Brady Skills

Brady Skills Series—EMT-B
EDUCATIONAL CONSULTANTS
Baxter Larmon, PhD, MICP
Heather Davis, MS, NREMT-P
Video Leader’s Guide
AUTHORS
Bob Elling, MPA, REMT-P
Kirsten Elling, BS, REMT-P
Table of Contents
Introduction 3
Teaching Tips 4
Correlation with Content in Brady Textbooks 5
Credits 8
Tape 1: Patient Assessment 10
Tape 2: Patient Assessment 19
Tape 1: Airway Management 30
Tape 2: Airway Management 41
Tape 1: Medical Emergencies 53
Tape 2: Medical Emergencies 64
Tape 1: Trauma Emergencies 71
Tape 2: Trauma Emergencies 80
2
Introduction
Welcome to the Brady Skills Series Video Leader’s Guide! This guide has been prepared as a
resource for you, the EMS educator, who has chosen to use the Brady Skills Series as part of
your training program. This guide begins with a correlation showing where in each of Brady’s top
EMT-B texts each of these skills is covered. Next, each of the skills has a complete leader’s
guide to help you incorporate this valuable content into your lessons.
We have designed the guide so that each skill includes the following teaching elements:
the program segment name; the time codes that show where on the tape the segment begins and
ends (don’t forget to set your time code at the beginning of the tape); the objectives of the
segment; and an overview to the segment, which includes the necessary equipment,
assessment, skill close-up, and ongoing assessment. We’ve also listed and defined a few key
terms that are used in the segment. Finally, we’ve provided questions to ask your students to
stimulate discussion during your lessons.
The tapes have been extensively reviewed and carefully prepared to be an adjunct to
your EMS instruction, as well as a means of demonstrating to your students a uniform manner in
which the skills of the EMT-B should be performed. We hope you will find the Brady Skills Series
helpful in your EMT-B classroom as well as useful for in-service continuing education. Most
important, we hope the series will help your students grow to become excellent EMS providers
and help improve the quality of care they deliver to their patients. After all, isn’t that what it’s all
about!
See you in the streets!
The Brady Skills Series Development Team
3
Teaching Tips
Video is not intended to replace the teacher. However, if used correctly, video can enhance the
teacher’s effectiveness in many of the following ways:
• Portray re-enactments so students can visualize “model” behaviors.
• Display actual emergency scenes and critical injuries or medical conditions that cannot
be easily simulated or role-played in the classroom. This is important to providing a
sense of realism to training.
• Provide a concise, to-the-point message that is consistent and high quality.
• Introduce environments that would be too difficult or expensive for the class to explore.
• Reduce the time it takes to demonstrate skills.
• Scenes can be replayed to reinforce key points.
• Standardize training techniques and ensure coverage of key points.
So how can you best utilize video in your classroom? First, select a video that meets your
lesson’s objectives, and always preview the video. Many available videos have errors or adhere
to old training standards. You need to decide whether the detriment of showing the outdated
technique (and correcting it) outweighs the benefits to showing the specific video in the first place.
Videos with live footage may provide a sense of realism but often do not display “model”
behaviors to which you would like your students exposed.
Always introduce the video you are about to show. Engage the students by asking some
questions that directly relate to the topic on the video. Explain why you chose this video, and try
to focus their attention to some key points or what you are looking for them to get out of the video.
Make sure your projection equipment is the right size and in proper working order for the size of
the classroom you are using. Adjust the sound volume and cue up the video before your class
begins. Finally, stay there and watch the video with your students so your wrap-up discussion of
the key points or student impressions of the video can begin promptly.
4
Correlation with Content in Brady Textbooks
•
th
Limmer/Emergency Care, 9 Edition
•
rd
Limmer/Essentials of Emergency Care, 3 Edition
•
th
Mistovich/Prehospital Emergency Care, 6 Edition
Tape 1 Emergency Essentials of Prehospital

Patient Assessment and Care Emergency Care Emergency Care
Preparatory
Body Substance Isolation Chapter 2 Chapter 2 Chapter 2
(BSI) Page 16-17 Page 21-22 Page 20-23
Lifting and Moving Chapter 5 Chapter 5 Chapter 6
Patients Page 85-91 Page 59-73 Page 84-87
Introduction to Patient Chapter 8 Chapter 6 Chapter 9
Assessment Page 163 Page 104 Page 147-149
Initial Assessment and Chapter 7 Chapter 6 Chapter 9
Scene Size-up Page 106 Page 105-117 Page 150-164
Vital Signs Chapter 9 Chapter 7 Chapter 5
Page 180-188 Page 118-121 Page 72-79
Patient Assessment and Care Emergency Care Emergency Care
Preparatory
Trauma Patient with a Chapter 10 Chapter 8 Chapter 9
Significant MOI Page 219-226 Page 128-137 Page 169-184
Trauma Patient with No Chapter 10 Chapter 8 Chapter 9
Significant MOI Page 226 Page 137-139 Page 184-185
Medical Patient Chapter 11 Chapter 9 Chapter 9
Responsive Page 235-238 Page 143-148 Page 185-192
Medical Patient Chapter 11 Chapter 9 Chapter 9
Unresponsive Page 238-241 Page 149-151 Page192-194
Detailed Physical Exam Chapter 10 Chapter 8 Chapter 9
Page 219 Page 131-132 Page 194-206
Ongoing Assessment Chapter 12 Chapter 9 Chapter 9
Page 247-251 Page 150 Page 207-211

Airway Management Care Emergency Care Emergency Care
Head-Tilt, Chin-Lift Maneuver Chapter 6 Chapter 6 Chapter 7
Page 110 Page 80-81 Page 99
Jaw Thrust Maneuver Chapter 6 Chapter 6 Chapter 7
Pocket Mask Chapter 6 Chapter 6 Chapter 7
BVM Two Person Chapter 6 Chapter 6 Chapter 7
Page 114 Page 87-89 Page 112-114
Insertion of OPA Chapter 6 Chapter 6 Chapter 7
Page 117-118 Page 91 Page 105
Insertion of NPA Chapter 6 Chapter 6 Chapter 7
Page 121 Page 91 Page 105
Oral Suction Chapter 6 Chapter 6 Chapter 7
Page 122-125 Page 82-85 Page 102
Suctioning through and Chapter 35 Chapter 29 Chapter 44
Endotracheal Tube Page 785 Page 501 Page 903
5
Airway Management Care Emergency Care Emergency Care
Oxygen Tank Assembly Chapter 6 Not Available Chapter 7
Page 133-135 Page 117-119
Administering Oxygen Chapter 6 Chapter 6 Chapter 7
Non-Rebreather Mask Page 132-138 Page 96 Page 119-120
Administering Oxygen Chapter 6 Chapter 6 Chapter 7
Nasal Cannula Page 138 Page 96-97 Page 120-121
Nasogastric (NG) Tube Chapter 35 Chapter 29 Chapter 44
Page 783-784 Page 499-500 Page 900-902
Sellick’s Maneuver Chapter 35 Chapter 6 Chapter 44
Page 778 Page 98 Page 889-890
Ventilatory Management Chapter 35 Chapter 29 Chapter 44
Assist with Endotracheal Page 795 Page 493-496 Page 890-896
Intubation
Combitube Page 789 Page 503 Page 910-912
Stoma Patient Page 115-116 Page 89 Page 122-123
Using a Pulse Oximeter Chapter 9 Not Available Not Available
Page 190

Medical Emergencies Care Emergency Care Emergency Care
Administration of Activated Chapter 16 Chapter 12 Chapter 21
Charcoal Page 309 Page 180 Page 395-397
Administration of Glucose Chapter 19 Chapter 15 Chapter 13
Page 374-377 Page 225 Page 260-261
Metered Dose Inhaler Chapter 17 Chapter 13 Chapter 14
Page 329-331 Page 195 Page 273-280
Nitroglycerin Chapter 16 Chapter 14 Chapter 15
Page 311 Page 204-206 Page 301-304
Epinephrine Auto Injector Chapter 20 Chapter 16 Chapter 20
Page 393-397 Page 239-240 Page 382-387
Nebulizer Not Available Chapter 13 Not Available
Page 193
Medical Emergencies Care Emergency Care Emergency Care
Automated External Chapter 18 Chapter 14 Chapter 16
Defibrillator Page 349-363 Page 211-214 Page 316-324
Soft Restraints Chapter 23 Chapter 19 Chapter 26
Page 456-457 Page 279 Page 492-494
Assisting with Childbirth Chapter 24 Chapter 20 Chapter 27
Page 471 Page 290-296 Page 507-509
6
Trauma Emergencies Care Emergency Care Emergency Care
Bleeding and Shock Chapter 26 Chapter 21 Chapter 29
Page 503-519 Page 305 Page 552-558
Dressing and Bandaging Chapter 26 Chapter 21 Chapter 29
Page 506-507 Page 308 Page 552-553
Long Bone Splinting Chapter 28 Chapter 23 Chapter 32
Page 577-578 Page 346-347 Page 622-623
Joint Splinting Chapter 28 Chapter 23 Chapter 32
Page 579 Page 348-350 Page 624-625
Hare Traction Splint Chapter 29 Chapter 23 Chapter 32
Page 595-598 Page 360-363 Page 626-627
Sager Traction Splint Chapter 28 Chapter 23 Chapter 32
Page 599 Page 363 Page 628
Sling and Swathe Chapter 28 Chapter 23 Chapter 32
Page 588-589 Page 351-352 Page 622, 629
Trauma Emergencies Care Emergency Care Emergency Care
Cervical Collar Chapter 10 Chapter 8 Chapter 34
Page 201-206 Page 134-135 Page 667-670
Kendrick Extrication Chapter 28 Chapter 24 Chapter 34
Device (KED) Page 600-601 Page 399-400 Page 679-680
Immobilizing a Supine Chapter 29 Chapter 24 Chapter 34
Patient Page 636-637 Page 394-395 Page 667-670
Immobilizing a Standing Chapter 29 Chapter 24 Chapter 34
Patient Page 638-641 Page 390-392 Page 670-678
Helmet Removal Chapter 29 Chapter 24 Chapter 34
Page 638-644 Page 386-388 Page 682-684
Rapid Extrication Chapter 29 Chapter 24 Chapter 34
Page 631-632 Page 397-398 Page 679-681
7
Credits
Educational Consultants
• Baxter Larmon, PhD, MICP
Professor, UCLA School of Medicine
Director, UCLA Center for Prehospital Care
• Heather Davis, MS, NREMT-P
Clinical Instructor, UCLA School of Medicine
Clinical Coordinator, UCLA Center for Prehospital Care
Brady Medical Review Panel
• D.A. Hnatow, MD
Assistant Professor and Chief
Division of Emergency Medicine, Department of Surgery
The University of Texas Health Science Center at San Antonio
• Bob Elling, MPA, REMT-P
Senior Associate
High Quality Endeavors, Ltd.
US Army Medical Review Panel
• LTC Michael Huott, Medical Corps
US Army Medical Department Center & School, Department of Combat Medical Training
• Major Allen Whitford Medical Corps
US Army Medical Department Center & School, Department of Combat Medical Training
Executive Producers
• Greg Vis, Visible Productions
• LTC Patrick Wilson, Department of the Army, Office of the Surgeon General
Producer
• Linda Stone, Stone Productions
Video Editing
• NonLinear Creative, Detroit, MI
• 3 Point Productions, Novi, MI
Cameras
• Eric Smith
• Bill DeWeese
Script Adaptation
• Deb Parks
Brady Publishing
• Publisher: Julie Levin Alexander
• Executive Editor: Marlene McHugh Pratt
• Assistant Editor: Monica Silva
• Managing Editor: Lois Berlowitz
• Senior Media Editor: John J. Jordan
• Senior Marketing Manager: Katrin Beacom
• Production Editor: Jeanne Molenaar
• Manufacturing Buyer: Pat Brown
• Design Director: Cheryl Asherman
• Software Testing: Steve Hartner
• Secondary Videography: Hector Grillone
Visible Productions
• CEO: Paul Baker
• COO: Lewis Sadler
• Executive VP: John Sundquist
• Video Technician: Sean McCracken
• Interface Design: Joshua Sadler
• Programmer: James Douglas
8
Leader’s Guide Authors
• Bob Elling, MPA, REMT-P
• Kirsten Elling, BS, REMT-P
Special Thanks –
Locations and Equipment
• Los Angeles County Fire Department–Ed Martinez
• UCLA Department of Emergency Medicine
• Laerdal Medical Corporation
• Microflex Gloves
Narrator
• Bruce Freestone
Brady Actors
• SSG Victor Anda, US Army
• Dave Carlson, Visible Productions
• Sgt Diane Colligan, US Army
• Jim Farley, EMT-P
• SSG Michael LaClair, US Army
• K.C. Kainsinger, UCLA
• Steven Leapley, EMT-P
• Carlos Lopez, Los Angeles County Fire Department
• Sgt Jonathan Paradis, US Army
• Lindsey Simpson, EMT-P
• Jade Swendseid, Los Angeles County Fire Department
• Gina-Raye Swensson
• Todd Swensson, EMT-B
9
Tape 1 Patient Assessment
Segment Name: Body Substance Isolation (BSI)
Time Codes: Begin: 1:01:00 End: 1:07:10
Objectives
• List the various types of Body Substance Isolations (BSI) equipment and when it should
be worn.
• List 8 questions to consider when determining what type of BSI precautions to take.
• Describe the most effective means of preventing contamination.
• Describe what to do when you have been exposed.
• Describe your company’s policy exposure control plan.
Overview
I. Wear the following BSI equipment:
• Gloves – when hands may contact body fluids.
• Eye protection – when body fluids may contact eyes or when airborne particles
are present.
• Mask – when body fluids may enter the mouth or when airborne particles are
present.
• Gowns – when significant amount of body fluid is present or patient may have a
communicable disease.
II. Equipment
• Gloves, latex or vinyl
• Eye protection
• Mask, appropriate particulate protection
• Gowns
• Hand-washing solution
III. Assessment
• Ask yourself the following questions when determining which BSI precautions to
take:
• Is there any blood or body fluid present or is there any risk of
exposure to blood or body fluid that is currently not present?
• Is there any risk of the patient spitting or vomiting?
• Is the patient coughing?
• Is there urine or feces present?
• Is there the possibility that the patient could be suctioned?
• Is there the possibility of placing your fingers in the patient’s
mouth?
• Are there objects at the scene that may have to be touched that
could have blood or body fluids on them?
• At the end of the call is there the risk of contaminated material at
the scene that needs to be cleaned up or is there equipment that
needs to be cleaned?
IV. Skill Close-up
• Explain to the patient the reasons for taking BSI precautions.
• Apply gloves.
• Apply eye protection or face shield.
• Apply mask, if appropriate.
• Provide appropriate assessment and treatment.
• Remove personal protection, once exposure is not an issue.
• Dispose of all contaminated material from the scene, and place in an appropriate
disposal bag or container.
• Wash hands as soon as possible with any approved infection control soap or solution.
V. Ongoing Assessment
• Assess BSI frequently and replace as needed.
10
Key Terms
Body Substance Isolation (BSI) precautions – a form of infection control based on the
presumption that all body fluids are infectious. BSI calls for always using appropriate barriers to
infection at the emergency scene, such as gloves, masks, gowns, and protective eyewear.
Exposure control plan – standards (Title 29 CFR 1910.1030) developed by Occupational Safety
and Health Administration (OSHA) for EMS-Bs to use when dealing with bloodborne pathogens.
An EMS service or employer establishes an exposure control plan and provides annual refresher
training.
Teaching Activities
Questions to ask before or after viewing tape:
• How does your service clean up a blood spill?
• When is it appropriate to suspect the patient may have TB?
Additional activities associated with the tape:
• Allow adequate time to practice the skill of hand washing and BSI application.
Other ideas:
• Teach the students the proper technique for hand washing.
Segment Name: Lifting and Moving

Objectives
• List four things to consider prior to lifting or moving any object.
• List four rules related to body mechanics.
• List four things you can do to prevent injury while lifting.
• List six points to remember when pushing or pulling.
• Describe the power lift and power grip.
• Describe the three types of moves and provide an example of each.
• List six types of lifts and moves.
Overview
I. Prior to lifting any object consider the following:
• The patient’s weight
• Will additional assistance be required?
• What are the physical lifting abilities of you and your partner?
• Plan how you will accomplish the lift and communicate it.
II. Another important aspect of body mechanics involves following a few simple rules
when lifting:
• Position your feet on a firm surface and shoulder width apart.
• Use your legs, not your back, to lift.
• Do not lean over and compensate when lifting with only one hand.
• Keep the weight as close to your body as possible.
III. To prevent injury when reaching you should:
• Keep your back in a locked-in position.
• Avoid twisting while reaching.
• Avoid reaching more than 20 inches in front of you.
• Avoid a prolonged reach when a strenuous effort is necessary.
IV. When pushing or pulling you should try to:
• Push, rather than pull, when practical.
• Keep your back in a locked-in position.
• Keep the line of the pull through the center of your body by bending your knees.
• Keep the weight close to your body.
• Avoid pushing or pulling overhead.
• Keep your elbows bent and close to your sides.
11
V. To prevent injury, use the power lift or the power grip.
• The power lift involves squatting rather than bending at the waist and keeping the
weight as close to you as possible.
• The power grip involves using as much of the surface area of your hands and
palms as possible.
VI. There are three classifications of moves:
• Emergency moves
• Urgent moves
• Non-urgent moves
VII. Skill Close-up
• One-rescuer assist
• Two-rescuer assist
• Direct ground lift
• Firefighter’s drag
• Blanket drag
• Firefighter’s carry
Key Terms
Body mechanics – the proper use of the body to facilitate lifting and moving and prevent injury.
Emergency moves – moves, which must be made immediately, but only when definite life
threats exist.
Non-urgent move – moves that are performed when no harm will come to the patient due to the
delay or to the external environment. The patient will generally receive complete emergency
medical care prior to being moved in a non-urgent manner.
Power grip – gripping with as much hand surface as possible in contact with object being lifted,
all fingers bent at the same angle, hands at least 10 inches apart.
Power lift – also called the squat lift position. It is a lift from a squatting position with weight to be
lifted close to the body, feet apart and flat on the ground, body weight on or just behind balls of
feet, back locked in. The upper body is raised before the hips.
Urgent move – moves that are used when the patient must be moved quickly but with
precautions for spinal injury.
Teaching Activities
• Describe an example of a situation where an emergency move would be appropriate.
• Describe an example of a situation where an urgent move would be appropriate.
• Allow adequate time to practice the use of the stair chair, wheeled ambulance cot, and
lifts.
Other ideas:
• Arrange for an ambulance to be at the class and have students practice using the
stretcher and loading it into the ambulance.
• It is also a good idea to let each student ride the stretcher to gain an appreciation for
what it feels like as a patient.
Segment Name: Patient Assessment

Objectives
• List in order the assessment steps in the patient assessment algorithm.
• List two primary components of the scene size-up.
• List the four primary components of the initial assessment.
• List the equipment needed to conduct an initial assessment.
• Explain how AVPU is used to rapidly determine a patient’s mental status.
• Provide five examples of high priority patients.
• List a number of problems associated with the initial assessment and describe how to
correct them.
12
Overview
I. The EMT-B will perform the following assessment steps on each call:
• Scene size-up
• Initial assessment
• Make a decision: Is this trauma or medical?
• For trauma patients, determine if the mechanism of injury (MOI) was significant
or non-significant and follow the algorithm based on the determination.
• For medical patients, determine if the patient is responsive or non-responsive
and follow the algorithm based on your determination.
• Ongoing assessment
II. Scene Size-up
• Determine if the scene is safe.
• Assess the need for additional resources.
III. Initial Assessment
• Form a general impression of the patient.
• Assess the ABCs.
• Correct any life-threats as they are discovered.
• Make a priority transport decision.
IV. Equipment
• BSI equipment
• Stethoscope
• Oxygen delivery devices
• Airway management equipment
• Jump kit containing emergency supplies such a bandages, dressing, etc.
V. Skill overview
• Verbalize your general impression of the patient, noting obvious observations
such as level of distress, positioning of the patient, and surroundings.
• Determine the patient’s mental status using AVPU.
• Assure a patient airway.
• Once you’ve assured an open airway, assess the rate and quality of breathing.
• If breathing is inadequate assist ventilations.
• Ensure that lung sounds are present and equal.
• Apply oxygen as needed.
• Assess the circulation.
• Check central and peripheral pulses for rate, strength, and regularity.
• If circulation is absent begin CPR.
• Assess skin color, temperature, and condition.
• Control any external bleeding with direct pressure.
• Decide the patient’s priority in terms of immediate transport vs. further on-scene
assessment and care.
VI. Skill Close-up
• Form a general impression of the patient and verbalize it.
• Determine mental status using AVPU.
• Determine whether the patient is Alert.
• Responsive to Verbal stimuli
• Responsive to Painful stimuli
• Unresponsive to any stimuli
• Assess ABCs.
• Treat life-threats as they are discovered.
• Make a priority transport decision.
• Examples of high-priority conditions include:
• Difficulty breathing
• Shock (hypoperfusion)
• Complicated childbirth
• Chest pain with systolic blood pressure less than 100
• Severe pain anywhere
13
VII. Ongoing Assessment
• If the patient’s condition deteriorates, reevaluate the ABCs.
• Reassess vital signs.
VIII. Problem Solving
• Failure to treat life-threatening conditions
• Manage life-threats as soon as you recognize them.
Key Terms
AVPU – a memory aid for alert, verbal response, painful response, unresponsive as a
classification of a patient’s level of responsiveness.
Patient assessment algorithm – a flow diagram of the key steps in the patient assessment
process.
Teaching Activities
• What are examples of high priority patients?
• What are examples of low priority patients?
• Allow adequate time to practice patient assessment.
Other ideas:
• Once students have mastered the skills of assessment, give them realistic scenarios
involving a moulaged patient found at the bottom of a stairway to assess and manage as
a team.
Segment Name: Vital Signs

Objectives
• Explain what baseline vital signs are and how they differ from serial vital signs.
• Describe when first to obtain a full set of vital signs.
• List the equipment needed to obtain a set of vital signs.
• List the terms for abnormal respiratory rates that are too fast and too slow.
• Describe the locations to palpate a distal pulse.
• Explain when a pulse rate should be counted for a full minute.
• List seven respiratory rhythms and patterns.
• List the four categories of quality of respiration.
• Describe three types of abnormal breath sounds.
• Describe three signs of abnormal breathing.
• Explain what the systolic and diastolic fractions of a blood pressure reading are.
• Describe how to take a blood pressure by auscultation and by palpation.
• List the features of the skin that are assessed by the EMT-B.
• Describe normal and abnormal findings of the pupils.
• List the vital signs findings that should be documented on a prehospital care report
(PCR).
Overview
I. Vital signs are measurable objective assessment findings and include:
• Pulse
• Respiration
• Blood pressure
• Skin: color, temperature, and condition
• Pupils
II. Baseline and Serial vital signs
• Baseline vital signs are a complete set of vital signs taken after the initial
assessment is performed.
• Serial vital signs allow for trending of a patient’s condition.
III. Equipment
• BSI equipment
14
• Documentation form (PCR or assessment card)
• Pen
• Stethoscope
• Blood pressure cuff
• Watch with second hand or digital readout
• Penlight
IV. Assessment
• Vital sign assessment should be completed after the initial assessment and
repeated every 5 minutes on an unstable patient and every 15 minutes on a
stable patient.
V. Skill Close-up: Pulse
• Evaluate pulse – rate, rhythm, and strength.
• Normal adult rate is between 60 – 100 bpm.
• Abnormal adult pulse rates:
1. Any pulse rate above 100 bpm is rapid. A rapid pulse rate is
called tachycardia.
2. Any pulse rate below 60 bpm is slow. A slow pulse rate is called
bradycardia.
• Pulse rhythm reflects regularity.
• Strength may be described as strong, thready, or weak.
• Locate the radial pulse on the lateral part of the patient’s wrist.
• You might also use the carotid, brachial, femoral, and dorsalis pedal pulses.
• Assess the heart rate by counting the number of pulses you feel in one minute.
• Note any irregularity in rhythm.
• Note the quality of the pulse. It should be strong and easily palpated.
1. Any pulse that is thready, or hard to feel, can be an indication of
shock or other medical problems.
• Document the rate and quality of the pulse, as well as the time of assessment, on
the prehospital care report.
• When counting the pulse and the pulse is irregular or the rate is very slow, you
will need to count for one full minute in order to be accurate.
• Avoid pressing too hard on the pulse point during assessment.
VI. Skill Close-up: Respiration
• Evaluate respiration – rate, depth, rhythm, pattern, and quality.
• Normal adult respiration rate for an adult at rest is between 12 – 20 bpm.
• Depth is described as normal, shallow, or deep.
• Rhythm and pattern are described as:
• Healthy – exhalations are twice as long as inhalations
• Irregular
• Hypoventilation – slow and shallow respiration
• Hyperventilation – sustained increased rate and depth of
respiration
• Sigh – deep inhalation followed by a slow audible exhalation
• Apnea – temporary absence of breathing
• Tachypnea – increased respiration rate, usually 24 or more
breaths per minute in adults
• The quality of a patient’s breathing may fall into any of four categories:
• Normal – effortless, automatic, regular rate, even depth,
noiseless, and free of discomfort
• Dyspnea – difficult or labored breathing
• Wheezing or whistling sound
• Rattling or bubbling
• The steps for evaluating breathing:
• Look for the presence of breathing by watching for chest rise and
fall.
15
• In the absence of chest rise and fall or if breathing is inadequate,
begin ventilations.
• Observe the patient’s position. Most patients in respiratory
distress prefer to be seated upright or standing.
• Hunching forward with elbows outward is called tripod
positioning and indicates severe respiratory distress.
• Abnormal noises during breathing include:
• A high-pitched noise like stridor can indicate upper airway
obstruction.
• Whistling or wheezing sounds may indicate lower airway
obstruction.
• Bubbling (rhonchi), wet, or crackling (rales) can indicate fluid in
the airway.
• Signs of labored breathing include:
• Use of accessory muscles
• Nasal flaring
• Retractions above the collarbones or between the ribs
(intercostal)
• Respirations that are very fast, very deep, or interrupted (apnea) can be signs of
serious medical conditions.
• Determine the respiratory rate by counting the number of times the patient
breathes in one minute.
• Document the respiratory rate, quality, and any rhythms that you might observe
as well as the time, on the prehospital care report.
VII. Skill Close-up: Auscultated Blood Pressure
• The top or first number reported is the systolic blood pressure. This is the
pressure created when the heart contracts and forces blood into the arteries.
• The bottom or second number is the diastolic blood pressure. It measures the
pressure remaining in the arteries when the left ventricle relaxes and refills, or
the residual pressure in the system.
• Auscultated blood pressures are more accurate than palpated blood pressures.
• Procedure:
• Remove or roll clothing to expose bare skin on the upper arm.
• Select the appropriate size BP cuff.
• The cuff should measure two-thirds of the length of the upper
arm, from elbow to shoulder.
• Place the cuff on the bare arm, following the instructions on the
cuff for putting it over the artery.
• With your fingertips, locate the brachial pulse on the medial
upper arm near the antecubital fossa, or the crease of the elbow.
• Place the diaphragm of the stethoscope over this pulse point.
• With the bulb valve closed, inflate the cuff until the pulse is no
longer heard or felt.
• Listen for the sound of the pulse returning as the pressure in the
cuff is slowly released.
• Note the number on the cuff’s gauge as soon as you hear the
first pulse beat. This is the systolic pressure – the top number of
the BP fraction.
• Continue to deflate the cuff, this time listening for the point at
which the beats fade. This is the diastolic blood pressure – the
BP fraction’s bottom number.
• Record the measurements (in even numbers) and time.
VIII. Skill Close-up: Palpated Blood Pressure
• An estimated blood pressure can be obtained by palpation.
• Less reliable and usually lower than obtained by auscultation
• No diastolic pressure is obtained with this method.
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• Procedure:
• Inflate the cuff until the radial pulse disappears.
• Slowly release the pressure in the cuff until the pulse reappears.
• Check the gauge for systolic blood pressure.
• Report your findings as blood pressure over palpation, as well as
the time of the reading.
IX. Skill Close-up: Skin
• In assessing the skin, you should check color, temperature, condition, and in
children under 6 years, capillary refill time.
• The best place to assess skin color in adults:
• Nail beds
• Inside the cheek
• Inside the lower eyelid
• The best place to assess skin color in infants and children:
• Palms of the hands
• Soles of the feet
• Variations in color may suggest poor circulation or other problems:
• Pale skin may be a sign of blood loss, shock, heart attack, fright,
anemia, hypotension, or emotional distress.
• Cyanotic skin points to inadequate oxygenation and perfusion,
inadequate respirations, heart attack or poisoning.
• Both the temperature and condition of the skin can vary as well:
• Cool, clammy skin is a sign of shock or anxiety.
• Cold, moist skin means that the body is losing heat.
• Cold, dry skin results from an exposure to cold.
• Hot, dry skin or hot, moist skin indicates a high fever or heat
exposure.
• “Goose bumps” accompanied by shivering, chattering teeth, blue
lips, and pale skin can result from chills, cold exposure, pain,
fear, or a communicable disease.
• Evaluate the color of the patient’s skin by observing the overall complexion plus
the inside of the lower eyelid, the nail beds, or the inside of the cheek.
• If the skin feels cool, check a more central body temperature by placing your
hand on the abdomen beneath the clothing.
• Assess the condition of the skin for moisture.
• Document skin color, temperature, and condition on the prehospital care report.
X. Skill Close-up: Pupils
• Pupils should normally be round and reactive to light.
• Note the pupil size before you shine any light into them.
• Shine a penlight into the eye.
• The pupil should constrict when the light is shining into it and enlarge when you
remove the light.
• Repeat with the other eye.
• Pupils that are dilated, constricted to pinpoint size, unequal in size or reactivity,
or nonreactive may indicate a variety of conditions including drugs, head injury,
or eye injury.
• Any deviations from normal should be reported and documented.
17
Key Terms
Accessory muscles – muscles used in respiration during respiratory distress, disease, trauma or
during strenuous exercise.
Apnea – absence of breathing.
Bradycardia – heart rate less than 60 beats per minute.
Cyanosis – a blue or gray color resulting from lack of oxygen in the body.
Diastolic pressure – the pressure remaining in the arteries when the heart is relaxed and
refilling.
Hyperventilation – increase of air in the lungs above the normal amount.
Hypoventilation – decrease of air in the lungs below the normal amount.
Intercostal – situated or extending between the ribs.
Nasal flaring – an abnormal widening of the openings of the nose; an indication of respiratory
distress.
Rales – abnormal rattling or crackling sound in the lungs.
Rhonchi – coarse snoring sound in the upper airways.
Systolic pressure – the pressure created when the heart contracts and forces blood out into the
arteries.
Tachycardia – a rapid heart rate; any pulse rate above 100 beats per minute.
Tachypnea – abnormally fast breathing.
Teaching Activities
• When is it most appropriate to use palpation to take a blood pressure?
• Why is capillary refill not a routine assessment in an adult?
• Allow adequate time to practice taking a full set of vital signs.
Other ideas:
• Consider having each student in the class obtain a complete set of vital signs on the rest
of the class and logging them for an assignment.
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Tape 2 Patient Assessment
Segment Name: Assessment of the Trauma Patient with a Non-Significant
Mechanism of Injury
Objectives
• Describe when the EMT-B makes the determination that the MOI is significant or non-
significant.
• List the equipment utilized to perform an assessment on a trauma patient.
• Describe the steps of the focused trauma assessment.
Overview
I. All trauma patients should be evaluated for spinal precautions, life threats, and rapid
transport decision.
• Rapid trauma examination vs. focused trauma assessment
• Life-threatening injuries are treated as they are discovered
II. Equipment
• BSI equipment
• Long spine board
• Cervical collar
• Head blocks or towel rolls
• 2” or 3” tape
• Backboard straps
• Blood pressure cuff and stethoscope
• Pen light
• Scissors
• Bandaging supplies
• Portable suction unit and rigid Yankauer® tip
• Oropharyngeal airways (OPAs) and/or nasopharyngeal airways (NPAs)
• Oxygen and appropriate tubing
• BVM and reservoir and tubing
• Non-rebreather mask
III. Skill Close-up
• Scene size-up; consider the mechanism of injury (MOI).
• Significant or non-significant MOI
• Perform an initial assessment and obtain the chief complaint, assess for:
• Mental status
• Airway and breathing
• Circulation
• Determine patient’s treatment priority and make a transport
decision.
• Reconsider the MOI.
• Perform a focused trauma assessment based on chief complaint and MOI.
• You should look and feel for the familiar DCAP-BTLS signs:
• Deformities
• Contusions
• Abrasions
• Punctures/penetrations
• Burns
• Tenderness
• Lacerations
• Swelling
• Obtain baseline vital signs.
• Obtain a focused history.
19
Key Terms
DCAP-BTLS – a memory aid to remember deformities, contusions, abrasions,
punctures/penetrations, burns, tenderness, lacerations, and swelling; signs and symptoms of
injury found by inspection or palpation during patient assessment.
Focused trauma assessment – the step of patient assessment that follows the initial
assessment and concentrates on a specific body area based on the chief complaint and MOI.
Mechanism of injury (MOI) – a force or forces that may have caused an injury.
Oropharyngeal airways (OPAs) – a curved device inserted through the patient’s mouth, into the
pharynx, to help maintain an open airway.
Nasopharyngeal airways (NPAs) – a flexible breathing tube inserted through the patient’s nose,
into the pharynx, to help maintain an open airway.
Teaching Activities
• What are two examples of patients who have a non-significant MOI?
• Why is it unnecessary to do a detailed physical exam on a trauma with non-significant
MOI?
• Allow adequate time to practice the focused physical exam of a patient with a cut hand or
a twisted ankle and no significant MOI.
Other ideas:
• Consider practicing scenarios in realistic settings such as at the bottom of the stairs
(significant MOI) and at the curb after stepping in a pothole (non-significant).
Segment Name: Assessment of the Trauma Patient with a Significant

Mechanism of Injury (MOI)
Objectives
• Describe when the EMT-B makes the determination that the MOI is significant or non-
significant.
• List nine examples of significant mechanisms of injury (MOI).
• List three additional significant MOIs for children.
• List the equipment utilized to perform an assessment on a trauma patient.
• Describe the steps of the rapid trauma assessment.
Overview
I. All trauma patients should be evaluated for spinal precautions, life-threats, and rapid
transport decision.
• Rapid trauma examination vs. focused trauma assessment
• Life-threatening injuries are treated as they are discovered.
II. Rapid trauma assessment
• Reconsider the mechanism of injury (MOI).
III. Significant mechanisms of injury (MOI) include:
• Ejection from a vehicle
• Death in the same passenger compartment
• Falls of more than 15 feet or 3 times the patient’s height
• Rollover of a vehicle
• High-speed vehicle collision
• Vehicle-pedestrian collision
• Motorcycle crash
• Unresponsive or altered mental status
• Penetrations of the head, chest, or abdomen
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IV. Additional significant MOIs for children include:
• Falls from more than 10 feet
• Bicycle collision
• Vehicles in medium-speed collision
V. Equipment
• BSI equipment
• Cervical collar
• Pen light
• Scissors
• Portable suction unit and rigid Yankauer® tip
• Oropharyngeal airways (OPAs) and/or nasopharyngeal airways (NPAs)
• Oxygen and appropriate tubing
• BVM and reservoir and tubing
• Non-rebreather mask
VI. Skill Close-up: Rapid Trauma Assessment
• Approach the patient from his or her front; introduce yourself and instruct the
patient not to move.
• Perform initial assessment.
• Verbalize a general impression based on assessment of the
environment and patient’s chief compliant and appearance.
• Determine the need for stabilization of the spine.
• Provide manual stabilization on the first contact with any patient
you suspect may have an injury to the spine.
• Assess the mental status.
• Assess airway and breathing.
• Assess circulation.
• Determine patient’s treatment priority and make a transport
decision.
• Focused history and physical exam of the trauma patient with significant MOI:
• Continue manual stabilization of the head and neck.
• After assessing head and neck, apply a cervical collar and
continue to maintain manual stabilization.
• Consider requesting ALS personnel.
• Reconsider transportation decision.
• Reassess the mental status.
• Perform a rapid trauma assessment.
• You should look and feel for the familiar DCAP-BTLS signs:
• Deformities
• Contusions
• Abrasions
• Burns
• Tenderness
• Lacerations
• Swelling
• Begin at the head.
• Check the neck for DCAP-BTLS, plus jugular vein distention and
crepitation of bones in the cervical spine.
21
• Assess the chest for DCAP-BTLS, plus crepitation, paradoxical motion and
breath sounds.
• Assess the abdomen for DCAP-BTLS, plus firmness, softness, and distention.
• Assess the pelvis for DCAP-BTLS by observing and by applying gentle
downward pressure on the pelvic bone.
• Do not rock the pelvis girdle as it may cause spinal injury.
• Assess all four extremities for DCAP-BTLS, plus distal pulse, motor function, and
sensation (PMS).
• If possible, roll the patient to his or her side and assess the posterior and
buttocks for DCAP-BTLS, then carefully roll the patient onto a long board.
• Obtain baseline vital signs.
• Obtain a SAMPLE history.
Key Terms
Crepitation – the grating sound or feeling of broken bones rubbing together; also called crepitus.
Paradoxical motion – movement of a part of the chest in the opposite direction to the rest of the
chest during injury.
Rapid trauma assessment (RTA)– a rapid assessment of the head, neck, chest, abdomen,
pelvis, extremities, and posterior of the body to detect signs and symptoms of injury.
Teaching Activities
• What are two examples of patients who have a significant MOI?
• Why should the detailed physical exam be done enroute to the hospital on most patients
with significant MOI?
• Allow adequate time to practice the RTA of a patient whose scenario involves significant
MOI.
Other ideas:
• This is the time to consider the use of a moulage kit to add realism to scenarios.
Segment Name: Detailed Physical Exam

Objectives
• Describe when the detailed physical exam (DPE) is performed on most patients.
• List the equipment needed to conduct a DPE.
• List the steps of the DPE.
Overview
I. The detailed physical exam (DPE) is most commonly performed on trauma patients
with a significant mechanism of injury (MOI) enroute to the hospital.
II. Equipment
• BSI equipment
• Cervical collar
• Pen light
• Scissors
• Splinting devices
III. Assessment
• During the DPE you will inspect and palpate each part of the body for DCAP-BTLS:
• Deformities
• Contusions
22
• Abrasions
• Burns
• Tenderness
• Lacerations
• Swelling
IV. Skill Overview
• Assure proper BSI.
• Expose the patient.
• Conduct a systematic examination of the patient beginning with the head.
• Inspect the scalp, cranium, and face for DCAP-BTLS, plus
crepitation.
• Check the ears and nose for DCAP-BTLS, plus bleeding or
drainage of clear fluid.
• Inspect the mouth for DCAP-BTLS, plus loose or broken teeth,
foreign objects, swelling or lacerations of the tongue, and
unusual odors on the breath.
• Check the eyes for DCAP-BTLS, plus unequal pupil size,
reactivity, discoloration, foreign bodies, and blood in the anterior
chamber.
• Check the neck for DCAP-BTLS, plus jugular vein distention and
crepitation of bones in the cervical spine.
• Assess the chest for DCAP-BTLS, plus crepitation, paradoxical motion, and
breath sounds.
• Assess the abdomen for DCAP-BTLS, plus firmness, softness, and distention.
• Assess the pelvis for DCAP-BTLS by observing and by applying gentle
downward pressure on the pelvic bone.
• Note any pain, tenderness, lack of motion, or crepitation.
• Do not rock the pelvis girdle as it may cause spinal injury.
• Assess all four extremities for DCAP-BTLS, plus distal pulse, motor function, and
sensation (PMS).
• If possible, roll the patient to his or her side and assess the posterior and
buttocks for DCAP-BTLS, then carefully roll the patient onto a long board.
• Treat any injuries not attended to during the rapid trauma assessment.
• Transport the patient if you have not already done so.
V. Skill Close-up
• Assure BSI.
• Expose the patient.
• Conduct a systematic examination of the patient beginning with the head.
• Treat any injuries not attended to during the rapid trauma assessment.
• Transport the patient if you have not already begun to do so.
VI. Problem Solving
• If the patient’s condition worsens during the exam, repeat the initial assessment,
reassess the ABCs and treat life-threatening injuries.
• Disorganization leads to missed steps.
• Repeat assessment.
• If at any point the patient’s condition worsens, repeat the initial assessment.
23
Key Terms
Detailed physical exam (DPE) – an assessment of the head, neck, chest, abdomen, pelvis,
extremities, and posterior of the body to detect signs and symptoms of injury. The examination of
the head includes detailed examination of the face, ears, eyes, nose, and mouth. It is usually
done enroute to the hospital after earlier on-scene assessments and interventions are completed.
Teaching Activities
• Why should the DPE be done enroute to the hospital?
• When would be an example of a patient with significant MOI where the EMT-B may not
have ample time to do the DPE?
• Allow adequate time to practice the DPE.
Other ideas:
• Consider having your mock patient wear scrubs with Velcro seams and apply moulage or
make-up for bruises that fit the story of the scenario.
Segment Name: Assessment of the Medical Patient - Responsive

Objectives
• Explain when the EMT-B should obtain information about the nature of illness (NOI).
• Describe how to obtain a focused history from the responsive patient.
• List the assessment steps in order for the responsive medical patient.
• List the equipment needed to perform an assessment on a medical patient.
• List the two main techniques used to complete a focused physical exam.
• Explain why good communication skills are a key component in assessment of the
medical patient.
• Describe some common problems associated with the patient interview.
Overview
I. In contrast to the trauma patient assessment, the medical patient assessment
requires thorough history taking:
• Obtain information from the responsive patient prior to a physical exam.
• For the unresponsive patient obtain information from family, bystanders, and
observations at the scene.
II. For the responsive medical patient perform the steps in this order:
• History of present illness (HPI)
• SAMPLE history
• Focused physical assessment (exam based on chief complaint and observed
signs and symptoms)
• Baseline vital signs
III. Assessment
• Scene size-up
• Perform initial assessment.
• Determine the nature of illness (NOI).
IV. Equipment
• Stethoscope
• Pen light
• Scissors
V. Skill Close-up
• Take BSI precautions.
• Perform a scene size-up as you approach or come on scene.
• Determine that the scene is safe and free of hazards.
• Determine the NOI (i.e.: an overdose, vomiting, or shortness of breath).
24
• Verbalize your general impression of the patient regarding his/her level of
distress and other obvious findings such as positioning and surroundings.
• Determine level of consciousness of the patient using the AVPU scale.
• If the patient can communicate, ask for his/her chief complaint.
• Ensure airway patency.
• Assess the rate and quality of breathing.
• Apply high-flow oxygen as appropriate.
• Assess the skin: color, temperature, and condition (CTC).
• Control external bleeding with direct pressure.
• Initiate shock management as indicated.
• Determine the priority of the patient and make a transport decision.
• Patients with life-threats to the ABCs should be prepared for
immediate transport.
• Stable patients can be treated on the scene and transported with
less urgency.
VI. Focused History and Physical Exam
• Gather history of the present illness using OPQRST:
• Onset – What were you doing when the pain started?
• Provocation – Does anything make it better or worse?
• Quality – Describe the pain. What does it feel like?
• Radiation – Does the pain move anywhere? Does it stay in one
place?
• Severity – How bad is the pain? On a scale of 1-10, one being
very little and 10 being very severe.
• Time – When did the pain start? How long have you had the
pain?
• Gather a past medical history, commonly known as SAMPLE history:
• Signs and symptoms
• Allergies
• Medications
• Pertinent past history
• Last oral intake
• Events leading up to the call
VII. Complete a focused physical exam using two main techniques.
• Inspection
• Palpation
• Assess the patient’s baseline vital signs:
• Respiration
• Pulse
• Blood pressure
• Skin CTC
• Examine the appropriate body system(s) based on the chief complaint and
observation findings discovered during the initial assessment.
• Determine the appropriate treatment plan.
• Utilize on-line medical control when appropriate.
• Perform interventions and reassess.
• Reevaluate the transport decision.
• Perform the ongoing assessment.
• Good communication skills are key.
• The patient interview is an excellent means to reduce patient fear and promote
cooperation.
• Create an environment conducive to conversation.
• Be respectful to the patient by asking questions of the patient first.
25
• Language barrier may require finding an interpreter or alternate means of
communication.
• Phrase open-ended questions and follow up questions for clarification.
• Use closed-ended questions when the patient has difficulty
breathing or trouble speaking.
Key Terms
Focused physical assessment – examination based on chief complaint and observed signs and
symptoms.
OPQRST – a memory aid for the questions asked to get a description of the present illness or
elaborate on the chief complaint: Onset, Provocation, Quality, Radiation, Severity, and Time.
Teaching Activities
• What is the most common type of responsive medical complaint in your district?
• Why are the OPQRST questions sometimes subtly different for different chief
complaints?
• Allow adequate time to practice assessment of a responsive medical patient.
Other ideas:
• Consider using props for simulations such as medication canisters, poison containers,
beer bottles, or other devices that add to the story.
Segment Name: Assessment of the Medical Patient - Unresponsive

Objectives
• Explain how the EMT-B obtains information about the nature of illness (NOI) in an
unresponsive patient.
• Describe how to obtain a focused history about a patient who is unresponsive.
• List the sequence of assessment steps in order for the unresponsive medical patient.
• List the equipment needed to perform an assessment on a medical patient.
• List the two main techniques used to complete a focused physical exam.
• Explain why good communication skills are a key component in assessment of the
medical patient.
Overview
I. Assessment of the medical patient is highly dependent on the focused history.
• For the unconscious medical patient the history will need to be pieced together
from the family, bystanders, and findings at the scene.
II. For the unresponsive medical patient perform the steps in this order:
• Rapid medical assessment (head-to-toe exam)
• Baseline vital signs
• Possible request for ALS support (if not yet done in the initial assessment)
• History of present illness (HPI), or the SAMPLE history, if possible
III. Assessment
• Scene size-up
• Perform initial assessment
• Determine nature of illness (NOI) if possible
IV. Equipment
• Stethoscope
• Pen light
• Scissors
26
V. Skill Close-up
• Perform a scene size-up as you approach or come on the scene.
• Determine that the scene is safe and free of hazards.
• Determine the NOI such as an overdose, vomiting, or shortness of breath.
• If the patient appears unconscious and is on the ground or could
have otherwise suffered trauma, direct manual stabilization of
the cervical spine.
• Verbalize your general impression of the patient regarding his/her level of
distress and other obvious findings such as positioning and surroundings.
• Determine level of consciousness of the patient using the AVPU scale.
• If the patient can communicate, ask for his/her chief complaint.
• Ensure airway patency.
• If the airway is not open, do so using the head-tilt/chin lift
maneuver as long as no trauma is present.
• Insert an airway adjunct to assure patency.
• Assess the rate and quality of breathing.
• Assure lung sounds are present and equal bilaterally.
• Apply high-flow oxygen as appropriate.
• Suction as necessary.
• Assess skin: color, temperature, and condition (CTC).
• Control external bleeding with direct pressure.
• Initiate shock management as indicated.
• Determine the priority of the patient and make a transport decision.
• Patients with life-threats to the ABCs should be prepared for
immediate transport.
• Stable patients can be treated on scene and transported with
less urgency.
VI. The rapid physical exam is the first major step in the assessment of the unresponsive
medical patient.
• Assess head, neck, chest, abdomen, pelvis, extremities, and posterior.
• In addition to inspecting and palpating each of these areas for DCSP-BTLS,
other things to look for in a medical patient include:
• Neck – jugular vein distension or medical identification devices
• Chest – presence and quality of breath sounds
• Abdomen – distension, firmness or rigidity
• Pelvis – incontinence of urine or feces
• Extremities – distal PMS and medical identification devices
• Assess vital signs
• Pulse
• Respirations
• Blood pressure
• Skin signs and pupils
• Take a history of the present illness and a SAMPLE history by interviewing
bystanders and relatives:
• Signs and symptoms
• Allergies
• Medications
• Pertinent past history
• Last oral intake
• Events leading up to the call
• The physical exam and history should reveal enough information to determine
the patient’s presenting problem and formulate a treatment plan.
• Perform any interventions as necessary and transport to an appropriate
treatment facility.
27
Key Terms
Rapid physical exam – a rapid assessment of the head, neck, chest, abdomen, pelvis,
extremities, and posterior of the body to detect signs and symptoms of the NOI or injury.
Teaching Activities
• If an unknown medication is prescribed to the patient, what are the ways the EMT-B can
quickly learn about the med?
• What is the value of having a first responder check the patient’s refrigerator?
• Allow adequate time to practice the assessment of a medical patient who is not
responsive.
Other ideas:
• This is a good time to show samples of the Medic Alert® devices that are commonly
used. Many times these companies will provide samples to instructors for EMS
education.
Segment Name: Ongoing Assessment

Objectives
• List two reasons for performing the ongoing assessment.
• State when the ongoing assessment is completed in the patient assessment process.
• List the equipment needed to complete the ongoing assessment.
• State how often the ongoing assessment should be repeated for both stable and unstable
patients.
Overview
I. The Ongoing Assessment (OA) is the opportunity to:
• Reassess a patient’s signs and symptoms.
• Evaluate the effectiveness of any treatment.
II. The ongoing assessment is completed prior to arrival at the receiving facility.
III. The management of life-threatening conditions takes priority over performing an
ongoing assessment.
IV. Equipment
• Pen light
• Stethoscope
V. Assessment
• Begin by repeating the initial assessment and managing any life-threats to the
ABCs.
• Reassess vital signs, noting any changes.
• Repeat the focused physical exam.
VI. Skill Overview
• Repeat the initial assessment to detect any life-threatening problems. This
assessment includes:
• Reassessment of the patient’s mental status
• Maintain an open airway.
• Monitor the breathing rate and quality.
• Reassess pulse rate and quality.
• Monitor the skin: color, temperature, and condition.
• Reestablish, as necessary, priorities in patient treatment and/or
transport.
• Repeat the focused assessment as it relates to the chief complaint.
• Evaluate the effectiveness of any interventions.
28
VII. Skill Close-up
• Assure BSI.
• Reassess mental status using AVPU.
• Changes in mental status can indicate an improvement or
deterioration in the patient’s neurological function and should be
reported to medical direction.
• Reassess the ABCs and support as needed.
• Reassess patient priority and transport decision.
• Obtain vital signs and identify any trending or changes over time.
• Repeat the focused physical exam.
• Evaluate the effectiveness of any intervention.
• Repeat the ongoing assessment every 5 minutes for unstable patients and every
15 minutes for stable patients.
• If the patient’s condition worsens at any time reassess the initial assessment.
• Reevaluate interventions as to do no harm.
• Transport the patient to the appropriate treatment facility.
Key Terms
Ongoing Assessment (OA) – a procedure for detecting changes in a patient’s condition. It
involves: repeating the initial assessment, reestablishing patient priority, repeating and recording
vital signs, repeating the focused assessment, and checking interventions.
Trending – the inclination to proceed in a certain direction or rate; used to describe the prognosis
or course of a symptom or disease.
Teaching Activities
• If a splint was applied to the patient, what ways can this intervention be reevaluated?
• If a bronchodilator were administered by the EMT-B with permission from medical control,
how would the intervention be reevaluated?
• Allow adequate time to practice the ongoing assessment.
Other ideas:
• When having students practice the ongoing assessment, provide portable radios so they
can also practice giving an ambulance-to-hospital radio report.
29
Tape 1 Airway Management
Segment Name: Head-tilt, Chin-Lift maneuver
Objectives
• Describe the type of patient the EMT-B should consider for the head-tilt, chin-lift
maneuver.
• List the equipment needed to perform the head-tilt, chin-lift maneuver.
• Describe some of the potential problems associated with performing the head-tilt, chin-lift
maneuver.
Overview
I. The head-tilt, chin-lift maneuver is used on patients with a loss of muscle tone in the
airway having no actual or suspected cervical spine injury.
II. The head-tilt, chin-lift maneuver opens the airway by tilting the head back and lifting
the chin forward, which helps lift the tongue away from the back of the throat.
• This technique should not be used in a patient with a suspected cervical spine
injury.
III. Equipment
• BSI – gloves, goggles, mask or face shield
IV. Assessment
• The patient should be unresponsive, having an altered mental status.
• The patient may be in respiratory arrest or cardiac arrest.
• The patient should not have actual or suspected trauma to the head, neck, or
spine. These patients should have their airway opened using the jaw thrust
maneuver.
V. Skill Close-up
• Apply BSI.
• Place the patient in the supine position.
• Place one hand on the patient’s forehead and press down while you place your
other hand under the jaw bone and lift up.
• Assess for breathing and ventilate as needed.
VI. Ongoing Assessment
• Continuously monitor the patient.
• If no gag reflex is present insert an oropharyngeal airway (OPA).
VII. Problem Solving
• Only use the bony part of the jaw under the chin during this maneuver. If you
use the soft tissue under the chin an obstruction could occur during this
maneuver.
• Do not place your finger into the patient’s mouth during this maneuver, you may
be bitten.
• Try not to completely close the mouth during this maneuver.
• Note that on a small child the airway does not need to be hyperextended, just
extended.
• Be careful not to push on the tongue when grasping the jaw.
Key Terms
Head-tilt, chin-lift maneuver – a means of correcting blockage of the airway by the tongue by
tilting the head back and lifting the chin. Used when no trauma or injury to the head or neck is
suspected.
Teaching Activities
• What precautions should be made when doing a head-tilt, chin-lift on an infant?
• Why would this technique be inappropriate for a victim of trauma?
• Allow adequate time to practice the head-tilt, chin-lift maneuver.
30
Other ideas:
• When practicing this technique, have the student use both a mannequin and each other.
Be sure to emphasize the use of BSI.
Segment Name: Jaw Thrust Maneuver

Objectives
• Describe the type of patient the jaw thrust maneuver is used on.
• List the equipment needed to perform the jaw thrust maneuver.
• Describe the steps to perform a jaw thrust maneuver.
• List the possible problems associated with performing a jaw thrust maneuver.
Overview
I. An open airway is essential in those who cannot do so for themselves.
II. The jaw thrust maneuver is the only technique for the patient who is unconscious or
unresponsive with an actual or suspected spinal cord injury.
• Opens the airway with little or no movement to the head or neck
III. Equipment
• BSI – mask, glove, goggles or eye shield
IV. Assessment
• The patient should be unresponsive and suspected to have head, neck, or
cervical spinal injury.
• The patient may also have an altered mental status.
• The patient may be suffering from respiratory or cardiac arrest.
V. Skill Close-up
• Apply BSI.
• Patient supine. If not, keep neutrally aligned, then roll as a unit to supine.
• Position yourself at the top of the patient’s head if possible.
• Without moving the head or neck, place your hands on either side of the patient’s
head near the orbits, using your fingers place them at the angle of the jaw, using
your index and middle fingers gently jut the jaw forward.
• Do not rotate the head.
• Assess for ventilation as needed.
• Continuously monitor airway.
• If no gag reflex, insert OPA.
• Only the jaw thrust maneuver should be considered in a patient with suspected
head or a spine-injured patient that needs an open airway.
• Do not place your finger into patient’s mouth during this maneuver.
• Try not to close the mouth during maneuver.
Key Terms
Jaw thrust maneuver – a means of correcting blockage of the airway by moving the jaw forward
without tilting the head or neck. Used when trauma or injury is suspected to open the airway
without causing further injury to the cervical spine.
Teaching Activities
• Why is it essential to jut the jaw for the jaw thrust maneuver?
• What should the EMT-B do to maintain a jaw thrust if the patient with a cervical collar
applied becomes difficult?
• Allow adequate time to practice the jaw thrust maneuver.
Other ideas:
• In addition to practicing on a mannequin, make sure all students practice on each other to
assure they are competent at the skill.
31
Segment Name: Pocket Mask
Objectives
• Describe some of the advantages of using a pocket mask to assist with ventilations.
• List the equipment needed to perform ventilations using the pocket mask.
• Describe how to place a pocket mask on a patient.
• Describe the differences between ventilating adults, children, and infants.
• Describe some of the potential problems associated with the use of a pocket mask.
Overview
I. Mouth-to-mask is an option for ventilating patients.
• Small and compact
• Clear face mask
II. Equipment
• BSI equipment
• Pocket mask with one-way valve and oxygen inlet
• Suction if available
• Oxygen tank and regulator
III. Assessment
• Check the patient’s mental status.
• Check his/her airway.
• Check breathing rate, volume, and quality.
• Check circulation.
• Check skin signs.
IV. Skill Close-up
• Place yourself at the patient’s head if possible.
• Open the airway using the head-tilt, chin-lift maneuver, or the jaw thrust
maneuver if there is any indication of trauma or cervical spine injury.
• Suction as necessary.
• Insert oropharyngeal or nasopharyngeal airway if possible.
• Connect oxygen tubing to pocket mask oxygen inlet.
• Turn oxygen regulator liter flow gauge to 15 liters per minute.
• Center the pocket mask on the patient’s face.
• Place your thumbs over the top of the mask and place your little, ring, middle,
and index fingers on the patient’s mandible near the angle of the jaw.
• Pull the jaw up to the mask.
• Take a deep breath and exhale into the one-way valve at the top of the mask.
• Adult ventilation should be delivered over a 1- to 2-second period and the rate is
1 every 5 seconds.
• Children and infants’ ventilations should be delivered over 1 to 11/2 seconds and
the rate is 1 every 3 seconds.
• Remove your mouth from the one-way valve during each exhalation.
• If the patient does not have a pulse and both ventilations and compression are
necessary, perform CPR.
• Continuously monitor patient during ventilation for chest rise and lung
compliance.
VI. Problem Solving
• There is a high risk of contamination with this procedure.
• Consider the use of a BVM (especially if you have a second rescuer to assist).
• When secretions or vomit is present in the mask, immediately clear and suction
the patient.
• Conserve energy while using a pocket mask.
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Key Terms
Pocket mask – a device, usually with a one-way valve, to aid in artificial ventilation. A rescuer
breathes through the valve when the mask is placed over the patient’s face. Also acts as barrier
to prevent direct contact with the patient’s face. Can be used with supplemental oxygen when
fitted with an oxygen inlet.
Teaching Activities
• Why is it important not to push the mask onto the face?
• What is the advantage of having two hands to seal the mask?
• Allow adequate time to practice the use of the pocket mask.
Other ideas:
• If students do not have their own personal pocket mask, it is essential to properly
disinfect the masks prior to different students using the mask.
Segment Name: Bag-Valve Mask (BVM) Ventilation, Two-Person Technique

Objectives
• Explain why the bag-valve mask (BVM) is the preferred method of ventilation over mouth-
to-mouth, mouth-to-mask, and flow-restricted devices.
• Describe how to ventilate an adult, child, and infant.
• Discuss the problems associated with ventilating with a BVM.
Overview
I. The BVM is the preferred method of ventilation over mouth-to-mouth, mouth-to-mask,
and flow-restricted devices.
II. The BVM consists of the following components:
• A self-inflating bag with a one-way non-rebreathing valve
• A clear face mask with an inflatable air cushion
• Attached oxygen supplemental reservoir bag or tube attached to the BVM
III. The American Heart Association has issued the following guidelines on ventilations
by a BVM:
• If supplemental oxygen is available, administer 6 to 7 mL/kg, which would be
approximately 400 to 600 ml, over 1 to 2 seconds for an adult.
• If supplemental oxygen is unavailable, deliver 10 mL/kg, which would be
approximately 700 to 1,000 ml, over 1 to 2 seconds for an adult.
• BVM systems without a reservoir supply approximately 50% oxygen. Systems
with an oxygen reservoir provide nearly 100% oxygen.
IV. Assessment
• BSI precautions
• Establish a patent airway.
V. Equipment
• BSI equipment
• Oral or nasal airways in various sizes
• Suction unit
• Bag-valve mask with attached oxygen reservoir
• Full oxygen tank and regulatory
VI. Skill Overview
• Ensure that the equipment is operational.
• The patient should be in the supine position.
• Position yourself at the head of the patient.
• Use a manual maneuver to open the airway.
• Insert an oral or nasal airway, if available.
33
• The first EMT-B centers the mask on the patient’s face, to make a good mask
seal.
• The second EMT-B begins squeezing the bag slowly.
• Ventilate once every 5 seconds in an adult, once every 3 seconds in children and
infants.
• Each ventilation should be delivered over 2 seconds in adults and 1 to 1_
seconds for children and infants.
• The BVM should be attached to oxygen cylinder.
• Visualize the chest for chest rise on each ventilation.
• Feel the compliance (ease of ventilation of the bag on each ventilation).
• If no chest rise during ventilation, consider an airway obstruction.
• Document use and proper ventilations.
• Continuously monitor ventilations, chest rise and fall, and lung compliance.
• If the patient regains spontaneous respirations, assess the respirations for
adequacy.
• The mask used with the BVM must be clear to note any vomiting or secretions.
• Stop and suction immediately when vomitus or secretions are
present.
• When increased compliance is detected consider an obstruction or increased
pressure in the chest cavity.
Key Terms
Bag-valve mask device – a hand-held device with a face mask and self-refilling bag that can be
squeezed to provide artificial ventilations to a patient. Can deliver air from the atmosphere or
oxygen from a supplemental oxygen supply system.
Compliance - ease of ventilation of the bag on each ventilation.
Teaching Activities
• What are examples of patients who may have increased lung compliance?
• When ventilating with a BVM, if air is leaking around the mask what should the EMT-B
do?
• Allow adequate time to practice the skill of BVM ventilations.
Other ideas:
• Make sure to emphasize that this skill is best done with two rescuers. It is possible to do
this technique properly with one rescuer, however it is much less effective. Be sure to
practice BVM ventilation on a regular basis to maintain proficiency.
Segment Name: Insertion of the Oropharyngeal Airway

Objectives
• Explain when the EMT-B would use an oropharyngeal airway (OPA).
• List the equipment needed to aid in the insertion of an OPA.
• Describe the steps to insert an OPA in an adult, child, and infant.
• Describe the potential problems associated with the use of an OPA.
Overview
I. The oropharyngeal airway (OPA) is an airway adjunct.
• Must be used in conjunction with manual airway maneuvers
• Comes in many sizes for adults, children, and infants
• Oral airways should be considered in any patient who is not breathing or who is
unresponsive without a gag reflex.
• Insertion of an oral airway in a patient with a gag reflex can cause him to vomit.
• Can also trigger spasms in the upper airway
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II. Equipment
• BSI equipment
• Full set of OPAs
• Suction unit with a rigid tip Yankauer®
III. Assessment
• Use a painful stimulus to assess for unresponsiveness.
• Examine the patient for the proper size.
• Measure the airway (center of the mouth to angle of jaw, or
corner of mouth to tip of the ear lobe).
• Improper size can cause an airway obstruction.
• If the patient gags during insertion, immediately remove the OPA.
IV. Skill Overview
• Place the patient in a supine position.
• Use the head-tilt, chin-lift maneuver or the jaw thrust maneuver if a cervical
spinal injury is known or suspected.
• Select the proper size oral airway.
• Measure the airway.
• Open the patient’s mouth using the cross-finger technique.
• Insert the airway with the tip pointing to the top of the mouth (in adults only) and
slide it along the roof of the mouth.
• Gently rotate the airway 180 degrees to flip it over the tongue.
• Continue to insert the OPA until it lies flat on the top of the tongue and the
phalange rests on the lips.
• If the OPA is too large or too small remove it and select the
proper size.
• Place the mask you will use for ventilation over the airway adjunct you have
inserted.
• If the patient begins to gag at any point in this procedure, remove the airway at
once following the anatomical curvature.
• Reassess the patient’s breathing and begin ventilations as necessary.
• Document insertion of an OPA and changes in patient’s condition.
• Continuously monitor the patient’s airway patency. If a gag reflex returns,
immediately remove the OPA.
VI. Problem Solving
• Improper size can cause an obstruction.
• Insertion of an OPA can help you determine if the patient has a gag reflex.
• Be prepared for vomiting; have suction ready.
• Suction may be difficult to perform with the airway in place.
• Remove the OPA to suction, then reinsert.
• If you are aggressive during insertion of an OPA, you can cause trauma, spasms,
and swelling in the upper airways.
• An OPA might be used as a bite block in suspected seizure patients or a bite
block with endotracheal intubation.
• The insertion technique for a child or infant is to use a tongue depressor to hold
the tongue, then to slide straight in without flipping it over the tongue.
35
Key Terms
Gag reflex – vomiting or retching that results when something is placed in the back of the pharynx. This
is tied to the swallow reflex, which is designed to cap the glottic opening with epiglottis.
Oropharyngeal airway (OPA) – a curved device inserted through the patient’s mouth into the
pharynx to help assist maintaining an open airway.
Teaching Activities
• Why do some patients, particularly children, develop bradycardia when the back of the
throat is stimulated?
• If the patient has clenched teeth from a seizure, should an OPA be used?
• Allow adequate time to practice the skill of OPA insertion.
Other ideas:
• Emphasize that there are different types of OPAs (e.g.: Berman type and Cathguide
style). Make sure the students understand that the diameter of a suction catheter that
would fit through a Cathguide is too small to effectively suction the patient. It is best to
remove the OPA when suctioning the patient.
Segment Name: Insertion of the Nasopharyngeal Airway

Objectives
• Explain when the EMT-B would use a nasopharyngeal airway (NPA).
• List the equipment needed to aid in the insertion of an NPA.
• Describe the steps to insert an NPA.
• Describe the potential problems associated with the use of an NPA.
Overview
I. The nasopharyngeal airway (NPA) is an airway adjunct.
• A disposable, uncuffed, plastic or soft rubber tube
• Sizes vary from 17 to 20 cm in length and diameter ranges from 20 to 36 French.
• When in place, the NPA rests between the tongue and the posterior pharyngeal wall.
• The NPA does not stimulate a gag reflex.
II. Equipment
• BSI equipment
• NPAs of various sizes
• Water-soluble lubricant (e.g.: KY® jelly, Lubifax®, Surgilube®)
• Suction equipment
III. Assessment
• Use caution in a patient with suspected facial trauma.
• Select the proper length.
• Measure from the end tip of the nose to the ear lobe.
• Incorrect size may cause an obstruction or improper ventilation.
IV. Skill Close-up
• Place the patient preferably in a supine position with the head in a neutral
position.
• Assess the mental status.
• Select proper size NPA.
• Apply a water-soluble lubricant to the NPA before inserting.
• Insert the airway with the bevel pointing toward the base of the nostril or toward
the septum.
• Slowly push the airway into the nostril.
• Never force the NPA.
• If resistance is felt, remove the NPA, apply more lubricant and
reinsert.
36
• Continue to insert the airway into the nostril, advancing until the proximal flange
rests against the nostril.
• Assess the patient’s breathing.
• Document insertion of the NPA.
• Continuously monitor patient respirations.
• Monitor for gag reflex. If gag reflex becomes present, immediately remove the
NPA.
• Improper insertion can cause bleeding in the nostrils.
• Be prepared for vomiting by having suction ready.
• Examine the posterior pharynx for any bleeding that may have
occurred and suction if necessary.
VI. Problem Solving
• If the patient’s mental status improves and a gag reflex returns, immediately
remove the NPA.
• Keep suction ready during removal of NPA.
• Improper size can cause an obstruction.
• Lubrication is essential prior to insertion.
• Aggressive insertion may cause trauma, spasms, swelling, and bleeding.
• Be prepared for vomiting; have suction ready.
• Suction may be difficult to perform with the airway in place.
• Remove the NPA to suction, then reinsert.
Key Terms
Nasopharyngeal airway (NPA) – a flexible breathing tube inserted through the patient’s nose
into the pharynx to help maintain an open airway.
Nasal septum – the wall that separates the nostrils.
Teaching Activities
• What type of lubricant can be used on an NPA?
• Why doesn’t an NPA stimulate a gag reflex in the patient?
• Allow adequate time to practice NPA insertion on a mannequin.
Other ideas:
• When a patient has clenched teeth and lots of secretions, insert an NPA and you can
suction with a catheter down the tube.
Segment Name: Oral Suctioning

Objectives
• Explain why clearing a patient’s airway of secretions and/or vomitus is such a high priority
in patient care.
• List the three types of power sources for suction units.
• List the equipment needed to perform oral suctioning.
• Explain why BSI precautions are strongly urged when performing suctioning.
• Describe the potential problems associated with suctioning.
Overview
I. Clearing a patient’s airway is the highest priority.
• Immediate removal of any aspirated materials and/or fluids is essential.
II. Many types of suction units are available; each unit consists of the following:
• A suction source
• A collection container
• Thick-wall, non-kinking, wide-bore tubing
• Rigid (hard) suction tips or flexible (soft) catheters
37
III. Suction units can be either mounted or portable.
• May be powered manually, by oxygen source or electricity
IV. Improper suctioning can cause trauma, swelling, spasms, hypoxia, and aspiration.
V. Equipment
• BSI equipment
• Suction units
• Suction tubing
• Suction catheters and/or rigid suction tips
• Collection container
• Sterile water or irrigation solution
VI. Assessment
• Full BSI precautions are essential for this skill.
• Be prepared well in advance for the potential use of suction.
VII. Skill Close-up
• Apply BSI precautions.
• Assemble suctioning equipment; check that suction is working.
• Place yourself at the patient’s head.
• Turn on the suction unit.
• Place patient on his or her side, or turn head to the side if possible.
• Open the patient’s mouth using a cross-finger technique; remove any airway that
may be in place.
• Slowly insert the catheter into the mouth with the curve or distal part of the
catheter pointing towards the jaw.
• Place the Yankauer® so that the convex, or bulging-out side is against the roof of
the mouth. Insert the tip to the base of the tongue.
• Insert no further than the base of the tongue.
• If a gag reflex begins, pull back slightly.
• Begin suctioning by placing your finger over the hole in the catheter tube.
• Move the suction catheter from side to side in the oral cavity.
• Never suction for more than 15 seconds at a time in adults; no more than 5
seconds in children and infants.
• If the catheter or tubing becomes clogged with materials, use sterile water or
irrigation solution to clean or clear the catheter and/or tubing.
• Allow a few seconds between suctions, giving the patient time to relax.
• Ventilate between suctioning attempts.
• Document your suction procedure.
VIII. Ongoing Assessment
• Constantly monitor for materials and/or fluids that may need to be removed:
• Monitor for signs of hypoxia during suction.
• Be especially aware of vagal stimuli in infants/children, which
causes bradycardia.
IX. Problem Solving
• Deep insertion of a catheter can stimulate a gag reflex.
• When tubing becomes clogged, use sterile water or irrigation solution to clear the
tube, or replace the tubing and catheter.
• Exposure while cleaning suction equipment is a high risk.
Key Terms
Vagal stimuli – actions that stimulate the tenth cranial nerve causing bradycardia, such as
touching the back of the throat when suctioning.
Yankauer® – a disposable commercial rigid tip suction catheter.
Teaching Activities
• Why is it important to carry a portable suction unit to the patient’s side?
• Why is it important to test the suction unit on each shift?
38
• Allow adequate time to practice suctioning a mannequin.
Other ideas:
• Try challenging your students with chunky soup in the appropriate mannequin in a
simulation needing suctioning.
Segment Name: Suctioning through an Endotracheal Tube

Objectives
• List the indications for suctioning through an endotracheal tube.
• List the equipment needed to perform endotracheal suctioning.
• Describe the steps to perform endotracheal suctioning.
• Discuss some of the common problems associated with endotracheal suctioning.
Overview
I. The goal of this skill is to clear the airway of unwanted debris and/or fluids.
• This skill should be done under the direction of an advanced provider.
• To reduce risk of infection in the patient’s lung, this skill is performed with sterile
technique.
II. Equipment
• BSI equipment
• Suction unit
• Soft suction catheters
• Sterile water
III. Assessment
• Visible secretions in the endotracheal tube
• Gurgling sounds
• Resistance in ventilations (increased compliance)
IV. Skill Close-up
• Observe BSI precautions.
• Explain the procedure to the conscious patient.
• Check and assemble the equipment.
• Pre-oxygenate the patient.
• In the case of pulmonary edema, your partner should hyperventilate the patient
prior to suctioning.
• Approximate the length of the catheter.
• Keep the catheter sterile during measurement.
• Place the soft catheter into the ET tube without applying suction.
• Place your non-dominant thumb over the hard plastic hole at the proximal end of
the catheter and apply suction.
• Slowly withdraw the suction catheter with a twisting motion.
• Clean the catheter in sterile water.
• When setting down the catheter, make sure you put it in a sterile environment if it
is to be used again.
• Hyperventilate and repeat the procedure if necessary.
• Assess the patient immediately after suctioning for signs of hypoxia (e.g.:
bradycardia).
39
VI. Problem Solving
• The risk of exposure during this procedure is high, so always utilize full BSI
precautions.
• Hypoxia can result by taking too long to perform the suction procedure.
• Pre-oxygenate the patient well before suctioning.
• Never suction, or interrupt ventilation, for more than 15 seconds.
• If you do not measure the catheter you can cause the following complications:
• A coughing reflex
• Bronchospasms
• Dysrhythmias
• Injury to the mucosa of the lower airways
• Employing suction pressure that is too high can cause these
same complications.
• If the tip of the catheter becomes clogged, place the tip of the catheter into sterile
water and draw water through the catheter.
Key Terms
Bronchospasms –constriction of the air passages of the lung by spasmodic contraction of the
bronchial muscles.
Hyperventilate – to provide ventilations at a higher rate than normal.
Pulmonary edema – accumulation of fluid in the lungs.
Teaching Activities
• Why is it important to keep the catheter sterile when deep suctioning?
• Why is it imperative that a mask and eye shield be used when deep suctioning?
• Allow adequate time to practice endotracheal suctioning.
Other ideas:
• Since this skill may be one of the optional EMT-B skills, check with your medical director
to be sure it is acceptable practice.
40
Tape 2 Airway Management
Segment Name: Oxygen Tank Assembly
Objectives
• List the various sizes of oxygen cylinders and the amounts of oxygen they contain.
• List the equipment needed to assemble an oxygen delivery system.
• Describe the steps for an oxygen cylinder assembly.
Overview
I. Most oxygen tanks and regulators have standard fittings that only work one way.
II. Portable cylinders for the field include:
• D cylinders which contain about 350 liters of oxygen
• E cylinders which contain about 625 liters of oxygen
III. Onboard tanks found in the ambulance (fixed systems) include:
• M cylinders which contain about 3,000 liters of oxygen
• G cylinders which contain about 5,300 liters of oxygen
• H cylinders which contain about 6,900 liters of oxygen
IV. Equipment
• Oxygen cylinder with yoke
• Oxygen regulator
• On E size cylinders, or smaller, the pressure regulator is secured
to the cylinder valve assembly by a yoke assembly.
• Cylinders larger than E size have a valve assembly with a
threaded outlet.
• Flowmeter – 3 types
• Bourdon Gauge Flowmeter (useful for most portable units)
• Constant Flow Selector Valve (useful with any size oxygen
cylinder)
• Pressure-Compensated Flowmeter (useful for fixed delivery
systems)
• Oxygen key
V. Assessment
• Inspect equipment for damage prior to assembly.
• Oxygen tanks are usually green or have a green strip and are labeled “oxygen.”
• Make sure the regulator has an O-ring or washer.
• Oxygen should be stored at room temperature.
VI. Skill Overview
• Place the cylinder in a secure, upright position.
• Remove the seal or cap protecting the cylinder outlet or valve.
• Open the valve. This will remove any dust or debris from the valve assembly.
• Select the correct pressure regulator and flowmeter.
• Align the pins and hand tighten the “T” screw or tighten a threaded connection
with a non-ferrous wrench.
• Place the oxygen key on the tank valve screw.
• Slowly open the valve to charge the oxygen regulator.
• Check the pressure gauge to see that an adequate amount of oxygen is present
in the tank.
• Attach tubing and the oxygen device of choice.
• Open the main valve and adjust the flowmeter.
• Document the oxygen flow rate delivered to the patient.
• Continuously monitor the pressure in the oxygen cylinder and be prepared to
change an empty cylinder.
• When transporting a patient with an oxygen cylinder secure the cylinder.
41
• Regularly check hydrostatic expiration dates.
• Do not use damaged tanks or regulator gauges.
• If you open a cylinder and hear a leak, turn off the pressure and check the O-
ring; replace as needed.
Key Terms
Flowmeter – also called a regulator; a valve that indicates the flow of oxygen in liters per minute.
O-ring – a plastic washer that fits between the flowmeter and oxygen cylinder to prevent gas from
leaking out when the tank is turned on.
Oxygen cylinder – a steel or aluminum cylinder filled with oxygen under pressure.
Teaching Activities
• How can you find out if an oxygen tank has been hydrostat-tested recently?
• What are five safety rules to consider when using oxygen tanks?
• Allow adequate time to practice the skill of exchanging oxygen tanks and regulators.
Other ideas:
• Discuss how your service receives oxygen when the tanks are empty. If a cascade
system is used, discuss the policy and procedure for filling tanks.
Segment Name: Administering Oxygen by a Non-Rebreather Mask

Objectives
• List the indications for the use of a non-rebreather mask (NRB) on a patient.
• List the oxygen concentration ranges an NRB is able to deliver.
• Describe the steps to place an NRB on a patient.
• Describe the ongoing assessment of a patient wearing an NRB.
Overview
I. Non-rebreather mask (NRB) device delivers the highest concentration of oxygen in
the prehospital setting.
• Delivers oxygen concentrations ranging from 80 to 100%.
II. Indications for utilizing an NRB include:
• Cyanosis
• Cool, clammy skin
• Shortness of breath
• Chest pain
• Severe injuries
• Altered mental status
III. NRBs can be used in combination with oropharyngeal airways (OPAs) and
nasopharyngeal airways (NPAs).
IV. Equipment
• Full oxygen tank and regulator
• NRB
V. Assessment
• The patient should be breathing.
• Select the appropriate size NRB.
VI. Skill Close-up
• Introduce yourself to the patient and explain the need for an NRB.
• Make sure that the oxygen tank is full and that the pressure is within accepted
limits.
• Attach the NRB to the nipple on the oxygen regulator.
• Set the flowmeter at 12-15 liters per minute or at the rate specified by medical
direction.
42
• Allow the reservoir bag to fill completely.
• Position the NRB over the patient’s nose and mouth and instruct the patient to
breathe normally while the mask is in place.
• Slip the elastic strap over the patient’s head so that it rests above the patient’s
ear and tighten the strap as needed.
• Document the use of an NRB and the rate of oxygen delivery.
VII. Ongoing assessment
• Check to see that oxygen is turned on and flowing; continuously monitor the
pressure.
• Remind the patient to breathe normally.
• Check the position of the mask for comfort and effectiveness.
• Reassure the patient to avoid the fears associated with claustrophobia.
Key Terms
Non-rebreather mask (NRB) – a face mask with a reservoir bag device designed to deliver high
concentrations of oxygen. The patient’s exhaled air escapes through a valve so it is not mixed
with the gas inhaled from the reservoir.
Teaching Activities
• Should airway adjuncts be used together with a non-rebreather mask?
• Why shouldn’t you use an adult-sized NRB on a child?
• Allow adequate time to practice applying an NRB.
Other ideas:
• Emphasize that the mask should be monitored to assure the bag does not remain empty
or that sheets or clothing do not block the valves on the mask.
Segment Name: Administering Oxygen by a Nasal Cannula

Objectives
• List the indications for the use of a nasal cannula on a patient.
• List the oxygen concentration ranges a nasal cannula is able to deliver.
• Describe the steps to place a nasal cannula on a patient.
• Describe the ongoing assessment of a patient wearing a nasal cannula.
Overview
I. Nasal cannulas provide low-concentration oxygen ranging from 24-44%.
II. The main indication for the use of a nasal cannula is the patient who feels suffocated
by an NRB.
• May be indicated for COPD patients with minimal respiratory distress
• May be indicated for the patient who is nauseous or vomiting
III. Contraindicated in the patient with a nasal obstruction
• Should not be utilized on patients requiring high-flow oxygen
IV. Equipment
• Full oxygen tank and regulator
• Nasal cannula of various sizes
V. Assessment
• Patient must have adequate respirations and the ability to breathe through the
nose.
• Patient requires low to moderate concentration of oxygen.
43
VI. Skill Close-up
• Explain the need for oxygen administration to the patient. Then go over the
procedure you intend to follow.
• Attach the nasal cannula tubing to the oxygen regulator.
• Set the liter flow between 1 and 6 liters per minute.
• Insert the two prongs into the patient’s nostrils.
• Position the tubing of the cannula over the patient’s ear.
• Bring the remainder of the tubing under the patient’s chin, and secure the slip
loop by gently sliding the plastic adjust in place.
• Document the use of a nasal cannula and the liter flow.
• Check position of cannula.
• Check the regulator for continuous flow.
• If the patient is unable to breathe through his/her nose initially, placing a nasal
cannula into the nostrils will be ineffective. Consider an oxygen mask in this
case.
• Remind the patient to breathe normally.
• Rescuers may wear a nasal cannula while providing mouth-to-mouth or mouth-
to-mask ventilations to increase oxygen concentration delivery with ventilations.
Key Terms
COPD – an acronym for chronic obstructive pulmonary disease (e.g.: chronic bronchitis,
emphysema, or black lung).
Nasal cannula – a disposable device that delivers low concentrations of oxygen through two
prongs that rest in a patient’s nostrils.
Teaching Activities
• If a COPD patient is in respiratory failure should a nasal cannula be used?
• If a COPD patient is always on home oxygen by nasal cannula and called EMS for a
sprained ankle, with no increase in respiratory distress, should a nasal cannula be used
and if so, what liter flow?
• Allow adequate time to practice the skill of using a nasal cannula.
Other ideas:
• Review your local protocols for oxygen administration.
Segment Name: Nasogastric (NG Tube) Intubation

Objectives
• List the indications for the use of a nasogastric tube (NG tube).
• List the equipment needed for the intubation of an NG tube.
• Describe the steps on the insertion of an NG tube.
• Describe the possible complications associated with NG tube intubation.
Overview
I. Nasogastric (NG tube) intubation is the insertion of a tube into the stomach through
the nasal passage.
• NG tube can be attached to suction to remove stomach contents including air,
blood, or vomit.
• Pediatric indications are for gastric distention in the unresponsive patient or when
gastric distention interferes with ventilation.
• In the hospital, NG tubes may be used to deliver medications or nutritional
substances.
II. NG tube insertion is contraindicated where nasal bleeding, facial trauma, or basilar
skull fractures are present.
44
III. Assessment
• Assess the unresponsive patient or patient who is being ventilated for increased
gastric distention.
IV. Equipment
• BSI precaution
• Various sizes of NG tubes
• Emesis basin
• Water-soluble lubricant
• Tape
• 20cc syringe
• Stethoscope
V. Skill Close-up
• Prepare all equipment.
• Maintain adequate oxygenation of patient.
• Measure tube length before insertion – nose to ear to xiphoid process. This
predicts how far the tube will be inserted.
• Lubricate the tube and gently insert the tube through one nostril. Motion should
be downward along the nasal floor.
• Insert the tube to pre-determined, measured location.
• Confirm placement of the tube in the stomach.
• Listen over epigastrium as air is injected through tube with
syringe (10-20cc).
• A bubbling sound or rush of air should be heard by auscultation.
• Apply suction to the syringe. Gastric contents should be aspirated in the tube.
• Secure NG tube with tape.
• Attach NG tube to suction device to decrease gastric distention.
• Assess NG tube for proper placement and dislodgement.
• Patient may need to be restrained to prevent self-removal of NG tube.
• Trauma or vomiting may occur during insertion.
• During insertion the tubing may coil in the back of the throat; partially remove the
tubing, then reinsert.
• When securing the tube avoid sharply bending and occluding the tube at the
nostril.
• Tubing may clog with stomach contents; flush tubing with normal saline (5-10cc).
Key Terms
Nasogastric tube (NG tube) – a tube designed to be passed through the nose, nasopharynx,
and esophagus. In the prehospital setting it is used to relieve distention of the stomach,
especially in children and infants.
Xiphoid process – the inferior portion of the sternum.
Teaching Activities
• What is the problem with gastric distention in the field?
• Why do children tend to be affected by gastric distention more frequently than adults?
• Allow adequate time to practice the skill of NG tube placement.
Other ideas:
• Not all EMT-Bs are trained to utilize this skill. Check with your Medical Director to see
what the local protocol is.
Segment Name: Sellick’s Maneuver
45
Objectives
• Describe some of the potential scenarios for the use of Sellick’s maneuver.
• Describe two of the potential problems associated with the use of the Sellick’s maneuver.
Overview
I. Sellick’s maneuver is also referred to as cricoid pressure.
• Allows for improved ventilation while helping to prevent gastric regurgitation
• Used to assist in the placement of an endotracheal tube
II. Equipment
• BSI equipment
III. Assessment
• Unresponsive patient with no gag reflex
IV. Skill close-up
• Apply firm but gentle posterior pressure. Using the thumb and index finger of
one hand, apply pressure to the anterior and lateral aspects of the cricoid
cartilage, just next to the midline.
• Document that the maneuver was done.
• Assess the neck for swelling or signs of trauma after the maneuver is performed.
VI. Problem Solving
• Be prepared for vomiting after releasing cricoid pressure.
Key Terms
Cricoid cartilage – the ring-shaped structure that circles the trachea at the lower edge of the
larynx.
Sellick’s maneuver – also called cricoid pressure; pressure applied to the cricoid cartilage to
suppress vomiting and bring the vocal cords into view.
Thyroid cartilage – also known as the Adam’s apple; the largest cartilage in the larynx.
Teaching Activities
• Why should the Sellick’s maneuver be utilized?
• How does the Sellick’s maneuver work?
• Allow adequate time to practice the skill of Sellick’s maneuver.
Other ideas:
• Explain how this may be helpful to prevent regurgitation during intubation attempts, as
well as bring the cords into view.
Segment Name: Ventilatory Assist with Endotracheal Intubation

Objectives
• Explain the EMT-B’s role in assisting with endotracheal intubation.
• List the equipment needed for endotracheal intubation.
• Describe the steps to assist ventilations of a patient who is intubated.
• List the most common problem associated with endotracheal intubation.
Overview
I. The gold standard for airway management is the endotracheal tube (ET tube).
• Provides direct control of the airway
II. In some areas of the country EMT-Bs are permitted to perform endotracheal
intubation.
• EMT-Bs may assist with endotracheal intubation.
• EMT-Bs may ventilate an intubated patient.
III. Equipment
• BSI equipment
• BVM, with reservoir attachment
• Oxygen cylinder
46
• Suction unit and catheter
• ET tube (proper size)
• Stylet
• Laryngoscope
• Laryngoscope blades (straight, curved)
• Water-soluble lubricant
• 10cc syringe
• Towel
• Esophageal intubation detector device or end tidal CO2 monitor
• Commercial tube restraints
• Oral airway
• ET tube securing device, commonly tape
• Stethoscope
IV. Assessment
• Ventilation by endotracheal intubation should only be done with the direction of
an advanced life support provider.
V. Skill Close-up
• Position yourself at the patient’s head.
• With a BVM attached to oxygen, ventilate at a rate of 12 times a minute.
• Slowly squeeze the bag over 2 seconds for each ventilation.
• Notify the ALS provider immediately of any complications.
• Continuously monitor chest rise during each ventilation.
• ET tubes can be displaced with movement or during various procedures.
• Advise the advanced provider immediately if you suspect tube
displacement.
Key Terms
Endotracheal tube – a tube designed to be inserted into the trachea. Oxygen, medication, or a
suction catheter can be directed into the trachea through an endotracheal tube.
Laryngoscope – an illuminating instrument that is inserted into the pharynx to permit
visualization of the larynx and vocal cords.
Stylet – a long, thin, flexible metal probe used to provide shape to a flexible tube.
Teaching Activities
• What is your agency’s policy on EMT-Bs ventilating a patient with an ET tube?
• Why is it so important that the ET CO2 be checked after any movement of the patient?
• Allow adequate time to practice assisting ventilating an intubated mannequin.
Other ideas:
• EMT-Bs should work together with ALS personnel in scenarios where the patient needs
to be ventilated prior to intubation, then assist after intubations.
Segment Name: Insertion of Esophageal Tracheal Combitube® (ETC Airway)

Objectives
• List the major advantages of the esophageal tracheal Combitube® as an airway device.
• List the equipment needed for the use of a Combitube®.
• List the indications and contraindications for the use of a Combitube®.
• Describe the steps for placing a Combitube® and how the EMT-B verifies tube
placement.
• List the problems associated with the use of the Combitube® and how to correct them.
47
Overview
I. The esophageal tracheal Combitube® is a double lumen airway device.
• In some areas of the country EMT-Bs are permitted to utilize the Combitube®.
• Combitube® comes in two sizes.
• This device does not require visualization of the trachea.
II. Combitube® is a back-up airway device which offers several major advantages:
• It is a “blind technique” that does not require visualization of the trachea.
• The Combitube® may prevent vomit from entering the trachea, thus protecting
the airway.
• The Combitube® allows for rapid intubation of the patient independent of the
patient’s position.
III. Equipment
• BSI equipment
• Oxygen cylinder
• BVM and reservoir
• Combitube® (appropriate size for patient)
• Water-soluble lubricant (KY® jelly, Lubifax®, or Surgilube®)
• Large 100cc syringe
• Small 20cc syringe
• Stethoscope
IV. Assessment
• The Combitube® is indicated when:
• Patients are unconscious and lack a gag reflex
• Endotracheal intubation is not allowed or cannot immediately be
performed, even though strongly indicated
• Endotracheal intubation is unsuccessful after two attempts
• In-line immobilization of the patient prevents endotracheal
intubation
• Bleeding, vomiting, or a patient’s anatomy obstructs the direct
visualization required for endotracheal intubation
• The Combitube® is contraindicated when:
1. Patients are less than 16 years of age
2. Patients are less than 5 feet tall
3. Esophageal disease is present
4. Patients are conscious with a gag reflex
5. Patients have swallowed a caustic substance
V. Skill Overview
• Position yourself at the patient’s head.
• Prior to insertion of the Combitube®, the airway should be cleared of any
materials or fluids that might cause an obstruction.
• Assist ventilations as needed.
• Assess the patient for contraindications (e.g.: age and size).
• Assemble and check equipment.
• Lubricate the distal end of the tube.
• Keep the patient supine with the head in a neutral position.
• Consider hyperventilation prior to performing insertion of the airway.
• Perform a jaw-lift maneuver and place the tube into the mouth and gently insert
into the airway.
• Insert the Combitube® until the airway’s black rings meet the level of the
patient’s teeth.
• Using the large syringe, inflate the pharyngeal cuff with 100cc of air.
• Using the small syringe, inflate the distal cuff with 10 to 15cc of air.
• Attach the BVM to tube #1, and slowly begin ventilations.
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• Place the stethoscope over the patient’s stomach and auscultate for gurgling
sounds.
• If no gurgling sounds, auscultate the lungs and watch for chest
rise; continue ventilations.
• If gurgling sounds are heard, stop ventilations on tube #1 and
move BVM to tube #2, begin ventilations again.
• Auscultate the stomach and lungs again; if no gurgling is heard
and chest rise and breath sounds are heard, continue ventilating
on tube #2.
• Consider hyperventilation for 2 minutes after insertion, then resume normal
ventilation rate.
• Continuously monitor chest rise and stomach distension.
• Monitor the pilot balloons to ensure the cuffs are inflated.
• Reevaluate lung sounds after every movement of the patient.
• Visualize the airway for materials and/or fluids.
• If you meet resistance while inserting the tube, do not force the tube.
• If you are unsure of tube placement, remove the tube and reinsert.
• Be prepared for vomiting when removing the tube.
• Use caution in patients with facial trauma.
• If you suspect cervical spine injury, do not hyperextend the head or neck.
• Do not take a long time to insert the tube; stop and ventilate if tube insertion is
prolonged.
• Prior to tube insertion, suction the airway when any fluids or materials are
present.
• Air pressure must be maintained in cuffs; remove the syringes after inflations and
monitor pilot balloons; keep the syringes nearby in case they are needed.
• To remove the Combitube® take these steps:
• Have suction ready.
• Place the patient on his or her side.
• Deflate the pharynx cuff.
• Deflate the distal cuff.
• Remove tube gently.
• Reassess the patient.
Key Terms
Combitube® – The esophageal tracheal Combitube® is a double lumen airway device designed
to be placed in either the esophagus or the trachea to assist in ventilation of a patient.
Teaching Activities
• How should the Combitube® be stored in your EMS unit?
• What is the proper procedure for disinfecting a Combitube®?
• Allow adequate time to practice the skill of Combitube® insertion into an airway
mannequin.
Other ideas:
• Not all agencies use this device, nor are all EMT-Bs trained in its insertion. Review your
Medical Director’s policy on the use of the Combitube®.
Segment Name: Ventilatory Management Stoma Patient
Objectives
• List the information the EMT-B should obtain about a patient with a stoma.
• Describe the steps to ventilate a patient with a full and partial laryngectomy.
• Describe how to assess for effectiveness of ventilations through a stoma.
49
• Explain the possible complications associated with ventilating a stoma and how to correct
them.
Overview
I. Stomas are surgical openings in the neck that are used to breathe.
• When a patient presents with respiratory distress or arrest you may ventilate
through the stoma.
• Mucous plugs often obstruct a stoma causing respiratory distress; attempt to
clear the obstruction from the stoma using a suction catheter.
II. Assessment
• Assess the stoma for obstruction first.
• Attempt to ascertain information about the stoma:
• Reason it was placed
• When it was placed
• Whether the patient relies entirely on the “neck breather”; some
patients have a partial laryngectomy and are able to breathe
through their mouth and nose
III. Skill Close-up
• Remove any items of clothing, such as scarves or ties, from the area of the stoma.
• Clear the stoma of obvious mucous plugs or secretions.
• Leave the patient’s head in a neutral position.
• Select a mask, most often a pediatric mask, that fits securely over the stoma and
can be sealed against the neck.
• Hold the mask seal with your hand, and ventilate the patient at the appropriate
rate for his or her age.
• Assess for effectiveness of ventilations.
• Watch for chest rise and fall.
• If unable to ventilate, suspect a partial laryngectomy and seal the
nose and mouth with one hand by placing the palm over the lips
and pinching the nose between the third and fourth fingers.
Reattempt your ventilations.
• If you are unable to ventilate through the stoma, consider sealing
the stoma and ventilate through the mouth and nose.
IV. Ongoing Assessment
• Continuously monitor the stoma for secretions. Suction may be required multiple
times before the airway is patent.
• Assess the effectiveness of ventilations:
• Good mask seal
• Chest rise and fall
• Lung sounds
• Skin color
• Pulse oximetry
V. Problem Solving
• If mucous is too thick to suction, and the materials are available to you, consider
injecting 3-5ccs of normal saline through the stoma to break up the plug and aid
in its removal.
• If you are unable to ventilate through the stoma, a small endotracheal tube can
be inserted through the stoma into the trachea. Follow local protocols in
performing this procedure.
Key Terms
Stoma – a permanent surgical opening in the neck through which the patient breathes.
Teaching Activities
• What is the difference between a partial and complete laryngectomy?
• How is it possible for a patient with a stoma to talk?
50
• Allow adequate time to practice the skill of ventilating a stoma.
Other ideas:
• Review where your agency carries the needed equipment to ventilate a stoma, and
discuss how to suction the stoma.
Segment Name: Using a Pulse Oximeter

Objectives
• List the indications for the use of the pulse oximeter.
• List the two readings the pulse oximeter provides.
• Describe the various places to apply a pulse oximeter probe.
• Explain why the pulse oximeter does not provide an accurate reading for every patient.
• Describe the possible problems associated with the use of a pulse oximeter and how to
correct them.
Overview
I. A pulse oximeter is a photoelectric device which measures hemoglobin that is
saturated with oxygen.
• Consists of a portable monitor and a sensor probe
• Clips onto a finger, toe, or ear lobe
• Records the reading as oxygen saturation percentage or SpO2
• Non-invasive device
II. Normally, SpO2 is around 95% to 99%. Saturation below 95% may represent varying
levels of hypoxia. Be aware, however, that some patients may present normally with
an SpO2 of less than 95%. A good example would be a COPD patient who normally
retains high levels of CO2.
III. Equipment
• Pulse oximeter
• Various sizes of probes (adult, child, infant)
• Extra batteries
• Acetone wipe (to remove fingernail polish)
IV. Assessment
• Do not delay assessment or oxygen administration to apply the pulse oximeter.
• A pulse oximeter is most useful in two situations:
• Evaluating the effectiveness of any interventions you may
perform, such as artificial respirations, oxygen therapy,
bronchodilator therapy, or BVM ventilations
• Alerting you to a deterioration of the patient’s oxygen saturation
• When using a pulse oximeter, keep in mind that readings will not be accurate in
all patients. For example:
• Carbon monoxide (CO) poisoning
• Chronic cigarette smokers
• Anemic patients
• Certain poisons
• Hypoperfused or hypothermic patients
V. Skill Overview
• Select appropriate size sensor.
• Connect the sensor lead to the monitor and clip the sensor probe to the patient’s
fingertip, or other suitable location.
• Attach the sensor cable to the pulse oximeter and turn it on.
• Observe SpO2 and heart rate. Ensure screen heart rate matches patient’s pulse
rate.
• Some pulse oximeters may display a pulsatile waveform, which
should correspond with the patient’s pulse rate.
51
• Once you get an accurate reading check the oximeter reading every 5 minutes.
A convenient time to do this is when you check the patient’s vital signs.
• Document the SpO2, and the amount of oxygen being delivered to the patient.
• Check to see that the probe is still attached to the patient as they can be easily
dislodged; some models have an alarm to alert you when the probe is off.
• Some models turn themselves off after a certain amount of inactivity.
• If you are having difficulty keeping a probe in place, consider taping it on.
• If you are having difficulty getting a reading, consider using an alternate location
(e.g.: ear lobe).
• Nail polish can interfere with a reading; use an acetone wipe to remove polish.
Key Terms
Anemia – a condition in which there is a lack of blood.
Pulse oximeter – is a photoelectric device, which measures the level of oxygen circulation
through a patient’s blood vessels.
Teaching Activities
• Why would a firefighter who has smoke inhalation have a false SpO2 reading?
• Why might the SpO2 be inaccurate on a patient who is in shock?
• Allow adequate time to practice the skill of SpO2 detection.
Other ideas:
• Demonstrate the use of the earlobe sensor to the group.
52
Tape 1 Medical Emergencies
Segment Name: Administration of Activated Charcoal
Objectives
After viewing this segment, the student should be able to:
• Describe when to consider the administration of activated charcoal to a patient.
• List the contraindications for the administration of activated charcoal.
• List the potential side effects of activated charcoal.
• List the equipment needed to administer activated charcoal.
• Describe the assessment of a patient who has swallowed a poison or taken an overdose,
including the ongoing assessment.
• Explain the five rights of medication administration.
• Describe how to administer activated charcoal.
• Discuss the problems associated with administration of activated charcoal.
Overview
I. Activated charcoal is used to treat patients who have swallowed a poison or taken an
overdose.
• Antidote
• Binds to poison to minimize absorption
II. Contraindications for activated charcoal include:
• Inability to swallow
• Altered mental status (AMS)
• Ingested acids or alkalis
• Poisoning by cyanide, organic solvents, iron, ethanol and methanol
III. Side effects
• Vomiting and/or nausea
• Abdominal cramping
• Constipation
• Black stool
IV. Equipment
• Activated charcoal
• Covered container with lid
• Straw
• Suction unit
• Emesis basin
V. Assessment
• Determine the patient’s mental status.
• Perform initial assessment and focused history and physical exam.
• Determine substance ingested.
• Identify possible contraindications.
• Determine when taken.
VI. Obtain medical consent to administer medication.
• Report information to medical control.
• Request and confirm order to administer medication.
VII. Confirm the five rights of medication administration:
• Right patient
• Right drug
• Right dose
• Right route of administration
• Right time
53
VIII. Administration of activated charcoal
• Measure and mix the preparation.
• Adult dose is 25-50 grams / pediatric dose is 12.5-25 grams (confirm with local
protocols)
• Explain the procedure to the patient.
• Instruct the patient to drink the mixture through the straw.
• Prepare for vomiting.
• If the patient vomits or spits up the dose, consider a second dose (obtain medical
consent for second dose).
• Document
IX. Ongoing assessment
• Monitor and reassess.
• Be prepared for vomiting.
X. Problem Solving
• Never force a patient to swallow medication.
• Notify medical control.
• Use an opaque cup to mask the medication’s appearance.
Key Terms
Activated charcoal – a powder, usually pre-mixed with water, that will absorb some poisons and
help prevent them from being absorbed by the body.
Adverse reaction – any reaction to a procedure or drug administration other than the desired
action.
Contraindications – specific signs or circumstances under which it is not appropriate and may
be harmful to administer a particular drug to a patient.
Indications – specific signs or circumstances under which it is appropriate to administer a drug to
a patient.
Side effect – any action of a drug other than the desired action.
Teaching Activities
• What is your state, regional, or local treatment protocol for poisoning?
• Why is activated charcoal inappropriate to administer to a patient with an altered mental
status?
• Allow adequate time to practice the skill of activated charcoal administration.
Other ideas:
• In this instance it may be appropriate to substitute a milkshake as a reward for the
student’s attention to details.
• List a number of substances that would be appropriate use for activated charcoal.
• Discuss your Medical Director’s and the regional Poison Control’s view on activated
charcoal as well as use of Ipecac.
Segment Name: Administration of Glucose

Objectives
• Describe when to consider the administration of oral glucose to a patient.
• List the contraindications for administering oral glucose.
• Describe the assessment of a patient experiencing a hypoglycemic episode, including the
ongoing assessment.
• List the equipment needed to administer oral glucose.
• Describe how to administer oral glucose.
• Discuss the special considerations associated with administration of oral glucose.
54
Overview
I. Oral glucose is used to treat patients with a history of diabetes exhibiting an altered
mental status (AMS) and the ability to swallow.
• Oral glucose is a form of glucose.
• Can reverse a diabetic’s hypoglycemic condition.
• Time of administration can make a critical difference.
• Preparation comes in a tube.
II. Assessment
• Determine if the patient takes insulin or an oral hypoglycemic agent, as well as
when these medications were taken last.
• Determine when the patient had eaten last.
• Determine if the patient has had overexertion or recent illness.
• Determine is there has been vomiting.
• Determine if the onset of AMS was rapid or slow.
• Determine if the patient is able to swallow and has a gag reflex.
III. Equipment
• BSI
• Oral glucose tube
• Tongue depressor
• Suction
IV. Skill Close-up
• Obtain medical consent.
• Consult with medical control for medication administration instructions.
• Review protocols or standing orders.
• Reassess patient’s ability to swallow.
• Explain the procedure to the patient.
• Confirm the five rights of medication administration:
• Right patient
• Right drug
• Right dose
• Right time
• Patient may self administer
• Document
• Monitor patient for subtle mental status changes.
• Monitor airway.
• Monitor vital signs.
VI. Problem solving
• Patient may have a glucose monitor that may be used by the EMT-B if approved
by local protocol.
• Do not give anything orally to a patient with the inability to swallow or intact gag
reflex.
• Utilize ALS for patients with the inability to swallow or intact gag reflex.
Key Terms
Diabetes mellitus – also called “sugar diabetes” or just “diabetes,” the condition brought about
by decreased insulin production. The person with this condition is a diabetic.
Hypoglycemia – low blood sugar.
Insulin – a hormone produced by the pancreas or taken as a medication by many diabetics.
Oral glucose – a form of glucose given by mouth to treat an awake patient with an altered mental
status and a history of diabetes.
55
Teaching Activities
• What is the role of insulin in the diabetic patient?
• Why is the field treatment of low blood sugar more urgent than high blood sugar?
• Allow adequate time to practice administering oral glucose to a simulated hypoglycemic
patient. You may want to substitute cake frosting for the classroom setting to be realistic.
Other ideas:
• If the Medical Director or ALS instructor is available it would be helpful to review how a
glucometer works since many patients will have these devices in their home.
Segment Name: Metered Dose Inhaler

Objectives
• Describe when to consider the administration of a metered dose inhaler (MDI) to a
patient.
• List the contraindications for an MDI.
• Explain what a bronchodilator is and list the most common bronchodilator medications.
• Describe the assessment of a patient experiencing respiratory distress, including the
ongoing assessment.
• List the equipment needed to administer an MDI.
• Describe how to assist a patient with an MDI.
• Discuss the special considerations associated with administration of an MDI.
Overview
I. Metered dose inhalers (MDIs) administer a prescribed dose of medication
• Usually to patients with a history of chronic pulmonary disease
• The most common medication found in MDIs are bronchodilators
II. Bronchodilators are drugs that dilate, or enlarge the air passages, making breathing
easier.
• Bronchodilators begin to work immediately.
• Effects last for hours.
• The device administers a specific measured (metered) dose of medication.
• A spacer can be utilized to help administer the medication.
III. The most common bronchodilators include:
• Albuterol (Proventil, Ventolin®)
• Metaproterenol (Metaprel®, Alupent®)
• Isoetharine (Bronchosol®, Bronkometer®)
IV. MDIs are usually self-administered by the patient.
• EMT-Bs may assist the patient when they are unable to self-administer.
• EMT-Bs must consult with medical control or local protocol on the appropriate
dose, as well as guidelines on multiple dosing.
V. Use of an MDI is indicated when:
• A patient is short of breath and/or has signs and symptoms of difficulty breathing.
• The MDI has been prescribed to a patient by a physician.
• Local protocols or medical direction has approved the use of the device.
VI. Use of an MDI is contraindicated when:
• The patient is unable to use the device (i.e. unresponsive).
• The patient has already taken the maximum number of doses prior to the arrival
of EMT-Bs.
• Permission has not been given by local protocols or medical direction.
56
VII. Assessment
• Determine if the patient has taken the MDI prior to your arrival and if so, how
many times.
VIII. Equipment
• BSI
• MDI
• Stethoscope
• Oxygen
IX. Skill overview
• BSI
• Right patient
• Right drug
• Right dose
• Right time
• Check expiration date and that this medication is prescribed to this patient.
• Shake MDI before use.
• Best used at room temperature.
• Explain the procedure to the patient and obtain consent.
• Assist the patient with the MDI.
• Place oxygen on the patient.
• Document.
X. Ongoing Assessment
• Reassess vital signs, pulse oximetry and other pertinent physical findings.
• Continuously monitor the patient for drug effects, including adverse reactions.
• Document any changes.
XI. Problem Solving
• Timing and coordination is key in MDI administration.
• Consider the use of a spacer.
• Wait at least two minutes prior to administering additional doses.
Key Terms
Asthma – a condition triggered by an allergen, exercise, or emotional stress. Asthma affects
young and old patients with episodic attacks that occur at irregular intervals. The patient is free of
symptoms between attacks. During an attack, bronchioles in the lungs constrict and mucus is
produced. This causes wheezing and severe difficulty breathing.
Bronchodilator – a drug designed to dilate the constricted bronchial tubes in order to make
breathing easier.
Metered dose inhaler (MDI) – a patient self-administered prescribed inhaler, usually a
bronchodilator.
Spacer – a “spacer” device between an inhaler and the patient allows more effective use of
medication. If the patient has a spacer, it should be attached to the inhaler before use.
Teaching Activities
• Can the use of an MDI hurt a patient? If so, give examples of someone it could hurt.
• Why are spacers often used for children who use an MDI?
• Allow adequate time to practice administration of an MDI with a simulated medication and
patient.
Other ideas:
• Sometimes the manufacturers produce MDIs that can be used for training, which do not
actually contain medication.
57
Segment Name: Nitroglycerin
Objectives
• Describe when to consider the administration of nitroglycerin (nitro) to a patient.
• Describe what type of medication nitro is and how it works.
• List the indications for the administration of nitro.
• List the contraindications for the administration of nitro.
• List the possible side effects of nitro.
• Describe the assessment of a patient experiencing chest pain, including the ongoing assessment.
• List the equipment needed to administer nitro.
• Describe how to assist a patient with nitro.
• Discuss the special considerations associated with administration of nitro.
Overview
I. Nitroglycerin (nitro) is a potent vasodilator which helps to dilate the coronary arteries
that supply the heart with blood.
• Relieves the chest pain associated with angina.
• Patients that are prescribed nitro are instructed to take the medication when they
experience chest pain and may have taken it before the EMT-B arrives on scene.
• Assisting a patient with nitroglycerin may help to reduce myocardial damage.
• Absorption rate is 1 to 2 minutes with a duration of 30 minutes.
II. To assist a patient with nitro, all of the following indications must be met:
• The patient complained of chest pain.
• The patient has a history of cardiac problems.
• The patient’s physician has prescribed nitro.
• The patient has the medication and it is prescribed to them.
• The patient’s systolic blood pressure is greater than 100.
• Medical direction, a medical standing order, or local protocol allows you to assist
with nitro.
III. Contraindications for administering nitro include:
• The patient’s systolic blood pressure is less than 100.
• The patient has already taken the maximum prescribed doses.
• The patient is unable to open his or her mouth.
• The patient has taken Viagra® within the last six hours.
• The patient has a head injury.
• The patient is an infant, child, or falls below an age limit set by local protocols.
• Presence of significant trauma
IV. Possible side effects include:
• Hypotension
• Headache
• Changes in pulse rate
V. Equipment
• Patient’s nitro tablets or spray
• Stethoscope
VI. Assessment
• Complete an initial assessment of the patient.
• Administer high concentration oxygen.
• Complete a focused history and physical exam.
• Make sure the patient meets the indications for using nitro.
• Make sure the patient exhibits none of the contraindications.
• Take full set of vital signs including blood pressure prior to administration.
VII. Skill Overview
• BSI
58
• Consult with medical direction and/or review any standing medical orders or
protocols.
• Right patient
• Right drug
• Right dose
• Right time
• Check expiration date.
• Ask the patient when the nitro container was opened and how it was stored.
• Nitro is sensitive to light, heat, and age.
• Ask when the patient last took nitro and what the reaction was.
• Have the patient take a comfortable position that will allow for ability to lay supine
if necessary.
• Remove the oxygen mask and administer the medication.
• Assist the patient with the nitro.
• Replace the oxygen mask.
• Reassess blood pressure within two minutes.
• Document.
VIII. Ongoing Assessment
• Monitor the patient’s vital signs every 5 minutes.
• Ask the patient about response or relief.
IX. Problem Solving
• The most common and significant problem with nitro is a hypotensive response.
• First time users of nitro or patients who drank alcohol or who are taking
antihypertensive medications can have more prominent hypotensive effects.
• Place the patient in a supine position and elevate the legs.
• Wear PPE to prevent absorption of the medication into your own system.
• Headaches are a common side effect of the medication.
• If the patient does not have nitro with them provide immediate transport and
request ALS back up.
Key Terms
Nitroglycerin – a medication that dilates the blood vessels.
Vasodilator – a drug, which acts to widen or dilate the blood vessels.
Teaching Activities
• What is the significance of finding a patient who has a nitro patch or paste applied to his
chest wall?
• Why does fresh nitro produce a headache for the patient?
• Allow adequate time to practice the skill of nitro administration with mint TicTacs®
(candy) in a simulated patient. Binoca® breath spray is another option.
Other ideas:
• Discuss the value of nitrates in the management of other cardiac patients.
59
Segment Name: Epinephrine Auto Injector
Objectives
• Describe when to consider the administration of an epinephrine auto injector (Epi pen) to
a patient.
• List the contraindications for an auto injector.
• Describe the assessment of a patient experiencing allergic reaction, including the
ongoing assessment.
• List the equipment needed to administer an auto injector.
• Describe how to assist a patient with an auto injector.
• Discuss the special considerations associated with administration of an auto injector.
Overview
I. Epinephrine auto-injector (Epi pen)
• A life-saving self-administered medication
• Prescribed by a physician to a specific patient
• EMT-Bs may assist administration (depending on State, Regional or local
protocols)
• Disposable prepackaged single dose
• Usually administered in the thigh
II. Equipment
• BSI
• Patient’s auto-injector
• Sharps or biohazard container
• Oxygen equipment
III. Assessment
• Complete an initial assessment on the patient.
• Administer high concentration oxygen to the patient.
• Assess for signs of allergic reaction, which may include:
• Altered level of consciousness
• Rash
• Hives
• Edema
• Shortness of breath
• Signs of hypotension or shock
• Pale, cool, moist skin
• Rapid pulse
• Thirst
• Hypotension
IV. Skill Overview
• BSI
• Obtain the patient’s auto-injector.
• Make sure the medication is visible and is not cloudy or discolored.
protocols.
• Right patient
• Right drug
• Right dose
• Right time
• Check expiration date.
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• Expose the thigh area.
• Place the auto-injector device on the lateral thigh midway between the knee and
the waist.
• Administer the medication.
• Dispose of the injector in a sharps or biohazard container.
• Document.
• Reassess vital signs and patient condition.
• Consider the need for a second dose if the patient’s condition deteriorates and
medical control approves.
• Assess blood pressure, pulse, respirations, skin signs, and other earlier positive
physical findings.
VI. Problem Solving
• The spring-loaded device needs firm pressure against the thigh.
• Make sure that you are pressing hard enough.
• Needle stick injuries are possible; if one occurs consult local protocols and
implement needle stick procedures immediately.
• Immediately consult with medical control if the patient experiences any adverse
effects from the medication.
Key Terms
Anaphylaxis – a severe or life-threatening allergic reaction in which the blood vessels dilate,
causing a drop in blood pressure, and the tissues lining the respiratory system swell, interfering
with the airway. Also called anaphylactic shock.
Epinephrine auto injector – a syringe with a spring-loaded needle that will release and inject
epinephrine into the muscle when the auto-injector is pushed against the thigh.
Urticaria – a skin reaction in which there is intense itchiness near pale, irregular raised patches
of skin. Also called a “nettle rash.”
Teaching Activities
• Why is it important to determine if the patient has a second epi auto-injector and to bring
it along to the hospital?
• What are examples of allergies patients may have?
• Allow adequate time to practice this skill with an auto-injector trainer and a simulated
patient.
Other ideas:
• The manufacturer of the medication can provide an auto-injector trainer to use in training
students in this technique.
Segment Name: Administration of Nebulized Medication

Objectives
• Describe when to consider the administration of a nebulized medication to a patient.
• List the medications that might be used in a nebulizer.
• List the contraindications for the use of a nebulizer.
• Describe the assessment of a patient experiencing respiratory distress, including the
ongoing assessment.
• List the equipment needed to administer a nebulized medication.
• Describe how to assemble the nebulizer.
• Describe how to assist a patient with a nebulizer.
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• Discuss the special considerations associated with administration of a nebulized
treatment.
Overview
I. A nebulizer is a device which aerosolizes medications into a mist for delivery directly
into the lungs.
• A fast, non-invasive way to administer medication.
• Requires an air compressor or oxygen delivery system.
• The patient has to be alert enough to assist in the delivery process.
II. Equipment
• BSI
• Medication
• Hand-held nebulizer
• Connection tube
• Nebulizer chamber
• T-tube
• 6-inch flex
• Mouthpiece
• Oxygen tank and regulator
III. Assessment
• Complete initial assessment.
• Administer high-concentration oxygen.
• Determine if the patient has the ability to use the hand-held nebulizer.
• Determine the drug to be administered (albuterol, Atrovent).
IV. Skill Overview
• BSI
protocols.
• Right patient
• Right drug
• Right dose
• Right time
• Check expiration date and that the medication is prescribed to this patient.
• Add the medication to the nebulizer chamber attach lid.
• Connect the mouthpiece to one end of the T-tube and the flex tube to the other
end.
• Attach oxygen-connecting tube from nebulizer to the oxygen source.
• Adjust oxygen to 6 liters per minute.
• Ask the patient to sit upright and hold the nebulizer.
• Ask the patient to place the mouthpiece in his/her mouth tightly and breathe
deeply and slowly through the mouth until the medication is gone.
• Document.
• Reassess vital signs and patient condition.
• Consider the need for a second dose if the patient’s condition deteriorates and
medical control approves.
• Assess blood pressure, pulse, respirations, skin signs, and other earlier positive
physical findings.
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VI. Problem Solving
• For the procedure to be effective, the patient has to be alert and have a fair
respiratory volume.
• Contact medical control for options if treatment is not effective or patient
deteriorates.
Key Terms
Chronic obstructive pulmonary disease (COPD) – an irreversible disease in which there is an
obstruction in the lungs causing respiratory difficulty.
Nebulizer – a device, which causes a gas such as oxygen to flow through a liquid medication,
turning it into a vapor that can be continuously inhaled.
Teaching Activities
• What are examples of patients who may need a nebulizer treatment?
• What is a wheeze?
• Allow adequate time to practice administering a nebulizer treatment using sterile water
(instead of actual medication) on a simulated patient.
Other ideas:
• To simulate the sensation of difficulty breathing that a patient with reactive airway
disease may have, ask the students to imagine breathing through a cocktail straw while
someone is sitting on their chest!
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Tape 2 Medical Emergencies
Segment Name: Automated External Defibrillator
Objectives
• Explain the need for an automated external defibrillator (AED) and its role in the chain of
survival.
• List the equipment needed to administer shocks to a patient using an AED.
• List the indications for the use of an AED.
• Describe the procedure to use an AED.
• Explain what to do when an AED specifies “no shock indicated.”
• Explain the steps to take when pulses return after shock(s) have been administered.
• Describe the steps to take in the ongoing assessment.
• Discuss the special considerations associated with the use of an AED.
Overview
I. Automated External Defibrillator (AED)
• One of the most important links in the chain of survival.
• A device that delivers an electrical shock through the chest wall to the heart
which is fibrillating or is in ventricular tachycardia.
• The goal is to stop the heart from fibrillation so the normal pacemaker can take
over.
• Simple to operate allowing for many potential users.
• Two types of AED – monophasic and biphasic (user will not know the difference).
II. Equipment
• BSI
• AED
• Defibrillator pads
• Razor
• Oxygen
• Ventilator
• Bag-valve mask
III. Assessment
• Patient must be unconscious, non-breathing, and without a pulse (signs of
circulation).
• If CPR is in progress have the responder stop CPR to verify pulselessness and
breathing status. Look for external blood loss.
IV. Skill close-up
• Upon arrival, briefly question those on the scene about the arrest events.
• If someone is performing CPR direct them to stop momentarily for assessment.
• Lay the patient supine on a dry, non-metallic surface.
• If a pulse or signs of circulation are absent perform or resume CPR.
• One EMT-B performs CPR while another sets up the AED.
• Determine whether the patient is a candidate for the AED.
• If the patient is at least 8 years old and has not sustained
trauma, proceed with the AED.
• If the patient is younger than 8 years old or has sustained trauma
do not attach the AED unless instructed to do so by medical
direction. Continue CPR and transport.
• Turn on AED, attach defibrillator pads to the patient’s chest, and follow
instructions provided by the AED.
• If the device detects a shockable rhythm, prepare to shock.
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• If the device does not detect a shockable rhythm, check the patient’s pulse. If
no pulse, resume CPR for one minute then reanalyze.
• Even if a pulse returns, in most cases the patient will require ventilatory
assistance.
1. If breathing is adequate, apply high-concentration oxygen by
non-rebreather mask.
2. If breathing is not adequate, ventilate the patient with high-
concentration oxygen.
• If pulses have returned, check the blood pressure and respirations.
• If no pulse returns, continue CPR and reanalyze with the AED as directed by
medical control or local protocol.
• Continue on with the reassessment of the initial assessment.
VI. Problem Solving
• Safety for the patient and the responders is essential during defibrillation.
• Move the patient to a safe area when necessary.
• Remove any nitro patches from the patient.
• Do not allow anyone to touch the patient during the AED’s assessment and
defibrillation.
• The AED will not function properly if there is any patient movement (i.e.: CPR or
ventilations) or the defibrillation pads are not placed securely on the patient.
• Hypothermic patient – consult your local treatment protocols.
• Batteries
VII. Transport the patient as soon as one of the following occurs:
• You have administered six shocks.
• You have received three consecutive “no shock indicated” readings (separated
by one minute of CPR).
• The patient regains pulses.
Key Terms
Automated External Defibrillator (AED) – an automated defibrillator with a microprocessor that
interprets the rhythm and determines whether or not it is appropriate to deliver a shock.
Biphasic – a newer method in which a defibrillator delivers a shock. The energy goes in one
direction, then reverses itself and moves in the opposite direction between the two electrodes.
Defibrillator pads – self-adhesive pads (patches) that attach to the patient and plug into the AED
for the purpose of monitoring and defibrillation.
Monophasic – is one method in which a defibrillator delivers a shock. The traditional direct
current shock goes from one electrode to the other.
Teaching Activities
• How should the electrodes be placed if you feel a pacemaker battery under the skin?
• Why is it so important that AEDs be available in places of mass public occupancy?
• Allow adequate time to practice the use of an AED.
Other ideas:
Note: become familiar with the AED protocols and Public Access Defibrillation (PAD) projects.
Some states allow defibrillation of children less than 8 years old with the appropriate AED, as well
as require these devices in the schools.
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Segment Name: Application of Soft Restraints
Objectives
• Describe when it is appropriate to consider the use of reasonable force and soft
restraints.
• Explain the goal of the use of soft restraints.
• Describe the assessment and ongoing assessment of a patient who is, or may be, a
danger to himself or others.
• List the equipment needed to apply soft restraints.
• Explain the approach to take with the patient that needs to be restrained.
• Explain the possible dangers to the patient, as well as the rescuers when soft restraints
are used.
• Discuss the special considerations associated with the use of soft restraints.
Overview
I. When it has been determined that the patient is a danger to himself or others,
reasonable force and restraint may be used.
• The goal is to restrain the patient and not harm him or her.
II. Assessment
• Always consider physiologic causes for the patient’s behavior.
• Make sure the patient is not carrying a weapon.
• You can perform a “pat-down” during the patient assessment.
• Attempt to determine what triggered the patient’s unruly behavior.
• Quickly perform a scene assessment.
• Make sure the scene is safe. Law enforcement should be required to intervene if
the patient is extremely combative or wielding a weapon.
• Always have an exit plan and stay at least an arm’s distance from the patient.
III. Equipment
• Soft restraints
• Sufficient personnel, one person per extremity at a minimum
• Surgical mask or oxygen mask
• BSI
• Wipe tape, sheets
IV. Skill Close-up
• BSI
• Plan your actions ahead of time.
• Assign one person to each limb.
• Rescuers should act all at once to overwhelm the patient.
• Attempt to grab clothing or large joints, avoid placing pressure on the neck or
chest.
• Avoid the mouth as some patients may try to bite.
• An EMT-B should be assigned to reassure the patient throughout the procedure.
• Secure all limbs with restraints approved by local protocol.
• The patient should be secured on the ambulance stretcher in a supine or lateral
position.
• If the patient is spitting at rescuers, a surgical mask or oxygen mask (connected
to oxygen) can be placed over the patient’s face.
• Continually monitor distal circulation in restrained extremities.
• Once restrained do not leave the patient at any time.
• Consider having extra personnel in the ambulance’s patient compartment during
transport.
• Monitor ABCs.
• Do not remove restraints unless sufficient personnel are available to restrain the
patient.
• Document how and why the patient was restrained.
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• Constantly reassess restrained extremities during transport.
• Monitor ABCs.
• Reassess vital signs.
VI. Problem Solving
• Be familiar with the type of restraints carried in your ambulance.
• Practice using them before you need them.
• Consider ALS resources for chemical restraint.
Key Terms
Chemical restraints – drugs, which may be used to sedate or calm a patient who may be
harmful to himself or others.
Reasonable force – to place whatever reasonable restraints are required on the patient as
quickly as possible, and with the least amount of discomfort to the patient, and with the least
amount of force.
Soft restraints – humane restraints such as wide roller gauze or commercial restraints designed
for the purpose of humane restraint.
Teaching Activities
• Why is it dangerous and no longer allowed, to restrain a patient in the prone position?
• Why is it dangerous to “hog tie” a patient?
• Allow adequate time to practice patient restraint in a room that has mats and no furniture.
Other ideas:
• Consider reviewing a copy of the Position Paper of the National Association of EMS
Physicians on patient restraint in Emergency Medical Services with the students.
• If there is any danger to EMS personnel it is strongly advised that the police be contacted
prior to restraint of the patient.
Segment Name: Childbirth

Objectives
• Describe the stages of labor.
• List the indications of imminent delivery.
• Review the questions to ask in the focused history of a pregnant patient.
• List the equipment needed to assist a patient with childbirth.
• Describe the assessment of a patient experiencing labor.
• Describe how the EMT-B can best prepare the patient and assist the patient with delivery
of the baby.
• Describe how to clamp and cut the umbilical cord.
• Describe the steps in delivery of the placenta.
• List the steps in the ongoing assessment of infant and mother.
• Describe the possible complications of childbirth.
• Explain the steps to take when vaginal bleeding becomes excessive after delivery.
Overview
I. Childbirth is a natural process, the EMT-B may assist.
• Pregnancy is divided into 9 months or 3 trimesters.
• Labor is divided into the following three stages:
1. The first stage begins when contractions start and cervix
becomes fully dilated.
2. The second stage ends when the baby is delivered.
3. The third stage ends with the delivery of the placenta.
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• When contractions begin, they usually last for 30 seconds to 1 minute and occur
at 2- to 3- minute intervals. Contractions less than 2 minutes apart are a sign
of delivery.
• A transport decision will need to be made based on the indications of imminent
delivery.
II. Assessment
• Begin to evaluate the mother by asking the following questions:
• What is the due date?
• What prenatal care have you received?
• Have you had any complications in your pregnancy?
• Is this your first pregnancy?
• Describe your contractions, how long and how far apart are
they?
• Have you had any vaginal discharge; if so, what color and how
much?
• Has your water broken?
• Do you have the urge to urinate or defecate?
• Do you have the urge to push?
• Obtain a SAMPLE history and baseline vital signs.
• Be observant for hypertension.
• Examine for crowning (the baby’s head visible through the vaginal opening).
• Be reassuring and respectful of the patient’s privacy.
III. Equipment
• BSI
• Obstetric kit which contains the following:
• Sterile gloves
• Plastic bag to store placenta
• Umbilical cord clamp or ties
• Umbilical cord scissors
• Towels or sheets to keep delivery area as sterile as possible
• Bulb syringe (to suction baby)
• Sanitary pad (to help control bleeding)
• Gauze sponges or towels (to dry baby)
• Baby blanket
IV. Skill Close-up
• BSI
• Remove clothing that obstructs the vaginal area.
• If possible, clean vaginal area with antiseptic towelettes.
• Using sheets, drape the patient leaving vaginal area exposed.
• As the baby’s head presents, support the head and apply slight counter-
pressure.
• Spread your fingers across the head avoiding the fontanelles.
• If the amniotic sac has not ruptured, gently tear it open.
• Once the head has delivered, quickly suction the baby’s mouth, then nose.
• If the umbilical cord is wrapped around the baby’s neck, gently remove it.
• If you cannot remove the cord, clamp the cord in two places and
cut.
• After the head, the anterior shoulder will deliver first. As the anterior shoulder
delivers, apply gentle downward pressure.
• After the anterior shoulder, the posterior shoulder will deliver. As the posterior
shoulder delivers, apply gentle upward pressure.
• Support the trunk and feet as the rest of the baby delivers.
• After delivery, dry off the baby and continue to monitor the airway, suctioning as
needed.
• Wrap the baby in blankets to conserve warmth.
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• Keep the baby at the same level as the vaginal opening until the umbilical cord
stops pulsating.
• To cut the cord, place one clamp 7 inches from the baby and a second clamp 10
inches from the baby and cut between the clamps.
• Note the time of birth.
• Placental delivery usually begins within 10-15 minutes after the baby has
delivered.
• Never pull on the placenta.
• Save the placenta for examination in the ED.
• Monitor the mother and baby during transport to the hospital.
• For the baby:
• Immediately assess baby after birth and 5 minutes later.
• Monitor breathing, heart rate, crying, movement, and skin color.
• Maintain warmth.
• If the baby is not breathing after 30 seconds of stimulation, resuscitation will be
necessary. The EMT-B should focus on these measures:
1. Drying
2. Warming
3. Positioning
4. Suctioning
5. Tactile stimulation
6. Oxygen
7. Bag mask ventilation
8. Chest compression
• For the mother:
1. Placenta usually delivers several minutes after childbirth.
2. Keep all afterbirth tissue. The receiving physician will examine it
for abnormality.
3. The mother may continue to bleed vaginally but usually no more
than 500cc.
4. If excessive bleeding occurs, sanitary pads may be placed over
(not into) the vagina to help control bleeding.
5. Massage the uterus through the abdomen, stimulating uterine
contractions, which stop bleeding.
6. Nursing the baby also promotes the release of oxytocin, a
hormone that causes uterine contractions.
7. Monitor for signs and symptoms of hypovolemic shock.
8. Transport in position of comfort.
VI. Problem Solving
• Breech presentation (buttocks or feet first)
• Prolapsed cord (umbilical cord presents first)
• Limb presentation (arm or leg presentation)
• Meconium
Key Terms
Breech presentation – when the baby appears buttocks or both legs first during birth.
Limb presentation – when a baby’s limb protrudes from the vagina before the appearance of
any other body part.
Meconium staining – amniotic fluid that is greenish or brownish-yellow rather than clear as a
result of fetal defecation; an indication of possible maternal or fetal distress during labor.
Obstetric Kit – a childbirth delivery kit.
Prolapsed umbilical cord – when the umbilical cord presents first and is squeezed between the
vaginal wall and the baby’s head.
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Teaching Activities
• Why is good prenatal care so important?
• What are the effects of delivering an infant to a mother who is addicted to narcotics?
• Allow adequate time to practice skill of childbirth with a mannequin.
Other ideas:
• Review newborn resuscitation and the inverted triangle.
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Tape 1 Trauma Emergencies
Segment Name: Bleeding Control / Shock Management
Objectives
• List the signs and symptoms of shock.
• Describe the three types of external bleeding.
• Describe the primary methods for controlling external bleeding.
• List the equipment needed for controlling bleeding.
• Describe how to assess the patient with external bleeding.
• Describe how to bandage and dress a bleeding injury.
• Explain how to treat a patient who is in shock.
• Explain the special considerations associated with the use of occlusive dressings, air
splints, PASG, and tourniquets.
• Describe the special techniques used for managing impaled objects, avulsions,
amputations, and open neck and chest wounds.
Overview
I. Signs of shock include:
• Pale, cool, clammy skin
• Nausea and vomiting
• Thirst, dilated pupils, cyanosis
• Vital sign changes to include:
Increased pulse, followed by decreased pulse
Increased respirations, labored, shallow, irregular
Decreased blood pressure
II. Types of external bleeding
• Arterial
• Venous
• Capillary
III. Methods for controlling bleeding
• Direct pressure
• Elevation
• Pressure points
IV. Equipment needed for controlling bleeding includes:
• Gloves, goggles, mask, and/or gown
• Absorbent materials
• Bandaging materials
• Pressure dressing
• Occlusive dressing
• Tape
V. Assessment
• BSI
• Estimate amount of blood loss.
• Expose.
• Recognize signs of shock.
• Manage life-threatening bleeding.
VI. Treatment
• BSI
• Expose.
• Apply direct pressure.
• Elevate.
• If bleeding persists, apply more pressure, bandages and elevate.
• Locate arterial pulse proximal to the injury site and apply pressure.
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• Bandage dressing in place.
• Assess distal circulation.
• Position the patient and transport.
• Reassess.
VII. Treatment for shock
• Position the patient.
• Maintain airway and apply oxygen.
• Explain procedure to patient and obtain consent.
• Elevate legs.
• Prevent heat loss.
• Monitor patient.
• Reassess.
• Occlusive dressings
• Air splints /PASG
• Tourniquets
IX. Dressing and Bandaging
• Prevents further bleeding
• Prevents further contamination
• Once in place do not remove bandage.
X. Special Techniques
• Impaled objects
• Avulsions
• Amputations
• Open chest wounds
Key Terms
Amputation – the surgical removal or traumatic severing of a body part, usually an extremity.
Arterial bleeding – is characterized by bright red, spurting blood, which indicates that an artery
has been damaged or severed.
Avulsion – the tearing away or tearing off of a piece or flap of skin or other soft tissue. This term
also may be used for an eye pulled from its socket or a tooth dislodged from its socket.
Capillary bleeding – is characterized by dark red blood oozing slowly from a wound.
Occlusive dressing – any dressing that forms an airtight seal.
PASG – pneumatic anti shock garment. A large air splint used for the treatment of shock, pelvic
injuries or instability accompanied by shock, and to control bleeding in massive soft-tissue injuries
to the lower extremities.
Tourniquet – a device used for bleeding control that constricts all blood flow to and from an
extremity.
Venous bleeding – is characterized by a dark red, steady flow of blood, which indicates a vein is
severed or damaged.
Teaching Activities
• How do the types of bleeding differ?
• What is a pressure point and what are two examples of one?
• Allow adequate time to practice bleeding control.
Other ideas:
• Demonstrate how to immobilize a pencil in the eye or a sheet of glass in a patient’s back.
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Segment Name: Immobilizing a Long Bone
Objectives
• List the signs of a dislocated or fractured long bone.
• Describe the types of splints used to immobilize a fracture.
• List additional equipment used to splint a fracture.
• Describe the assessment of a patient with a possible fracture including ongoing
assessment.
• Explain the procedure for splinting a long bone.
• Describe the hazards of incorrect splinting.
Overview
I. Signs and symptoms
• Exposed bone ends
• Joints locked in position
• Pain, paralysis, paresthesia
• Pallor of the injury site
II. Types of splints
• Rigid
• Formable
• Traction
III. Equipment needed to splint a long bone
• Rigid or formable splint
• Cravats, Kling bandage, or tape
• Padding
IV. Assessment
• Safety /BSI
• Manage ABCs.
• Rapid Trauma Assessment (RTA) / Focused Physical Exam (FPE).
• Recognize signs of shock.
• Assess for pain, pallor, paresthesia, pulses, and paralysis on injured extremity.
V. Skill overview
• BSI
• Stabilize the injury.
• Expose the injury.
• Select appropriate splint.
• Explain procedure to the patient and obtain consent.
• Assess distal pulses, motor function and sensation (PMS).
• Apply splint.
• Reassess PMS.
• Document.
VI. Ongoing assessment
• Reassess distal PMS.
• Reevaluate splint.
VII. Hazards of incorrect splinting include:
• Loss of pulses distal to the injury
• Most rigid splints require padding.
• Splint is too loose.
• Splint is too tight.
• Open fractures with protruding bone ends
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Key Terms
Closed fracture – an internal injury with no open pathway from the outside.
Crepitus – the grating sound or feeling of broken bone rubbing together.
Open fracture – an injury in which the skin has been broken or torn through from the inside by an
injured bone or from the outside by something that has caused a penetrating wound with
associated injury to the bone.
Paralysis – loss of muscle function caused by injuries or disease of the nerves, brain, or spinal
cord.
Paresthesia – an abnormal sensation such as numbness or tingling.
Traction splint – a special splint that applies constant pull along the length of a lower extremity
to help stabilize the fractured bone and to reduce muscle spasms. Traction splints are used
primarily on femoral shaft fractures.
Teaching Activities
• What is a long bone?
• Give four examples of long bones.
• Allow adequate time to practice long-bone splinting.
Other ideas:
• Demonstrate how traction could be applied to a long bone when no traction splint is
available.
Segment Name: Joint Immobilization

Objectives
• List the signs and symptoms of a dislocated joint.
• List the equipment needed to splint a joint injury.
• Describe assessment of a joint injury including ongoing assessment.
• Describe the procedure for splinting a joint injury.
• Explain the special considerations associated with open fractures.
• Explain the special techniques used to immobilize an ankle, knee, wrist, elbow, and
fingers.
Overview
I. Signs and symptoms of a dislocated joint
• Pain, tenderness and/ or bruising
• Deformity and swelling
• Grating or crepitus
• Severe weakness or loss of function
• Locked joint
II. Equipment
• Rigid splint
• Formable splint
• Cravat, Kling, Ace bandage, or tape
• Padding
• Cold pack
III. Assessment
IV. Skill overview
• BSI
• Select appropriate splint.
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• Assess distal pulses, motor response, and sensation (PMS).
• Apply splint.
• Reassess PMS.
• Apply cold pack.
• Document.
V. Ongoing assessment
VI. Problem solving
• Splint in position found, in most cases.
• Open fractures / exposed bone ends
• Rigid splints often require padding.
• Using a cold pack to reduce swelling
VII. Special techniques
• Ankle
• Knee
• Wrist
• Elbow
• Fingers
Key Terms
Dislocation – the disruption or “coming apart” of a joint.
Teaching Activities
• Why shouldn’t an injured elbow or knee be straightened before splinting?
• Allow adequate time to practice splinting joints.
Other ideas:
• Demonstrate how to immobilize a bent, injured knee by using 2 board splints and cravats
to triangulate.
Segment Name: Applying a Hare Traction Splint

Objectives
• List the signs and symptoms of a mid-shaft femur fracture.
• List the equipment needed to splint a mid-shaft femur fracture.
• Explain the potential for the development of shock due to a femur fracture.
• Describe the assessment of a patient with a suspected femur fracture, including ongoing
assessment.
• Describe the procedure for applying a Hare traction splint.
• Explain the special considerations associated with compound and open fractures.
Overview
• Pain and tenderness
II. Equipment to apply a Hare traction splint includes:
• Hare traction splint
• Ankle hitch
• Splint straps or cravats
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III. Assessment
• Manage ABCs.
• Perform Rapid Trauma Exam (RTE) or Focused Physical Exam (FPE).
• Recognize potential for shock due to significant blood loss.
IV. Skill overview
• Traction splint is contraindicated for knee, ankle, or hip dislocation/ fracture.
• BSI
• Measure and apply splint.
• Reassess PMS.
• Move patient onto long spine board and reassess.
• Document.
• Reevaluate the splint.
VI. Problem solving
• Hemorrhage from femoral artery
• Compound fractures
• Open fractures
Key Terms
Ankle hitch - a strap used with a traction splint or with a single-padded board splint to
immobilize injured knees or legs.
HARE traction splint - a bipolar commercial traction splint.
Teaching Activities
• Why does a femur fracture need traction?
• Why don’t we use a traction splint on a hip fracture?
• Allow adequate time to practice traction splinting.
Other ideas:
• Demonstrate alternative methods of tying an ankle hitch with a cravat when the
commercial Hare traction ankle hitch is not available.
Segment Name: Applying a Sager Splint

Objectives
• List the signs and symptoms of a mid-shaft femur fracture.
• List the equipment needed to splint a mid-shaft femur fracture.
• Explain the potential for the development of shock due to a femur fracture.
• Describe the assessment of a patient with a suspected femur fracture, including ongoing
assessment.
• Describe the procedure for applying a Sager traction splint.
• Explain the special considerations associated with compound and open fractures.
76
Overview
II. Equipment
• Sager traction splint
• Sager ankle hitch
• Straps or cravats
III. Assessment
• Manage ABCs.
• Recognize potential for shock due to significant blood loss.
IV. Skill overview
• Traction splint is contraindicated for knee, ankle, or hip dislocation/ fracture.
• BSI
• Explain procedure to the patient.
• Measure and apply splint.
• Reassess PMS.
• Move patient onto long spine board and reassess.
• Document.
• Reevaluate the splint’s effectiveness.
VI. Problem solving
• Hemorrhage from femoral artery
• Compound /open fractures
Key Terms
Sager splint - a unipolar commercial traction splint.
Teaching Activities
• What is the difference between a simple and compound femur fracture?
• Why is it necessary to use traction when splinting a fractured femur?
• Allow adequate time to practice Sager® traction splinting.
Other ideas:
• Demonstrate alternative methods of tying an ankle hitch with a cravat when the
commercial Sager traction hitch is not available.
77
Segment Name: Sling and Swathe Immobilization of a Shoulder Girdle
Objectives
• List the signs and symptoms of a dislocated /fractured shoulder.
• List the equipment needed to splint a shoulder injury.
• Describe assessment of a patient with a shoulder injury including ongoing assessment.
• Describe the procedure for splinting a shoulder injury using a sling and swathe.
• Explain the special considerations associated with open and compound fractures/
dislocations.
• Describe the special considerations of an associated Spinal Cord Injury (SCI).
Overview
I. Signs and symptoms of a fracture/ dislocation of the shoulder girdle (humerus,
clavicle or scapula)
• Dropped shoulder
II. Equipment
• Triangle bandages or cravats
• Safety pin
• Padding/ pillow
III. Assessment
• Manage ABCs.
IV. Skill overview
• BSI
• Apply sling and secure with swathe.
• Document.
• Reevaluate the splint’s effectiveness.
VI. Problem solving
• Open fractures/ dislocation
• Compound fractures/ dislocation
• Associated Spinal Cord Injury (SCI)
• Knots impeding on soft tissue or spine
78
Key Terms
Sling – a triangle bandage used to support the shoulder and arm.
Swathe – a triangle bandage tied around the chest and injured arm, over the sling.
Teaching Activities
• If the shoulder is dislocated with the arm upright, how can the injury be splinted?
• Why is it not standard practice to just pop a shoulder dislocation back into place?
• Allow adequate time to practice sling and swathe application.
Other ideas:
• Demonstrate alternative methods of tying a sling and swathe to immobilize a shoulder
injury.
79
Tape 2 Trauma Emergencies
Segment Name: Application of a Cervical Collar
Objectives
• List the indications for the need of a cervical collar.
• Describe the procedure for measuring a cervical collar.
• Explain the steps in applying a cervical collar.
• Describe some of the special considerations for applying a cervical collar.
Overview
I. Spinal immobilization should be considered:
• With significant MOI
• Complaint of head, neck, or back pain
• Soft-tissue damage to the head, face, or neck from trauma
• Altered mental status (AMS)
• Reports or shows signs of any blow above the clavicle
II. Equipment
• Cervical collar (adjustable or full set)
III. Assessment
• Manage ABCs.
• Instruct patient not to move.
• Manually stabilize the patient’s head.
• Assess for pain, pallor, paresthesia, pulses, and paralysis in all extremities.
IV. Skill overview
• BSI
• Maintain manual stabilization of the head and neck.
• Assess pulse, motor, and sensory function (PMS) in all extremities.
• Measure and apply cervical collar.
• Reassess PMS in all extremities.
V. Do not hyperextend the neck or restrict the airway.
• Reassess distal PMS in all extremities.
• Note changes in mental status.
• AMS
• Intoxication
• Remove earrings, clothing
• Hair
Key Terms
Cervical collar – a rigid collar applied to neck to protect the cervical spine.
Significant MOI – certain mechanisms of injury, which carry with them a greater risk of serious or
life-threatening injury.
Teaching Activities
• Why are soft collars inappropriate for field use?
• If you are having difficulty maintaining a jaw thrust maneuver on a trauma patient with a
difficult airway, is it acceptable to remove the cervical collar?
• Allow adequate time to practice applying rigid cervical collars.
80
Other ideas:
• Demonstrate applying a cervical collar on supine patients found in difficult positions (e.g.:
on a stair case, under a car).
Segment Name: Kendrick Extrication Device (KED)

Objectives
• Describe when to apply a KED to a patient.
• List the equipment needed to apply a KED.
• Describe the assessment of the patient requiring the need for a KED, including the
ongoing assessment.
• List the steps in applying a KED.
• Explain the special considerations associated with the use of a KED.
Overview
I. KED is used to immobilize a seated patient with a potential spinal injury.
II. Equipment
• KED
• Cervical collars
• Head blocks, towels, blankets, or other padding
• Tape
III. Assessment
• Manage ABCs.
• Assess for pain, pallor, paresthesia, pulses, and paralysis in all extremities.
IV. Skill Overview
• BSI
• Approach from the front.
• Explain the need for spinal immobilization and the procedure and obtain consent.
• Assess distal pulse, motor, and sensory function (PMS) in all extremities.
• Apply KED.
• Move patient to long board and secure to the board.
• Document.
• Note changes in mental status.
• Be alert for vomiting.
VI. Problem Solving
• Secure torso to the board before the head.
• Pad voids as needed.
Key Terms
Kendrick Extrication Device (KED) – a commercial vest-style extrication device used to
immobilize seated patients.
81
Teaching Activities
• When is it appropriate to use a KED as opposed to the rapid extrication technique?
• Why is it important that the device be secured tightly under the armpits?
• Allow adequate time to practice application of the KED.
Other ideas:
Demonstrate how a KED can be used to immobilize a small child as well as how it can be used to
immobilize a fractured hip in an adult.
Segment Name: Immobilizing a Supine Patient

Objectives
• List the indications for immobilizing a supine patient to a long spine board.
• List the equipment used to immobilize a supine patient.
• Describe the assessment of the patient with a potential spinal injury, including the
ongoing assessment.
• List the steps taken to immobilize a supine patient to a long spine board.
• List the special considerations taken with a patient immobilized to a long spine board.
Overview
I. Supine spinal immobilization should be considered:
• With significant MOI
• With complaint of head, neck, or back pain
• When the patient has sustained penetrating injury, laceration, or contusion to the
head or scalp
• Patient is unconscious for unknown reason
II. Equipment
• Cervical collars
• Head blocks, towels, blankets, or other padding
• Tape
• Back board straps
III. Assessment
• Conduct an initial assessment evaluating the MS-ABCs and prioritize the patient.
• Explain the need and procedure for spinal immobilization and obtain consent.
• Assess for pain, pallor, paresthesia, pulses, and paralysis.
IV. Skill Overview
• BSI
• Maintain the patient in a neutral position.
• Explain the need for spinal immobilization, explain the procedure and obtain consent.
• Assess PMS in all extremities.
• Inspect and palpate cervical vertebrae.
• Roll the patient on the side and inspect the back.
• Move the patient to long board and secure to the board.
• Pad voids as necessary.
• Document.
82
• Monitor the patient’s mental status.
VI. Problem Solving
• Move the patient as a unit to prevent manipulation of the spine.
• Secure the patient’s torso to the board first and the head last.
• Strap the bony prominences of the body (hips, upper chest, legs) to the board.
Key Terms
Cervical vertebrae – seven cervical vertebrae (stacked bones) are found in the neck.
Teaching Activities
• Why is it necessary to pay close attention to the means of egress when planning to
immobilize a supine patient on a long spine board?
• If it will be necessary to carry a patient who is immobilized on a long spine board over a
mile out of the woods, what else should be considered to make it possible?
• Allow adequate time to practice skill of supine immobilization.
Other ideas:
Once the students are able to do this skill in the classroom setting, consider giving them a
situation in the stairwell or in a tight bathroom.
Segment Name: Immobilizing a Standing Patient

Objectives
• Explain when it would be appropriate to immobilize a standing patient.
• List the equipment needed to perform a rapid takedown.
• Describe the assessment of a patient requiring a rapid takedown, including ongoing
assessment.
• Describe the steps to immobilize a standing patient.
• Discuss the problems associated with immobilizing a standing patient.
Overview
I. A rapid takedown with spinal immobilization should be considered:
• A standing or ambulatory patient that sustained a significant MOI
• Chronic back pain patients found in a standing position
II. Equipment
• Cervical collar
• Head block, towels, blankets, or other padding
• Tape
• Back board straps
III. Assessment
• Conduct an initial assessment evaluating MS-ABCs and prioritize the patient.
• Explain the need and procedure for spinal immobilization and obtain consent.
IV. Skill Overview
• BSI
• Approach the patient from the front.
83
• Manually stabilize the patient’s head from behind.
• Explain the need for spinal immobilization, explain the procedure and obtain
consent.
• Assess PMS in all extremities.
• Place a long spine board against the patient’s back.
• Grasp the board and while supporting the patient, lower the board down to the
ground.
• Secure the patient to the board.
• Pad voids as needed.
• Document.
VI. Problem Solving
• Move the patient as a unit to prevent manipulation of the spine.
• Secure the patient’s torso to the board first and then the head last.
• Strap the bony prominences of the body (hips, chest, legs) to the board.
Key Terms
Rapid takedown – also known as Standing Takedown, allows immobilization of the patient in the
position found.
Teaching Activities
• If you and your partner need to utilize the assistance of an untrained helper, why is it so
important to place the helper in front of the board as opposed to the position behind the
board?
• Why is it important to remember, “as the shoulders lean back and touch the backboard so
should the back of the head” and at that point, the head should never again lose contact
with the board?
• Allow adequate time to practice the standing takedown.
Other ideas:
• This is not a 2-person technique. There is a minimum of 3 people needed to properly do
the technique. Practice with one of the helpers in front of the board being untrained,
being careful to go slow and instruct as you go.
• Practice this technique with a 4 rescuer, supporting the board from behind, for the
th
situation of an obese patient.
84
Segment Name: Helmet Removal
Objectives
• List the indication for removing a helmet from a patient.
• List the indications for keeping the helmet in place.
• List the equipment needed for a helmet removal from a patient.
• Describe the steps in the procedure of removing a helmet from a patient.
• Describe the common problems associated with removing a helmet from a patient.
• Explain why it is necessary to examine the helmet for cracks or other damage.
Overview
I. Finding a patient with a helmet may be common in sports and cycling.
II. Indications for removing the helmet include:
• Helmet interferes with assessment and management of the airway.
• Helmet interferes with immobilization.
• The helmet is too loose and allows for movement of the head or neck.
• The patient exhibits signs of respiratory or cardiac arrest.
III. Indications for keeping the helmet in place include:
• No immediate airway or breathing problems
• No reason to ventilate with a BVM
• Helmet does not interfere with assessment of the airway and breathing
• The helmet does not impede proper spinal immobilization
• Removal of the helmet may cause further injury
IV. Equipment
• Cervical collar
• Towel rolls
V. Assessment
• Instruct the patient not to move.
• Explain the procedure and obtain consent.
VI. Skill Overview
• BSI
• Explain the need for spinal immobilization and the procedure and obtain consent.
• Assess distal pulse, motor, and sensory function (PMS) in all extremities.
• Open, remove, or cut chin strap.
• Hold the occipital area of the head and stabilize the mandible.
• Support and hold the head while the helmet is removed.
• Remove the helmet, maintaining the head in a neutral position.
• Move patient to a long spine board.
• Document.
• Reassess distal PMS is all extremities.
85
• Shoulder pads may require removal or padding behind the head.
• Large earrings may catch on your fingers or the helmet, be careful or remove as
necessary.
• Eye glasses will need to be removed before the helmet, if possible.
• Examine helmet for cracks indicating significant MOI.
Key Terms
Occipital skull – the back region of the skull.
Priaprism – persistent erection of the penis that may result from spinal injury and some medical
problems.
Teaching Activities
• Why will it be difficult to assess the airway of a motorcyclist who is found unconscious
with a full-face helmet in place?
• When would it be appropriate to consider removing earrings from the biker prior to
actually removing a helmet?
• Allow adequate time to practice helmet removal using football and motorcycle helmets.
Other ideas:
• Obtain a set of shoulder pads and practice the helmet-removal procedure on a victim who
is lying on grass to simulate an actual incident.
• It is helpful to meet with the athletic trainer for the teams your unit may respond to ahead
of time to work out procedures and protocols for dealing with injured athletes.
Segment Name: Rapid Extrication

Objectives
• Describe the indications for performing a rapid extrication.
• List the equipment needed to perform a rapid extrication.
• Explain the steps of a rapid extrication.
• Explain the components of the ongoing assessment for the patient who has been rapidly
extricated.
• List common problems associated with rapid extrication.
Overview
I. Rapid extrication is indicated for the critical or unstable (high priority) patient.
• Actual or impending cardiac arrest
• Respiratory failure
• Decompensated shock
• Rising intracranial pressure
• Severe upper airway difficulties
• Cardiorespiratory instability
• Uncontrollable external bleeding
• Chest pain with a BP less than 100 systolic
• Unresponsive patient
• Responsive but confused and not following commands
• Penetrating injuries to the head, neck, chest, abdomen, or pelvis
• A patient in an unsafe situation requiring an urgent move
II. Equipment
• Cervical collar
• Straps
• Head blocks
• Tape
86
III. Assessment
• Instruct the patient not to move.
• Explain the procedure and obtain consent.
IV. Skill Overview
• BSI
• Confirm the patient is in a critical or unstable (high priority) condition.
• Explain the need for spinal immobilization, the procedure, and obtain consent.
• Assess distal pulses, motor, and sensory function (PMS) in all extremities.
• Place a long spine board under the patient’s buttocks.
• Rotate the patient into a parallel position with the board.
• Lay the patient supine.
• Secure the patient to the board.
• Document.
• Reassess every 5 minutes.
VI. Problem Solving
• Excessive movement
• Length time for extrication
• Patient is extremely tall or obese
Key Terms
Rapid extrication – an urgent move from a motor vehicle, which takes into consideration the
need for spinal precautions.
Critical status – the highest priority patient transport rating.
Unstable status – the second highest priority transport rating.
Teaching Activities
• Why is it imperative that the hands holding the head/neck and chest not be moved until
they are first taken over by another rescuer when switching positions?
• If there are only 3 rescuers, how can a stretcher be utilized to act as the 4 rescuer?
th

• Allow adequate time to practice rapid extrication.
Other ideas:
• This skill should be practiced as a team in actual vehicles so it can be accomplished
safely in 3 minutes.
• Practice in small cars with consoles, as well as a pickup truck, where there is no room to
place a rescuer behind the patient.
87

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Brady Skills Series—EMT-B

Video Leader’s Guide

The Brady Skills Series Development Team

Tape 1 Emergency Essentials of Prehospital

Tape 1 Emergency Essentials of Prehospital

Tape 1 Emergency Essentials of Prehospital

Segment Name: Lifting and Moving

Segment Name: Patient Assessment

Segment Name: Vital Signs

Segment Name: Assessment of the Trauma Patient with a Significant

Segment Name: Detailed Physical Exam

Segment Name: Assessment of the Medical Patient - Responsive

Segment Name: Assessment of the Medical Patient - Unresponsive

Segment Name: Ongoing Assessment

Segment Name: Jaw Thrust Maneuver

Segment Name: Bag-Valve Mask (BVM) Ventilation, Two-Person Technique

Segment Name: Insertion of the Oropharyngeal Airway

Segment Name: Insertion of the Nasopharyngeal Airway

Segment Name: Oral Suctioning

Segment Name: Suctioning through an Endotracheal Tube

Segment Name: Administering Oxygen by a Non-Rebreather Mask

Segment Name: Administering Oxygen by a Nasal Cannula

Segment Name: Nasogastric (NG Tube) Intubation

Segment Name: Ventilatory Assist with Endotracheal Intubation

Segment Name: Insertion of Esophageal Tracheal Combitube® (ETC Airway)

Segment Name: Using a Pulse Oximeter

Segment Name: Administration of Glucose

Segment Name: Metered Dose Inhaler

Segment Name: Administration of Nebulized Medication

Segment Name: Childbirth

Segment Name: Joint Immobilization

Segment Name: Applying a Hare Traction Splint

Segment Name: Applying a Sager Splint

Segment Name: Kendrick Extrication Device (KED)

Segment Name: Immobilizing a Supine Patient

Segment Name: Immobilizing a Standing Patient

situation of an obese patient.

Segment Name: Rapid Extrication

Additional activities associated with the tape:

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