NDICATIONS - PDF document

013 NDICATIONS : Inability to adequately oxygenate and ventilate using less invasive methods CONTRAINDICATIONS : Ability to oxygenate and ventilate using less invasive measures Age less than 12 years old EQUIPMENT : Chlorhexidine # 10 blade scalpel Bougie 6 . 0 mm endotracheal tube 10 ml Syringe BVM Quantitative ETCO 2 PROCEDURE : 1 . Position the patient supine and extend the neck as needed to improve anatomic view . 2 . Prep neck with Chlorhexidine

3 . Using your non - dominant hand , stabilize the larynx and locate the following landmarks : thyroid cartilage ( ) and cricoid cartilage . The cricothyroid membrane lies between these cartilages . 4 . Make an approximately a 3 cm vertical incision 0 . 5 cm deep through the skin and fascia , over the cricothyroid membrane . With finger , dissect the tissue and locate the cricothyroid membrane . 5 . Make approximately a 1

. 5 cm horizontal incision through the cricothyroid membrane . 6 . With your finger , bluntly dilate the opening through the cricothyroid membrane . 7 . Insert the bougie curved - tip first through the incision and angled towards the . 8 . . This confirms tracheal position . 9 . Advance a 6 . 0 mm endotracheal tube ( ensure all air aspirated out of cuff ) over the bougie and into the trachea . 10 . Remove bougie w

hile stabilizing ETT ensuring it does not become dislodged 11 . Inflate the cuff with 5 10 ml of air . 12 . Confirm appropriate proper placement by symmetrical chest - wall rise , auscultation of equal breath sounds over the chest and a lack of epigastric sounds with ventilations using bag - valve - mask , condensation in the ETT , and quantitative waveform capnography . 13 . Secure the ETT . 14 . Reassess tube placement frequently , espe

cially after movement of the patient . 15 . Ongoing monitoring of ETT placement and ventilation status using waveform capnography is required for all patients . PARAMEDIC - PREREQUISITE REQUIRED ADULT rerequisite Procedure 67 . 4 urgical Cricothyrotomy Bougie Assisted ADULT he New Hampshire Bureau of EMS has taken extreme caution to ensure all information is accurate and in accordance with profes sional standards in effect at the time of publication

. These protocols , policies , or procedures MAY NOT BE altered or modified . 2015 7 . 4 cricothyroid membrane Director , Hospital EMS Coordinator , and Bureau of EMS within 48 hours of an event . Use of notification of the Bureau of EMS . Surgical Cricothyrotomy - Bougie Assisted Prerequisite Protocol LICENSURE: Paramedic EXPERIENCE : Prior to class participants are to have watch ed the following: http://emcrit.org/procedures/bougie - ai

ded - cric/ htt ps://vimeo.com/125228375 EDUCATION: Surgical Cricothyrotomy – Bougie Assisted Program approved by the Medical Control Board . Medical Director or designee to oversee program MEDICAL DIRECTION Direct oversight of the program Recommendation for program QM review of all cricothyrotomy cases RECOMMENDATION The Medical Director and the Head of EMS Agency must mutually agree to participate in the program. QM/PI PRO

GRAM Medical Director to review all cricothyrotomy p erformed or attempted. Remediation: 2 people to look at problem calls (Medical Director and NH EMS) and come up with a consensus as to remediation. REPORTING R eport s to NH EMS via TEMSIS NH EMS will report to MCB COMPETANCE/EXPIRATION Annually RESOURCES M RH agreement with participating Med ical Director or designee. EQUIPMENT: Chlorhexidine, #10 blade scalpel, Bougie, 6.0 mm endot

racheal tube, 10ml Syringe, BVM, Quantitative ETCO2. Cricothyrotomy manikin or lab tracheas Candidate;________________________ Date:__________ _____INITIAL ______RETEST Evaluator:______________________ Time allowed: 10 minutes Start:_________ Stop:_________ Total Time:__________ SCEN

E SIZE UP (scene information will be provided by the evaluator) Scene safety and proper BSI 1 Verbalizing indications and contraindications 2 Position patient supine and extend neck. 1 Prepare neck with Chlorhexidine. 1 With non - dominate hand stabilize larynx and locate cricothyroid membrane. 1 Make an approximately 3cm vertical incision by 0.5cm deep through the skin and fascia, over the cricothyroid membrane. 1 Insert finger

and dissect the tissue and locate the cricothyroid membrane. 1 With finger, bluntly dilate the opening through the cricothyroid membrane. 1 Make approximately 1.5cm horizontal incision through the cricothyroid membrane. 1 Insert bougie curved - tip first through the incision and angled towards the pati ent’s feet. 1 Advance the bougie into the trachea felling for “clicks” of tracheal rings and unitl it cannot be advanced any further. 1

Advance 6.0mm endotracheal tube over bougie and into trachea. 1 Remove bougie while stabilizing endotracheal tube, ensuring it does not become dislodged. 1 . Inflate the cuff with 5 - 10mL air. 1 Confirm placement:  Symmetrical chest - wall rise  Equal breath sounds over chest and lack in epigastric  Condensation in the endotracheal tube  Quantitative waveform capnography 1 1 1 1 Secure endotracheal tube.

1 Reassess tube placement and ongoing waveform capnography. 1 Total 21 __________ Critical Criteria _____Inability to locate cricothyroid membrane _____Does anything to harm self, patient or partners SURGICAL CRICOTHYROTOMY BOUGIE ASSISTED Points Possible Points Awarded Surgical Cricothyrotomy - Bougie Assisted Course Outline OBJECTIVES  To assess, obj

ectively measure, and demonstrate competence in the skill of surgical cricothyrotomy , bougie assisted .  To increase participant comfort and knowledge of indications, contraindications, medications, and procedures used during bougie assisted surgical cricothyrotomy.  To enforce and practice the medical decision making and proc edural skills utilized during bougie assisted surgical cricothyrotomy through experiential learning. INTENDED AUDIENCE:

 NH Paramedics COURSE STRUCTURE:  Course and instructor introduction .  I ntro duction to the materials, supplies and SIM equipment.  NHBEMS Surgical Cricothyrotomy – Bougie Assisted Power Point  Review: http://emcrit.org/procedures/bougie - aided - cric/  Review: htt ps://vimeo.com/125228375  Review the NH Surgical Cricothyrotomy – Bougie Assisted Prerequisite Protoc ol.  SIM - DEMO: Observe a

bougie assisted cricothyrotomy in action (SIM - instructor demonstration/discussion/video debriefing)  Participant participation: o Participants to work with Medical Director, or designee, to develop psychomotor skills to perform procedure proficiently.  Final Skills Assessment: P articipant to demonstrate proficiency in surgical cricothyrotomy, bougie assisted to the Medical Director’s , or designee ’ s , satisfaction .  F

inal Written Exam: Participants are to pass NHEMS approved written examination with a score of 80% or greater. Surgical Cricothyrotomy – Bougie Assisted Checklist _________1. Protocol Prerequisite Application signed by both EMS Unit leader and Medical Dirctor. _________2. Provider Level & Experience List of eligible providers and NH Paramedic license number. _________3. Medical Direction

Name of Medical Direct or or designee overseeing training. _________4. Recommendation A letter from the Medical Director attesting to the training and competency of the providers listed in (Items 2 & 4 may be combined). __________5. Quality Management Program Provide a copy of your Surgical Cricothyrotomy Quality Management Plan. PART Saf - C PATIENT CARE PROTOCOLS

Saf - C 5922.01 Procedures … (d) Prerequisites required by protocol shall be established by the EMS Medical Control Board in accordance with RSA 153:A - 2 XVI (a). (e) Protocol prerequisites, when required, shall address each of the following elements: (1) The protocol title and number to which the prerequisites relate; (2) The provider licensure level necessary to car ry out the protocol; (3) The name of the medical director, or designee,

who will oversee the training module; (4) The MRH and EMS head of unit recommendations to the division; (5) The provider experience criteria; (6) All quality management program elements; (7) Reporting requirements for monitoring and skill retention; (8) Equipment and staff support resources necessary; (9) Provider renewal criteria, and (10) Training requirements. NEW HAMPSHIRE D

EPARTMENT OF SAFETY DIVISION OF FIRE STANDARDS AND TRAINING & EMERGENCY MEDICAL SERVICES NH EMS PREREQUISITE APPLICATION PLEASE PRINT (BLACK INK) OR TYPE PROTOCOL NAME_____________________________________________________PROTOCOL NUMBER_________ LEGAL NAME OF UNIT ____________________________________________UNIT LICENSE NUMBER____________ BUSINESS STREET ADDRESS _______________________________________________________________________

STREET CITY STATE ZIP CODE MAILING ADDRESS ________________________________________________________________________________ STREET/PO BOX CITY STATE ZIP CODE HEAD OF UNIT ______________________________________________TITLE_________________________________ CONTACT TELEPHONE____________________________FAX (IF AVAILABLE

) _ _______________________________ EMAIL ADDRESS (IF AVAILABLE)_______________________________________________________________ _ _____ MEDICAL RESOURCE HOSPITAL _______________________________ _____________________________________ MEDICAL DIRECTOR OR DESIGNEE__________________________________________________________________ MEDICAL DIRECTOR PHONE________________________________________________________________________ TYPE OF APPLICA

TION (CIRCLE) INITIAL RENEWAL _____________________________________________ _________________________________________________ HEAD OF UNIT DATE MEDICAL DIRECTOR OR DESIGNEE DATE ATTACHED IS SUPPORTING DOCUMENTION F OR ALL ELEMENTS LISTED IN Saf - C 5922.01 (e) WITH A LIST OF LICESNED PROVIDERS TRANED UNDER Saf - C 5922. Page 2 blank Surgical Cricothyroto

my Bougie Assisted Prerequisite Protocol NH Department of Safety NH Fire Academy & Emergency Medical Services NH Bureau of EMS 2015 b. Ne r ve d a m a g e c. T h y r oid g l a nd d a m a g e d. A ll of the a bove 10. Th e i d e al s u r gi c al i n c i s i o n s f or cr i c o t h y r o t o m y s h o u ld b e : a. 2.5 c m v er ti ca l th e n 1.0 c m ho r i z ont a l b. 2.0 c m

v er ti ca l th e n 1.5 c m ho r i z ont a l c. 3.0 c m v er ti ca l th e n 1.0 c m ho r i z ont a l d. 3.0 c m v er ti ca l th e n 1.5 c m ho r i z ont a l 1. T o p er f o r m a s u r gi c al c r i c o t h y r o t o m y, t h e p a t i e n t m u st b e p a r aly ze d : a. T R U E b. F A L S E 2. Th e c o rr e c t o r de r of t h e se a n a t o m i c al s t r u ct ur e s s t a rt i n

g at t h e h e ad a n d w o r k i n g i nf er io r ly is: a. C r i c oid car til a g e , cr i c oid m e mb ra n e , t h y r oid c ar ti la g e , t h y r oid m e mb ra n e b. T h y r oid m e mb r a n e , t h y r oid car til a g e , c r i c oid m e mb r a n e , c r i c oid c a r til a ge c. T h y r oid car til a g e , t h y r oid m e mb ra n e , c r i c oid c ar t i la g e , cr i c oid m e mb r a ne d. C

r i c oid m e mb ra n e , c r i c o id car til a g e , t h y r oid m e m b r a n e , t h y r oid c ar til a g e 3. Th e “ A d a m ’ s A pp l e ” is a n o t h e r n a m e f or w h a t ? a. C r i c oid car til a g e b. H y oid bone c. T h y r oid car til a g e d. The t rac h e a 4. W h i c h i te m is n ot r e qu i re d e qu i p m e n t f or a s ur gi c al cr i c o t h y r o t o m y? a

. W a v ef o r m ca pn o g ra p h y b. B o u g ie c. B V M d. #11 B l a de 5. W h i c h p a t i e n t is an a p p r o p r ia t e s u r gi c al c r i c o th y r o t o m y c a nd i d a te ? a. 10 y /o m a le a i rw a y b u r ns w ith di ff i c ult B V M v e n t il a tions b. 88 y /o fe m a le w ith S O B th a t is re sponding w e ll to C P A P c. 35 y /o m a le a n a p h y l a x is

p a ti e nt w ith a fa il e d int u ba tion 2 ◦ l a r y n g e a l e d e m a d. 23 y /o fe m a le a sthm a tic p a ti e nt re spondi n g to o x y g e n a nd inh a l e d β a g onis t s 6. A ET T s h o u ld b e p ass e d ov e r t h e B o u gi e , c uf f i n f la te d w i t h 5 - 10 m L of ai r , a n d s ec u re d . a . 5.5 b. 6.0 c . 6.5 d. 7.0 7. How s h o u ld t h e cr

i c o t h y r o t o m y p a t i e n t b e p osi t io n e d , ass u m i n g t h er e i s n o n ec k tr a u m a? a. S upin e , n ec k e x t e nd e d b. S upin e , n ec k f l e x e d c. S e mi f o w l er s, n ec k e x t e nd e d d. S e mi f o w l er s, n ec k f l e x e d 8. A ll t h e f oll o w i n g s u p p o r t tr a c h e al p la c e m e n t , e x ce p t : a. A pp rec i a ti n g t a c tile “

c li c ks” w hile a dv a n c ing t h e B o u g ie b. The B o u g ie fa iling to f ully a d v a n c e b e c a use of a p e rce i v e d obst r u c tion c. S mooth B V M v e ntil a tions d. C a pno g r a p h y w ith a n a p p r op r i a te w a v ef o r m a nd Et C O 2 v a lu e s 9. W h i c h of t h e f oll o w i n g i s an e xa m p le of a cr i c o th y r o t o m y c o m p li c a t io n ?