The Alberta College of Paramedics

The Alberta College of Paramedics Alberta Occupational Competency Profile (AOCP) Upgrade Gap Training Program Emergency Medical Responder (EMR) Airway Management Module Study Guide

Table of Contents Acknowledgements & General Information...i Training Program...1 AOCP s...2 Introduction, Objectives and Learning Activities...5 Anatomy of Upper and Lower Airway...7 Physiology of the Respiratory System...10 Airway Management...12 Oxygen Therapy...20 Pulse Oximetry...24 Summary...26 Exam...27 Glossary of Terms...31 References...34 Lab Skills Checklists...36

Acknowledgements & General Information INTRODUCTION The overall goal of this program is to provide standardized upgrade gap education to ensure that all regulated practitioners of the Alberta College of Paramedics (College) meet the Health Professions Act, Paramedic Regulation and the scope of practice as defined by the Alberta Occupational Competency Profiles (AOCP) for the profession. The Alberta Occupational Competency Profiles (AOCP) were developed through the facilitation of Dr. Bill DuPerron of Alberta Health and Wellness. Many College regulated practitioners were involved in compiling and organizing information about the roles and functions of paramedics, emergency medical technicians and emergency medical responders into the Profile. The completion of the AOCP for the College is an important milestone for the profession. The document is a result of a collaborative partnership with the College and Alberta Health and Wellness plus the work and effort of members of the College. The Competency Profile describes the vast expanse of competencies in Alberta at the present time as well as additional changes in scope of practice, which are identified in the Upgrade Gap Training Program. Each module in the Gap Training Program covers the additional competencies for a specific Competency Cluster as identified in the AOCP for each of the three disciplines regulated by the College. The Profile includes the knowledge, skills, attitudes, and judgments related to a variety of roles held by registered practitioners of the College. BACKGROUND The Health Professions Act (HPA) governs all regulated health professions in Alberta. The HPA was passed by the Alberta Legislature in May 1999 and in December 2001 the Order in Council proclaiming the Health Professions Act was signed by the Lieutenant Governor. The HPA replaces a regulatory system (the Health Disciplines Act) that included multiple statutes that had different registration, continuing competence and investigation and disciplinary processes. Under the HPA, previous legislated exclusive scopes of practice will be eliminated and replaced with an overlapping scope of practice model based on restricted activities. Restricted activities are health services that only authorized persons may provide. STRUCTURE OF THE HPA The HPA will deal with processes such as registration, continuing competence, professional conduct, restricted activities, investigation and discipline that apply to all the professions. Each of the 28 professions will have their own regulation that will address in detail, profession specific areas such as required qualifications for entry into the profession. The Paramedic profession is expecting to be governed by the HPA in the near future. Alberta College of Paramedics Introduction of the Upgrade Gap Training Program i

ABOUT THE AOCP Most of the competencies have been learned in basic education; other competencies have been acquired through advanced education, on the job training, and experience. All EMRs, EMTs and EMT-Ps have the basic competencies; however, competency on the job will vary depending on job requirements, and policy and procedure of the employing agency. The Profile provides a cumulative view of the competencies within the Scope of Practice and within the general and specialized areas of that practice. The College has developed the following educational module for upgrading the knowledge and skills of registered practitioners to meet the Alberta Occupational Competency Profiles (AOCP), the new Regulation and scope of practice. HISTORY OF THE PROCESS On March 4, 2000, the Paramedic Association of Canada adopted the National Occupational Competency Profile (NOCP), which included both a new classification and generic competencies for four professional designation levels of Paramedicine. On March 22, 2000, the Alberta College of Paramedics Council made the commitment that the Alberta College of Paramedics AOCP would meet or exceed the NOCP. ACKNOWLEDGEMENTS Alberta College of Paramedics Continuing Competency Ad Hoc Education Committee Members: Douglas Britton, MEM, EMT-P, Chair Renee Linssen, EMR, Vice-Chair William Coghill, MEM, EMT-P, CHCA Ruth Farrow, EMT-P, MLT Christine Patterson, MEM, EMT Richard Poon, BSc., EMT-P, MEd Marilyn Ringness, BSc., EMT-P Barry Straub, EMT-P Donna Lefurgey, CEO/Registrar Laurie Mitchell, Registration Division Leader Package Development and Design Portage College Prehospital Care Programs Lac La Biche, Alberta In collaboration with Alberta College of Paramedics Continuing Competency Ad Hoc Education Committee Alberta College of Paramedics Introduction of the Upgrade Gap Training Program ii

Module Creation and Research Portage College Prehospital Care Programs Lac La Biche, Alberta In collaboration with Alberta College of Paramedics Continuing Competency Ad Hoc Education Committee About the Authors (Portage College) Portage College (formerly Alberta Vocational Center, Lac La Biche) was established in 1968. The College currently offers over 30 certificate and diploma programs in six areas of study: Business, Human Services, Native Cultural Arts, Trades and Technical, Health and Wellness and Academic Upgrading. Over 1800 students are served annually through campuses in 13 northern Alberta communities, with another 1,300 taking short term or customized training programs each year. Portage College has been offering prehospital care training program since the mid 1980s. Portage College is currently approved by the Alberta College of Paramedics for the following Paramedicine programs: Emergency Medical Responder (EMR) Emergency Medical Technician (EMT) Emergency Medical Technologist-Paramedic (EMT-P) Disclaimer Portage College and the Alberta College of Paramedics have attempted to ensure that the information is in context relevant to the practitioner and is as concise as possible. Portage College has used a variety of resource materials in order to provide a solid base of up-to-date information. If any of the information contained within this module contradicts the direction you have received from your employer/medical director, the policy of your employer should take precedence over the information in this module. As a regulated practitioner of the Alberta College of Paramedics, while under the Health Disciplines Act, you may only deliver health services which fall within your scope of practice and is in accordance with the provisions of the Health Disciplines Act or the Health Professions Act when the HPA is implemented. Any content contained in this module that is beyond your scope or not within your current competence does not authorize you to deliver those health services. That is, if a given health service is not within your scope of practice and/or you have not yet attained the competency, you may not deliver that health service. Alberta College of Paramedics Introduction of the Upgrade Gap Training Program iii

Alberta Occupational Competency Profile (AOCP) Training Program Learning Goal This educational training is intended to review and upgrade the competencies of The Alberta College of Paramedics registered practitioners in order to meet the requirements of the new regulation under the Health Professions Act (2000) including the Alberta Occupational Competency Profile (AOCP) and scope of practice. Program Objective To provide standardized education to registered practitioners to ensure that all regulated members of the Alberta College of Paramedics meet the regulation and defined scope of practice for the profession. Program Format The Alberta Occupational Competency Profile (AOCP) training program will combine independent study modules and scheduled lab skills assessment sessions. Certification will be granted on successful completion of all program requirements. Independent Study Modules There are three EMR AOCP continuing education modules to be completed. 1. Pharmacology 2. Airway Management 3. Trauma & MCI Lab Skill Assessment All skills identified for each module will be assessed during the lab skills assessment for that module. Exam Mastery of the each module s content will be assessed through multiple-choice exams during the lab sessions. These exams are open book and can be found in each module following the module summary. EMR Airway Management 1

EMR Airway Management Competencies This module meets the following competencies of the Alberta Occupational Competency Profile (AOCP). A-2 Knowledge of Anatomy and Physiology A-2-4 Demonstrate an understanding of the respiratory system: Identify the organs of the respiratory system Identify the regions of the pharynx and describe their roles in respiration Describe the structure of the larynx and explain its function in respiration and voice production Explain the structure and function of the trachea List the events involved in inspiration and expiration Explain how compliance and airway resistance relate to breathing Describe how the oxygen carrying capacity of the blood is affected by oxygen and carbon dioxide A-6 Knowledge of Ambulance Equipment A-6-6 Identify equipment required for airway management, including but not limited to: Oxygen tanks Oxygen delivery devices Oxygen regulators Suction devices Oropharyngeal airway Positive pressure ventilation device Pocket mask Nasopharyngeal airway F-2 Perform Oximetry Testing F-2-1 Demonstrate knowledge of inclusion criteria: Altered mental status Hemodynamic instability Priority symptoms History of cardiac/pulmonary disease Use of sedative/narcotic drugs, etc F-2-2 Demonstrate the knowledge of pulse oximetry technology. F-2-3 Demonstrate knowledge of limitations: Environmental Equipment Patient Influences Medications EMR Airway Management 2

H-3 Determine Care for Respiratory Alterations H-3-3 Demonstrate the ability to develop and integrate a treatment plan for a patient presenting with alterations of the respiratory system, including but not limited to: Upper airway obstruction Anatomical Foreign body H-3-4 Evaluate efficacy of applied treatment plan and redirect treatmentutilizing principles of clinical decision making for the patient presenting with alterations of the respiratory system. H-13 Determine Care for Pediatric Patients H-14-3 Demonstrate the ability to develop and integrate a treatment plan for a pediatric patient, including, but not limited to: Foreign body airway obstruction (FABO) I-1 Perform Airway Management I-1-1 Demonstrate knowledge and ability to perform basic airway management skills: Manual maneuvers Head/tilt chin lift Modified jaw thrust Modified chin lift Heimlich maneuver Abdominal thrust Foreign body airway obstruction (FBAO) Simple adjuncts Oropharyngeal Airway (OPA) Nasopharyngeal airway (NPA) Suctioning techniques Oral suctioning Chest thrust Back blows (infants only) I-2 Perform Oxygen Therapy I-2-1 Discuss the indications for oxygen administration. I-2-2 Demonstrate knowledge and ability to administer oxygen with a nasal cannula. I-2-3 Demonstrate knowledge and ability to administer oxygen using low concentration mask. I-2-4 Demonstrate knowledge and ability to administer oxygen using a nonrebreather mask. I-2-6 Discuss potential complications and safety issues related to oxygen administration. I-2-7 Demonstrate the knowledge and understanding to calculate how long various sizes of oxygen cylinders will last with various flow rates. EMR Airway Management 3

I-2-8 I-2-9 Demonstrate the knowledge and understanding to discuss differences between portable and fixed oxygen delivery systems. Demonstrate knowledge to setup portable oxygen delivery devices. I-3 Perform Patient Ventilation I-3-1 Demonstrate knowledge and ability to ventilate a patient, including, but not limited to: Pocket mask Bag-valve-mask (BVM) EMR Airway Management 4

Airway Management Module Overview Introduction Anyone who has taken CPR training knows the importance of airway control. Emergency Medical Responders (EMR) have the knowledge and ability to react quickly when managing a compromised airway, integrating skills and equipment that exceed basic CPR knowledge of airway management. Imagine a scene where a 17-year-old female hit her head on a diving board while jumping into a pool. She is unresponsive, apneic, with a weak carotid pulse at a rate of 36 per minute. She has a large hematoma over her left eye; her skin is cyanotic, cool and diaphoretic. Due to the trauma c-spine control is necessary, making airway management of this patient that much more difficult. This module is designed to review the knowledge and skills that you perform as a practicing EMR, which will help you make the right decisions when managing a compromised airway. Learning Objectives Upon completion of this module the EMR will be able to: 1. Describe the anatomy of the upper and lower airway. 2. Explain the physiology of the respiratory system. 3. Discuss and perform effective airway management. 4. Demonstrate knowledge and application of oxygen therapy. 5. Demonstrate knowledge of pulse oximetry and its effectiveness in airway management. EMR Airway Management 5

Learning Activities Recommended Resources Each module identifies specific content students must cover to meet the module learning objectives. http://www.airwaycarnival.com/ Key Terms Students are to define the Key Terms identified for each learning objective. Exam Mastery of the module content will be assessed through a multiple-choice exam during the lab sessions. This exam is open book and can be found in this module following the module summary. Lab Skills Practice Students are to review the skills identified in the Lab Skills Checklist provided in Appendix A. Review of these checklists is essential preparation for the lab skill assessments, which are mandatory for successful completion of this module. EMR Airway Management 6

Objective 1 Describe the Anatomy of the Upper and Lower Airway Our respiratory system allows oxygen to enter our body during inhalation and carbon dioxide to exit our body during exhalation. Proper exchange of these two gases (respiration) is necessary to meet the body s metabolic needs and maintain its homeostasis (a steady and normal internal environment). There are many illnesses and injuries that can inhibit respiration. To properly apply your skills to maintain a patent airway and ensure proper ventilation, you must have a clear understanding of the structures that make up the upper and lower airways. Upper Airway Mosby s EMT-I Nose During normal breathing, air enters the nose where it is warmed, cleansed, and humidified. Pharynx Allows air to flow in and out of the respiratory tract and food/liquids to pass into the digestive system. Has three regions: nasopharynx, oropharynx and hypopharynx. Nasopharynx is the uppermost from the nasal opening to back of the soft palate. Oropharynx the part of the pharynx between the soft palate and the upper edge of the epiglottis. Hypopharynx the portion of the pharynx below the upper edge of the epiglottis, opening into the larynx and esophagus. EMR Airway Management 7

Epiglottis Leaf-shaped structure just above the larynx. Prevents food and liquid from entering the trachea. Larynx Contains vocal cords, thyroid cartilage, and cricoid cartilage (the only complete ring of cartilage in the Trachea). Commonly referred to as the voice box. Vocal cords Suspended between cartilage. Controlled by several small muscles. Fine movement important for speaking and protecting the airway from liquids or solids. Lower Airway Mosby s EMT-I Trachea A tube supported by C-shaped rings of cartilage. Divides into right and left mainstem bronchi at the level of the sternal angle. The right mainstem bronchus is more directly in line with the trachea than the left. This is why foreign bodies are more likely to enter the right bronchus. EMR Airway Management 8

Alveoli Small air sacs with very thin walls surrounded by capillaries. The place where oxygen is transferred into capillaries to bind to the hemoglobin that is attached to the red blood cells. CO 2 collected by red blood cells is transferred to the alveoli. Exchange of oxygen and CO takes place in millions of alveoli with each 2 breath. Objective 1: Key Terms Respiration Homeostasis Nose Pharynx Epiglottis Larynx Vocal Cords Trachea Alveoli EMR Airway Management 9

Objective 2 Explain the Physiology of the Respiratory System Proper airway management also requires a thorough understanding of the mechanics of oxygenation and ventilation. Knowledge of normal respiratory physiology is paramount to successful airway management. Inhalation Active part of breathing. During inhalation, the diaphragm moves downward, intercostal muscles lift the ribs upward and outward, and accessory muscles lift the sternum and upper ribs. This increases the volume of the chest cavity resulting in a decrease of intrathoracic pressure (pressure within the thoracic cavity). Because atmospheric pressure (outside force on the body exerted by the weight of the air) is now greater than the intrathoracic pressure, air flows into the body filling the lungs. Exhalation Passive process. During exhalation, the diaphragm and intercostal muscles relax, decreasing the size of the thoracic cavity, which increases the intrathoracic pressure. Because the intrathoracic pressure is now greater than atmospheric pressure, air flows out of the lungs. Respiration There are two types of respiration: pulmonary and cellular. Pulmonary respiration is the exchange of oxygen and CO 2 between the alveoli and the blood of the pulmonary capillaries. This is possible through the process of diffusion (the movement of a gas from an area of higher concentration to an area of lower concentration). Cellular respiration is the same exchange of gasses but this occurs between blood in the body s capillaries and various body tissues. Oxygen and CO 2 exchange are dependant on many factors. Careful ventilation of the patient must be performed in order to prevent respiratory acidosis or respiratory alkalosis. Unnecessary hyperventilation of the patient can cause respiratory alkalosis, which results in an increase in hemoglobin (Hb) affinity for oxygen, but a decrease in the release of oxygen to the tissues of the body. Conversely, hypoventilation can cause respiratory acidosis, which can cause an increase in the release of oxygen to the tissues but a decrease in the affinity of Hb to oxygen. EMR Airway Management 10

Respiratory Acidosis: CO 2 is retained usually due to hypoventilation. H 2 CO 3 is formed in the blood. Respiratory Alkalosis: CO 2 is eliminated in excessive amounts due to increased respiratory rate. This is usually a compensatory response to metabolic acidosis. (Metabolic acidosis - when normal metabolism is impaired- acid forms. The acid is not respiratory so, by definition, it is metabolic acid ). Ventilation This is the actual mechanical process that moves air in and out of the lungs. Proper respiration (both pulmonary and cellular) is not possible without ventilation Hypoventilation (reduced rate or depth of breathing), often resulting in hypercarbia (an abnormal rise of carbon dioxide; greater than 45 mmhg). Objective 2: Key Terms Inhalation Exhalation Respiration Hemoglobin Hypoventilation Intrathoracic pressure Atmospheric pressure Diffusion Hypercarbia Ventilation Cellular respiration Pulmonary respiration Affinity EMR Airway Management 11

Objective 3 Discuss and Perform Effective Airway Management Early recognition and intervention of airway problems can mean the difference between life and death. This is why assessing the airway is one of the first and most important components of our patient assessment. Obstruction of the upper airway may be caused by a number of factors including secretions, vomitus, tongue and foreign bodies. These or the interruption of basic airway techniques can rapidly lead to hypoxia (lack of oxygen to the body s tissues and cells) causing cellular death. Continuous observation of the patient s airway is crucial in order to anticipate any potential problems that may compromise the airway. Suction One of the greatest threats to a patient s airway is vomiting and aspiration (pathology of inhaling vomitus or mucous into the respiratory tract). Proper airway management and suction can minimize and avoid the complications associated with this potential problem. Each suctioning attempt should be restricted to 10-15 seconds or less if the airway becomes clear. If the airway is not clear suctioning must continue until it is. The airway must be cleared before any ventilation is begun. The patient should be pre-oxygenated with 100% oxygen both before each attempt. Suction should not be activated during insertion of the catheter because it depletes the airway of oxygen. Once the catheter is properly positioned, suction should be applied and the catheter withdrawn. Various types of suctioning units exist including handheld, battery powered, oxygen powered and fixed or mounted. Suction units are extremely important and must be always well maintained and in good working order. The two most common portable suction units are: Battery powered suction unit Handheld suction unit EMR Airway Management 12

Soft Suction Catheter It is a long, easy-to-use flexible tube, long enough to extend into the lower respiratory tract. (Note: EMR s are not allowed to suction the hypopharynx (farther than you can see), therefore, it must always be measured prior to using it to clear an OPA or NPA). Advantages: Comes in multiple diameter sizes. It can be inserted: Into the oropharynx or through an oropharyngeal airway (OPA-measure from the corner of the mouth to the earlobe). Into the nasopharynx or through a nasopharyngeal airway (NPA- measure from the tip of the nose to the tragus). Note: This is contraindicated in all patients with facial trauma or a suspected basilar scull fracture. Through an ET tube. (Note: Not in the EMR scope of practice.) Disadvantages: The soft suction catheter is ineffective in removing large volumes of secretions rapidly. It is often unable to retrieve even smaller food particles. Thick secretions have to be cleared from the catheter by sucking sterile water or saline through the catheter between suctioning attempts. Rigid (Tonsil-tip or Yankauer ) suctioning Advantages: Will not bend or kink. Removes larger particles. Standard size (measuring is not indicated; insert the catheter only as far as you can see, suctioning on the way out). Effective in removing large volumes of secretions rapidly. Multiple holes in catheter tip decreases blockages. Disadvantages: Its use is limited to suctioning of the oropharynx. Vigorous insertion can cause lacerations or other injuries. Basic Airway Maneuvers The most common cause of airway obstruction is the tongue. This blockage is directly related to the position of the patient s head and jaw. Since the submandibular muscles support the tongue, without sufficient muscle tone (e.g. decreased level of consciousness) the tongue will relax and fall backwards, partially obstructing the airway. Partial airway obstruction can be identified by the presence of snoring-like respirations. However, if not corrected this can become a complete airway obstruction leading to hypoxia, apnea and death. Simple airway maneuvers can correct this obstruction creating a clear airway. EMR Airway Management 13

Head-tilt, Chin-lift Place the patient in a supine position and kneel at the patient s side with one hand on the patient s forehead and one hand below the chin. Gently lift the chin and tilt the head back. This maneuver pulls the tongue forward and opens the airway. Modified Jaw-thrust This technique requires no manipulation of the neck and is indicated when you are suspecting the patient has a spinal injury. This is done by tightly placing your thumbs on the zygomatic arch. Place your middle fingers on either side of the angle of the mandible with ring and little fingers for support. Next thrust the jaw forward by pushing the middle fingers up on the angle of the jaw and using the thumbs on the zygomatic arch for leverage, if needed. EMR Airway Management 14

Modified Jaw-lift This airway maneuver allows you to lift the mandible and tongue up without inserting your thumb into the patient s mouth as in the standard jaw-tongue lift. Simply grasp the patient s jaw with your thumb under the chin and your index finger under the bottom lip, then lifting the jaw up. This can be done with or without c-spine control; however, it is not intended to maintain airway patency for any extended period of time due to the difficulty of holding this position. Simple Airway Adjuncts In addition to the basic airway maneuvers, commercial airway devices have been developed that accomplish the same goal; lifting the tongue off the posterior pharynx creating a patent airway. The advantage of these commercial airways is that the caregiver that was maintaining the basic airway maneuver can now be free to assist in other elements of the patient care. Oropharyngeal Airway (OPA) The OPA is indicated in any unconscious patient that does not have an intact gag reflex (If the patient s gag reflex is intact, the patient will gag, possibly vomit and could potentially aspirate). This device is designed to fit the natural curvature of the upper airway. Its various sizes allow it to be used with all ages (#00 for neonates - #6 for large adults). This is why measuring (from the corner of the mouth to the earlobe) is necessary to ensure the right size OPA is used for each patent. Procedure: Insertion of the OPA is a simple technique. For adults, insert the OPA with the curve inverted and move the distal end (tip) along the roof of the patient s mouth. Once you have reached the hypopharynx, rotate the OPA 180 degrees and continue insertion until the outer flange of the OPA is sitting flat against the patient s lips or teeth. For pediatrics, insertion is done differently because the tip of the OPA could damage the soft, undeveloped palate of this patient. Do not invert the OPA. With the use of a tongue depressor, hold the tongue out of the way and insert the OPA while following the natural curve of the tongue until the outer flange is sitting flat against the patient s lips or teeth. Made of plastic, the OPA not only allows for air to move freely into the pharynx but because of its placement between the teeth, the mouth will always be in an open position. This is practical when suctioning or should the patient suffer a seizure while in your care. EMR Airway Management 15

Types and Sizes Measuring the OPA Mosby s EMT-I Nasopharyngeal Airway (NPA) The NPA is very similar to the OPA but instead of inserting it into the oropharynx, the NPA is designed for insertion into the nasopharynx. The NPA should not stimulate the gag reflex; therefore, use in the semi-conscious patient is indicated. It is also very useful in maintaining a patent airway in patients who are seizing or experiencing trismus (a clenched jaw). This funnel shaped, soft rubber airway is designed to follow the natural curvature of the nasopharynx. The distal end is beveled, designed to guide it along the septum of the nose during insertion. Prior to use, a water-soluble gel should be added to the distal (bevel) end of the NPA, to lubricate the passage of the nasopharynx as it is inserted. The NPA comes in various sizes (20 French-36 French), also requiring measurement (form the tip of the nose to the tragus of the ear). Types and Sizes Measuring the NPA Mosby s EMT-I EMR Airway Management Placement after insertion 16

Contraindications: Avoid utilizing the nasopharyngeal airway in any patient predisposed to nosebleeds or who may have a nasal obstruction. Further to this, it should NEVER be used in the presence of a suspected basilar skull fracture, as the tube can inadvertently pass into the brain. Procedure: To properly size the airway, it should be slightly smaller in diameter than the patient s nostril (a rough rule is to also compare its diameter size to the diameter of the patients pinky finger ). The length is calculated by measuring from the tip of the patient s nose to the tragus of the ear. Obviously, selecting the appropriate sized airway is important, as a tube that is too small will not extend past the tongue and one that is too long may pass into the esophagus and result in hypoventilation and gastric distension when providing artificial ventilation. If no trauma history, hyperextend patient s head and neck. Maintain appropriate and effective ventilatory function. Ensure adequate oxygenation/ventilation prior to attempting airway insertion. Lubricate the exterior of the tube with a watersoluble gel to prevent/minimize trauma during the insertion. If possible, use a lidocaine gel in the conscious or semi-conscious patient, as the anesthetic effect on the mucosa will provide for an easier and more comfortable airway insertion. Push up on the tip of the nose and pass the tube into the right nostril, directing it straight back. The tube is held with the arch of the airway down towards the patient s face, with the bevel of the airway presenting its flat side to the patient s septum. Avoid pushing against any resistance, as this may cause trauma and kinking of this airway. If resistance is felt, attempt to ease the passage by slightly rotating the tube between your fingers as you advance. If the tube still cannot be passed, attempt to insert a smaller diameter airway. If the septum is deviated and insertion into the right nostril cannot be accomplished, the left nostril must be used. Insert the airway with the bevel towards the septum, rotating it until the funnel rests against the nare. If the patient gags as the last ½ is inserted, retract the airway slightly until it is tolerated by the patient and reinsert. Verify placement by assessing for clear breath sounds and adequate chest rise. The Emergency Medical Responder can also feel for airflow (when the patient exhales) at the proximal end of the device. Ventilate/oxygenate the patient as needed and required. Please Note: Insertion of the nasopharyngeal airway may injure the nasal mucosa, leading to bleeding, aspiration of clots into the trachea, and the need for suctioning to remove the secretions or blood. Forceful insertion may lacerate the adenoids, causing considerable bleeding. The EMR must be able to maintain a patent airway using a nasopharyngeal airway. EMR Airway Management 17

Foreign Body Airway Obstruction (FBAO) There has been great confusion over the new guidelines for the BLS treatment of an unconscious airway obstruction. Much of this confusion stems from the Canadian Heart Association and American Heart Association having different recommendations in their publications. To further complicate this issue, the ECC Guidelines 2000 provide different recommendations for the lay rescuer than for the healthcare provider. This section is dedicated to dispersing this cloud of confusion by providing you the Canadian Heart Association s recommendations and the rational behind them. BLS Treatment of Airway Obstruction with Chest Compressions In the American Heart Association ACLS Provider Manual (Appendix 1), abdominal thrusts are recommended to relieve airway obstruction. In Canada, the foundation recognized that previous guidelines often resulted in poor skill retention and performance. In addition, Class llb evidence suggests that chest compressions may create peak airway pressure that is equal to or greater than the pressure created by abdominal thrusts. In the interest of simplifying teaching and improving skill retention, Canada has adopted chest compressions as the recommended means of relieving airway obstruction for both healthcare providers (targeted responders) and the lay public (lay rescuer). [Heart and Stroke Foundation of Canada. (2003) Early Advanced Care, ACLS PLUS TM, A Canadian supplement to the ACLS Provider Manual (p.8). Heart and Stroke Foundation of Canada.] Adult: Conscious Choking Standing Position 1. Make a fist with one hand. 2. Place thumb side of the fist on the patient s abdomen, slightly above the navel and well below the breastbone. 3. Grasp the fist with the other hand and provide quick upward thrusts into the patient s abdomen. 4. Repeat the thrusts and continue until the object is expelled or the patient becomes unconscious. EMR Airway Management 18

Child: Conscious Choking Standing Position 1. Stand or kneel behind the patient, arms directly under the patient s axillae, encircling the patient s chest. 2. Place flat, thumb side of one fist against the patient s abdomen, in the midline slightly above Grasp the fist with the other hand and exert a series of up to 5 quick inward and upward thrusts. Do not compress the xiphoid process or the lower margins of the ribcage because force applied to these structures may damage internal organs. 3. Deliver each thrust as a separate, distinct movement, with the intent to relieve the obstruction. Continue the series of up to 5 thrusts until the foreign body is expelled or the patient becomes unresponsive. Unresponsive Airway Obstruction ADULT/CHILD/INFANT 1. Scene Safety 2. Determine Unresponsiveness 3. Phone First 4. Open Airway 5. Check for Breathing 6. Give 2 slow breaths if they do not go in, reposition and attempt again 7. Give chest compressions if rescue breaths do not go in (Adult: 15 compressions, Child/Infant: 5 compressions) 8. Look in mouth, repeat steps 4-8 as necessary Please Note: No blind finger sweeps for any age group Objective 3: Key Terms Aspiration Suction Soft Suction Catheter Rigid Suctioning Head-Tilt, Chin Lift Modified Jaw Thrust Modified Jaw Lift Oropharyngeal Airway (OPA) Nasopharyngeal airway (NPA) EMR Airway Management 19

Objective 4 Demonstrate Knowledge and Application of Oxygen Therapy There are many pathologies that can inhibit the body s normal oxygenation and ventilation. Continuous reassessment of the patient s airway, breathing and circulation is necessary as the patient s status can change at any time. It is important to continuously assess the patient for signs of respiratory distress indicating hypoxia (lack of oxygen to the body s tissues and cells) including tachypnea (increased respiratory rate), tachycardia (increased heart rate), cyanosis (bluish discoloration of the skin), and accessory respiratory muscle use. Administering oxygen to the patient may be all that is necessary to reverse these signs and eliminating the hypoxia. Oxygen Cylinders Medical oxygen is usually supplied as a compressed gas in seamless steel or aluminum with either green or white markings on the cylinder. The pressure of a full oxygen cylinder will be 2000 to 2200 psi; it must be reduced to 40 to 70 psi before administration to a patient, this is done through the regulator. There are two types of regulators available for oxygen cylinders 1) pressure-compensated flow meter (affected by gravity - must be kept upright) and 2) the Bourdon-gauge flow meter (not affected by gravity - can be used in any position). Due to the high pressure within the cylinder, no oil or other petroleum products can come in contact with the regulator. These compounds under high pressure can ignite causing fire. Cylinder Size & Constant Volume in Liters (L) Pressure (psi) D= 0.16 400 2000 E= 0.28 660 2000 M = 1.56 3450 2000 In order to determine the time remaining on an oxygen cylinder, it is necessary to know: the remaining pressure in the tank, the flow rate of the oxygen being delivered, the size of the cylinder being used and its constant (the number representing a specific cylinder size used in the formula for calculating useful time remaining on an oxygen cylinder, when set at a specific liter flow). With this information, a simple formula is used to compute the remaining time. It is necessary to leave a safe residual pressure in a tank so it does not run dry and reduces refilling costs. Usually local oxygen filling services will allow for ~200psi as a safe residual pressure. EMR Airway Management 20

To determine the Flow Rates the formula is as follows: Formula: [Cylinder pressure remaining (psi) safe residual pressure (200psi)] x Constant = Time remaining (min.) Flow Rate (L/min) Example: D cylinder being used at 10 liters/minute with 1500 psi remaining: [1500 psi 200 psi] x 0.16 = 20.8 minutes (Time remaining at 10L/min) 10 L/min Oxygen Delivery Oxygen is delivered in a variety of ways. The following are oxygen delivery devices that are required for basic airway management. Nasal Cannula - If the flow meter is set between 1 and 6 liters per minute, oxygen concentrations in inspired air can range from about 24% to 40%. Simple Face Mask - With flow rates of 6 to 10 liters per minute, oxygen concentrations of 40% to 60% can be obtained in inspired air. Non-Rebreather Mask The oxygen flow rate must be set at whatever level will prevent complete collapse of the bag usually between 10-15 liters/min. Oxygen concentrations of up to 90% of inspired air can be obtained with this device. Pocket Mask - Because of constant concerns about transmission of communicable diseases, the use of a pocket mask (folds into a case small enough to fit into your pocket) as a barrier may be considered in cases where artificial ventilation (timed exhalation directly into the patient s airway; a type of positive pressure ventilation) is provided. Pocket masks are available which contain an oxygen port for supplementing the oxygen to the patient at 40% to 60% and a one-way valve to protect the provider from coming in contact with the patient. This mask when ventilating, can deliver higher percentages of oxygen than mouth-to-mouth and larger volumes of air than the bag-valve-mask devices. Bag-Valve-Mask (BVM) - This positive pressure device allows for the delivery of high concentrations of oxygen while providing ventilation to the patient. It will deliver more than 90-95% oxygen at 10-15 L/min with the reservoir bag attached (40%-50% without the reservoir bag). When performed correctly, this is the gold standard for ventilating when providing basic airway management. It should be used with an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA) in place. EMR Airway Management 21

The BVM is also used with more advanced airway adjuncts including the endotracheal tube, the Combitube, and the Laryngeal Mask Airway (LMA ). Limited experience with the bag-valve-mask can lead to improper technique (E.g. poor mask seal) causing inadequate ventilation and oxygenation, which will be detrimental to the patient. Regular practice and experience is necessary to use this device correctly. Ventilation Accurate assessment of both oxygenation and ventilation is necessary to recognize and treat patients with respiratory distress and failure (see objective 4). The decision to ventilate should be made on more than just a respiratory rate that is too fast or too slow. Patient assessment, signs, symptoms and evaluation of oxygenation with pulse oximetry (normal SP0 2 is >95%) are necessary to assess oxygenation. The evaluation of ventilation should include assessment of the patient s tidal volume (chest rise and auscultation of lung fields) in addition to the respiratory rate. If inadequate oxygenation and ventilation are noted in the patient, then positive pressure ventilation with a bag-valve-mask (BVM) is necessary. To reduce the risk of gastric inflation that might lead to regurgitation and aspiration of stomach contents, the ECC Guidelines 2000 recommend reductions in both volume and speed at which rescuers provide ventilations, but only if supplemental oxygen is provided. The recommended volume with supplementary oxygen is 6 to 7 ml/kg delivered over an inspiratory period of 2 or more seconds (not up to 2 seconds). The new recommendations for volume with oxygen is 400 to 600 ml for the adult patient. This reduction in volume is only when supplementary oxygen is used because supplementary oxygen will maintain oxygenation despite the reduced volume. If supplemental oxygen is unavailable, the rescuer should try to deliver the same tidal volume recommended for mouth to mask ventilation, 10 ml/kg or 700 1000 ml. It is difficult to estimate the volume delivered, but the tidal volume should result in very obvious chest rise. American Heart Association, (2003). ACLS: Principles and Practice, (p. 135) Compliance (the stiffness or flexibility of lung tissue) is the ease at which air flows into the lungs during positive pressure ventilation. Good compliance is when there is minimal resistance to airflow. This would be the case if it was easy to squeeze the BVM during ventilations. Poor compliance would indicate high airway pressures making the BVM extremely difficult to squeeze. Some causes of this could be airway obstruction, tension pneumothorax (collapsed lung causing an increase in intrathoracic pressure), chest wall injuries and bronchoconstriction (constriction of the bronchioles; occurs in asthmatics). EMR Airway Management 22

Sellick s Maneuver Despite the best efforts when ventilating patients with a BVM and OPA, a certain amount of air will enter the esophagus, and over time cause gastric distension. This can impede ventilations by increasing intrathoracic pressure and decrease the ability for chest expansion. This will also increase the potential for the patient to vomit and possibly aspirate. Sellick s maneuver applies gentle pressure posteriorly on the anterior cricoid cartilage. Since the esophagus lies just behind the cricoid cartilage, this maneuver will effectively close the esophagus, redirecting air into the trachea. This maneuver should be done simultaneously during ventilation of a patient. Procedure: To locate the cricoid cartilage, palpate the thyroid cartilage (Adam s Apple) and feel the depression just below it (cricothyroid membrane). The prominence just inferior to this depression is the ring of cricoid cartilage. Using thumb and index finger, of one hand, apply gentle pressure to the anterior and lateral aspects of the cricoid cartilage just next to the midline. Please Note: If the patient begins to vomit immediately release the Sellick s maneuver, and roll the patient on their side. If you don t the high pressure created from the active regurgitation can rupture the patient s closed esophagus and cause massive internal bleeding. Objective 4: Key Terms Hypoxia Tachypnea Tachycardia Cyanosis Regulator Constant Safe Residual Pressure Artificial Respiration Positive Pressure Ventilation Tension pneumothorax Bronchospasm Thyroid cartilage Cricothyroid Membrane Compliance Sellick s Maneuver EMR Airway Management 23

Objective 5 Demonstrate Knowledge of Pulse Oximetry and its Effectiveness in Airway Management Pulse oximetry is a non-invasive (does not enter the body) measurement of arteriole hemoglobin oxygen saturation and pulse rate in the peripheral tissues. It is accurate and easy to use. Pulse oximetry has proven to be a valuable assessment tool in the field and is essential to patient care, especially for patients with respiratory or hemodynamic compromise, history of cardiac or pulmonary disorders or altered mental status. It uses a sensor probe, which contains two light-emitting diodes and two sensors. One diode detects oxygenated hemoglobin and the other deoxygenated hemoglobin. The oximeter uses this information to calculate the ratio of oxygenated vs. deoxygenated hemoglobin and determines the oxygen saturation percentage (Sa0 2 ). This percentage is then visually displayed either as a number, a bar graph or waveform depending on the make and model of the pulse oximeter. There are many types of sensor probes. The most common is the clip type designed for peripheral capillary beds, placed onto a fingertip, toe or earlobe. Pediatric sensor probes come with an adhesive tape, which allows for better attachment of the sensor so it cannot be easily pulled off. The pulse oximeter will continually reflect any changes in the oxygenation of the patient, usually before these changes are noticed in other vitals signs. This makes it an invaluable tool when assessing the efficacy of oxygen therapy. It is helpful to have a baseline oxygen saturation on your patient before treatment begins. This information will be useful when formulating a treatment plan for the patient. Oxygen saturation readings will also help to assess any improvement in the patient, as a result of the treatment, allowing you to change the treatment if necessary. Please Note: However, if your patient is critical NEVER withhold oxygen to obtain an oxygen saturation. These patients need oxygen now; the oxygen saturation is not initially important in these situations. The body s normal oxygen saturation range is 95% - 99%. Mild hypoxia is indicated with a range of 91% - 94%. This would require the administration of supplemental oxygen via a nasal cannula. Moderate hypoxia is readings between 86% and 91% - use of a higher concentration mask would be warranted. Less than 85% would need immediate intervention with support of 100% oxygen and possibly the use of a BVM. The goal of oxygen therapy is to maintain an oxygen saturation above 95%. This reading should always be recorded with other vital signs. EMR Airway Management 24

Though very accurate, the pulse oximeter can display false readings in certain situations. The sensors cannot differentiate between oxygen and carbon monoxide molecules so with carbon monoxide poisoning, a patient can be hypoxic even though the saturation is above 95%. High intensity light, nail polish, esthetic nails, and dirt will not allow the light emitted by the diode, to pass through the capillary bed of the finger. Therefore, it will be unable to calculate the saturation. Hemodynamic instability (low blood pressure; poor perfusion) of various causes (e.g. shock, hypothermia) will also inhibit the sensors because there is not enough circulation in the capillary beds due to peripheral vasoconstriction (constriction of the arterioles; shunting of blood). In patients with anemia or those suffering from hypovolemia, the saturation can be normal but because the level of hemoglobin within the blood is so severely depleted, the patient will in fact be hypoxic. Please Note: The pulse oximeter must detect a pulse for it to work accurately. Do not trust the oxygen saturation reading until you have confirmed that the patient s pulse corresponds with the pulse indicator on the machine. This pulse indicator can be an audible noise or visual, either as a flashing light, bar graph or waveform. Fig. P1 Pulse oximeter Fig. P2 Adult Sensor Fig. P3 Pediatric Sensor Objective 5: Key Terms Pulse Oximetry Non-invasive SaO 2 Hemodynamic Instability Peripheral Vasoconstriction Anemia Hypovolemia EMR Airway Management 25

Summary Airway management is the most critical component of patient care. Knowledge of airway anatomy and respiratory physiology are paramount to anticipating and intervening in potential airway complications. Continuous assessment of your patient s ABC s is critical to providing good patient care. Maintaining proficiency of your airway management skills requires regular practice and review, which will make all the difference when managing your next complicated airway. EMR Airway Management 26

Exam 1. The preferred procedure for opening the airway is the maneuver. a. Jaw-thrust b. Jaw-lift c. Sellick s d. Head-tilt/chin-lift 2. Lifting the mandible forward: a. Displaces the tongue b. Pulls the tongue forward c. Lifts the epiglottis over the glottic opening d. All of the above 3. Acute hypoventilation will result in an increase in: a. Carbon dioxide b. PH c. Oxygen saturation d. PaO2 4. Cricoid pressure is used to: a. Insert an OPA b. Relieve obstructed airway c. Remove fluids from the oropharynx d. Prevent regurgitation 5. Gurgling sounds heard on inspiration and/or expiration indicate: a. The accumulation of fluids or vomitus in the upper airway b. Swelling of the upper airway c. Obstruction of the airway by the tongue falling back against the oropharynx d. Spasm of the bronchial airways 6. The movement of oxygen from an area of greater concentration to an area of lesser concentration is called: a. Diffusion b. Osmosis c. Active transport d. Filtration 7. The thin, leaf shaped structure that closes over the opening of the trachea during swallowing to prevent substances from entering is called the: a. Vallecula b. Epiglottis c. Glottis d. Cricoid membrane EMR Airway Management 27

8. The portable Oxygen tank size D holds L of Oxygen: a. 400 b. 660 c. 2000 d. 3450 9. An abnormal rise of Carbon dioxide is known as: a. Hypoxia b. Hypoxemia c. Hypercarbia d. Anoxia 10. When suctioning a patient, the recommended amount of time is a maximum of seconds. a. 5 b. 10 c. 15 d. 30 11. Oxygen is transported from the lungs to the body cells by the: a. Plasma b. White Blood Cells c. Red Blood Cells d. Hemoglobin 12. To reduce the risk of gastric distension when using a BVM is to: a. Reduce volume and speed up rate b. Reduce ventilation time 1 ½ to 2 seconds c. Push on the stomach to expire air d. Reduce ventilation rate to less than 12 per minute 13. Where does the oxygen & CO2 exchange occur? a. Alveoli b. Pleural Space c. Bronchus d. Trachea 14. NRB masks deliver up to % of Oxygen. a. 16 % b. 90 % c. 70 % d. 100% EMR Airway Management 28

15. The OPA is properly measured from: a. The earlobe to the nose b. The corner of the mouth to the nose c. The corner of the ear to the corner of the mouth d. The ear to the chin 16. False SpO 2 readings are caused by: a. Nail Polish b. Esthetic Nails c. Dirt d. All of the above 17. What is a safe residual pressure for oxygen tanks? a. 100 psi b. 150 psi c. 300 psi d. 200 psi 18. What device measures the Oxygen levels in Patients & is commonly used in the Pre Hospital setting? a. Pulse Oximeter b. End Tidal CO 2 Detector c. ET detector d. Stethoscope 19. The normal range of Oxygen saturation in the body is: a. 90 % - 94 % b. 95 % - 99 % c. 85 % - 90 % d. 92 % - 94 % 20. Oxygen flow for assisted ventilations with a BVM is set at: a. 10 15 L b. 8 10 L c. 8 12 L d. 6 9 L 21. The function of the Pharynx is: a. Allow air flow in to the respiratory system b. Humidifies and warms the air that in inhaled c. Allow solids and liquids to pass into the digestive tract d. Both A & C EMR Airway Management 29

22. What causes Cellular Death? a. Dyspnea b. Hypoxia c. Tachypnea d. Hypovolemia 23. Disadvantages of using the Soft Suction Catheter is: a. Ineffective in removing large volumes of secretions rapidly b. Often unable to retrieve even smaller food particles c. Sterile water or Saline must be suctioned to prevent clogging d. All of the above 24. Define homeostasis: a. Gasses needed by the body for metabolic requirements b. A steady and normal internal environment c. The levels of Oxygen in the circulatory system d. None of the above 25. When foreign materials accidentally enter the lung during inspiration, it is called: a. Percussion b. Regurgitation c. Aspiring d. Aspiration EMR Airway Management 30

Glossary of Terms Objective 1: Key Terms Respiration The exchange of oxygen and carbon dioxide between the atmosphere and the body cells. Homeostasis The tendency of biological systems to maintain relatively constant conditions in the internal environment while continuously interacting with and adjusting to changes originating within or outside the system. Nose The specialized structure of the face that serves both as the organ of smell and as a means of bringing air into the lungs. Pharynx The throat; the musculo-membranous cavity, about 5 inches long, behind the nasal cavities, mouth, and larynx. Epiglottis The lidlike cartilaginous structure overhanging the entrance to the larynx. Larynx The muscular and cartilaginous structure, lined with mucous membrane, situated at the top of the trachea and below the root of the tongue and the hyoid bone. Vocal cords The folds of mucous membrane in the larynx, the superior pair being called the false, and the inferior pair the true, vocal cords. Trachea The air passage extending from the throat and larynx to the main bronchi; called the windpipe. Alveoli A little hollow, as the socket of a tooth, a follicle of an acrinous gland, or one of the thin-walled chambers of the lungs, surrounded by networks of capillaries through whose walls exchange of carbon dioxide and oxygen takes place. Objective 2: Key Terms Inhalation The drawing of air or other substances into the lungs. Exhalation The giving off of watery or other vapor, or of an effluvium. Respiration The exchange of oxygen and carbon dioxide between the atmosphere and the body cells. Hemoglobin - The main functional constituent of the red blood cell, serving as the oxygen-carrying protein. Hypoventilation Reduction in the amount of air entering the pulmonary alveoli, which causes an increase in the arterial carbon dioxide level. Intrathoracic Pressure pressure within the thoracic cavity. Atmospheric Pressure outside force on the body exerted by the weight of the air. Diffusion the movement of a gas from an area of higher concentration to an area of lower concentration. Hypercarbia Excess of carbon dioxide in the blood. Ventilation The process of exchange of air between the lungs and the ambient air. Cellular Respiration The same exchange of gasses but this occurs between blood in the body s capillaries and various body tissues. EMR Airway Management 31

Pulmonary Respiration The exchange of oxygen and CO2 between the alveoli and the blood of the pulmonary capillaries. Affinity - attraction; a tendency to seek out or unite with another object or substance Objective 3: Key Terms Aspiration The inspiration into the airway of foreign material. Suction The aspiration of gas or fluid by mechanical means. Soft Suction Catheter A long, easy to use flexible tube used for suction. Rigid Suctioning A hard tube used to suction large volumes of fluid. Head-Tilt/Chin-Lift The combination of two movements to open the airway with one hand on the patient s forehead and one hand on his chin, gently lift the chin and tilt the head back. To be used in non trauma patients. Modified Jaw Thrust Manual airway used when spinal precautions are taken. Place your thumbs on the zygomatic arch, with you index fingers on either side of the mandible and push forward. Modified Jaw Lift Grasps the patients jaw with your thumb under the chin and your index finger under the bottom lip and lift up on the jaw. Oropharyngeal Airway (OPA) An airway adjunct used to secure an airway through the oropharynx. Nasopharyngeal Airway (NPA) A soft, uncuffed plastic tube used to secure an airway through the nasopharynx. Objective 4: Key Terms Hypoxia Diminished availability of oxygen to the body tissues. Tachypnea Very rapid respirations. Tachycardia Abnormally rapid heart beat, usually taken to be over 100 beats per minute. Cyanosis A bluish discoloration of the skin and mucous membranes due to excessive concentration of reduced hemoglobin in the blood. Regulator Mechanical device designed to regulate system flow pressure in response to upstream or downstream pressure change. Constant The number representing a specific cylinder size used in the formula for calculating useful time remaining on an oxygen cylinder, when set at a specific liter flow. Safe Residual Pressure Oxygen cylinders should only be allowed to empty to the point where the regulator reads 200 psi. This is referred to as the safe residual pressure. Artificial Respiration The method of forcing air into the lungs in a person who still has a pulse but whose breathing has stopped. Positive Pressure Ventilation Air forced into the lungs by external over pressure Tension Pneumothorax A collapsed lung causing an increase in intrathoracic pressure. Bronchospasm Bronchial spasm. EMR Airway Management 32

Thyroid Cartilage The shield shaped cartilage of the larynx; the prominence it produces on the neck is the Adam s Apple. Cricothyroid Membrane The depression just below the thyroid cartilage Compliance The stiffness or flexibility of lung tissue. Sellick s Maneuver Gentle pressure applied to the anterior cricoid cartilage to effectively close off the esophagus, redirecting air into the trachea. Objective 5: Key Terms Pulse Oximetry A non-invasive measurement of arteriole hemoglobin oxygen saturation and pulse rate in the peripheral tissues. Non-invasive Not entering the body. SaO2 oxygen saturation of the blood. Hemodynamic Instability Low blood pressure; poor perfusion. Peripheral Vasoconstriction Constriction of the arterioles; shunting of blood. Anemia A condition in which there is reduced delivery of oxygen to the tissues. Hypovolemia Abnormally decrease volume of circulating fluid in the body. EMR Airway Management 33

References American Academy of Orthopedic Surgeons. (2002) Emergency Care and Transportation of the Sick and Injured. Jones and Bartlett Publishers. American Academy of Pediatrics. (2000). Pediatrics Education for Prehospital Professionals. Jones and Bartlett Publishers. American Heart Association. (2001, 2002) ACLS Provider Manual, American Heart Association. American Heart Association. (2002) PALS Provider Manual, American Heart Association. Bledsoe, B., Porter, R., & Cherry, R. (2000). Paramedic Care: Principals and Practice, Introduction to Advanced Prehospital Care. New Jersey: Prentice- Hall, Inc. Bledsoe, B., Porter, R., & Cherry, R. (2003). Essentials of Paramedic Care. New Jersey: Prentice-Hall, Inc. Campbell, John Emory. (2004). BTLS Basic Trauma Life Support. New Jersey: Pearson Education, Inc. Heart and Stroke Foundation of Canada. (2003) Early Advanced Care, ACLS PLUS;A Canadian supplement to the ACLS Provider Manual, Heart and Stroke Foundation of Canada. Miller Keane (1997), Encyclopedia & Dictionary of Medicine, Nursing & Allied Health Sixth Edition, W.B. Saunders Company. Portage College Prehospital Care 2004 curriculum from the Emergency Medical Responder, Emergency Medical Technician, and Paramedic programs. Shade,B.R., Rothenberg, M.A., Wertz, E., Jones, S.A., Collins, T.E., (2002), Mosby s EMT Intermediate Textbook, Second Edition, Elsevier Health Science. EMR Airway Management 34

Appendix A EMR Airway Management 35

Lab Skills Checklist SKILL GUIDELINES - INSERT AN NPA Apply PPE precautions Perform patient assessment Determine treatment plan List indications, contraindications and complications for this procedure Prepare equipment (Measure for appropriate size: Tip of nose to tragus) (NPA should be just smaller than nostril; patient s little finger) Have suction ready Determines LOC (AVPU) If no c-spine control: head-tilt-chin-lift; with c-spine: at 2/3 insertion have partner perform jaw thrust Select largest and least deviated nostril (usually right) Lubricate tip of airway with water soluble gel Insert airway into selected nostril with bevel towards septum in anterior to posterior direction Continue insertion until flange rests on nare If patient gags, withdraw until tolerated and consider insertion of shorter airway If resistance is met on insertion consider other nostril Evaluate air exchange Reassesses patient and note any complications Document PCR Comments: Instructor Name & Initials: Date: EMR Airway Management 36

Lab Skills Checklist SKILL GUIDELINES - PERFORM PULSE OXIMETRY Apply PPE precautions Perform patient assessment Obtain history and baseline vital signs Determine treatment plan List indications, contraindications and complications for this procedure Prepare equipment Assess patients fingers for temperature, nail polish, fake nails etc, and clean as required Place sensor on finger for adults, toe in infants Ensure monitor is reading, reposition as necessary Note display reading for SpO 2 and pulse Adjust ventilation and oxygen therapy as required Reassess patient and note any complications Document PCR Note: It is not recommended to withhold oxygen for baseline SpO 2 reading. If patient needs oxygen, give oxygen first then assess oxygen saturation. Comments: Instructor Name & Initials: Date: EMR Airway Management 37