures of oxygen can cause retina damage in premature infants.
  

• 
  None
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To remove mucus or foreign material from the upper airway or endotracheal tube

Suction machine with connecting tubing and reservoir

Flexible suction catheters 8, 10, 14 and 18 French

Yankauer suction tip

Bulb syringe

Meconium aspirator

Water/saline as necessary to flush the tubing

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Protect the airway prior to suctioning by turning the patient to the side if possible.
   
3. 
   Select flexible suction catheter for suctioning the nasal pharynx, endotracheal tube or stoma.
   
4. 
   Suctioning the mouth and pharynx:
   

• 
  Measure suction catheter from the corner of the mouth to the ipsilateral (same side) earlobe.
  
• 
  Open the mouth using the cross-finger technique.
  
• 
  Insert catheter tip into the area of the mouth/pharynx to be suctioned.
  
• 
  Apply suction as the catheter is withdrawn from the mouth.
  
• 
  Flush tubing and catheter with water as necessary.
  
• 
  Repeat as necessary to remove foreign material/liquids from the airway.
  
• 
  Limit each suctioning episode to 15 seconds or less.
  
• 
  Oxygenate the patient with 5-6 breaths with supplemental oxygen after each suctioning episode.
  

5. 
   Suctioning the endotracheal tube/tracheostomy:
   

• 
  Use sterile suction catheter and as sterile technique as possible.
  
• 
  Use a new sterile suction catheter for each suctioning event.
  
• 
  Oxygenate the patient with 5-6 breaths with supplemental oxygen before and after each suctioning episode.
  
• 
  Insert the suction catheter down the endotracheal tube or into the stoma opening until it reaches the area where secretions/foreign matter are present.
  
• 
  Apply suction to the catheter as it is withdrawn from the tube/stoma.
  
• 
  If thick material is present, Normal Saline (2.5-5 ml) may be instilled into the endotracheal tube or stoma prior to suctioning to help liquefy the secretions.
  
• 
  If an intubated patient needs to be extubated, suction the oral pharynx and around the exterior of the tube above the inflated cuff before the cuff is deflated.
  

6. 
   Rigid suction catheter
   

• 
  Open the mouth, using the cross finger technique.
  
• 
  Watch the tip of the Yankauer as it is inserted into the area to be suctioned.
  
• 
  Apply suction as the tip is moved across the area when material is to be removed.
  
• 
  Limit suctioning to no more than 15 seconds at a time.
  
• 
  Oxygenate the patient with 5-6 breaths with supplemental oxygen after each suctioning episode.
  

7. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

1. 
   Observe universal precautions. (see guideline # 107)
   
2. 
   Hold the mucous trap upright with suction bulb compressed while inserting the suction catheter tip into the infant’s mouth.
   
3. 
   Keep the collection bottle in a vertical position.
   
4. 
   Slowly release the compressed bulb while moving the suction tip across the infant’s pharynx.
   
5. 
   Suction for a maximum of 15 seconds at a time.
   
6. 
   Oxygenate with supplemental oxygen for 5-6 breaths after each suctioning event.
   
7. 
   Assess the infant’s respiratory status after each suctioning procedure.
   
8. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

1. 
   Observe universal precautions (see guideline # 107)
   
2. 
   Squeeze air from the bulb before insertion.
   
3. 
   Suction the mouth first, then each nostril.
   
4. 
   Release pressure on the bulb gradually while removing the bulb tip from the mouth or nose.
   
5. 
   Expel contents (suctioned material) out of the bulb before next suctioning attempt.
   
6. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

• 
  Clears foreign material and liquids from the airway.
  

• 
  Removes air as well as foreign matter.
  
• 
  Can introduce bacteria into the airway.
  

Suctioning, cont.

• 
  Hypoxia
  
• 
  Oral trauma
  
• 
  May stimulate vomiting
  

• 
  None
  

END

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To ventilate patient when the bag-valve-mask device is not available

To administer supplemental oxygen

To reduce exposure to the patient’s upper respiratory secretions

Pocket mask with oxygen port and one-way valve

Oxygen source and delivery tubing

Oral or nasopharyngeal airway of size appropriate for patient

Oral airway size selection includes 40-100 mm

Nasopharyngeal airway size (French) selections include 12 through 34.

Suction machine and catheters
PROCEDURE

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Select and insert an oral or nasopharyngeal airway. (see guideline # 2006, 2007)
   

3. 
   Suction as necessary. (see guideline # 2002)
   
4. 
   Attach one-way valve to the pocket mask at the top opening.
   
5. 
   Attach the oxygen source with tubing to oxygen port of the pocket mask and adjust liter flow to 8-15 liters/min.
   
6. 
   Position self at the top of the head of the patient.
   
7. 
   Seal the mask over the patient’s face, maintaining an open airway. Consider potential c-spine injury.
   
8. 
   Hold mask in place on the patient’s face with one hand on each side of the mask, maintaining an open airway by lifting the chin up and forward. Observe C-spine precautions, avoiding a head tilt.
   
9. 
   Ventilate the patient by blowing into the top of the one-way valve with sufficient force to attain an observable chest rise.
   
10. 
    If resistance is felt, reassess the airway, taking such measures as are necessary to obtain and maintain an open airway.
    
11. 
    Remove mouth from the pocket mask, allowing patient to exhale while holding the mask firmly on the face.
    
12. 
    Repeat ventilations at AHA guideline rates.
    
13. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Barrier device to provide mouth-to-mouth ventilation without direct contact with secretions
  
• 
  Provides supplemental oxygen
  
• 
  Easier to obtain a face seal by using 2 hands to seal the face mask
  

• 
  Does not prevent aspiration
  

• 
  Gastric distention with air
  

• 
  Facial or upper airway trauma
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To assist respirations in a patient whose respiratory effort is absent or inadequate

To oxygenate a patient

To assist ventilations in an intubated patient

Self-inflating bag with valve assembly and oxygen reservoir, (adult, child or infant)

Transparent face masks, sizes 0 to 4

Oral airways Available sizes 40, 50, 60, 80, 90, 100 mm

Nasopharyngeal airways Available sizes 12 through 34 French

Oxygen source with connecting tubing

Suction machine and catheters

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Select size of bag-valve-mask appropriate for patient (adult, child, infant).
   
3. 
   Suction as necessary. (see guideline # 2002)
   
4. 
   Connect the bag-valve-mask with oxygen reservoir to the oxygen source with the tubing and open source to deliver 15 L/min. (see guideline # 2001)
   
5. 
   Select an appropriate size transparent face mask to cover the area between the bridge of the patient’s nose and the indentation beneath the patient’s lower lip.
   
6. 
   Select an appropriate size oral airway. (see guideline # 2006)
   
7. 
   Position self at the top of the head of the patient.
   
8. 
   Open the airway using the cross-finger technique and place an oral airway in the patient’s mouth. A nasopharyngeal airway may be substituted for an oral airway. (see guideline # 2006, 2007)
   
9. 
   If no cervical injury is suspected, tilt the patient’s head back. For patients with a potential cervical injury, use the jaw thrust to open the airway.
   
10. 
    Grasp the patient’s mandible with your left hand and lift the jaw anteriorly.
    
11. 
    Place the nose end of the face mask over the ridge of the patient’s nose and then place the chin end over the patient’s lower lip.
    
12. 
    Using one hand, firmly press the face mask against the patient’s face while continuing to lift the jaw anteriorly.
    
13. 
    Compress the bag-mask with the other hand with enough speed and force to deliver 400-600 cc of air (to an adult) through the valve into the mask over a 2 second period. For children and infants, ventilate with a volume sufficient to produce an adequate chest rise.
    
14. 
    Monitor the patient’s chest rise with each compression of the bag. The chest should fall when the pressure on the bag is released and the patient exhales.
    

15. 
    Continue to ventilate the adult patient at AHA guideline rates, adjusted for the patient’s individual needs.
    
16. 
    If adequate chest is not achieved with compression of the bag, reevaluate the airway (reposition, check for obstruction, etc.) and repeat the sequence.
    
17. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

Note: If 2 rescuers are available, one should maintain the airway and face seal of the mask and the second squeezes the bag.

• 
  Provides for ventilation with supplemental oxygen
  
• 
  Reduces exposure to upper airway secretions
  

• 
  Requires special equipment, training and continued practice
  
• 
  Can be difficult to maintain a face seal
  
• 
  Does not prevent aspiration
  

• 
  Gastric inflation
  

• 
  Facial trauma with disruption of the boney framework of the face and jaw
  

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX