Emergency medical services primarily came into formal existence in the United States to serve one very important need: to provide field resuscitation to patients with severe cardiopulmonary conditions and major trauma. EMS physicians should be expert resuscitators evidenced by their mastery of all the techniques needed to provide the highest level of care. This is also the skill set needed to train and educate the EMS providers with which they work due to the obvious value of this basic prehospital intervention. 1,2
Cardiopulmonary resuscitation (CPR)
Standard CPR
Automated compression devices
External defibrillators
Automated external defibrillators
Multifunction monitor/defibrillators
Airway and ventilatory management
Airwayg positioning
Airway adjuncts
Nasopharyngeal airways
Oropharyngeal airways
Bag-valve mask
NIPPV
Continuous positive airway pressure (CPAP)
Bilevel positive airway pressure (BiPAP)
Endotracheal Intubation
Direct laryngoscopy
Video-assisted laryngoscopy
Intubation adjuncts
Lighted stylets
Gum elastic bougie
Supraglottic airway devices
Rescue airway procedures
Percutaneous and surgical cricothyrotomy
Needle cricothyrotomy with transtracheal jet insufflation
Retrograde intubation
Airway placement confirmatory devices
Colorimetric carbon dioxide detectors
Capnography
Ventilators
Vascular access
Peripheral venous access
Central venous access
Intraosseous access
Adult
Pediatric
Arterial lines
Radial
Femoral
Neonatal vascular access
Umbilical lines
Central lines
Peripheral access
Cardiopulmonary Resuscitation (CPR) is the manual or mechanical method of creating artificial circulation to temporarily provide vital organs, especially the brain and heart, with oxygenated blood until normal cardiopulmonary activity can be restored in a person in cardiac arrest.
Cardiopulmonary arrest
- Essential Equipment
Pocket mask or bag-valve mask
Automatic external defibrillator or multifunction monitor/defibrillator
- Technique
Step 1: Assess for responsiveness, absence of breathing, or presence of abnormal breathing/gasping.
Step 2: Apply automatic external defibrillator (AED) or multifunction monitor/defibrillator.
If witnessed arrest or CPR initiated prior to arrival, use AED as indicated or multifunction monitor/defibrillator as indicated by rhythm interpretation.
Ensure continued CPR during charging. 3
If unwitnessed arrest or defibrillation not indicated, go to Step 3.
Step 3: Assess circulation by checking for a pulse for 10 seconds.
Adults and children: carotid/femoral
Infants: brachial
Step 4: If no pulse, begin cycle of compressions to ventilations at a ratio of 30:2 (universally for all ages). In children, if two providers are available for resuscitation, a ratio of 15:2 should be used.
Compressions:
Adults and children: Compress at least 5 cm (at least 2 in) at a rate no less than 100 compressions/min.
Infants: Compress 4cm (1.5 in) at a rate no less than 100 compressions/min.
Rescue breathing: Rescue breaths should be given once chest compressions have been initiated. Each breath should be delivered over 1 second with sufficient tidal volume to cause a visible chest rise.
Step 5: Continue compressions to ventilations at a ratio of 30:2 for 5 cycles. After 5 cycles: stop. Reassess pulse. Reanalyze rhythm. Use AED or multifunction monitor/defibrillator as indicated. If defibrillation is not indicated or the patient remains pulseless, return to Step 4.
- Technique
Failure to perform adequate compression depth and/or rate
Inadequate chest recoil between compressions
Failure to minimize frequency and duration of interruptions
Automated compression devices may be used to replace manual compression during CPR in an adult patient. Defibrillator pads must be applied to the patient before application of the automated compression devices. These devices may be programed to provide either 30:2 CPR or continuous chest compressions with interposed manual ventilations. There are two types of automated compression devices used in clinical practice: Physio Control LUCAS-2 and Zoll AutoPulse.
The LUCAS Chest Compression System is a piston-driven device that is designed to deliver consistent, uninterrupted, effective compressions at a consistent rate and depth (Figure 59-1).
Indications These devices may be considered when a nonpregnant adult patient with no traumatic injuries is found in cardiopulmonary arrest. 4,5
- Essential Equipment
LUCAS-1 or LUCAS-2
- Technique
Step1: Unpack.
Step 2: Connect air (or battery).
Confirm that the On/Off knob is in the Adjust position.
If not already connect, attach the air hose to the connector.
If using the air driven version—attach the connector to a portable air cylinder (or) a pressure regulator, open the air valve.
Step 3: Attach to the patient.
Take the back plate out of the bag and approach the patient.
Instruct those performing CPR to interrupt chest compressions.
Work in a pair, one person on each side of the patient.
Take a hold of the patient’s arms. Take care to support the patient’s head.
Lift up the patient’s upper body and lay the back plate below the armpits. Ensure that the patient’s arms are outside of the back plate.
Continue manual chest compressions.
Take the upper part of the LUCAS out of the bag and pull up once on the release rings to check that the claw locks are open.
Interrupt manual chest compressions.
Place the upper part of the LUCAS over the patient’s chest so that the claw locks of the support legs will engage with the back plate.
Check by pulling upward that both support legs have locked against the back plate.
Step 4: Adjust device.
To achieve effective compressions, ensure that the suction cup is centered over the sternum.
Set the On/Off knob to Adjust position.
Lower the suction cup with the height-adjustment handles until the pressure pad inside the suction cup touches the patient’s chest without compressing the chest.
If there is a distance between the pressure pad inside the suction cup and the sternum, LUCAS cannot be used.
Step 5: Start mechanical chest compressions.
Turn the On/Off knob to Active position. LUCAS device will initiate compressions.
Check to ensure proper functioning.
When lifting the patient, stop compressions. To stop compressions, turn the On/Off knob to the Lock position.
Step 6: Apply stabilization strap.
Step 7: Secure the patients arms to the straps on the support legs.
- Technique
Ineffective compressions if not positioned properly.
If the patient is too large, the support legs cannot be locked to the back plate without compressing the patient.
Only suitable for use in an adult patient.
Contraindicated in patients with traumatic injury.
Contraindicated in pregnant patients.
Rib fractures, bruising, and soreness of the chest are not uncommon. 6
The AutoPulse is a mechanical chest compression system with a load distributing band that provides improved circulation by squeezing the entire chest at a consistent, uninterrupted, effective rate and depth (Figure 59-2). The device uses a pressure sensor to calculate the amount of compression required for each specific patient.
- Indications
The AutoPulse System is designed for adults with weight of no more than 136kg with chest circumference of 76 to 130cm and chest width of 25 to 38cm. A patient weighing in excess of 136kg may be suitable for the AutoPulse if they do not have a chest size of more than 130cm.
- Essential Equipment
AutoPulse Resuscitation System
AutoPulse batteries
Technique
There are two basic methods that can be applied:
Log roll method: at least three people required
Step 1: Extend and then open the AutoPulse LifeBand and place the device next to the patient.
Step 2: Log roll the patient away from the device.
Step 3: Slide the AutoPulse device next to the patient and tuck the band on the patient side under the patient.
Step 4: Log roll the patient back onto the device. Check alignment and adjust placement if necessary.
Step 5: Close the LifeBand, fully extend, and then place on the patient’s chest.
Sit forward method: at least three people required
Step 1: Extend and then open the LifeBand and have the AutoPulse resting at the head of the patient.
Step 2: Have two providers slip an arm under the patient’s armpit and sit the patient forward.
Step 3: Slide the AutoPulse down the bed, to the patient’s buttocks.
Step 4: Lay the patient back down on the board. Check alignment and adjust placement of necessary.
Step 5: Close the LifeBand, fully extend, and then place on the patient’s chest.
- Technique
Ineffective compressions if not positioned properly.
Limited use based on weight and chest circumference.
Only suitable for use in an adult patient.
Contraindicated in patients with traumatic injury.
Rib fractures and superficial skin injuries are not uncommon.
Early defibrillation is the most important intervention in improving survivability in cardiac arrest; therefore, most EMS services carry external defibrillators. There are two types of external defibrillators: automated external defibrillator and multifunction monitor/defibrillator.
- Indication
Defibrillation is performed when a patient in cardiac arrest is found to have the unsustainable rhythm of ventricular fibrillation or pulseless ventricular tachycardia.
- Essential Equipment
Automated external defibrillator or multifunction monitor/defibrillator
Conductive pads
Automated external defibrillator (AED) is a simple computerized rhythm analyzing device that provides visual and audible instructions for the safe defibrillation of patients in cardiac arrest. It is used by many BLS agencies and first responder organizations.
- Technique
Step 1: Power on device.
Step 2: Apply self-adhesive pads to the patient’s chest.
Step 3: Press Analyze button.
Step 4: If indicated by AED, verify All Clear and press Shock button (may repeat up to three shocks).
Step 5: After three shocks or any “no shock indicated” signal, check for pulse. If no pulse, perform CPR.
- Technique
Ease of use and public availability may delay activation of 9-1-1 system.
The multifunction monitor/defibrillator is a much more sophisticated device used by ALS agencies. Most of these devices have cardiac monitoring, pacing, cardioversion, and defibrillation capabilities. Defibrillation is facilitated using hands-off combination monitoring/defibrillation.
- Technique
Step 1: Turn on the monitor/defibrillator.
Step 2: Apply ECG leads to the patient to analyze rhythm.
Step 3: Apply conductive pads to the patient’s torso in the anterolateral position (Figure 59-3).
Step 4: If cardiac rhythm is conducive to defibrillation, prepare to deliver the electric charge to the patient.
Step 5: Select energy level and press Charge button.
Step 6: After ensuring All Clear, press the discharge/shock button to deliver the charge to the patient.
Step 7: Reevaluate the patient’s cardiac rhythm. If still required, the unit can be recharged to deliver another electric charge to the patient if indicated.
- Technique
Failure to remove any fluid materials on the chest wall (conductive jelly, saline, sweat, urine, water) can result in arcing and thermal burns to the thorax.
Repeated shocks may cause localized skin irritation/erythema.
Failure to ensure an All Clear may lead to inadvertent electrical charge being delivered to rescue personnel.
Synchronized cardioversion is performed at lower energies than defibrillation. In addition, it is important to set the monitor to a synchronization mode. This is important because inadvertent conversion of a perfusing rhythm to a nonperfusing rhythm is possible if the defibrillator is not set to the proper mode.
Transcutaneous pacing is a temporizing lifesaving procedure for symptomatic bradycardia. 7 It is important to note that this is used until a temporary transvenous or permanent pacemaker can be placed. Confirmation of capture can be difficult. If there is concern regarding the monitor confirmation, then the patients pulse can be assessed to confirm that the pulse corresponds to the pacer output. Furthermore, field ultrasound can be used for confirmation of ventricular capture.
Airway management is a fundamental lifesaving skill required of all prehospital providers. Basic airway management includes patient positioning and the use of airway adjuncts to establish or maintain a patent airway. Basic airway management is the cornerstone skill from which advanced airway procedures progress.
- Indication
To establish and or maintain a patent airway by mechanically displacing the mandible and thereby lifting the tongue out of the oropharynx
- Essential Equipment
None
- Technique
Head-tilt chin lift: in any patient without suspected cervical spine injury (Figure 59-4)
Jaw thrust maneuver: effective in patients with suspected cervical spinal injury (Figure 59-5)
Step 1: Place the index and middle fingers of each hand posterior aspects of the mandible to push it upward.
Step 2: Simultaneously, place the thumb of each hand on the chin and push downward to open the mouth.
- Indication
A nasopharyngeal airway (NPA) can be used to maintain a patent airway in patients with inadequate breathing who exhibit an intact gag reflex or clenched jaw (Figure 59-6).
- Essential Equipment
Properly sized NPA
Water-soluble lubricant or anesthetic jelly
Suction system
- Technique
Step 1: Open the airway with airway positioning technique.
Step 2: Choose the proper size NPA by measuring from nasal opening to ear lobe.
Step 3: Lubricate the NPA and insert into the nostril with the beveled side against the nasal septum.
Step 4: Gently advance and rotate 90° so the NPA is concave upward.
Step 5: Advance carefully along the floor of the nasopharynx until the flange rests against the nostril.
- Technique
Placement may lead to aspiration of gastric contents.
Airway trauma may lead to epistaxis.
Incorrect size or placement will compromise effectiveness.
Insertion into a patient with a basilar skull fracture, may cause displacement of the device into the cranial vault.
- Indication
An oropharyngeal airway (OPA) can be used to maintain a patent airway in patients with inadequate breathing who exhibit no gag reflex (Figure 59-7). Use of an OPA in a patient with an intact gag reflex may trigger vomiting and lead to aspiration of gastric contents. An OPA may also be used as a bite block to help prevent a patient from biting, occluding, and lacerating an endotracheal tube.
- Essential Equipment
Properly sized OPA
Suction system
- Technique
Step 1: Open the airway with airway positioning technique.
Step 2: Choose the proper size OPA by measuring from the corner of the mouth to the ear lobe.
Step 3: Adults—insert the OPA upside down until resistance is met, then rotate 180° and advance until flange is at the lips.
Pediatric patients—use a tongue depressor to hold the tongue down and guide the OPA into position right side up.
- Technique
Insertion of the OPA into a patient with an intact gag reflex can trigger vomiting and aspiration of gastric contents.
Incorrect size or placement may exacerbate airway obstruction.
Placement may cause oral trauma.
- Indications
Assisted ventilation for both adults and pediatric patients with the absence of spontaneous breathing or inadequate breathing
- Essential Equipment
Bag-valve mask with oxygen reservoir
Oxygen supply and tubing
- Technique
Step 1: Open the airway with airway positioning technique.
Step 2: Insert NPA or OPA to maintain patent airway.
Step 3: Ensure proper mask size—mask should completely cover the nose and mouth, but not leak.
Step 4: Create a good seal between the mask and the patient’s face by using one or two person techniques and ventilate the patient (Figure 59-8).
Noninvasive positive pressure ventilation (NIPPV) is an effective noninvasive method of providing positive pressure ventilation for patients who need ventilator support but can still maintain their airway. NIPPV is commonly used in the prehospital setting for cases of acute pulmonary edema secondary to CHF, COPD, and asthma exacerbations. 8 -10 NIPPV has been demonstrated to reduce the need for endotracheal intubations and relieve symptoms in these patient populations. The two methods of NIPPV used in the prehospital environment are continuous positive airway pressure and bilevel positive airway pressure (BiPAP). NPPV is contraindicated in the patient with apnea or agonal respirations, severe maxillofacial trauma, potential basilar skull fracture, severe epistaxis, or bullous disease.
Continuous positive airway pressure delivers continuous positive air pressure throughout the respiratory cycle. Bilevel positive airway pressure differs from CPAP in that it delivers two levels of positive pressure during the different phases of the respiratory cycle. BiPAP units can provide more relief, but are less practical for prehospital use because they are larger, more expensive and require more energy than CPAP.
- Indication
Continuous positive pressure ventilation (CPAP) can be used in the prehospital setting for cases of acute cardiogenic pulmonary edema, COPD, asthma, traumatic respiratory distress, ARDS, and pneumonia in order to maintain a level of positive airway pressure. The patient must have spontaneous respirations and be able to maintain their own airway.
- Essential Equipment
CPAP unit—ideally it is small, relatively inexpensive, easily portable and tolerates leaks with independent setting for IPAP and EPAP.
Oxygen supply.
Power source.
- Technique
Step 1: Ensure the patient has adequate respirations and is able to maintain their own airway.
Step 2: Select a proper size mask that is tight enough to allow a good, comfortable seal.
Step 3: Set IPAP at 8 to 10 and EPAP at 3 to 4cm H2O initially, using supplemental O2 at 3 to 5L/min.
Step 4: Monitor the patient’s condition by assessing changes in vital signs (BP, pulse, heart rate), pulse oximetry, and patient comfort. Adjust setting with each IPAP/EPAP change, increasing EPAP at 1 to 2cm incrementally with IPAP kept constant at a ratio (EPAP:IPAP) of 1:2.5.
Step 5: Continued hypercapnia is treated by increasing IPAP alone in 1- to 3-cm increments.
Use caution when using NIPPV at pressures approaching 15cm H2O. High pressures (>15cm H2O) may cause excessive intrathoracic pressure reducing essential preload and afterload, resulting in hypotension.
- Technique
A good mask seal can prove challenging, requiring multiple adjustments.
Gastric distension may lead to vomiting and aspiration.
Increased intragastric pressure may lead to abdominal compartment syndrome.
The patient may develop excessive secretions leading to airway compromise.
Endotracheal intubation is an advanced airway procedure during which an endotracheal tube is placed through the larynx into the trachea in patients who need definitive airway control. Endotracheal intubation is used to ensure airway patency, provide ventilations, and protect against aspiration. Prehospital endotracheal intubation is an area on which EMS physicians must focus. 11
- Indications
Respiratory or other emergencies requiring definitive airway control
- Essential Equipment
PPE
Suction catheter and source
Bag-valve mask
Oxygen
Endotracheal tube and stylet
10mL syringe
Endotracheal tube holder or adhesive tape
End-tidal CO2 detector (capnography preferred)
Stethoscope
Laryngoscope with appropriate blades
Alternative rescue devices (bougie, laryngeal mask airway, CombiTube, King)
Surgical airway kit
Medications for anesthesia, sedation, or rapid-sequence intubation
- Technique
Step 1: Ensure all equipment is readily accessible and functioning.
Inflate the cuff of the endotracheal tube to check for leaks.
Insert the stylet into the endotracheal tube—ensure stylet does not extend beyond the end of the tube.
Step 2: Unless there are contraindications (suspected cervical spine injury), place the patient in “sniffing” position by placing a pillow or folded towel under the patient’s occiput.
Step 3: Preoxygenate with 100% oxygen for 3 minutes using nonrebreather mask or bag-valve mask.
Step 4: While holding the laryngoscope in your left hand, open the patient’s mouth with your right hand and inspect the oral cavity.
Step 5: Remove debris or dentures.
Step 6: Insert the laryngoscope blade with your left hand into the right of the patient’s mouth, sweeping the tongue to the left.
Step 7: Advance the blade slowly and locate the epiglottis.
If using a Macintosh blade, place the blade tip into the epiglottic vallecula.
If using a Miller blade, place the blade tip posterior to the epiglottis.
Step 8: Elevate the laryngoscope upward and forward at a 45° angle to lift the mandible and expose the vocal cords.
Pay special attention not to lever back against the patient’s teeth; this can result in dental or and does not enhance the view of the cords
Step 9: Suction the airway as required.
Step 10: While maintaining your view of the vocal cords, insert the endotracheal tube into the right side of the patient’s mouth.
Step 11: Pass the tube through the vocal cords until the balloon disappears into the trachea.
Step 12: Advance the tube until the balloon is 3 to 4cm beyond the vocal cords.
Step 13: Inflate the endotracheal balloon with air, attach bag-valve mask, and start ventilations.
Step 14: Assess for proper tube placement using an end-tidal CO2 detector (capnography or colorimetric), auscultation over the epigastrium, and auscultation of both lung fields for symmetry. Ultrasound (when available) may also be used, especially when auscultation is impractical (eg loud extrication scene, air medical transport). 12
Step 15: Continue ventilations and secure the tube using a commercial tube holder or adhesive tape.
- Technique
Failure to recognize esophageal intubation.
Failure to recognize mainstem bronchus intubation.
Tube dislodgement can occur during patient movement.
Oropharyngeal trauma from laryngoscopy or endotracheal tube placement.
Vomiting and aspiration of gastric contents.
Potential for laryngospasm and bronchospasm.
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