Emergency Medical Response INSTRUCTOR S MANUAL

Transcription

1 Emergency Medical Response INSTRUCTOR S MANUAL

2 Contents Acknowledgments 3 SECTION A: ADMINISTRATION Chapter 1: Introduction 9 Course Purpose Course Objectives Course Participants Instructor Responsibilities Chapter 2: Course Design 11 Course Content Participant Resources Emergency Medical Response textbook Emergency Medical Response Workbook Instructor Resources Emergency Medical Response Instructor s Manual Emergency Medical Response DVD PowerPoint Slides Test Bank Quizzes Instructor s Corner EMR Interactive Additional Resources for Instructors and Participants Training Equipment and Red Cross Retail Products Additional Red Cross Courses Chapter 3: Setting Up and Running This Course 15 Recommended Class Size Course Length Classroom Space Class Safety Health Precautions for Course Participants Participants with Disabilities and Special Health Considerations Chapter 4: Requirements for Successful Course Completion 18 Criteria for Course Completion and Certification Final Practical Evaluation Final Written Exams Exam Security Reporting Procedures Participant Course Evaluation Awarding Certificates Continuing Education Units for Professionals SECTION B: TEACHING TOOLS Lesson Outline Lesson 1: Lesson 2: Lesson 3: Lesson 4: The Emergency Medical Responder 29 Bloodborne Pathogens: Preventing Disease Transmission 37 The Well-Being of the Emergency Medical Responder 51 Medical, Legal and Ethical Issues 58 Lesson 5: The Human Body 67 Lesson 6: Lifting and Moving Patients 74 Lesson 7: Putting It All Together 97 Lesson 8: Scene Size-Up 102 Lesson 9: Primary Assessment 111 Lesson 10: History Taking and Secondary Assessment 134 Lesson 11: Communication and Documentation 164 Lesson 12: Skills Review 173 Contents 1

3 Lesson 13: Putting It All Together 175 Lesson 14: Airway and Ventilation 181 Lesson 15: Airway Management 213 Lesson 16: Emergency Oxygen 232 Lesson 17: Skills Review 242 Lesson 18: Putting It All Together 245 Lesson 19: The Circulatory System and Cardiac Emergencies 250 Lesson 20: CPR and Automated External Defibrillation 257 Lesson 21: Skills Review 281 Lesson 22: Putting It All Together 283 Lesson 23: Medical Emergencies 288 Lesson 24: Poisoning 302 Lesson 25: Substance Misuse and Abuse 311 Lesson 26: Environmental Emergencies 318 Lesson 27: Behavioral Emergencies 338 Lesson 28: Putting It All Together 346 Lesson 29: Shock 351 Lesson 30: Bleeding and Trauma 356 Lesson 31: Soft Tissue Injuries 369 Lesson 32: Injuries to the Chest, Abdomen and Genitalia 378 Lesson 33: Injuries to Muscles, Bones and Joints 386 Lesson 34: Injuries to the Head, Neck and Spine 401 Lesson 35: Skills Review 421 Lesson 36: Putting It All Together 423 Lesson 37: Childbirth 429 Lesson 38: Pediatrics 437 Lesson 39: Geriatrics 446 Lesson 40: Special Needs Patients 451 Lesson 41: Putting It All Together 455 Lesson 42: EMS Support and Operations 461 Lesson 43: Access and Extrication 468 Lesson 44: Hazardous Materials Emergencies 473 Lesson 45: Incident Command and Multiple-Casualty Incidents 478 Lesson 46: Disasters, Terrorism and Weapons of Mass Destruction 485 Lesson 47: Special Operations 498 Lesson 48: Putting It All Together 506 Lesson 49: Final Practical Evaluation 512 Lesson 50: Final Written Exam 514 SECTION C: APPENDICES Appendix A: Teaching Strategies 519 Appendix B: Materials, Equipment and Supplies Checklist 526 Appendix C: American Red Cross Emergency Medical Response DVD 528 Appendix D: Participant Progress Log 530 Appendix E: Final Written Exams, Answer Sheets and Answer Keys Emergency Medical Response Instructor s Manual

4 LESSON 14 Airway and Ventilation Lesson Length 115 minutes (185 minutes with Enrichments) Materials, Equipment and Supplies Emergency Medical Response textbook PowerPoint slides 1 26 LCD projector, screen and computer Emergency Medical Response DVD DVD player and monitor Non-latex disposable gloves (multiple sizes) and other personal protective equipment (PPE), as indicated Adult and infant manikins (one for every two participants; child manikins optional) Lesson Objectives Knowledge Decontamination supplies Resuscitation masks (adult and pediatric; one for each participant) Bag-valve-mask resuscitators (BVMs) (adult and pediatric; one for every two participants) Examples of delivery systems for asthma medications and peak flow meters, such as asthma training inhalers ( Enrichment: Assisting the Patient with Asthma [optional]) After completing this lesson, participants will be able to Describe the structure and function of the respiratory system. List the signs of inadequate breathing. Describe how to care for a patient experiencing respiratory distress. Explain why basic airway management and ventilation skills take priority over many other basic life-support skills. Describe how to perform mouth-to-mouth, mouth-to-nose and mouth-to-stoma ventilations. Describe how to assess for breath sounds (Enrichment). Skill After completing this lesson, participants will be able to Demonstrate how to give ventilations using a resuscitation mask. Demonstrate how to give ventilations using a bag-valve-mask resuscitator (BVM). Demonstrate how to give ventilations if a head, neck or spinal injury is suspected. Demonstrate how to perform cricoid pressure (Sellick s maneuver) ( Enrichment skill ). Demonstrate how to assist a patient with an asthma inhaler ( Enrichment skill ). Lesson 14 : Airway and Ventilation 181

5 TOPIC: INTRODUCTION Time: 5 minutes PowerPoint slides 1 2 Activity: Review the opening scenario: Your medical emergency response team has been called to the fitness center by building security on a report that an employee complained of having difficulty breathing. You and your partner arrive and find the man conscious but in distress. The patient s chief complaint is difficulty breathing. He says he just overdid it on the treadmill. He appears to be out of breath and is having trouble speaking in full sentences. You begin a primary assessment and determine that the patient is in respiratory distress. Ask participants What should you do? What can you do to assist the patient with his breathing? Let participants provide responses, guiding them to important areas related to respiratory emergencies, such as assessing for an open airway and respiratory function, underlying causes and signs and symptoms of respiratory distress and respiratory arrest. Tell participants: Ensuring an open airway is the most important step that you can take in caring for a patient because a person cannot breathe without an open airway. A patient who can speak or cry is conscious, has an open airway, is breathing and has a pulse. TOPIC: THE RESPIRATORY SYSTEM Time: 10 minutes PowerPoint slides 3 4 Urge participants to review Chapter 4: The Human Body. The respiratory system is divided into the upper and lower airway tracts. The upper airway tract begins at the mouth and includes the nose, pharynx and larynx. The lower airway tract begins below the level of the vocal cords and includes the trachea, bronchi, bronchioles and alveoli. Breathing requires that the respiratory, circulatory, nervous and musculoskeletal systems work together. Injuries or illnesses that affect any of these systems may cause breathing emergencies. 182 Emergency Medical Response Instructor s Manual

6 Pathophysiology Breathing difficulties may occur for various reasons including Inadequate amount of oxygen breathed in during respiration. Breathing in a low-oxygen environment or when poisonous gases are in the air. Infection of the lungs. Illness, such as asthma, excess fluid in the lungs, excess fluid between the lungs and blood vessels or poor circulation. Upper airway problems due to swelling, obstruction or trauma. Ineffective circulation, such as from shock or cardiac arrest. Choking, caused by airway obstruction, is one of the most common causes of breathing emergencies and can occur due to anatomical or mechanical obstruction. An inadequate rate or depth of breathing leads to insufficient air volume moving in and out of the lungs. Respirations may be ineffective due to unconsciousness, altered level of consciousness, chest injury, poisoning, overdose or diseases, such as chronic obstructive pulmonary disease (COPD) or emphysema. Oxygenation refers to the amount of oxygen in the bloodstream. An insufficient amount of oxygen delivered to the cells is referred to as hypoxia, which may result from Obstructed airway. Shock. Inadequate breathing. Drowning. Strangulation. Choking. Suffocation. Cardiac arrest. Head trauma. Carbon monoxide poisoning. Complications of general anesthesia. TOPIC: RESPIRATORY EMERGENCIES Time: 20 minutes PowerPoint slides 5 9 Refer participants to Chapter 4: The Human Body for information about the physiology of respiration and Chapter 8: History Taking and Secondary Assessment for a review of information about respiratory rate and normal rate ranges. A respiratory emergency occurs when air cannot travel freely and easily into the lungs; it can be life threatening because it greatly cuts down on the oxygen the body receives or because it cuts off oxygen entirely. Lesson 14 : Airway and Ventilation 183

7 Unless the brain receives oxygen within 4 to 6 minutes, permanent brain damage or death can occur. There are two types of respiratory emergencies: Respiratory distress, which involves difficulty breathing Respiratory arrest, which involves the cessation of breathing Respiratory distress is a condition in which breathing becomes difficult; it can be caused by A partially obstructed airway. Illness. Chronic conditions, such as asthma. Electrocution, including lightning strikes. Heart attack. Injury to the head, chest, lungs or abdomen. Allergic reactions. Drugs. Poisoning. Emotional distress. Trouble breathing can be the first sign of a more serious emergency, such as anaphylaxis or a heart problem; therefore, recognizing the signs of breathing problems and providing care often are the keys to preventing these problems from becoming more serious emergencies. Patients with breathing problems will most likely be conscious. Breathing problems can be identified by watching and listening to the patient s breathing and by asking how the patient feels. Signs and symptoms of respiratory emergencies include Slow or rapid breathing. Unusually deep or shallow breathing. Gasping for breath. Wheezing, gurgling or high-pitched noises. Unusually moist or cool skin. Flushed, pale, ashen or bluish skin color. Shortness of breath. Dizziness or light-headedness. Pain in the chest or tingling in the hands, feet or lips. Apprehensive or fearful feelings. Activity Option A: Time: 5 minutes Ask participants if they have ever experienced a respiratory infection. Ask those that responded positively to share with the class what signs and symptoms they experienced. Possible responses may include Signs and symptoms, such as coughing with or without mucus, difficulty breathing, fever, chills, shortness of breath or chest pain. 184 Emergency Medical Response Instructor s Manual

8 Activity Option B: Time: 5 minutes Using the following scenario, ask participants to identify possible causes for the patient s condition and to suggest additional questions that would be appropriate to ask when determining what the patient is experiencing. You and your partner are summoned to a local conference center in response to an emergency call. A person who was scheduled to speak at a conference began complaining of difficulty breathing about 10 minutes before he was scheduled to speak. On arrival at the scene, you find the patient sitting on the floor, breathing rapidly. The patient states that all of sudden he began to feel dizzy and his lips started tingling. Possible responses may include Causes such as stress or anxiety related to speaking before a group of people or an underlying infection, heart failure or lung disease. Additional questions, such as Have you had an infection recently? Do you have a history of heart or lung problems? Do you have a history of asthma? Have you ever experienced this type of feeling before? Activity Option C: Time: 10 minutes Divide the participants into small groups and ask them to compare and contrast the signs and symptoms of COPD with an asthma attack. Then bring the groups back together to discuss their conclusions. Responses should include the following: Comparison of similarities including elevated shoulders and pursed lip breathing, wheezing, shortness of breath, coughing and confusion Contrasting differences include increased mucus, loss of appetite, tiring easily and age (middle aged or older patient) for COPD, and rapid, shallow breathing, sweating, chest tightness and age (typically child or young adult) for an asthma attack Activity Option D: Time: 10 minutes Divide the participants into seven small groups. Assign each group one of the following conditions: COPD, asthma, pneumonia, acute pulmonary edema, hyperventilation, pulmonary embolism and emphysema. Have participants use their textbooks to describe the condition and explore its signs and symptoms and care, then have each group present its information to the rest of the class. Lesson 14 : Airway and Ventilation 185

9 Responses should include the following: For COPD: COPD is a progressive lung disease characterized by difficulty breathing due to partial obstruction of the airways and loss of the alveolis ability to fill with air. Cigarette smoking is the most common cause. Other possible causes are inhalation of other lung irritants, pollution, dust or chemicals over a long period of time. Signs and symptoms include coughing with copious mucus; tendency to tire easily; loss of appetite; bent posture with elevated shoulders and pursed lips; fast pulse; round, barrel-shaped chest; and confusion (due to lack of oxygen to the brain). Care includes helping the patient focus on his or her breathing, as deep breaths help to fill the lungs with air and maintain flexibility in the chest wall. For asthma: Asthma is an ongoing illness involving airway swelling and inflammation that is more common in children and young adults. Exposure to a trigger, such as exercise, cold air, allergens or other irritants, affects the airways, causing them to swell and narrow. Signs and symptoms include coughing or wheezing noises, difficulty breathing, shortness of breath, sweating, tightness in the chest, rapid and shallow breathing, inability to talk without stopping for breathing, bent posture with elevated shoulders, pursed lips and feelings of fear and confusion. Acute care includes controlling environmental variables, medications (e.g., bronchodilators) and other forms of treatment. For pneumonia: Pneumonia is an infection due to virus, bacteria, fungus or other organism that causes inflammation of the lungs that leads to the air sacs filling with fluid, thus interfering with oxygen exchange. Signs and symptoms include high fever and chills, chest pain, shortness of breath, increased respiratory rate, breathing difficulty, congestion (in older adults) and altered mental status (in older adults). Care includes use of emergency oxygen administration. For acute pulmonary edema: Acute pulmonary edema is an abnormal buildup of fluid in the lungs causing severe respiratory distress, altered mental status and coughing, with some bloody sputum. Signs and symptoms develop gradually, such as difficulty breathing when lying flat, awakening at night with a feeling of breathlessness, unusual shortness of breath during activity and significant weight gain. Acute signs and symptoms include shortness of breath; difficulty breathing, such as wheezing or gasping; cyanosis; frothy (foamy) pink sputum; pale skin; excessive sweating; restlessness; anxiety and a feeling of apprehension; feeling of suffocating or drowning; and chest pain (when condition is caused by coronary artery disease). Care includes emergency oxygen administration as the first step. For hyperventilation: Hyperventilation is the faster and shallower or deeper-than normal breathing leading to a decrease in blood carbon dioxide levels, reducing blood flow to the brain and leading to fear, anxiety, confusion, dizziness, and numbness and tingling in the fingers and toes. Care focuses on calming the patient (if symptoms are not life threatening), listening to the patient s concerns and trying to reassure and encourage the patient to breathe slower or breathe through pursed lips and administering emergency oxygen if patient does not respond. For pulmonary embolism: Pulmonary embolism is a blockage in the arteries of the lungs that interferes with oxygen and carbon dioxide exchange leading to respiratory distress (degree depends on size of clot). Signs and symptoms include sudden onset of dyspnea; chest pain that is localized and does not radiate; coughing, including coughing up blood; and fainting. Larger clots can cause death very quickly. Rapid care and transport of the patient to a hospital is crucial. 186 Emergency Medical Response Instructor s Manual

10 For emphysema: Emphysema is a chronic disease caused by damage to the air sacs in the lungs; it also is degenerative, worsening over time with alveoli losing their elasticity, becoming distended with trapped air interfering with their proper function. Over time, the number of alveoli affected increases, leading to increasing difficulty with breathing. Signs and symptoms include shortness of breath (most common), cyanosis, barrel-shaped chest, fatigue, loss of appetite, weight loss, mild cough, breathing through pursed lips, restlessness, confusion and weakness. TOPIC: AIRWAY Time: 20 minutes PowerPoint slides Briefly review the two methods for opening the airway: the head-tilt/chin-lift technique and the jaw-thrust (without head extension) maneuver found in Lesson 9. Refer participants to Chapter 7: Primary Assessment. Have participants review the skill sheets for both techniques. Signs of an Open Airway An airway is open and clear when the following occur: The patient s chest rises and falls. Air is heard and felt coming out of the patient s mouth and nose as the patient exhales. The conscious patient is able to speak in full sentences without distress. The conscious patient is speaking in normal tones. Signs of an Inadequate Airway A patient with an inadequate airway needs close attention and monitoring. Any unusual sounds may be signs of an airway obstruction. The patient may be visibly unable to catch his or her breath or he or she may gasp for air and make grunting sounds. Stridor (a harsh, high-pitched sound on inhalation) may be due to a swollen larynx blocking the upper airway. Snoring may indicate that the tongue or other tissues in the mouth may be relaxed and blocking the upper airway. A patient who is awake and alert but unable to speak or can only speak a few words or has a hoarse-sounding voice may be having severe difficulty breathing. Inadequate breathing also may be due to trauma, infection or an allergic reaction. No air movement indicates apnea (the complete absence of breathing); the patient needs artificial ventilation. Sometimes, no detectable air movement may be due to an airway obstruction. Lesson 14 : Airway and Ventilation 187

11 If efforts to open the airway are unsuccessful and ventilations do not make the chest rise and fall, you must check for an airway obstruction, such as liquid, food, teeth, dentures, blood, vomit or other foreign objects. Causes of Airway Obstruction The two types of airway obstruction include mechanical and anatomical. Mechanical obstruction involves any foreign body lodged in the airway; it is an emergency situation that needs immediate attention. The most common cause of foreign body airway obstruction (FBAO) in adults is a solid object, such as food. In children younger than 4 years, large chunks of food and small objects, such as toy parts or balloons, commonly cause airway obstruction. An anatomical obstruction is most commonly due to the tongue. It occurs in an unresponsive patient, as muscle tone is lost allowing the tongue to fall back and block the airway. Other conditions that may cause an anatomical obstruction include swelling due to trauma, infection, asthma, emphysema or anaphylaxis. Trauma to the neck also may cause an obstruction. Techniques to Clear an Airway Obstruction Protocols vary related to the methods used to clear an airway obstruction. Abdominal thrusts, back blows and chest thrusts have been proven to effectively clear an obstructed airway in conscious patients. Unconscious patients with FBAO should receive a modified form of CPR. Techniques to Remove Foreign Matter from the Upper Airway Two techniques can be used to remove visible foreign matter and fluids from the upper airway of an unconscious patient: finger sweeps and suctioning. Finger sweeps involve removing an object or other foreign matter from a patient s mouth with a finger. It is performed only on an unconscious patient and only when foreign matter is seen in the patient s mouth. Be sure to always wear gloves when performing a finger sweep. Be sure to use the index finger for an adult and little finger for a child or an infant. Suctioning removes blood, fluids or food particles from the airway. Some suctioning devices cannot remove solid objects, such as teeth, foreign bodies or food. 188 Emergency Medical Response Instructor s Manual

12 Recovery Positions In some cases, the person may be unconscious but breathing. Generally that person should not be moved from a face-up position, especially if there is a suspected spinal injury. However, if you are alone and have to leave the person (e.g., to call for help), or you cannot maintain an open and clear airway because of fluids or vomit, place the patient in a modified high arm in endangered spine (H.A.IN.E.S.) recovery position to help keep the airway open and clear. TOPIC: ASSESSING BREATHING Time: 10 minutes PowerPoint slides Urge participants to review the information from previous lessons on opening the airway and on primary and secondary assessments. Inadequate Breathing Inadequate breathing is indicated by the following signs: Muscles between the ribs pulling in on inhalation Pursed lip breathing Nasal flaring Fatigue Excessive use of abdominal muscles to breathe Sweating Sitting upright and leaning forward (tripod position) Deviated trachea Abnormal breath sounds also are a sign of inadequate breathing; these may include Stridor. Wheezing. Crackles/rales. Inadequate Oxygenation Problems with inadequate oxygenation may occur for a variety of reasons. A reduction in oxygen in the body causes headaches, increased breathing rate, nausea and vomiting, altered mental status and, ultimately, death. Lesson 14 : Airway and Ventilation 189

13 TOPIC: ARTIFICIAL VENTILATION Time: 45 minutes PowerPoint slide 17 Artificial ventilation refers to the various mechanical ways that can be used to help a patient breathe. When delivering artificial ventilations, the force of air must be consistent and just strong enough to cause the chest to clearly rise in about 1 second; gastric distention can occur if too much force is used. A resuscitation mask allows you to breathe expired air into a patient without making mouth-to-mouth contact, reducing the risk of disease transmission. Approximately 16 percent oxygen is provided in an exhaled breath, enough to sustain life. However, this amount is considerably less than that which is delivered using a bag-valve-mask resuscitator (BVM) or emergency oxygen. If the patient vomits when providing ventilations, quickly turn the patient onto the side, supporting the head and neck and turning the body as a unit; after vomiting has stopped, clear the patient s airway using a finger sweep and suction if necessary and then turn the patient onto the back and continue with ventilations. Dentures help to support the patient s mouth and cheeks, making it easier to seal the resuscitation mask; they should be removed only if they become loose or block the airway. Ventilations may need to be provided through the nose if the patient s mouth is injured. The mask is placed over the patient s mouth and nose. On rare occasions, a patient may have an opening (stoma) in his or her neck for breathing. SKILL Session GIVING VENTILATIONS ADULT AND CHILD Activity: S You may choose either method below depending on the experience of the participants and whether your training facility can accommodate the Practice-While-You-Watch method, which works best when there is adequate practice space and a monitor large enough for everyone to see clearly. Inform participants that they only need to demonstrate giving ventilations to an adult and can point out the differences for giving ventilations to a child, such as using a properly sized resuscitation mask for the patient, tilting the head slightly past neutral and only giving 1 ventilation about every 3 seconds. 190 Emergency Medical Response Instructor s Manual

14 SKILL Session Practice-While-You-Watch Ask participants to take their textbooks, disposable gloves and resuscitation masks with them to the practice area. Explain to the participants that for this skill, they will follow along with and practice the steps for giving ventilations as they are guided by the DVD, using a manikin, disposable gloves and resuscitation mask. Show the DVD segment, Giving Ventilations Adult, Child and Infant (4:08). Do not interrupt this practice session to lecture or communicate anything other than guidance related to skill practice. In general, answering questions should occur after the video segment (and skill practice) has ended. Observe participants performing the technique and evaluate completion of the skill using the Skill Checklist. Be sure to point out any common errors, such as tilting a child s head too far back, failing to reassess for breathing and a pulse, not leaving the patient in a face-up position with return of breathing, not obtaining a seal with the resuscitation mask or using an improperly sized mask for the patient. Check off participant s progress on the Participant Progress Log. Watch-Then-Practice Tell participants to watch the DVD segment without practicing until you pause the DVD, even though the narration may say to follow along. After the DVD segment, tell them to practice the skill using a manikin, disposable gloves and resuscitation mask. If there is a 2-to-1 ratio of participants-to-manikins, partners should be instructed to follow along with the skill sheet and observe the other person practicing the skill. Show the DVD segment, Giving Ventilations Adult, Child and Infant (4:08). Initially guide participants through the steps listed on the skill chart, then encourage them to practice independently, without assistance. Observe participants performing the technique and evaluate completion of the skill using the Skill Checklist. Intervene and provide positive and corrective feedback as needed to each participant individually when possible. Be sure to point out any common errors, such as tilting a child s head too far back, failing to reassess for breathing and a pulse, not leaving the patient in a face-up position with return of breathing, not obtaining a seal with the resuscitation mask or using an improperly sized mask for the patient. Check off participant s progress on the Participant Progress Log. Lesson 14 : Airway and Ventilation 191

15 SKILL Session SKILL CHART SKILL Giving Ventilations Adult and Child SKILL COMPONENT After sizing up the scene, performing a primary assessment and following standard precautions, select a properly sized mask for the patient. Determine that there is a pulse but no breathing. 1. Assemble the resuscitation mask as necessary, and position the mask. 2. Seal the mask. 3. Open the airway by tilting the head back and lifting the chin. For a child, tilt the head slightly past neutral. Use the jaw-thrust (without head extension) manuever to open the airway if a head, neck or spinal injury is suspected. 4. Blow into the mask for approximately 1 second and watch for the chest to clearly rise. 5. Continue to give 1 ventilation about every 5 seconds for an adult. Give 1 ventilation about every 3 seconds for a child. Watch the chest clearly rise with each ventilation. Give ventilations for about 2 minutes. 6. Reassess for breathing and a pulse. Remove mask and look, listen and feel for breathing and a pulse for no more than 10 seconds. 7. If the patient is unconscious but breathing Leave the patient in a face-up position, especially if there is a suspected spinal injury. You are alone and have to leave the person (e.g., to call for help), or you cannot maintain an open and clear airway because of fluids or vomit, place the person in a modified H.A.IN.E.S. recovery position. 8. If the chest does not clearly rise Retilt the head and try another ventilation. Provide care based on the conditions found. 192 Emergency Medical Response Instructor s Manual

16 SKILL Session GIVING VENTILATIONS INFANT Activity: Ask participants to take their textbooks, disposable gloves and resuscitation mask with them to the practice area. Divide participants into small groups and guide groups through the steps listed on the skill chart. Have each participant demonstrate giving ventilations on the infant manikins while the other participants use their textbooks to give feedback. Observe each participant performing the technique and evaluate completion of the skill using the Skill Checklist. Intervene and provide positive and corrective feedback as needed to each participant individually when possible. Be sure to point out any common errors, such as tilting an infant s head too far back, failing to reassess for breathing and a pulse, not obtaining a seal with the resuscitation mask or using an improperly sized mask for an infant. Check off participant s progress on the Participant Progress Log. SKILL CHART SKILL Giving Ventilations Infant SKILL COMPONENT After sizing up the scene, performing a primary assessment and following standard precautions, select a properly sized mask for the patient. Determine that there is a pulse but no breathing. 1. Assemble the resuscitation mask as necessary, and position the mask. 2. Seal the mask. 3. Open the airway by tilting the infant s head to a neutral position and lifting the chin. 4. Blow into the mask for approximately 1 second and watch for the chest to clearly rise. 5. Continue to give 1 ventilation about every 3 seconds. Watch the chest clearly rise with each ventilation. Give ventilations for about 2 minutes. 6. Reassess for breathing and a pulse. Remove mask and look, listen and feel for breathing and a pulse for no more than 10 seconds. Lesson 14 : Airway and Ventilation 193

17 SKILL Session SKILL Giving Ventilations Infant (cont.) SKILL COMPONENT 7. If the infant is unconscious but breathing Place the infant in a recovery position as would be done for an older child. Alternatively hold an infant in a recovery position by Carefully positioning the infant face-down along your forearm. Supporting the infant s head and neck with your other hand while keeping the infant s mouth and nose clear. 8. If the chest does not clearly rise Retilt the head and attempt another ventilation. Provide care based on the conditions found. If preferred, review giving ventilations (adult, child and infant) first and then divide the class into groups to practice the two techniques. SKILL Session GIVING VENTILATIONS HEAD, NECK OR SPINAL INJURY SUSPECTED (JAW-THRUST [WITHOUT HEAD EXTENSION] MANEUVER) ADULT AND CHILD Activity: Ask participants to take their textbooks, disposable gloves and resuscitation mask with them to the practice area. Divide participants into small groups and guide groups through the steps listed on the skill chart. Have each participant demonstrate giving ventilations on the manikins while the other participants use their textbooks to give feedback. Observe each participant performing the technique and evaluate completion of the skill using the Skill Checklist. Intervene and provide positive and corrective feedback as needed to each participant individually when possible. Be sure to point out any common errors, such as tilting a child s head too far back, failing to reassess for breathing and a pulse, not leaving the patient in a face-up position with return of breathing, not obtaining a seal with the resuscitation mask or using an improperly sized mask for the patient. Check off participant s progress on the Participant Progress Log. 194 Emergency Medical Response Instructor s Manual

18 SKILL Session SKILL CHART SKILL Giving Ventilations Head, Neck or Spinal Injury Suspected (Jaw-Thrust [Without Head Extension] Maneuver) Adult and Child SKILL COMPONENT Always follow standard precautions when providing care. Size-up the scene for safety and then perform a primary assessment. Always select the properly sized mask for the patient. If there is a pulse, but no breathing and a head, neck or spinal injury is suspected 1. Assemble the resuscitation mask. 2. Position the mask. Kneel above the patient s head. Place the rim of the mask between the lower lip and chin. Lower the resuscitation mask until it covers the patient s mouth and nose. 3. Seal the mask. Place your thumbs along each side of the resuscitation mask. Use your elbows for support. Slide your fingers into position under the angles of the patient s jawbone. Without moving the patient s head, apply even, downward pressure with your thumbs to seal the mask. 4. Open the airway. Without tilting the head back, open the airway by pushing or thrusting the lower jaw up with your fingers along the jawbone. 5. Blow into the mask. Each ventilation should last about 1 second and make the chest clearly rise. 6. Continue to give 1 ventilation about every 5 seconds for an adult or 1 ventilation about every 3 seconds for a child. Watch the chest clearly rise when giving ventilations. Give ventilations for about 2 minutes. 7. Reassess for breathing and a pulse. Remove the mask and look, listen and feel for breathing and a pulse for no more than 10 seconds. 8. If the patient is unconscious but breathing Leave the patient in a face-up position, especially if there is a suspected spinal injury. You are alone and have to leave the person (e.g., to call for help), or you cannot maintain an open and clear airway because of fluids or vomit, place the person in a modified H.A.IN.E.S. recovery position. Lesson 14 : Airway and Ventilation 195

19 SKILL Session SKILL Giving Ventilations Head, Neck or Spinal Injury Suspected (Jaw-Thrust [Without Head Extension] Maneuver) Adult and Child (cont.) SKILL COMPONENT 9. If the chest does not clearly rise Retilt the head and try another ventilation. Provide care based on the conditions found. TOPIC: BAG-VALVE-MASK RESUSCITATOR VENTILATIONS DVD: Time: 15 minutes PowerPoint slides Show the DVD segment, Using a Bag-Valve-Mask Resuscitator Two Rescuers (1:39). Answer participants questions about the DVD segment. A BVM, a hand-held device used to ventilate patients in respiratory distress or respiratory arrest, consists of three parts: a bag, a valve and a mask. BVMs help to increase oxygen levels in the blood by using air in the surrounding environment instead of the air exhaled by the rescuer, they can be connected to emergency oxygen and protect against disease transmission and inhalation hazards. BVMs can deliver up to 21 percent oxygen when not used in conjunction with emergency oxygen. Effectiveness for delivering ventilations is increased when used correctly by two rescuers; they can be used with advanced airway adjuncts. Two rescuers should operate a BVM to ensure maintaining a tight seal on the mask. One rescuer opens and maintains the airway and seals the BVM. A second rescuer delivers ventilations by squeezing the bag at the correct intervals. BVMs may not always be available, and they may interfere with the timing of chest compressions during CPR. They also require you to monitor the patient to ensure full exhalation. 196 Emergency Medical Response Instructor s Manual

20 SKILL Session GIVING VENTLIATIONS USING A BAG-VALVE-MASK RESUSCITATOR TWO RESCUERS Activity: Ask participants to take their textbooks, disposable gloves and BVMs with them to the practice area. Divide participants into small groups and guide groups through the steps listed on the skill chart. Have each participant demonstrate using a BVM on the manikins while the other participants use their textbooks to give feedback. Observe each participant performing the technique and evaluate completion of the skill using the Skill Checklist. Intervene and provide positive and corrective feedback as needed to each participant individually when possible. Be sure to point out any common errors, such as selecting an incorrect size, positioning the mask improperly, failing to ensure a seal or failing to keep the airway open. Check off participant s progress on the Participant Progress Log. SKILL CHART SKILL Giving Ventliations Using a Bag-Valve-Mask Resuscitator Two Rescuers SKILL COMPONENT Always follow standard precautions when providing care. Size-up the scene for safety and then perform a primary assessment. Always select the properly sized mask for the patient. Assemble the BVM if necessary. If there is a pulse but no breathing 1. Position the mask over the patient s mouth and nose. 2. Seal the mask. 3. Open the patient s airway while maintaining the seal on the mask. 4. Begin ventilations. 5. Continue to give 1 ventilation about every 5 seconds for an adult or 1 ventilation about every 3 seconds for a child or an infant. Watch the chest clearly rise when giving ventilations. Give ventilations for about 2 minutes. 6. Reassess for breathing and a pulse. Remove the BVM and look, listen and feel for breathing and a pulse for no more than 10 seconds. Lesson 14 : Airway and Ventilation 197

21 SKILL Session SKILL CHART SKILL Giving Ventliations Using a Bag-Valve- Mask Resuscitator Two Rescuers (cont.) SKILL COMPONENT If the chest does not clearly rise Retilt the head and try another ventilation. Provide care based on the conditions found. If preferred, review giving ventilations and using a BVM first and then divide the class into groups to practice the three skills. WRAP-UP Time: 5 minutes PowerPoint slide 20 Emphasize the need for assessing and maintaining an open airway as a priority, reminding participants that a patient who can speak or cry is conscious, has an open airway, is breathing and has a pulse. Emphasize the need for assessing and maintaining an open airway as a priority, followed by ensuring adequate breathing. Review the closing scenario: While waiting for emergency medical services (EMS) personnel to arrive, you complete a SAMPLE history and secondary assessment. You have helped the patient into a position of comfort for breathing when he suddenly loses consciousness and stops breathing. He has a pulse. Ask participants: What care should you provide now? Responses should include To ensure the patient has an open airway and give ventilations. Give 1 ventilation about every 5 seconds. The two types of respiratory emergencies are respiratory distress and respiratory arrest. Breathing difficulties may occur for various reasons including inadequate inhalation of oxygen, low oxygen environment, illness, upper airway problems or ineffective circulation. Choking caused by airway obstruction is one of the most common causes of breathing emergencies. Primary and secondary assessments are guidelines to help assess a patient s condition. The two most common methods for opening the airway are the head-tilt/chin-lift technique and the jaw-thrust (without head extension) maneuver. 198 Emergency Medical Response Instructor s Manual

22 Abdominal thrusts, back blows and chest thrusts are effective methods to clear an obstructed airway in conscious patients. Finger sweep and suctioning may be used to remove visible foreign matter and fluids from the upper airway of an unconscious patient. Breathing abnormalities can be assessed by observing physical signs and breath sounds and by measuring the rate and depth of breathing. For a patient who is not breathing, artificial ventilation is provided by using a resuscitation mask or BVM. Assignment for the Next Lesson Read Chapter 11: Airway Management. Read Enrichment: Nasopharyngeal Airway (optional), pages Instructor Preparation Review Chapter 11: Airway Management. Review Enrichment: Nasopharyngeal Airway (optional), pages Review the DVD segments, Using a Mechanical Suctioning Device (1:59), Using a Manual Suctioning Device (0:57), Conscious Choking Adult and Child (2:34), Conscious Choking Infant, (1:13), Unconscious Choking Adult, Child and Infant (3:45). Review the skills and obtain any necessary equipment and supplies for Lesson 15. Lesson 14 : Airway and Ventilation 199

23 ENRICHMENT Assessing Breath Sounds Time: 5 minutes PowerPoint slide 21 For a sample of breath sounds, go to: Using a stethoscope to listen to lungs is an easy way to assess an unobstructed airway. Hearing air moving on inspiration and expiration indicates unobstructed airways. No sounds or reduced sound compared with other areas indicate decreased lung sounds. To listen to the lungs in the front Identify the midclavicular lines and move down the chest. Place the stethoscope at the second intercostal space, usually just above the sternum line. Listen on both sides and compare the sounds. To listen to the lungs from the side Identify the midaxillary lines. Place the stethoscope between the fourth and fifth intercostal spaces, approximately in line with the nipple. Listen on both sides and compare the sounds. To listen to the lungs on the back Identify the midscapular lines and move down below the scapula. Listen on both sides and compare the sounds. Abnormal sounds that suggest obstruction due to fluid accumulation or airway blockage include Wheezing, a high-pitched whistling sound heard during inspiration but most loudly on expiration. Rales, a popping, clicking, bubbling or rattling sound. Rhonchi, a snoring sound. Stridor, a wheeze-like sound heard on inhalation and exhalation. 200 Emergency Medical Response Instructor s Manual

24 ENRICHMENT Sellick s Maneuver (Cricoid Pressure) Time: 25 minutes PowerPoint slide 22 This topic should be taught only if local protocols allow and you meet the state and local requirements for teaching this skill. DVD: Show the DVD segment, Sellick s Maneuver (Cricoid Pressure) (0:59). Answer participants questions about the DVD segment. The Sellick s maneuver should be used during positive pressure ventilation situations when the patient requires intubation (a skilled procedure performed by more advanced medical personnel). This maneuver reduces the chance of air entering the esophagus, particularly in patients who are unresponsive and/or have no gag reflex. It enables the rescuer performing the intubation to have a better view of the vocal cords, which allows for easier insertion of the endotracheal tube. One rescuer performs the maneuver while another performs the intubation. The cricoid cartilage is located just below and behind the thyroid cartilage, encircling the esophagus. After locating the cartilage, pressure is applied on both sides using the thumb and index finger, pressing firmly toward the back of the neck. Pressure is applied until the intubation is complete. This maneuver is not used if The patient is vomiting or begins to vomit. The patient is responsive. A breathing tube will be placed by advanced-level providers when they arrive. Lesson 14 : Airway and Ventilation 201

25 SKILL Session (Enrichment) PERFORMING THE SELLICK S MANEUVER (CRICOID PRESSURE) Activity: Ask participants to take their textbooks and disposable gloves with them to the practice area. Divide participants into small groups and guide groups through the steps listed on the skill chart. Have each participant demonstrate the Sellick s maneuver on the manikins while another participant acts as advanced medical personnel and the other participants use their textbooks to give feedback. Observe each participant performing the technique and evaluate completion of the skill using the Skill Checklist. Intervene and provide positive and corrective feedback as needed to each participant individually when possible. Be sure to point out any common errors, such as applying too much pressure, not locating the cricoid cartilage properly or using the wrong fi ngers for applying the pressure. Check off participant s progress on the Participant Progress Log. SKILL CHART SKILL Performing the Sellick s Maneuver (Cricoid Pressure) SKILL COMPONENT Always follow standard precautions when providing care. If a patient is unconscious, and your assistance has been requested by more advanced medical personnel and the local protocols allow 1. Ensure the patient is in a face-up (supine) position. 2. Locate the cricoid cartilage. 3. Apply downward pressure on both sides of the cartilage with your thumb and forefinger. 4. Maintain firm, gentle downward pressure until the intubation is completed and you are instructed to stop by the paramedic or advanced emergency medical technician (AEMT). 202 Emergency Medical Response Instructor s Manual

26 ENRICHMENT Assisting the Patient with Asthma Time: 40 minutes PowerPoint slides There are three types of medication used in the management of asthma: Long-term control medications to control chronic symptoms and prevent attacks Quick-relief medications (rescue medications) to relieve symptoms during an asthma attack Medications for allergy-induced asthma that decrease sensitivity to a particular allergen and prevent the immune system from reacting to allergens Indications for asthma medication include recurrent wheezing, coughing, difficulty breathing and chest tightness; contraindications include increased risk for thinning of the skin and bruising. Delivery Systems for Asthma Medication Asthma medications are supplied in different delivery systems. Metered-dose inhaler is a small, hand-held aerosol canister with a mouthpiece; some are equipped with a spacer (a tube attached to the inhaler) that serves as a reservoir for the medication. Dry powder inhaler (DPI), similar to a metered-dose inhaler, is a small, hand-held device that delivers a dry powder form of the medication within a small capsule, disc or compartment inside the inhaler. Small-volume nebulizer delivers aerosolized medications (mist) over a few minutes. Pill or liquid form is available for some medications. Injection just under the skin is a recently developed method for giving asthma medications. Peak Flow Meter DVD: If available, show participants different types of delivery systems available for asthma medications. A peak flow meter measures a person s ability to push air out of the lungs in one quick breath. It is a hand-held asthma management tool that tracks a person s breathing. It helps to warn the person if his or her asthma is worsening and shows his or her response to treatment. Show the DVD segment, Asthma (2:52). Answer participants questions about the DVD segment. Lesson 14 : Airway and Ventilation 203

27 ENRICHMENT (cont.) Assisting the Patient in the Use of an Inhaler An EMR may be involved in assisting a patient in the use of an inhaler. It is necessary to obtain an order from medical direction via radio or phone contact with the medical director or through protocols and standing orders. The order is always verified by restating the name of the medication. You are responsible for knowing and following local protocols for assisting a patient with an asthma inhaler. After obtaining consent and ensuring that local protocols allow such action, follow these general guidelines: If the patient has prescribed asthma medication, help the person take it. Ensure that the prescription is in the patients name and is prescribed for quick relief or acute attacks. Ensure that the expiration date of the medication has not passed and read and follow all instructions printed on the inhaler prior to administering the medication. Shake the inhaler and then remove the cover from the mouthpiece. Position the spacer if you are using one. Have the patient breathe out fully through the mouth and then place the lips tightly around the inhaler mouthpiece. Have the patient inhale deeply and slowly as you or the patient depresses the inhaler canister to release the medication, which then is inhaled into the lungs. Ensure that the patient holds his or her breath for a count of 10. If using a spacer, the patient takes 5 to 6 deep breaths with the spacer still in the mouth, without holding the breath. Once the inhalation is complete, have the patient rinse his or her mouth out with water to reduce side effects. Reassess the patient s breathing. Always wash your hands immediately after providing care. After administration, be alert for possible common side effects including Increased heart rate. Palpitations. Nausea. Vomiting. Nervousness. Sleeplessness. Dry mouth. Cough. Hoarseness. Headache. Throat irritation. 204 Emergency Medical Response Instructor s Manual

28 SKILL Session (Enrichment) ASSISTING WITH AN ASTHMA INHALER Activity: Ask participants to take their textbooks and sample inhaler with them to the practice area. Divide participants into small groups and guide groups through the steps listed on the skill chart. Have each participant demonstrate assisting with an asthma inhaler on another participant while other participants use their textbooks to give feedback. Observe each participant performing the technique and evaluate completion of the skill using the Skill Checklist. Intervene and provide positive and corrective feedback as needed to each participant individually when possible. Be sure to point out any common errors, such as not checking the prescription for the inhaler, not shaking the inhaler before administration, failing to have the patient place his or her lips tightly around the mouthpiece or pressing the canister too soon or too late. Check off participant s progress on the Participant Progress Log. Ensure that adequate decontamination supplies are available to wipe the sample inhalers after demonstration by each of the participants. Participants should only simulate making mouth contact on the mouthpiece and pressing down on the training inhaler. Be aware that some individuals may react to the aerosol propellants in the training devices. SKILL CHART SKILL Assisting with an Asthma Inhaler SKILL COMPONENT Always obtain consent and wash your hands immediately after providing care. Read and follow all instructions printed on the inhaler prior to administering the medication to the patient. If the person has medication for asthma, help him or her take it: 1. Help the patient sit up and rest in a position comfortable for breathing. 2. Ensure that the prescription is in the patient s name and is prescribed for quick relief or acute attacks. Ensure that the expiration date of the medication has not passed. 3. Shake the inhaler. 4. Remove the cover from the inhaler mouthpiece. If an extension tube (spacer) is available, attach and use it. Lesson 14 : Airway and Ventilation 205