Understanding

1
Understanding Use of Prehospital Equipment

• Condell Medical Center EMS System
• Continuing Education
• March, 2004
• Prepared by Sharon Hopkins, RN, BSN, EMT-P

2
Objectives

• Upon successful completion of this program, the
  participant will be able to
• understand the rationale for using a pulse
  oximeter
• describe the proper procedure for using a pulse
  oximeter
• understand and interpret the information obtained
  when using the end tidal CO2 detector (ETCO2)

3
Objectives continued

• understand the rationale for using a blood
  glucose monitoring tool
• describe how to use a blood glucose monitoring
  tool
• understand the rationale for using a cervical
  collar and back board
• describe the measuring and application process
  when using a cervical collar

4
Objectives continued

• understand the rationale for using the HARE
  traction device
• describe the application process for the HARE
  traction device
• identify the proper method for documenting use of
  the above tools
• demonstrate an understanding of the Region X SOP
  In-field Spine Clearance

5
Objectives continued

• successfully complete the quiz with a score of
  80 or greater

6
Pulse Oximetry

• ?Definition
• a rapid and accurate
• noninvasive method for assessing the
  hemoglobin oxygen saturation level in peripheral
  tissues in patients
• oxygen is carried in red blood cells where it is
  chemically bound to hemoglobin (oxyhemoglobin)

7
Oxygen and Hemoglobin

• ?1 molecule of hemoglobin can carry up to 4
  molecules of oxygen. At this level the Hgb is
  considered to be 100 saturated with oxygen.

8
Pulse oximetry - How Does It Work?

• a probe is placed on a peripheral part of the
  body (ie digit, ear lobe, nose)
• source of light from probe travels at 2
  wavelengths - the visible red spectrum the
  infrared spectrum
• oxyhemoglobin absorbs more infrared light
• reduced hemoglobin oxygen saturation absorbs more
  red than infrared light
• pulse oximetry measures this difference in light
  absorption

9
Did you know?

• Absorption amounts are calculated and averaged
  over a 5-20 second time period
• There is a time delay between a potentially
  hypoxic event and the pulse oximetry device
  detecting the low oxygen saturation
• The pulse ox tends to respond after the fact
• The rule is to always evaluate the patient
  clinically - how are they doing?

10
On the other hand...

• The pulse ox can frequently detect a problem with
  oxygenation before you notice the problem
  clinically
• The pulse ox does not give any indication of the
  patients ventilation or breathing status
• The pulse ox will just measure oxygen saturation
  of the hemoglobin molecule
• You can get a false sense of security when
  supplemental oxygen is being given

11
Pulse Oximetry Operation

• Accuracy of readings are dependent on detecting a
  pulsatile flow of blood
• Pulse ox is accurate down to 70 saturation (lab
  experiences would only test subjects as far down
  as this level)
• An acceptable reading is gt95

12
Pulse ox inaccuracy could be related to

• ? Peripheral vasoconstriction
• hypovolemia
• severe hypotension
• cold response
• cardiac failure
• some cardiac dysrhythmias
• peripheral vascular disease
• ? Venous congestion - try to reposition the probe
  if readings are lower than expected

13
Inaccuracy also related to

• Shivering - change the site
• Bright ambient lights
• Nail polish - may give falsely low reading
  consider changing the site
• Anemia - less hemoglobin available to carry
  oxygen but whats there may be saturated
• Carbon monoxide exposure - saturation
  overestimated will have falsely high readings
  even though patient is hypoxic at cell level

14
What will not influence a pulse ox reading?

• Dark complexion
• Jaundiced skin
• Age
• Sex

15
Information you do not get from a pulse ox
reading includes

• The amount of oxygen dissolved in blood
• Ventilation or breathing status of the patient
  (ie respiratory rate or tidal volume)
• Adequacy of cardiac output
• Adequacy of blood pressure

16
What do the readings indicate?

• ? As a guide
• ? 95 - 99 - normal
• ? 91 - 94 - mild hypoxia
• ? 86 - 91 - moderate hypoxia
• ? 85 and lower - severe hypoxia

17
Always evaluate your findings with the clinical
picture - What is your assessment? Why do you
think the pulse ox is low?
18
Documentation when using the pulse oximetry

• ?Include
• date, time, reading
• indicate if the reading is on room air (RA)
• if supplemental oxygen is being given document O2
  flow amount and type of device
• note clinical appearance of patient including
  color, skin temperature, respiratory status

19
In summary, what you do get from a pulse ox is

• ? the oxygen saturation level of red blood cells
  in peripheral tissue by measuring the hemoglobin
  oxygen saturation

20
End Tidal CO2 Detector (ETCO2)

• ?A measurement of the carbon dioxide level at the
  end of a breath
• ?Purpose is to assist in assessing for the proper
  placement of an endotracheal tube
• ?This device does not replace other steps in
  evaluation of ET tube placement
• ?This device serves as another adjunct to
  evaluating ET tube placement

21
Background Material

• Carbon dioxide (CO2) is produced in the body
  during cellular metabolism
• CO2 is transferred to the heart via the venous
  system
• CO2 is then delivered to the lungs
• CO2 diffuses out in exhaled air from the lungs
  where it can be measured
• Therefore, ETCO2 reflects metabolism, circulation
  ventilation in a noninvasive method

22
What the ETCO2 indicates

• ?If carbon dioxide (CO2) is being exhaled, the
  ETCO2 detector will
• give a positive reading at the end of the
  ventilation (end tidal end of breath)
• indirectly indicate the presence of circulation
  during CPR (end-tidal concentrations related to
  the perfusion level accomplished during effective
  chest compressions)

23
ETCO2 - How Is it Used?

• ?After placement of an endotracheal tube (ET),
  primary confirmation steps take place
• direct visualization by person placing ET tube
• watch for symmetrical, bilateral chest rise
• perform 5 point auscultation listening over the
  epigastric area and 4 points over the lungs

24
Secondary confirmation of ET tube

• ?Activate the ETCO2 strip in the neck of the ambu
  bag by exposing the white plastic piece coated
  with a chemical indicator
• ?After delivering approximately 6 breaths and
  while performing other confirmation steps,
  evaluate the ETCO2 detector for color change
• ?color indicator able to fluctuate

25
ETCO2 does not work (ie nothing to measure)

• in full arrest in the absence
• of
• perfusion or ventilation
• (ie before CPR started)

26
The colors of the ETCO2 detector indicate

• ? Purple - no CO2 detected on exhalation
• purple is poor
• ? Blue - no CO2 detected on exhalation
• blue is bad
• ? Tan - recheck your CPR technique, reevaluate
  ET tube placement
• ? Yellow - exhaled CO2 detected
• yellow is yes

27
ETCO2 results

• ?Remember that CO2 production is decreased in
  arrest due to decreased cardiac output and
  decreased pulmonary blood flow
• ?If results are negative (purple or blue) you
  must correlate with a clinical assessment before
  you automatically assume that the ET tube
  position is incorrect!

28
Documentation of the ETCO2

• ?Information to be incorporated within the
  comments section.
• For example
• after intubation, bilateral chest rise noted
  with equal and bilateral breath sounds.
  ETCO2 indicator yellow.

29
Blood glucose monitoring

• ?Purpose
• to determine the glucose level of fresh blood
• ?Readings should always be evaluated
• while they are compared to the clinical
• presentation of the patient

30
Who needs to have a glucose level done?

• ?patients who are unconscious
• ?patients with altered mental status -
• this includes those patients
• who are post-ictal
• ?known diabetic patients
• with a diabetic related
• problem

31
How does the Precision Xtra work?

• ?Blood applied to the test strip reacts with the
  chemicals on the test strip
• ?The reaction produces a small electrical current
  that is measured
• ?Results are displayed on the
• monitor in 20 seconds

32
Calibrating your Precision Xtra

• ?You must use the calibrator test strip to
  calibrate (code) your monitor before using a new
  box of test strips
• ?Keep the calibrator until the box of strips is
  used up
• ?Insert contact bars of glucose calibrator into
  monitor
• ?Monitor will be turned on automatically
• ?Check that the lot displayed matches the lot
  number on the test strip foil package

33
To test a blood sample

• ?Insert contact bars of test strip into monitor
  until it stops
• ?Unit turns on automatically
• ?Confirm that the lot number is correct
• ?Apply small drop of blood to target area
• ?Read results on monitor in 20 seconds
• ?Discard test strip in proper waste receptacle

34
Whats the trick to getting a drop of blood?

• ?Cleanse the area using an alcohol pad
• ?Allow the area to air dry while performing your
  machine preparations
• ?You have 5 minutes to apply your test sample
  once the unit is turned on
• ?Hang the hand dependently
• ?Warm the site up if hands are cold

35
Obtaining a sample continued

• ?Take a sample from the ulnar side of a finger
  (easier for the patient to hold their finger
  sample to the test strip this way)
• ?Apply the sample of blood when apply blood
  appears in the window of the monitor
• ?You have 30 seconds to apply a 2nd drop of blood
  if necessary
• ?Results received in 20 seconds

36
When do I turn off the machine?

• Press the button on the device to turn off the
  machine after you have recorded your reading
• - or -
• The device automatically turns off in 30 seconds
  after the result is displayed

37
Trouble shooting

• ?Is the hand hanging dependently?
• ?Is the hand warmed up so theres blood flow to
  the site?
• ?Did you hold the site against a rigid surface so
  the lancet can make a good stick?
• ?Are you avoiding the callused tips of fingers as
  lancet sites?

38
What does the message mean?

• ? HI alternating with 600 mg/dL
• - glucose result is gt 600
• patient is hyperglycemic
• ? LO alternating with below 20 mg/dL
• glucose result is lt 20
• patient is hypoglycemic

39
What are acceptable glucose numbers?

• ?Normal readings 70-110 before a meal
• lt120 two
  hours after a meal
• ?Region X SOP hypoglycemia - lt60
• treat patient with administration of glucose IVP
  (D50) or glucagon if no IV access
• ?Region X SOP hyperglycemia - gt200
• treat patient with fluid challenge

40
Documentation of glucose monitoring

• ?Record levels obtained in glucose level boxes
  indicated as the 1st and 2nd levels
• ?Record the patients response to therapies
  provided (ie checkboxes for mental status, skin
  moisture, GCS or comments section as indicated)

41
Cervical Collars

• Designed to limit
• flexion (bending forward)
• extension (leaning backward)
• lateral movement (side-to-side)
• Cannot do the job alone must always be combined
  with other immobilization devices (ie backboard,
  head blocks, tape)

42
SOP for In-field Spine Clearance states

• A reliable patient
• without signs or symptoms of
• neck/spine injury and a
• negative mechanism of injury
• does not require
• full spinal immobilization

43
When in doubt about in-field
spine clearance, fully
immobilize the
patient
44
Full spinal immobilization if mechanism of
injury indicates

• ?high velocity MVC gt 40 mph
• ?unrestrained occupant of MVC
• ?compartment intrusion gt12
• ?ejection from vehicle
• ?rollover MVC

• ?motorcycle collision gt20 mph
• ?death in same vehicle
• ?pedestrian struck by vehicle
• ?falls gt 2 times the patient height
• ?diving injury

45
Full spinal immobilization if signs and symptoms
include

• ?pain in neck or spine
• ?tenderness/deformity of neck or spine upon
  palpation
• ?paralysis or abnormal motor exam
• ?paresthesia in extremities
• ?abnormal response to painful stimuli

46
Full spinal immobilization if patients
reliability clouded with

• ?signs of intoxication
• ?abnormal mental
• status
• ?communications
• difficulty
• ?abnormal stress
• reaction

47
No spinal immobilization is necessary if

• ?there is a negative mechanism of injury
• AND
• ?there are no signs or symptoms present
• AND
• ?the patient is reliable

48
Steps in cervical collar application when one is
required

• ?Manually immobilize the C-spine - neutral
  position with eyes forward, no traction
• ?Do not move the neck if movement
• increases muscle spasms
• neck pain increases
• neurological deficits are aggravated
• airway becomes compromised

49
Measuring for the collar size

• ?Measure the patient to size the collar
• ?using your fingers, measure from top of shoulder
  to bottom of chin
• ?size the collar from the bottom of the rigid
  plastic edge (not the foam edge)
• ?find the window closest to the top of your
  finger
• ?adjust the sizing and snap the lock into place

50
If the sizing is wrong

• A collar that is too short causes flexion
• A collar that is too tall causes hyperextension
• 
  Dont just follow
• 
  the leader!
• 
  Do it right!

51
If the majority of your patients are wearing a
no-neck sized cervical collar, then you have
failed to properly measure your
patient for the best
fit immobilization
possible
52
Cervical collar application continued

• ?Preform the collar - fold flex the collar ends
  inward to assist with the application
• ?Apply the collar while maintaining a neutral
  position on the head - eyes facing forward
• ?Maintain manual stabilization until the patient
  is secured to a long spine board, head restraints
  are secured in place, and the patient is secured
  to the backboard

53
Applying a Cervical Collar
54
The collar fits if

• ?there is no excess pressure on the anterior
  surface of the neck
• ?movement of the jaw is not seriously limited (a
  problem if the patient vomits and cant open
  their mouth)

55
Most important to accomplish is

• ?proper positioning
• ?a proper fit of the chin piece
• ?not adjusting the
  collar sizing
• 
  while the collar is on the
• 
  patient

56
An improperly fitted collar can do more harm
than good
57
Long Spine Boards

• ?Use minimizes further injury during transport
• ?Spider straps help to secure the patient to the
  backboard preventing shift in movement while the
  patient is on the backboard

58
Spine Board continued

• ?Straps placed
• at shoulders or chest to prevent compression and
  lateral movement of thorax
• around mid-torso but not inhibiting chest
  expansion
• across iliac crest to prevent movement of lower
  torso
• ?After immobilizing the torso, immobilize the
  head neck in a neutral, in-line position
• ?Legs will be secured above below knee

59
Spine board straps continued

• ?Padding
• for most adults on a backboard, there is space
  between the back of the head and the spine board.
• Consider adding non-compressible padding or
  folded towels.
• too little padding the head will hyperextend
• too much padding the head will be flexed forward

60
Helpful information on backboards

• ?For children
• younger children (esp lt 2 years old) padding may
  need to be added from shoulders to pelvis to
  accommodate the large occiputs
• ?For all patients
• secure upper forehead across supraorbital ridge
• secure lower portion of head across anterior
  portion of rigid cervical collar

61
Standing Back Board

• ?To be performed when the patient is standing at
  the scene but your assessment indicates a need
  for spinal immobilization
• ?Requires a minimum of 3 rescuers to be performed
  safely
• ?Manual cervical spinal immobilization is
  maintained throughout the procedure

62
Standing Back Board Process

• ?1st rescuer applies maintains manual in-line
  immobilization from behind
• ?cervical collar applied still maintaining manual
  control of c-spine
• ?2nd 3rd rescuers slide a long board behind the
  patient
• ?2nd 3rd rescuers each have a hand under
  patients axilla grasp the backboard in the
  closest preferably next highest grip

63
Standing Back Board Demonstration
64
Standing back board continued

• ?team moves to lay the patient and spine board
  down
• ?during the move, the hands immobilizing the
  cervical spine need to rotate their grip without
  causing movement of the head or neck
• ?once the patient board are flat, finish
  immobilization of patient to the board

65
Documentation of Standing Back Board Technique

• ?Spinal immobilization aid to patient box is to
  be checked off as usual
• ?As this is an unusual procedure, it needs to be
  added to the comments section the
  process/technique used to accomplish
  immobilization

66
Hare Traction Device

• ?Created gt 30 years ago
• ?Designed to gently place traction along the
  femur fracture
• ?Provides traction to the fracture to prevent
  further injury to the area

67
Purpose of the Hare Traction

• ?The pain of a femur fracture is often initiated
  with muscle spasm?bone ends override?further
  pain muscle spasm aggravating original injury
• ?Purpose of traction
• prevent overriding of bone ends
• reduce pain
• help relax muscle spasm

68
Unipolar traction - Sager

• ?Uses a single lengthening shaft to pull a foot
  harness against pressure applied to the pubic
  bone.
• ?Does not elevate or stabilize an extremity

69
Bipolar traction deviceHARE or Thomas

• ?Half ring fits up against ischial tuberosity
  of the pelvis
• ?Distal ratchet connects to a foot harness and
  pulls traction from the foot and against the
  pelvis
• ?Frame lifts and supports extremity
• ?Motion of limb is minimized

70
HARE Traction Device
71
Rules of splinting femur fracture

• ?visualize to assess the extremity
• ?check record distal pulse, movement,
  sensation (PMS) before after splinting
• ?mark the pulse if necessary to make finding it
  again easier
• ?if in doubt, splint a possible injury
• ?cover all wounds with sterile dressings, assume
  them to be open fractures

72
HARE Traction Applied

• Source
  Mosbys Paramedic Textbook

73
Contraindications for use of HARE traction device

• ?fractures to lower third of leg
• ?suspected pelvic fracture
• ?suspected hip injury
• ?suspected knee injury
• ?avulsion or amputation of foot or ankle

74
Associated insults

• ?bilateral femur fractures can hold up to 50 of
  the circulating blood volume
• assess patients for hypovolemia
• treat patients with femur fractures
• with supplemental oxygen
• and IV fluids

75
Documentation for HARE traction

• ?In aid given to patient box check off splint
  and write type applied
• ?In comments section you need to indicate the
  physical assessment findings and pre and post
  splinting PMS status
• ?Use pain scale (0-10) blanks in physical
  condition section to indicate the pain level of
  the patient

76
Any device that is not used frequently carries a
greater risk of being used improperly.Repetition
in practice builds confidence in the application
of these devices.
77
Bibliography

• Bhende, M S. End-tidal carbon dioxide detectors -
  are they useful in children? J. Postgrad Med
  1994, 40 78-82.
• Bledsoe, B, Porter, R, Cherry, R. Paramedic Care
  Principles Practice.
• Brady. 2001.
• Campbell, J E. Basic Trauma Life Support. Brady.
  2000.
• Limmer, D, Elling, B, OKeefe, M. Essentials of
  Emergency Care 3rd
• Edition. Brady. 2002
• Region X SOP, 2001 Implementation.
• Sanders, M J. Paramedic Textbook. Mosby. 2001
• Practical Application of Pulse Oximetry
• www.nda.ox.ac.uk/wfsa/html/u11/u110
  4_01.htm
• http//www.buyemp.com
• www.enw.org/ETCO2inCPR.htm
• Pulse oximetry
• www.nda.ox.ac.uk/wfsa/html/u05/u05_
  003.htm