Lisbon Fire Department Standard Operating Guidelines and Policies

To facilitate assisted ventilation in a patient with inadequate respirations

To prevent aspiration in a patient with decreased reflexes

EQUIPMENT
Laryngoscope handle with functioning batteries

Curved or straight laryngoscope blade of appropriate length with functioning light bulb

Endotracheal (ET) tube of appropriate size for the patient

Available sizes include adult 6.0 through 9.0 mm; pediatric (uncuffed) 2.5 through 5.5

Water soluble lubricant

Syringe to inflate cuff

Tape or commercial endotracheal tube holder

Stethoscope

Bag-valve-mask device with oxygen reservoir

Oxygen source with connecting tubing

Stylette

Magill forceps

Suction machine and catheters

Oral airway of appropriate size for the patient (sizes 50-100 mm available)

Personal protective equipment to prevent exposure to blood/body fluids

Fiberoptic assisted intubation equipment may be used per manufacturer recommendation

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Assure adequate ventilation and oxygenation of patient prior to attempting procedure.
   
3. 
   Assemble laryngoscope and blade, checking the battery and the security of the light bulb in the blade.
   
4. 
   Select an appropriate size endotracheal tube with an exterior diameter approximately equal to the diameter of the distal joint of the patient’s little finger.
   
5. 
   Attach the syringe to the endotracheal tube, inflate the cuff with 6-8 cc of air and check cuff of tube for leaks, deflate the cuff.
   
6. 
   Lubricate distal end of the endotracheal (ET) tube with water soluble gel.
   
7. 
   If stylette is to be used, insert into the lumen of the ET tube until the tip of the stylet is just distal to the cuff. Assure that it does not protrude beyond the tip of the tube by bending the looped
   

End page

1. 
   If the patient has a pulse, pre-oxygenate with at least 6 breaths with BVM prior to intubation attempt. If the patient is pulseless, follow AHA-CPR guidelines, minimizing compression interruptions.
   
2. 
   (Paramedic only) Consider sedation with Versed (see drug profile 023, guideline 113) or Rapid Sequence Intubation (see guideline 2018) as approved by your scope and medical director.
   
3. 
   Place the patient’s head in a slightly extended “sniffing”) position if no cervical injury is suspected. For patients with potential for cervical injury, in-line stabilization with the head in neutral position must be maintained by another individual.
   
4. 
   Holding the laryngoscope in the left hand, insert the blade into the right side of the patient’s mouth and move it gently toward the left, moving the tongue to the left and out of the way.
   
5. 
   Place the tip of the curved blade in the vallecula and the tip of the straight blade over the epiglottis.
   
6. 
   Lift up and anterior with the laryngoscope and blade to expose the posterior pharynx and the epiglottis. An assistant may apply cricoid pressure (Sellick’s Maneuver) as appropriate.
   
7. 
   Visualize the vocal cords. Avoid any leverage on the laryngoscope blade.
   
8. 
   Suction as necessary. (see guideline # 2002)
   
9. 
   Limit intubation attempts to no longer than 20 seconds. Abort the attempt at that time and ventilate the patient. Repeat the attempt.
   
10. 
    Insert the ET tube into the right side of the patient’s mouth. Do not obstruct the view of the cords.
    
11. 
    Pass the tube through the vocal cords until the cuff has passed approximately 1 cm below the level of the cords.
    
12. 
    Holding the ET tube firmly in place, remove the laryngoscope blade.
    
13. 
    With the tube properly placed in the trachea, inflate the cuff with 6-8 cc of air.
    
14. 
    Ventilate the patient through the ET tube using the bag-valve assembly and auscultate over the stomach to confirm the tube is not in the esophagus. Auscultate breath sounds to confirm proper placement. Observe chest rise with ventilation.
    
15. 
    At least 2 methods to confirm tube placement in the tracheal must be made. Methods include: visualization of the tube passing between the vocal cords, auscultation of breath sounds, observation of chest rise with ventilation, end-tidal CO₂ readings, esophageal intubation detector (syringe type).
    
16. 
    If the endotracheal tube has been misplaced in the esophagus, immediately remove the tube, ventilate the patient and repeat the sequence above.
    

airway adjunct should be considered.

b. Ventilate the patient for at least 30 seconds between attempts.

17. 
    Secure the tube with tape or ET tube holder. Document marking on tube at the corner of the mouth.
    
18. 
    Select and insert an oral airway. (see guideline # 2006)
    
19. 
    Ventilate patient with 100% oxygen via bag-valve device. Continue to ventilate patient while intubated.
    
20. 
    Frequently reassess breath sounds and respiratory status to confirm tube placement, especially after moving patient.
    
21. 
    Document position of the tube and quality of breath sounds upon arrival at the hospital.
    
22. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Positive control of the airway
  
• 
  Prevents aspiration when cuff is inflated
  
• 
  Provides for easy ventilation
  
• 
  Provides route for administration of selected medications
  
• 
  Permits easier suctioning of secretions from the airway
  

• 
  Requires special training and equipment
  
• 
  May be difficult to avoid cervical spine movement
  

• 
  Unrecognized misplacement of the tube can result in acute gastric dilation and rupture
  
• 
  Injury to the tracheal wall by the balloon cuff
  
• 
  Failure to recognize esophageal intubation results in hypoxia
  
• 
  Improper position of the tube (e.g. into mainstem bronchus)
  
• 
  Trauma to the upper airway during insertion
  
• 
  Potential for barotrauma (pneumothorax, tension pneumothorax) to the lungs with ventilations
  

• 
  Laryngospasm
  

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

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

To provide positive control of an airway, especially in those adult patients who have some respiratory effort, who have suspected cervical injury, who have an intact gag reflex or whose mouth cannot be opened.

To facilitate assisted ventilation in an adult patient with inadequate respirations

EQUIPMENT

Endotracheal tube of appropriate size for patient

Available sizes include adult 6.0 through 9.0 mm

Water soluble lubricant

Syringe to inflate cuff

Tape or commercial endotracheal tube holder

Stethoscope

Bag-valve-mask device with oxygen reservoir

Oxygen source with connecting tubing

Suction machine and catheters

Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Assure adequate ventilation and oxygenation of patient prior to attempting procedure.
   
3. 
   Select an appropriate size endotracheal tube, one size smaller that would be selected for oral intubation (Oral size = an exterior diameter approximately equal to the diameter of the distal joint of the patient’s little finger.)
   
4. 
   Attach the syringe to the endotracheal tube, inflate the cuff with 6-8 cc of air and check cuff of tube for leaks, deflate the cuff.
   
5. 
   Lubricate distal end of the endotracheal (ET) tube with water soluble gel.
   
6. 
   Maintain head in neutral position and ventilate the patient with at least 6 breaths prior to intubation attempt
   
7. 
   Advance ET tube gently through the nostril (bevel toward septum) straight back along the floor of the nasal passage until the tip of the tube reaches a level slightly above the patient’s vocal cords. Air will be heard moving through the tube. If resistance is met, repeat the attempt in the other nostril.
   
8. 
   When the patient next inhales, advance the tube through the cords.
   
9. 
   Advance the tube approximately 1 cm until the cuff clears the cords.
   

10. 
    Limit intubation attempts to no longer than 20 seconds. Abort the attempt at that time and ventilate the patient. Repeat the attempt.
    
11. 
    Ventilate the patient through the ET tube using the bag-valve assembly and auscultate breath sounds over the axillae to confirm proper placement. Auscultate over the stomach to confirm the tube is not in the esophagus. Observe chest rise with ventilation.
    
12. 
    At least 2 methods to confirm tube placement in the tracheal must be made. Methods include: visualization of the tube passing between the vocal cords, auscultation of breath sounds, observation of chest rise with ventilation, end-tidal CO₂ readings, esophageal intubation detector (syringe type).
    
13. 
    If the endotracheal tube has been misplaced in the esophagus, immediately remove the tube, ventilate the patient and repeat the sequence above.
    

b. Ventilate the patient for at least 30 seconds between attempts.

14. 
    Inflate the cuff with 6-8 cc of air. Secure the tube with tape or with a commercial endotracheal tube holder.
    
15. 
    Ventilate patient with 100% oxygen via bag-valve device. Continue to ventilate patient while intubated.
    
16. 
    Frequently reassess breath sounds and respiratory status to confirm tube placement, especially after moving patient.
    
17. 
    Document position of the tube and quality of breath sounds upon arrival at the hospital.
    
18. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Positive control of the airway
  
• 
  Prevents aspiration when cuff is inflated
  
• 
  Provides for easy ventilation
  
• 
  Provides route for administration of selected medications
  
• 
  Permits easier suctioning of secretions from the airway
  
• 
  Manipulation of cervical spine not needed
  
• 
  Better tolerated by a conscious patient
  
• 
  Do not need to open mouth of patient
  

• 
  Requires special training and equipment
  
• 
  Cannot be used on pediatric patients because of the anatomy of the airway
  

• 
  Unrecognized misplacement of the tube can result in acute gastric dilation and rupture
  
• 
  Injury to the tracheal wall by the balloon cuff
  
• 
  Failure to recognize esophageal intubation results in hypoxia
  
• 
  Improper position of the tube (e.g. into the mainstem bronchus)
  
• 
  Epistaxis
  
• 
  Potential for barotrauma to the lungs with ventilations
  

• 
  Laryngospasm
  
• 
  Suspected facial or basilar skull fractures
  

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

To increase back pressure in the airway during exhalation to help hold the alveoli and terminal bronchioles open, facilitating removal of carbon dioxide

Positive End Expiratory Pressure (PEEP) valve

Bag-valve-mask device with oxygen reservoir

Oxygen source with connecting tubing

Exhalation diverter cap (if needed)

Personal protective equipment to prevent exposure to blood/body fluid

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Confirm medical control order for a specific setting of the PEEP valve.
   
3. 
   Attach the exhalation diverter cap to the valve of the bag-valve-mask device if necessary.
   
4. 
   Attach the PEEP valve to the exhalation (diverter) cap.
   
5. 
   Dial the specified setting on the PEEP valve.
   
6. 
   Ventilate the patient with bag-valve device with 100% oxygen.
   
7. 
   Evaluate and monitor the patient response to treatment.
   
8. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

The PEEP valve may be beneficial In patients with a working assessment of:

• 
  Pulmonary edema
  
• 
  Inhalation injury
  
• 
  Aspiration
  
• 
  Near-drowning
  

• 
  Increase in the partial pressure of oxygen in the alveoli improves oxygen transfer into the blood stream.
  
• 
  Maintains open alveoli to facilitate gas exchange
  

• 
  Can increase the pressure in the airway enough to cause damage/rupture of airway structures.
  

• 
  Simple pneumothorax
  
• 
  Tension pneumothorax
  
• 
  Hypotension
  

• 
  Presence of simple or tension pneumothorax
  
• 
  Use with caution in patient with chronic obstructive or other restrictive lung disease (e.g. asthma, emphysema)
  

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
		With added module	XX	XX

To safely remove an indwelling endotracheal tube (oral or nasal) from the trachea

Bag-valve device with oxygen reservoir

Oxygen source with connecting tubing

Suction machine and flexible catheters

Syringe to deflate cuff

Non-rebreathing mask

Intubation equipment

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Perform per local medical direction.
   
3. 
   Evaluate and document the patient’s level of consciousness and ability to follow commands prior to extubation.
   
4. 
   Explain the procedure to the patient.
   
5. 
   Ventilate the patient for approximately 12 breaths with 100% oxygen.
   
6. 
   Suction out the mouth and oropharynx, using a soft tip suction catheter to remove all secretions that may be above the cuff of the endotracheal tube.
   
7. 
   Instruct the patient to take in a deep breath.
   
8. 
   Attach the syringe, deflate the cuff of the endotracheal tube and have the patent cough as the tube is gently removed from the airway.
   
9. 
   Instruct the patient to cough and to take deep breaths.
   
10. 
    Supplement the patient with high flow oxygen via a non-rebreathing mask for the duration of the prehospital care.
    
11. 
    Report the completion of the procedure and condition of the patient to medical control.
    
12. 
    Monitor the patient carefully for respiratory distress, prepared to intubate if necessary.
    
13. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Removes focus of discomfort and agitation from an alert patient who has an intact gag reflex and is ventilating adequately on his/her own.
  

Extubation (cont.)

• 
  May precipitate laryngospasm
  
• 
  Loss of positive airway control
  

• 
  Aspiration
  
• 
  Laryngospasm
  

• 
  Any patient unable to adequately ventilate or protect his/her own airway
  

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

To decompress gastric dilatation following placement of an endotracheal tube

Nasogastric tube

Water soluble lubricant

60 ml syringe

Stethoscope

Tape

Laryngoscope blade of appropriate size for the patient with functioning light bulb

Magill forceps of appropriate size for the patient (Adult and pediatric sizes available)

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Approximate the length of the nasogastric tube needed by measuring from the ear lobe to the tip of the nose and then to the umbilicus of the patient.
   
3. 
   Lubricate the tube with water-soluble lubricant.
   
4. 
   For the patient with an endotracheal tube in place, insert the nasogastric tube into the patient’s nostril, directing the advancement straight back along the floor of the nasal passage.
   
5. 
   For patients with suspected facial or basilar skull fracture, the tube should be inserted orally rather than nasally.
   
6. 
   Advance the tube until:
   

b. Gastric contents appear in the tube or

c. Gastric distention has been relieved.

7. 
   Check the posterior pharynx to be sure the tube is not curled up in the back of the mouth. If found curled in the pharynx, withdraw and reinsert the tube, advancing it if necessary with Magill forceps under direct visualization with a laryngoscope and blade.
   
8. 
   Inject approximately 30 ml of air into the nasogastric tube while listening over the stomach with the stethoscope to confirm placement.
   
9. 
   Secure placement of the tube with tape.
   
10. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered
    

• 
  Decompresses the stomach, reducing the chance of regurgitation and aspiration
  
• 
  Allows freer downward movement of the diaphragm, making ventilation easier
  

Nasogastric/orogastric tube (cont.)

• 
  May stimulate vomiting
  

• 
  Epistaxis
  
• 
  Accidental passage into the trachea may stimulate coughing
  

• 
  Facial or basilar skull fracture
  
• 
  Unprotected airway in the patient with an altered level of consciousness
  

GUIDELINE FOR PRACTICAL SKILLS

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

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

To maintain a patent airway and adequate oxygenation of the patient with a temporary or permanent tracheostomy

To remove or replace a temporary tracheostomy tube
EQUIPMENT

Suction machine and catheters

Normal Saline

Temporary tracheostomy tube with inner and outer tubes and placement obturator

Tracheostomy ties

(patient at home with tracheostomy should have spare tubes and ties available)

Endotracheal tube of appropriate size for neck opening

Available sizes include adult 6.0 through 9.0 mm; pediatric (uncuffed) 2.5 through 5.5

Bag-valve-mask device with reservoir bag

Oxygen source with connecting tubing

Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE - TEMPORARY TRACHEOSTOMY

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Evaluate respiratory status of the patient.
   
3. 
   Suction through the inner tube. 2.5-5 cc of Normal Saline may be installed into the tube and then suctioned out if secretions are very thick.
   
4. 
   The inner tube can be removed and the suctioning repeated.
   
5. 
   If the outer tube has been displaced or is blocked, remove it and replace it with the spare kept at home by the patient or with an endotracheal tube.
   
6. 
   To ventilate through a tracheostomy tube, attach the bag-valve directly to the tracheostomy tube. An adapter off an endotracheal tube may be needed to make the connection.
   
7. 
   Intubation is also usually possible through the upper airway structures. The cuff of the tube must extend below the opening in the neck.
   
8. 
   If ventilating from above, block the neck opening. If ventilating through the neck opening with an uncuffed tube, block the upper airway.
   
9. 
   Monitor the patient’s respiratory status.
   
10. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

End page

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Evaluate the respiratory status of the patient.
   
3. 
   Suction through the opening in the neck. The upper airway is surgically absent and aspiration from above or of gastric contents is not possible. (see guideline # 2002)
   
4. 
   2.5-5 cc of Normal Saline can be installed into the stoma and then suctioned out if secretions are very thick.
   
5. 
   Intubation and ventilation must occur through the stoma in the neck.
   
6. 
   Monitor the patient’s respiratory status.
   
7. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered.
   

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   If a tracheostomy tube is present, remove it.
   
3. 
   Suction as necessary. (see guideline # 2002)
   
4. 
   Insert the endotracheal tube through the opening until the cuff is past the opening.
   
5. 
   Inflate the endotracheal tube cuff with 6-8 cc air.
   
6. 
   Ventilate the patient with 100% oxygen via bag-valve device. If the patient has a temporary tracheostomy, the upper airway must be blocked unless a cuffed tube is in place.
   
7. 
   Auscultate breath sounds over the axillae to confirm proper placement. Special care is needed for the patient with a temporary tracheostomy to assure the endotracheal tube has entered the tracheal lumen and is not lodged in the soft tissue of the neck.
   
8. 
   Secure the endotracheal tube with tape.
   
9. 
   The endotracheal tube can only be shortened to the point where the cuff inflation line separates from the tube.
   
10. 
    Frequently reassess breath sounds and respiratory status to confirm tube placement, especially after moving the patient.
    
11. 
    Document the position of the tube and quality of breath sounds upon arrival at the hospital.
    
12. 
    Continue to ventilate the patient while intubated.
    
13. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Positive control of the airway
  
• 
  Prevents aspiration when cuff of endotracheal tube is inflated
  

• 
  Provides for easy ventilation
  
• 
  Provides route for administration of selected medications
  
• 
  Permits easier suctioning of secretions from the airway
  

• 
  Requires special training and equipment
  

• 
  Unrecognized misplacement of the tube can result in acute subcutaneous emphysema if the end of the tube is in the soft tissue space between the anterior neck and the trachea
  
• 
  Failure to recognize misplacement of the tube results in hypoxia
  

• 
  Improper position of the tube (very easy to advance the tube too far and enter the mainstem bronchus)
  
• 
  Trauma to the soft tissue of the neck or the trachea during insertion
  
• 
  Potential for barotrauma to the lungs with ventilations
  

• 
  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

To provide an open vent into the pleural space to decompress a suspected tension pneumothorax

14 gauge 3.25 inch IV catheter

Alcohol prep

Tape

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Confirm the order with medical control.
   
3. 
   Determine which side of the chest has a tension pneumothorax.
   
4. 
   Locate the suprasternal notch, move laterally to the midclavicular line and locate the second and third rib on the side of the pneumothorax.
   
5. 
   Remove the protective sheath and confirm the IV catheter is in place on the 14 gauge needle.
   
6. 
   Cleanse the insertion site with alcohol.
   
7. 
   Insert the needle and extracatheter at a 90º angle directly over the 3rd rib. When the tip of the needle has passed through the chest skin and touches the 3rd rib, alter the angle and “walk” the needle over the 3rd rib, advancing it into the pleural cavity.
   

8. 
   Listen for escape of air to confirm placement of the catheter.
   
9. 
   Withdraw the needle and tape the catheter in place.
   
10. 
    Dispose of contaminated materials in the appropriate receptacle.
    
11. 
    Reassess the patient’s condition and vital signs.
    
12. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Restless/agitated
  
• 
  Increased resistance to ventilation
  

• 
  Jugular vein distention
  
• 
  Decreased or absent breath sounds on the affected side
  
• 
  Mechanism of injury, nature of illness, iatrogenic interventions
  

Thoracic decompression (cont.)

• 
  Increase in blood pressure
  
• 
  Loss of jugular vein distention
  
• 
  Decreased dyspnea
  
• 
  Easier to ventilate patient
  
• 
  Improved color
  

• 
  Intercostal artery injury
  
• 
  Iatrogenic pneumothorax if original diagnosis is incorrect
  

• 
  None if the patient meets the clinical criteria
  

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

To provide an airway in a patient where other airway techniques have failed or are not indicated.

Antiseptic swabs

3.0 mm endotracheal tube adapter or 3 cc syringe and 7.0 endotracheal tube adapter

Syringes ranging between 5 cc and 12 cc

Scalpel #10

Hemostats and small rake retractors

Twill-tape or umbilical tape

Personal protective equipment to prevent exposure to blood/body fluids

Jet insufflator or BVM assembly

5.0 or 7.0 endotracheal tube or tracheostomy tube

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Confirm the order with medical control.
   
3. 
   Place patient in the supine position
   
4. 
   Palpate the cricothyroid membrane
   
5. 
   Prep the area with antiseptic swabs
   
6. 
   Assemble #12 or #14 over the needle catheter to a 5-12 ml syringe.
   
7. 
   Puncture the skin midline and directly over the cricothyroid membrane.
   
8. 
   Direct the needle at a 45 degree angle caudally.
   
9. 
   Carefully advance the needle through the cricothyroid membrane with constant aspiration (aspiration of air indicates entry into the tracheal lumen.
   
10. 
    Withdraw the stylet while gently advancing the catheter.
    
11. 
    Attach the needle to either a 3 mm ET tube adapter or combine a 3cc syringe and a 7mm ET tube adapter.
    
12. 
    Connect to Jet insufflator or BVM assembly. (Jet insufflator is used with an I:E ratio of 1:2).
    
13. 
    Secure the apparatus to the patient’s neck.
    
14. 
    Dispose of contaminated equipment in the appropriate receptacle.
    
15. 
    Report completion and results of the procedure to medical control.
    
16. 
    Reassess the patient’s condition.
    
17. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

1. 
   Place patient in the supine position
   
2. 
   Palpate thyroid notch, cricoid cartilage, and sternal notch for orientation.
   
3. 
   Prep the area with antiseptic swabs.
   
4. 
   Stabilize the thyroid cartilage.
   
5. 
   Make a skin incision with a #10 scalpel.
   
6. 
   Make a second incision through the cricothyroid membrane.
   
7. 
   Spread the edges with rakes or the scalpel handle
   
8. 
   Insert an appropriately sized cuffed ETT or tracheostomy tube directing it distally.
   
9. 
   Inflate the cuff and ventilate the patient with a BVM.
   
10. 
    Auscultate the lung fields
    
11. 
    Secure the endotracheal or tracheostomy tube by tying around neck.
    

18. 
    Dispose of contaminated equipment in the appropriate receptacle.
    
19. 
    Report completion and results of the procedure to medical control.
    
20. 
    Reassess the patient’s condition.
    
21. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Surgical technique not indicated if trachea is likely disrupted or fractured
  
• 
  Asphyxia
  
• 
  Aspiration
  
• 
  Cellulitis
  
• 
  Creation of false tissue passage
  
• 
  Subglottic stenosis/edema
  
• 
  Laryngeal stenosis
  
• 
  Hemorrhage or hematoma formation
  
• 
  Laceration of the esophagus
  
• 
  Laceration of the trachea
  
• 
  Mediastinal emphysema
  
• 
  Vocal cord paralysis
  

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

1. Assure scene safety and observe universal precautions (see guideline #107).
2. Assess the patient to assure that a pneumothorax is NOT present.
3. Explain the procedure to the patient.
4. Ensure an adequate supply of oxygen to operate the CPAP device.
5. Place the patient on continuous pulse oximetry.
6. Place delivery device (mask) over the patient’s mouth and nose.
7. Secure the mask with provided straps or other provided device.
8. Use 5 cm of water Positive End Expiratory Pressure (PEEP). (see guideline #111)
9. Check for air leaks.
10. Use supplemental O₂ very early in course to assure adequate Oxygen delivery (not applicable if using 100% fixed flow device)
11. Monitor and document the patient’s respiratory response to treatment.
12. Increase PEEP to achieve maximal benefit if needed (Max 7.5 cm for EMT-B and Intermediate Tech; 10 cm for Intermediate and Paramedic) {note: 5 cm is intended to acclimate the patient to the device}
13. Check and document complete vital signs every 5 minutes.
14. Continue to coach the patient to keep the mask in place and adjust as needed.
15. If respiratory status, level of consciousness or SvO₂ deteriorates, remove the device and consider Bag-Valve-Mask ventilations assistance or endotracheal intubation. (see guideline #2004, 2009)
16. Document procedure and results, including any unusual circumstances and/or difficulties encountered.
17. As PEEP increases and patient condition improves, supplemental O₂ may be reduced to maintain appropriate oxygen saturation

1. CPAP therapy needs to be continuous and should not be removed unless the patient cannot tolerate the mask or experiences continued or worsening respiratory failure.
2. Bag-Valve-Mask-assisted ventilation or intubation should be considered if the patient is removed from CPAP therapy.
3. Since PEEP can cause a reduction in BP, PEEP should be reduced if BPs falls below 100 mmHg

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

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

• 
  Provide optimal intubation conditions while minimizing risk of aspiration in the conscious patient, the combative patient, or the unconscious patient with a clenched jaw, where the need for immediate intubation has been established
  

• 
  Endotracheal intubation equipment (see guideline 2009)
  
• 
  Peripheral IV equipment (see guideline 3002)
  
• 
  Atropine, sedative and neuromuscular blocking agent (Succinylcholine for intubation, Vecuronium for maintenance if needed)
  
• 
  Cardiac monitor (see guideline 3009)
  
• 
  Pulse oximeter
  
• 
  End tidal carbon dioxide detection device
  
• 
  Alternative airway e.g. Combitube, cricothyroidotomy (see guideline 2008, 2016)
  
• 
  Suction equipment (confirmed operation)
  
• 
  Towel to pad head for airway alignment if needed and appropriate
  
• 
  Personal protective equipment to prevent exposure to blood or body fluids.
  

• 
  Obtain medical control orders/advice as needed.
  
• 
  Place patient on cardiac monitor and pulse oximetry.
  
• 
  Assure patient is placed on 100% oxygen for 5 minutes prior to the procedure.
  
• 
  Establish your ability to adequately ventilate the patient with a bag-valve-mask on 100% oxygen
  
• 
  Predict if patient will have a “difficult airway”. If yes, consider alternate airway options (e.g. BVM or Nasal Tracheal intubation).
  
• 
  Start IV in a peripheral vein (see guideline 3002)
  
• 
  Prepare equipment listed above.
  
• 
  Reconstitute succinylcholine or other neuromuscular blocking agent. (see drug profile 043,044)
  
• 
  Prepare the sedative selected (e.g. midazolam, etomidate). (see drug profile 007, 023, 034)
  
• 
  Consider Atropine (0.01-0.02 mg/kg with minimum dose of 0.1 mg) for reflex bradycardia, especially in children. (see drug profile 005)
  

Rapid sequence intubation

• 
  Administer sedative followed by neuromuscular blocker at appropriate interval to allow for effective sedation.
  
• 
  Perform Sellick’s Maneuver as patient loses consciousness to prevent regurgitation.
  
• 
  Monitor pulse oximetry. If SPO₂ falls below 90%, stop procedure and ventilate the patient. If SPO₂ was less than93% prior to administration of sedation/paralytic, do not allow it to drop more than 6% before aborting the procedure and ventilating the patient.
  

• 
  Once patient is fully relaxed (approximately 45 seconds if using Succinylcholine), perform endotracheal intubation (see guideline 3002).
  
• 
  Ventilate patient with bag-valve and 100% oxygen.
  
• 
  Confirm tube placement with auscultation and presence of end tidal CO₂.
  
• 
  Release Sellick’s Maneuver.
  

• 
  Secure ET tube.
  
• 
  Consider restraining the patient (chemically or physically). The patient (when sedation/paralytic wears off) may try to pull tube out.
  
• 
  Never allow a patient to be paralyzed and not sedated. All paralyzed patient must be continuously and effectively sedated.
  
• 
  Reevaluate ET tube position after each patient move and as condition dictates.
  
• 
  Document procedure and results, including any unusual circumstances and/or difficulties encountered.
  

• 
  Definition: Inability to successfully place ET tube after 3 attempts.
  
• 
  Evaluate if airway can be maintained with BVM or Combitube, selecting the most effective device to maintain the airway and ventilate.
  
• 
  Consider cricothyroidotomy
  

• 
  Facilitate intubation in a hypoxic patient who is conscious or restless/combative, including but not limited to head injuries, status epilepticus, respiratory insufficiency with altered level of consciousness, inhalation injuries.
  

• 
  Inability to further evaluate patient’s neurologic status
  

• 
  Inability to establish the airway after the patient has been paralyzed.
  

• 
  Indications that the endotracheal tube will be very difficult or you will be unable to successfully ventilate the patient once he/she has been paralyzed
  
• 
  Significant facial trauma
  
• 
  Laryngeal edema
  
• 
  Succinylcholine contraindications (see drug guideline043)
  

• 
  An alternative airway must be immediately available in case the endotracheal tube cannot be placed successfully.
  

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 blood flow back to the heart, which increases the preload of the heart

To prevent hyperventilation
INDICATIONS:

Cardiac arrest (patient currently without pulse and spontaneous ventilations)

ResQPOD

Oxygen source

Airway adjunct (Mask, Combitube, or ET tube)

Suction machine and catheters

Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE:

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Apply the ResQPOD to face mask with oral airway, Combitube, or Endotracheal Tube. Do not delay chest compressions.
   
3. 
   Maintain a tight face-mask seal at all times during chest compressions.
   
4. 
   Use a bag-valve-mask (BVM) ventilator, or bag-valve to provide ventilation.
   
5. 
   Follow standard AHA CPR guidelines.
   
6. 
   Establish advanced airway device (Endotracheal Intubation or Combitube) and assess placement per protocol.
   
7. 
   Place ResQPOD between adjunct and BVM.
   
8. 
   Turn on Ventilation LED timer. If programmed for one light every five seconds, ventilate patient once every other light or once every ten seconds. (note: this is a slight modification from the AHA guideline ventilation rate if using a ResQPod designed for the 2000 AHA guidelines).
   
9. 
   Remember importance of full chest recoil during chest compressions.
   
10. 
    Document the ResQPOD placement.
    
11. 
    Remove ResQPod if return of spontaneous circulation and respirations.
    

ResQPOD (continued)

• 
  Prevents hyperventilation
  
• 
  Greater preload of heart
  

• 
  Additional device during set up
  

• 
  Extra weight from ResQPOD could cause ET or Combitube to become dislodged
  

• 
  Cardiogenic shock
  
• 
  Suspected pneumothorax
  
• 
  Chest trauma
  
• 
  Flail chest
  
• 
  less than 12 y/o
  
• 
  less than 100 lbs.
  

Note: When BLS responds to cardiac arrest and airway being managed appropriately with face mask (good chest rise with ventilations), continue with ResQPOD on face mask until ALS arrives. If patient is vomiting, is greater then or equal to 5ft and/or ALS will be delayed more than 10 minutes, consider inserting Combitube, though endotracheal intubation is the preferred airway.

END

GUIDELINE FOR PRACTICAL SKILL

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

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

To give you an alternative airway just prior to where a surgical airway is the only option

To prevent aspiration in a patient with decreased reflexes

CONTRAINDICATIONS
1. Patients that may have a high risk of aspiration

2. Patients who are not profoundly unconscious and that may resist an LMA / oral airway insertion.

3. Severe maxillofacial or oropharyngeal

4. 
   Greater than 14 weeks pregnant
   

Laryngeal Mask Airways (LMA) of appropriate sizes

Syringe with the appropriate volume for LMA cuff inflation

10 to 12 FR suction catheter

Water-soluble lubricant

Tape or other device(s) to secure the LMA

Stethoscope

Ventilation equipment

Oxygen source

Suction device

1. 
   Verify the size of the LMA is the proper size for the patient per manufacturer recommendation
   
   1. 
      Recommended size guideline:
      
      1. 
         Size 1 less than 5kg
         
      2. 
         Size 1.5 5-10kg
         
      3. 
         Size 2 10-20kg
         
      4. 
         Size 2.5 20-30kg
         
      5. 
         Size 3 30kg to small adult
         
      6. 
         Size 4 adult
         
      7. 
         Size 5 large adult/poor seal with size 4
         
2. 
   Examine the LMA
   
   1. 
      Visually inspect the LMA for tears in the cuff or abnormalities
      
   2. 
      Make sure the tube is free of blockages or loose particles
      
   3. 
      Inflate the cuff to ensure that it does not leak
      
   4. 
      Deflate the cuff to ensure that it will maintain a vacuum
      

3. 
   Deflation and Inflation
   
   1. 
      Slowly deflate the LMA cuff to form a smooth flat wedge shape that will pass easily behind the epiglottis and the back of the tongue.
      
   2. 
      When inflating, the maximum air in the cuff should not exceed:
      
      1. 
         Size 1 4 ml
         
      2. 
         Size 1.5 7 ml
         
      3. 
         Size 2 10 ml
         
      4. 
         Size 2.5 14 ml
         
      5. 
         Size 3 20 ml
         
      6. 
         Size 4 30 ml
         
      7. 
         Size 5 40 ml
         
4. 
   Lubrication
   
   1. 
      Lubricate with a water soluble lubricant the LMA device
      
   2. 
      Only lubricate the device just prior to insertion
      
   3. 
      Lubricate the back of the LMA thoroughly (avoid too much to reduce the risk of an obstruction)
      
5. 
   Position the patients airway
   
   1. 
      Extend the head and flex the neck
      
   2. 
      Avoid LMA fold over
      
   3. 
      If possible, have a second person pull the lower jaw downward
      
   4. 
      Visualize the posterior oral airway.
      
   5. 
      Ensure the LMA is not folding over in the oral cavity while inserting
      

1. 
   Grasp LMA by the tube, holding it like a pen as near to the mask end as possible.
   
2. 
   Place the tip of the LMA against the inner surface of the patient’s upper teeth.
   
3. 
   With direct vision, press the mask tip upward against the hard palate to flatten it out
   
4. 
   With direct vision using the index finger, keep pressing upward as you advance the mask into the pharynx to ensure the tip remains flattened while avoiding the tongue.
   
5. 
   If no concern for c-spine injury, keep the neck flexed and head extended. Press the mask into the posterior pharyngeal wall using the index finger.
   
6. 
   Continue to push mask with your index finger and guide mask downward into position.
   
7. 
   Grasp tube firmly with the other hand then withdraw your index finger from the pharynx and simultaneously press gently downward with your other hand to ensure the mask is fully inserted.
   
8. 
   Inflate the mask with the recommended volume of air as shown above and do not overinflate the mask. It is normal for the mask to rise slightly as it is inflated to its proper position.
   
9. 
   Connect the LMA to a BVM or other ventilator device
   
10. 
    Confirm equal breath sounds over both lungs in all fields assuring no epigastrium sounds.
    
11. 
    Secure the LMA with the same technique as an ET tube.
    

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