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New Athletic Training Acute Care Clinical Skills
**Always have established Medical Guidelines/Protocols approved by your Medical Director** **Check State laws and regulations to ensure you can perform these new skills** I. Select appropriate size by measuring from patient's earlobe to tip of nose ensuring diameter is not larger then nostril. Lubricate NPA with water-soluble lubricant. Insert NPA into RIGHT nostril first making sure bevel is towards the septum. If resistance is met, then try other nostril. Ensure flange is resting on nostril. To remove, pull straight out. Contraindications for use are facial trauma, traumatic injury to nose, and head injury. Select proper size measuring OPA from patient's earlobe to corner of mouth. Opens mouth and partially inserts OPA as a bite block. Grab lower jaw and tongue with other hand. Insert OPA to the back of the throat without pushing tongue posteriorly. Rotate OPA until properly placed in airway and flange is resting on mouth. To remove, roll patient on side and then pull the OPA out following the curve of the device. Be prepared to suction. Contraindication is an intact gag reflex. Advanced Airways (ET, Combi-tube, King Airway, EOA, LMA) Paramedics are only prehospital emergency care professionals allowed to intubate with Endotracheal Tubes (ET). All other airways can be used by EMTs and AEMTs. Rarely used by ATs, but are used by EMS providers Roll patient on side. Clear large debris from airway with gloved fingers. Measure suction tubing or tip (corner of mouth to earlobe). Place tip into patient's mouth to the measured point. Begin squeezing the device to create suction and continue pumping the device. Sweep the suctioning tip back and forth in the posterior airway working outwards to the mouth. Do not suction for longer than 15 seconds at a time. Oxygen pressure regulator with flowmeter Only use medical grade oxygen (OXYGEN U.S.P.) New Athletic Training Acute Care Clinical Skills
"D" size is the most common, which holds about 350 liters of oxygen Using 15 LPM with a "D" cylinder will give you about 19 minutes of use. Make sure tank is hydrostatically tested every 5 years. Never stand a cylinder up unless it is secured. Always put it down on its side. Never smoke or use oxygen near an open flame. Never use grease, oil, or fat-base soaps on devices used with oxygen. Always turn oxygen cylinder off and bleed regulator when storing. Never use a metal that can spark or cause a spark as an oxygen key. Decreases the pressure in the tank (2000 psi when bottle is full) to a usable pressure. Usable pressures can vary from 30 to 70 psi Must regulator with correct pin-index safety system. Controls the amount of oxygen administered to patient. The LPM of oxygen flow plus the type of oxygen administration adjunct used will determine the percentage of oxygen administered. Non-rebreather masks [NRB] (80 – 90 % @ 15 LPM) Oxygen saturation – sends different colors of light into tissue and measures how much returns. The machine can then determine what proportion of oxygen is in the blood attached to the red blood cells (RBC). It DOES NOT measure how much blood is going past the sensor. 96 – 100 % is normal in a healthy person 86 – 90% indicates significant hypoxia New Athletic Training Acute Care Clinical Skills
Treat your patient not the machine. To check accuracy, take a pulse manually and then compare it to the pulse the pulse oximeter is providing. The two should be close. Carbon monoxide can give false high readings. Used to aerosolize a liquid medication into a breathable gas. Most commonly used medication is Albuterol (see drug sheets) Pure medication into aerosol chamber. Connect t-connector to top of chamber. Connect mouthpiece to one end and the accordion reservoir on the other. Connect oxygen tubing to the bottom of the aerosol chamber to the flowmeter of an oxygen cylinder (a nebulizer machine can be used). Flow rate for small volume nebulizer is 8 LPM. Place mouthpiece into mouth and have patient breath slow and deep (or breathe as they can). Continue treatment until all medication has been aerosolized. If patient cannot hold device to mouth, you can connect the aerosol chamber to a non-rebreather mask after removing the rubber discs and one-way valve with the reservoir bag from NRB mask. Then apply mask to face. How to use (in general – see specific device instructions): Prep device – Calibrate device (if required), then place new strip in meter Using a lancet, puncture the clean site on the finger Milk finger to get bead of blood to skin surface Place strip on device on finger at base of blood – blood should get sucked into strip. Apply pressure and then bandaid to puncture site High blood sugar (hyperglycemia) = over 140 – 160 mg/dl Low blood sugar (hypoglycemia) = 60 mg/dl or below with symptoms. Albuterol (used in both MDI and Nebulizer) New Athletic Training Acute Care Clinical Skills
The most accurate way to measure core body temperature in cases of heat illnesses. Make sure you have a thermometer that can be used rectally Ensures rectal temperature is indicated. Dons personal protective equipment. Place patient on side with top hip flexed. Apply probe cover to thermometer and then applies water soluble lubricant to tip of thermometer. Inserts thermometer into anal canal. Leaves thermometer in until device indicates a reading is ready. Note reading. Core temperature readings above 104-105 degrees F and CNS dysfunction are the two main criteria for diagnosis of exertional heat stroke. Immediate and heroic efforts must be made to cool patient down to 102 degrees F. Cold-water immersion is the fastest modality. Patient must be cooled first BEFORE transport to hospital. See NATA position statements (Exertional Heat Illnesses and Preventing Sudden Death) Limmer, D. & O'Keefe, M. F. (2005). Emergency Care (10th ed.). Upper Saddle River, New Jersey: Pearson Prentice Hall. Six Right of Medication Administration
Check medication for discoloration and precipitates Ensure administering right dose per protocols Administer the medication at the correct time interval (e.g., 15 minutes before practice with Albuterol MDI) Administer the medication at the appropriate time (signs and symptoms of anaphylaxis occur – administer epinephrine 1:1000 0.3 mg IM Note time of medication administration
Document everything above in patient care report Document medication effects (did the patient improve) Albuterol
Proventil, Ventolin
Class

Sympathetic Agonist
Description
Albuterol is a sympathomimetic that is selective for beta-2 adrenergic receptors. It
relaxes smooth muscles of the bronchial tree and peripheral vasculature by stimulating
adrenergic receptors of the sympathetic nervous system.
Actions
Albuterol is primarily a B2 agonist that relaxes smooth muscle, resulting in
bronchodilation. It also relaxes vascular and uterine smooth muscle.
Onset/Duration
Onset: 5-15 minutes
Peak effects: 30 minutes-2 hours
Duration: 3-4 hours
Indications

Treatment of bronchospasm associated with emphysema and asthma
Prevention of exercise-induced bronchospasm
Contraindications
Cardiac dysrhythmias associated with tachycardia
Hypersensitivity to the drug
Adverse Reactions
Hypertension
Chest Pain
Increased hypoxemia
Peripheral vasodilation
Nausea/Vomiting
Tremors
Excessive use may cause paradoxical bronchospasm
Drug Interactions
Sympathomimetics may exacerbate adverse cardiovascular effects
Antidepressants may potentiate the effects on the vasculature
Beta Blockers may antagonize albuterol
How Supplied
Premixed 0.083% 2.5 mg in 3 ml
Metered Dose Inhaler (MDI)

Adult Dose
2.5 mg (3 ml of 0.083%) nebulized over 5-15 minutes
May be repeated at the same dose every 20 minutes
1 to 2 puffs of MDI (follow protocol for additional dosing)
Aero-chamber (spacer) may be used to facilitate medication delivery
Pediatric Dose
1.25 mg (1.5 ml of 0.083%) diluted with 1.5 ml of 0.9% NS (total of 3ml) nebulized over
5-15 minutes. Dose may be repeated every 20 minutes.
1 to 2 puffs of MDI (follow protocol for additional dosing)
Aero-chamber (spacer) may be used to facilitate medication delivery

Special Considerations
May precipitate angina pectoris and dysrhythmias
Use caution in elderly patients and those with cardiovascular disease and hypertension
Lung sounds should be auscultated before and after each treatment
Patients receiving albuterol should be on a pulse oximetry and cardiac monitor (if
Encourage patients receiving nebulized treatments to deep breath on occasion during Nebulized albuterol treatments may be utilized with a face mask (for patient comfort) or be delivered by using a BVM (by means of additional equipment) Epinephrine
Epi Pen, Epi Pen Jr., Twinject
Class

Sympathomimetic
Description
Epinephrine is a naturally occurring catecholamine. It is a potent alpha, beta-1 and
beta-2 stimulant
Actions
Potent bronchodilator
Potent vasoconstrictor
Increases cardiac contractility

Onset/Duration
Onset: 1-5 minutes
Duration: 5-15 minutes
Indications

Epi-Pen (epinephrine injection, USP 1:1000) is indicated in the emergency treatment of
severe allergic reactions (Type I) including anaphylaxis to stinging and biting insects
allergen immunotherapy, foods, drugs, diagnostic testing substances and other
allergens, as well as anaphylaxis to unknown substances (idiopathic anaphylaxis) or
exercise-induced anaphylaxis.
Contraindications
None in the presence of anaphylaxis
Adverse Reactions
Myocardial ischemia even at low doses
Precipitation of angina pectoris (chest pain)
Palpitations
Restlessness
Weakness
Dysrhythmias
Hypertension


Drug Interactions
Potentiates other sympathomimetics
Albuterol treatment may potentiate tachycardia and chest pain.

How Supplied

Prefilled single dose auto-injector device. Twinject has 2 doses in one auto-injector.
Remove safety cap and hold in clenched fist (avoiding the tip to be pressed into
muscle), with a firm motion, press tip of auto-injector into lateral aspect of thigh muscle
and hold for ten seconds (to allow for the medication to be injected), remove the device
from the surface of the leg and immediately secure the device. Rub the injection site to
facilitate dispersement and absorption of the medication. If the device is a Twinject,
secure the device and prepare for the second dose. Follow manufacture
recommendations for preparing the device.

Adult Dose
0.3 mg IM (large muscle of lateral thigh)
Pediatric Dose
0.15 mg IM (large muscle of lateral thigh)
Special Considerations
Epinephrine should be protected from light. It should be stored in its protective sleeve
Severe anaphylaxis is a true medical emergency. Rapid recognition and rapid intervention is of upmost importance. Emergent transport of the patient should remain a primary concern, especially in the absence of an Epi-Pen auto-injector or the delay of it arriving at the patient. Patients receiving epinephrine auto-injectors should be transported emergent to the nearest hospital, due to the possibility of rebound bronchoconstriction or reoccurrence of the anaphylactic reaction. Oral Glucose
Glutose, GlucoGel, Insta-Glucose
Class

Carbohydrate
Monosaccharide
Description
Oral glucose is a think sugary gel utilized in hypoglycemic or presumed hypoglycemic
events to elevate serum glucose levels
Actions
Increases serum glucose levels by making glucose available in the blood supply
through absorption in the gastrointestinal tract. Administration should be limited to
patients with an intact gag reflex and the ability to swallow.
Onset/Duration/Excretion
Onset: 5-15 minutes
Duration: Variable (dependant on level of hypoglycemia and the body’s glucose

Indications

Known or suspected hypoglycemia
Contraindications
Altered level of consciousness
Inability to swallow
Adverse Reactions
Nausea
Aspiration

Drug Interactions
None
How Supplied
Tube containing 15 or 45 Grams of various flavored gel
Adult Dose
15-45 Grams PO for patients with an intact gag reflex and able to handle their own
May be repeated after ten minutes. If there is little or no response following the first dose, consider transport of the patient due to unpredictable absorption rates.
Pediatric Dose
5-25 Grams PO for patients with an intact gag reflex and able to handle their own
May be repeated after ten minutes. If there is little or no response following the first dose, consider transport of the patient due to unpredictable absorption rates.
Special Considerations

Symptomatic hypoglycemia nearly always means an altered mental status. Altered
mental status often means a scene safety issue. Make sure you are aware of
your environment, have the assistance you need, and leave if you become
uncomfortable.
Check a glucometer reading before administering glucose if at all possible. Repeat a glucometer reading at least 10 minutes after glucose administration. Also, it is acceptable to revive a hypoglycemic patient without using the entire Tube. This is done based on the promptness of the patient response. If the patient refuses transport it is important to get them something substantive to eat and that someone will be with them for awhile Commonly, there is an explanation for hypoglycemia if you look for it. (Poor compliance, increased stress, decreased sleep, illness, or change in insulin regiment, etc.) If a patient becomes symptomatically hypoglycemic following administration of oral hypoglycemics, they should generally be transported. The effects of long acting insulin are difficult to predict. Therefore, the effects of an intentional overdose on long acting insulin are prolonged and beyond the normal capability of the paramedic to treat and release. Also, if a patient’s family, friends, or relatives are present; they can be a good source of information about the patient’s habits and their normal recovery from hypoglycemia. Follow the Diabetic Treat and Release protocol for diabetics who do not desire Oxygen
Class
Naturally occurring atmospheric gas
Description
Oxygen is an odorless, tasteless, colorless gas present in room air at a concentration of
approximately 21%. Oxygen enters the body through the respiratory system and is
transported to the cells by hemoglobin, found in the red blood cells. It is an important
emergency drug used to reverse hypoxemia; in doing so it helps oxidize glucose to
produce ATP (aerobic metabolism) and helps to reduce the area of infarct tissue and an
acute myocardial infarction.
Actions
Required for the normal physiological process of all cells
Supplemental oxygen increases alveolar and therefore arterial oxygen tension. It
increases the diffusion gradient pushing oxygen to tissues. Decreases ventilatory and myocardial work load required to adequately oxygenate cells Increases myocardial contractility, increased peripheral vascular resistance Supplemental oxygen reduces both the magnitude and the extent of ST-segment
Onset/Duration/Excretion
Onset:

Indications
Confirmed or suspected hypoxia
Ischemic chest pain
Respiratory insufficiency
Prophylactically during air transport
Confirmed or suspected carbon monoxide poisoning
CNS injuries
Sickle cell crisis
Cardiac Arrest
Decreased LOC
Contraindication
There are no contraindications for oxygen.
Adverse Reactions
High-concentrations of oxygen may cause decreased LOC and respiratory depression
in patients with chronic carbon dioxide retention
High concentration of oxygen administered to premature infants may result in retrolental
fibroplasia (maintain between 30-40%)
Prolonged administration of high-flow, non-humidified oxygen may result in drying of
mucous membranes.
Possible bronchospasm if oxygen is extremely cold or dry.
Drug Interactions
None
How Supplied
Cylinders, green in color, with 100% compressed oxygen
Adult Dose
24-100% based on patient status
Pediatric Dose
24-100% based on patient status
Special Considerations
Oxygen vigorously supports combustion
Humidify oxygen if possible to prevent drying of the mucosa
COPD patients with a hypoxic drive must be monitored very closely for decreased
respiratory drive when oxygen is administered. Be prepared to ventilate the patient if
respiratory rate and volume decrease.
Oxygen toxicity- irritation of the bronchi and trachea, usually does not occur until oxygen
has been administered for > 24 hours at concentrations > 60%
Retrolental fibroplasia is caused by high concentrations of oxygen for > 24 hours in infants. Make sure that the high pressured cylinder is secured at all times Oxygen and oil do not mix. Do not use adhesive tape on the regulator. Never position yourself or the patient above the oxygen valve and regulator KING AIRWAY DEVICE
DESCRIPTION:
The KING LTD-S is a disposable supra-laryngeal airway created as an alternative to tracheal
intubation or mask ventilation. It is designed for positive pressure ventilation as well as for
spontaneously breathing patients. KING LTD-S models are equipped with a lumen on the back
side of the device to facilitate gastric suctioning. KING sizes #2 and #3 are not available in the
LTD-S model, so there is no lumen on the back side. These sizes are in the KING LT-D model
only. The KING Airway consistently achieves a ventilatory seal of 30 cm H20 or higher. It is
easy to insert and results in minimal airway trauma. The KING LTD-S is 100% latex free and is
provided sterile for single patient use.
INDICATIONS:
The KING LTD-S is intended for airway management in patient over 4 ft. in height for controlled
or spontaneous ventilation. KING LT-D may be used on patients weighing 12-35 kg (sizes 2,
and 2.5)
Immediate endotracheal intubation cannot be accomplished
Attempts at endotracheal intubation have been unsuccessful
Access to the patient's head is inhibited due to entrapment
Direct visualization of the larynx is inhibited due to profuse bleeding or vomiting.
CONTRAINDICATIONS:

Responsive patients with an intact gag reflex. Patient who have ingested caustic substances.

SIZING CHART:
KING Tube Size

PREPARATION:

Choose correct size based on patient’s height: Test cuff inflation system for air leak. Apply water-soluble lubricant to the distal tip.

PROCEDURE: INSERTION GUIDE:

Step 1:
Hold the KING LTD-S at the connector with dominant hand. With the non-dominant hand, hold mouth open and apply chin lift. Using a lateral approach, introduce tip into mouth. Advance the tip behind the base of the tongue while rotating tube back to midline so that the blue orientation line (blue line that runs the length of the tube) faces the chin of the patient. Without exerting excessive force, advance tube until base of connector is aligned with teeth or Inflate the KING LTD-S with the appropriate volume: Attach the resuscitator bag to the tube. While bagging the patient, gently withdraw the tube until ventilation becomes easy and free flowing (large tidal volume with minimal airway pressure). Adjust cuff inflation if necessary to obtain a seal of the airway at the peak ventilatory pressure

USER TIPS:

1. The key to insertions is to get the distal tip of the KING around the corner in the posterior
pharynx, under the base of the tongue. Experience has indicated that the lateral approach, in conjunction with a chin lift, facilitates the placement of the tube. Alternatively, a tongue blade can be used to lift the tongue anteriorly to allow easy advancement into position. 2. Insertion can also be accomplished via a midline approach by applying a chin lift and sliding the distal tip along the palate and into position in the hypopharynx. In this instance, head extension may be helpful. 3. As the tube is advanced around the corner in the posterior pharynx, it is important that the tip of the device be maintained at the midline. If the tip is placed or deflected laterally, it may enter into the pyriform fossa. Keeping the tip midline assures that the distal tip is properly placed in the hypopharynx. 4. Depth of insertion is key to providing a patent airway. Experience has indicated that initially placing the KING LTD-S deeper (base of connector is aligned with teeth or gums). Inflating the cuffs, and retracting until ventilation becomes easy and free flowing is preferred because: It ensures that the distal tip has not been placed laterally in the pyriform fossa. With a deeper initial insertion, only withdrawal is required to ensure a patent airway. A shallow insertion will require deflation of cuffs to advance the tube deeper. Withdrawal of the tube with the cuffs inflated results in a retraction of tissue away from the laryngeal inlet. When the patient is allowed to breathe spontaneously, airway obstruction can occur even though no obstruction was detected during assisted or positive pressure ventilation. During spontaneous ventilation, the epiglottis or other tissue can be drawn into the distal ventilatory opening resulting in obstruction. Advancing the tube 1-2 cm or initial deeper placement normally eliminates this obstruction. Ensure the cuffs are not over inflated. Cuffs should be inflated with the minimum volume necessary to seal the airway at the peak ventilatory pressures, (60 cm H20). Removal of the tube is well tolerated until the return of protective reflexes. It may be helpful to remove some of the air from the cuffs to reduce the stimulus during wake-up.

REMOVAL OF THE KING LTD-S:
1.
Suction above cuffs in the oral cavity if indicated. Fully deflate both cuffs before removal of the tube. Remove the tube when protective reflexes have returned. Esophageal Tracheal CombiTube (ETC)
Description
The Esophageal Tracheal CombiTube (ETC) airway is a two-tube system with thelumens separated by a partition wall. The distal end of the tube has a cuff for occludingthe structure into which it is placed (esophagus or trachea). Proximally, there is aballoon that occludes the pharynx. The device is inserted blindly, entering either theesophageal or tracheal lumen.
The majority of the time, the tube will enter the esophagus. In this case, ventilation isinitiated through the blue connector (tube #1), which leads to the esophageal lumen.
The distal end of this tube is closed, preventing the escape of air into the esophagus.
Escape of air through the mouth is prevented through inflation of the (proximal)pharyngeal balloon. Auscultation of bilateral breath sounds, and the absence of gastricsounds, confirms placement in the esophagus.
However, if you hear gastric sounds instead of breath sounds, the device is in thetrachea. In this case, ventilations should be performed through the shorter clearconnector (tube #2), without changing the position of the device. Air is now directed intothe tracheal lumen and the device functions like an endotracheal tube.
Indications
Immediate endotracheal intubation cannot be accomplished Attempts at endotracheal intubation have been unsuccessful Access to the patient's head is inhibited due to entrapment Direct visualization of the larynx is inhibited due to profuse bleeding or vomiting.
Contraindications
Patient is less than 16 years of age or less than 5 feet tall Esophageal Tracheal CombiTube (continued)
Advantages
It does not require visualization of the larynx The airway is anchored behind the hard palate because of the pharyngeal balloon The patient may be ventilated regardless of tube placement.
The pharyngeal balloon can prevent aspiration of teeth and other debris.
The stomach can be decompressed by passing the included suction tube through theesophageal tube.
Disadvantages
It is impossible to suction tracheal secretions when the airway is in the esophagealposition.
Placement of an endotracheal tube is difficult with the ETC in place It cannot be used in patients with a gag reflex Procedure Guidelines
1. Take appropriate universal precautions.
2. Maintain ventilatory support with a BVM and oxygenate the patient with 100% 3. Assemble and check equipment. Insure suction is functioning properly.
4. Place the patient's head and neck in neutral position (maintain C-spine stabilization 5. Insert the device, using a jaw-lift maneuver, to the depth indicated by the markings on the tube. The black rings on the tube should be positioned between the patient'steeth.
Esophageal Tracheal CombiTube (continued)
6. Once the ETC is in place, inflate the (proximal) pharyngeal cuff (labeled #1) with 100 ml of air. This firmly seals the device in the posterior pharynx, behind the hardpalate.
7. Inflate the distal cuff (labeled #2) with 10-15 ml of air.
8. Begin ventilations through the longer blue connector (tube #1), evaluate chest 9. Auscultate both lung fields and the epigastria. If you hear bilateral breath sounds and no gastric sounds continue to ventilate through the blue tube (tube #1).
10. If you hear air in the epigastria and no bilateral breath sounds, remove the BVM from tube #1 and ventilate through the clear tube (tube #2). Re-assess breathsounds and the absence of air in the epigastria.
11. Once confirmation of breath sounds and absence of air in the epigastria,
continue ventilations with 100% oxygen.
12. Monitor the patient’s vital signs (heart rate, pulse oximetry, BP, skin color, etc.).
13. Frequently re-evaluate the airway status by auscultation of breath sounds and 14. If the esophagus in intubated (ventilations are successful through tube #1), you may consider decompressing the stomach, as needed, by passing a flexible suctioncatheter through tube #2.
15. Document the procedure on the patient report form.

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