The Greater Miami Valley ems council, Inc. & State of Ohio ems region 2 Standing Orders Optional Skills Training Manual



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The Greater Miami Valley EMS Council, Inc.

& State of Ohio EMS Region 2
Standing Orders

Optional Skills Training Manual

This document includes the training materials and skills sheets for those procedures that are considered optional components of the Standing Orders. Prior to implementing any of the Departmental Options in the Standing Orders, Council strongly recommends the following:



  • Evaluation and approval by the Chief of the Department, including assessment of cost and training requirements.

  • Evaluation and approval by Department Medical Director.

  • Develop and implement a training plan (specific recommendations are included here for some procedures). Training plans must include any other required components (e.g., paramedics training for “Sedate to Intubate” administration must also be trained in use of a rescue cricothyrotomy device).

  • Deliver annual training and competency (written and skills) evaluation of those optional skills/procedures

  • Have a defined Quality Improvement Plan.

According to the Standing Orders, “No procedures, techniques, or drugs will be used without the proper equipment or beyond the training or capabilities of the pre-hospital personnel. Nothing may be used without specific pre-approval of the Medical Advisor for the local department or agency.” “Items that are enclosed in braces ({}) are at the option of the Department, and its Medical Director.


Departments are strongly encouraged to reproduce the sections of this document that apply to the optional skills, items, and procedures they intend to use. Materials for items not used by your Department may be deleted.
Listed on the next page are the optional items in the 2017 GMVEMSC Standing Orders.

Table of Contents

Optional Procedures……………………………………………………………………………4

King Airway …5

Combi-Tube……………………………………………………………………………………6

Sedate to Intubate……………………………………………………………………………...8

PerTrach………………………………………………………………………………...……10

Quick Trach…………………………………………………………………………………..12

EtCO2 Waveforms……………………………………………………………………………14

Acquisition & Transmission of 12-Lead ECGs………………………………………………17

12-Lead EKGs………………………………………………………………………………..18

Cardiac Alert………………………………………………………………………………….34

Morgan Lens………………………………………………………………………………….37

ALS Assist Skills for EMT-Basics……………………………………………………….......39

Rapid Sequence Intubation………………………………………………………………………...40


Post-Arrest Induced Hypothermia………………………………………………………………….44
GMVEMSC Optional Skills Approval Form……………………………………………….………45

Optional Procedures


Optional Procedures

EMR

EMT

Adv EMT

Paramedic

BAAM

 

 

 

X

BiPAP

 

 

 

X

CANA Auto-Injector

 X

X

X

X

Camera-Assisted Intubation







X

X

Carbon Monoxide Monitoring

 

X

X

X

Combi-Tube

 

X

X

X

Cyanide Kits (CyanoKit or traditional)

 







X

Dawn Soap

X

X

X

X

Digital Intubation

 

 

X

X

EtCO2 Waveforms

X

X

X

X

Flow-Restricted Oxygen Powered Ventilation Device

 X

X

X

X

IV Pump

 

 

 

X

King Airway

 

X

X

X

Lighted Stylet Intubation

 

 

X

X

Magnesium (Maalox or Mylanta)

 

 

 

X

Magnesium Sulfate (Epsom Salt)

 

 

 

X

Morgan Lens

 

 

 

X

Nitroglycerin Drip

 

 

 

X

12-Lead ECG Acquisition

 

X

X

X

12-Lead ECG Interpretation

 

 

 

X

Post-Arrest Induced Hypothermia










X

Sedate to Intubate

 

 

 

X

Stockpile (Cipro or Doxy)

 

 

 

X

Sudecon Wipes

X

X

X

X

Warmed IV Fluids

 

 

X

X

















Optional Skill

King Airway


Scope of Practice

EMT-Basic, Intermediate, and Paramedic



















Indications

1. Need for tracheal intubation










2. Inability to tracheally intubate










3. Unconscious, apneic, no gag reflex










* for EMT-Basics, the patient must also be pulseless



















Contra-Indications

1. Less than 4 feet tall










2. Known history of esophageal disease










3. Ingestion of caustics



















Complications

Stimulation of gag reflex










Soft tissue trauma










Tube extraction under high airway pressures

























Yes

No

Procedure

Takes or verbalizes appropriate BSI precautions

 

 




Places the patient in the "sniffing" position (consider c-spine precautions)

 

 




Pre-oxygenates

 

 




Choose the correct size

 

 




* Size 3 for patients 4 to 5 feet tall

 

 




* Size 4 for patients 5 to 6 feet tall

 

 




* Size 5 for patients over 6 feet tall

 

 




Applies a water-soluble lubricant to the distal tip

 

 




Without exerting excessive force, advance the tube until the base of the

 

 




connector is aligned with the patient's teeth or gums

 

 




Inflate the pilot balloon with the appropriate amount of air

 

 




* Size 3 = 50ml

 

 




* Size 4 = 70ml

 

 




* Size 5 = 80ml

 

 




Attach the Bag-Valve Mask; while ventilating the patient, gently withdraw the tube until ventilation becomes easy and free-flowing.

 

 




Adjust cuff inflation if necessary to obtain a seal

 

 




Confirm placement

 

 




* utilize multiple methods

 

 




Ventilate patient at the proper rate and tidal volume

 

 


Greater Miami Valley EMS Council, Inc. & Ohio EMS Region 2 Protocol

COMBITUBE

Indications:

  • Can only be used by trained personnel at the EMT-B, AEMT, or EMT-P level with Medical Director Approval... EMT only if apneic and pulseless

  • Patient must be adult and in respiratory arrest or have an absent gag reflex.

  • After two failed attempts to intubate patient with an endotracheal tube.



Contraindication

  • Patient under the age of 16 and/or under 5 feet tall.

  • Responsive patients with an intact gag reflex.

  • Patients with known esophageal disease.

  • Patients who have ingested caustic substances.

  • Patient with inhalation burns.


Application


  • Pre-oxygenate patient with a BVM at high flow Oxygen.

  • Prior to insertion, test cuff integrity by inflating each cuff with prescribed volume of air. Remove air and preset syringes at proper volume.

  • Lubricate distal end of Combitube with water-soluble lubricant.

  • Remove the oropharyngeal airway.

  • If a non-trauma patient, pre-position the head.

  • Perform a tongue-jaw lift.

  • Following the natural anatomical curvature, insert the Combitube until the upper teeth are between the two black lines on the tube.

  • Inflate the blue pharyngeal cuff to 100 cc. Expect the tube to move slightly upward. Remove syringe.

  • Inflate the white esophageal cuff to 15 cc. Remove syringe.

  • Ventilate with a BVM through blue tube. Auscultate for air at the epigastrium and then the lungs. Watch for chest rise. If equal breath sounds are heard and the chest rises equally, continue to ventilate through the blue tube.

  • If upon auscultation, air is heard at the epigastrium, immediately disconnect the BVM from the blue tube and attach it to the clear tube. Ventilate and reassess for breath sounds and chest rise.

  • If air is not heard at the epigastrium but chest rise or breath sounds do not occur, insert 10 cc more air into the pharyngeal (blue) cuff.

  • Ventilate patient with BVM at appropriate rate.

  • If ventilation is achieved through the blue tube, placement is in the esophagus. The stomach can be suctioned through the clear tube. A diverter is provided to direct any vomitus that may come up the tube away from the operator.

.
Caution


  • Do not force the Combitube. If resistance is met, redirect or withdraw and reinsert.

  • When facial trauma has resulted in sharp, broken teeth or dentures, remove dentures and exercise extreme caution when passing the tube to prevent the cuff from tearing.

  • If the Combitube is to be removed, first deflate the blue pilot balloon and then the white.

  • If you elect to intubate past the Combitube, deflate the blue pilot balloon and move the tube to the left side of the mouth while keeping the white balloon inflated.

  • Medications can be given through the Combitube only if the tube has been placed into the trachea. Then medications are injected into the clear tube. .

ADULT PROTOCOL SKILL EVALUATION

SUBJECT: COMBITUBE INSERTION
NAME____________________________ DATE________________________________
LEVEL: _____Paramedic _____Intermediate _____Basic



STEPS

1st Testing Comments

2nd Testing Comments

A. List the indications for use of the Combitube.







B. List the contraindications for use of the Combitube.







C. List the equipment required to perform Combitube insertion.







D. Pre-oxygenate patient.







E. Assemble/check/prepare airway device & other equipment.







F. Lubricate distal end of Combitube with water-soluble jelly.







G. Position patient’s head properly.







H. Perform tongue-jaw lift.







I. Insert device in the mid-line & to the depth that the printed ring is at the level of the teeth.







J. Inflate the blue pharyngeal cuff with the proper volume & remove syringe.







K. Inflate the distal white esophageal cuff with the proper volume & remove syringe.







L. Attach BVM to blue pharyngeal tube and begin ventilations.







M. If auscultation of breath sounds is positive and auscultation of gastric insufflation is negative, continue ventilation.







N. If auscultation of breath sounds is negative and auscultation of gastric insufflation is positive, immediately disconnect the BVM from the blue tube and attach it to the clear tube.







O. Ventilate & reassess for breath sounds & chest rise. If air is not heard at the epigastrium but chest rise or breath sounds do not occur, insert 10 cc more air in the pharyngeal (blue) cuff.







P. If auscultation of breath sounds is positive and auscultation of gastric insufflation is negative, confirm tube placement, using the End Tidal CO2 Detector for patients with a perfusing rhythm, or the Esophageal Detection Device for patients in cardiac arrest. Be able to discuss the indications and limitations of each device







Q. Secure device in place & reassess placement after any movement of patient.







Sedate to Intubate” Training Outline
“Sedate to Intubate” (StI) Overview

What is StI?

How does it differ from RSI?

Indications

Benefits

Risks

Contraindications

StI Pharmacology

Etomidate

Midazolam

Lidocaine

Pre-Requirements

EKG monitoring

IV

PulsOx


Oxygenation

Must be convinced that you will be able to intubate!

Must be trained on, approved on, and have the equipment to perform a surgical cricothyrotomy technique (e.g., PerTrach)

Recognition of the Difficult/Impossible Intubation Patient

Advanced Airway Assessment (e.g., Mallampati or Samsoon Airway Classes)

Review of Intubation Techniques

Review of PerTrach

StI Use and Sequence

Practice Stations:

Intubation

Difficult Intubation Situations

Rescue Airway Devices

StI Use and Sequence

Cricoid pressure to control vomiting, prevent gastric insufflation/distention

Management of esophageal intubation

Management of laryngospasm

Practical Testing:

Intubation

Difficult Intubation Situations

PerTrach


StI Use and Sequence

Written Testing


Course to be objective based (see below). Agenda and time spent on objectives must be approved by Department’s Medical Director. QI should be accomplished through Departmental QI and intubation sheets already in use by hospital respiratory therapists.
Sedate to Intubate Learning Objectives:

1. List the indications for rapid-sequence sedation

2. List the steps in performing rapid-sequence sedation

3. Describe and list the indications, contraindications, and dosages for Etomidate

4. Given a scenario, select the most effective means of providing a patent airway.
References:

1. Prehospital Emergency Pharmacology, 5th edition by Brady



2. PHTLS, 5th edition by Mosby}
ADULT PROTOCOL SKILL EVALUATION

SUBJECT: SEDATE TO INTUBATE (OPTIONAL)
NAME___________________________ DATE___________________________
LEVEL: _____Paramedic EVALUATOR___________________________


STEPS

1st Test

2nd Test

3rd Test

A. List indications for Sedate to Intubate Procedure










B. List potential complications associated with STI










C .Attempts at other methods










D. Pre-oxygenate the patient, providing ventilatory support via BVM @ 100% Oxygen if needed. Monitor for risk of gastric distention.










E. Establish: Cardiac Monitor, IV, and Pulse Oximetry. Have Suction, Intubation Equipment, and Rescue Airway assembled.










F. If used in patients suspected of increased Intracranial Pressure, administer Lidocaine, 100mg IVP










G. Etomidate, 0.3mg/kg IVP (Average dose 15-25 mg based on the average patient weighing between 50-100kg). If patient is still resistive to intubation, repeat initial Etomidate dose within two minutes. Follow witnessed waste procedures










H. Cricoid Pressure










I. Intubate










J. Midazolam 2-4mg IV, if patient is resisting post intubation and SBP >100










K. List procedure for failed attempt










L. List approved Rescue Airways











PerTrach
Attached is the PerTrach Evaluation Sheet. If your Department/Agency and Medical Director want you to use the PerTrach, you will then need to be trained and tested on this device, and retested annually. Preceding initial testing, there should be a short videotape on the device, and a practical station. You will first practice the simulated placement of the device. Following that, you will be tested on its use.
The PerTrach is an instrument for establishing a temporary percutaneous airway via a cricothyroid puncture. The Adult version is used for patients age 12 and above. Since this is an emergency airway device, you do not need permission from Medical Control. If it is indicated, do it!
The PerTrach is to be used only when other means of establishing an airway in the emergency situation are impossible, or totally ineffective. Causes of upper airway obstruction include epiglottitis, fractured larynx, foreign body aspiration, airway burns, laryngeal edema, laryngospasms, and massive facial trauma.
No paramedic may utilize this device until after successful completion of the Skill Evaluation.
Indications for use of the PerTrach:

  1. Complete airway obstruction not manageable with other airway techniques or devices.

  2. Partial airway obstruction which is impeding oxygenation, or which is likely to progress (e.g., laryngeal edema or spasm), and which is not manageable with other airway techniques or devices.

Equipment required to place and ventilate with the PerTrach:



  1. Betadine wipe

  2. Scalpel

  3. PerTrach Needle and Syringe

  4. Dilator

  5. Bag-valve-mask

  6. Oxygen

  7. Umbilical tape

Potential complications of PerTrach placement:



  1. Bleeding

  2. Puncture of the posterior tracheal wall, with esophageal insertion

  3. Mainstem bronchus intubation

Methods of tube confirmation:



  1. CO2 Detector for patients with a pulse.

  2. Pulse oximetry

  3. Esophageal detector device (EDD) for patients with no pulse.

  4. Bilateral breath sounds - Many people have died following this method of detection.

  5. Fogging of the tube.


PerTrach Training Materials Your Department Should Have on Hand
Cuffed PerTrach Tubes

Dilators

Trach blocks

Cric Simulator

PerTrach Video”


PROTOCOL SKILL EVALUATION

SUBJECT: PerTrach Cricothyrotomy

Combined Adult and Pediatric Evaluation
NAME____________________________ DATE________________________________

LEVEL: _____Paramedic





STEPS


1st Testing Comments


2nd Testing Comments

A. List the indications for use of the PerTrach.





B. List the equipment required to place and ventilate with the PerTrach.





C. List the potential complications of PerTrach placement.





D. Attempt to oxygenate patient during preparations to intubate.





E. Assemble equipment, and test the cuff on the tube.





F. Place patient in supine position, and palpate the cricothyroid membrane.





G. If time permits, prep area with betadine wash.





H. Pinch the skin over the cricothyroid membrane and make a one to two cm.

vertical incision in the midline.







I. Insert the needle with syringe attached through the incision, perpendicular to

the airway. Draw air through the syringe simultaneously with needle insertion,

until air is encountered, indicating entry in the trachea.






J. Remove syringe and incline needle to a 45o angle towards the carina before threading the filiform portion of the dilator into the airway, through the needle.

*The device is used with the thumb on the knob, while the second and third fingers

are curved under the flange of the tube. Force is applied with the thumb.







K. Squeeze the wings, then open them outward to split and remove the needle. It is helpful if a second rescuer holds the device in place while the operator uses both hands to split and remove the needle.





L. Exert pressure, and force the dilator into the airway, placing the tube into a

functional position, with the face plate against the skin.







M. Remove the dilator.





N. Inflate the cuff with 1 to 6 cc of air, and attach the BVM.





O. Assess lung sounds, and use as many other methods of tube confirmation as

are available. Check for leakage around the tube.







P. Secure the tube in place with the umbilical tape that is provided.







  1. List the sizes of PerTrachs, and the ages which are appropriate for each:

  • 3.0 mm Pediatric PerTrach: Ages 6 months to 1 year

  • 3.5 mm Pediatric PerTrach: Ages 1 to 4 years

  • 4.0 mm Pediatric PerTrach: Ages 3 to 10 years

  • Adult PerTrach






CAUTIONS

1. Retracting the leader portion of the dilator back through the unsplit needle can result in sheering off the leader, with a resultant endotracheal foreign body. If in doubt about placement, remove leader and needle together.

2. Insertion of the device through the thyroid cartilage can injure the vocal cords and other structures.

3. This is a single use only device.

4. Use great caution to avoid inserting the needle through the back wall of the trachea, and into the esophagus.

When preparing for this skill evaluation, be sure that you are able to meet the objectives A, B, and C.

Paramedic must be able to insert the device, completing steps F through N, within 60 seconds.
QuickTrach
Attached is the QuickTrach Evaluation Sheet. If your Department/Agency and Medical Director want you to use the QuickTrach, they will first need to purchase the QuickTrachs (Adult, Pediatric, or both). You will then need to be trained and tested on this device, and retested during all annual Standing Orders Check-Offs. Preceding initial testing, there should be a short videotape on the device, and a practical station. You will first practice the simulated placement of the device. Following that, you will be tested on its use.
The QuickTrach is an instrument for establishing a temporary percutaneous airway via a cricothyroid puncture. The Adult version is used for patients age 12 and above. Since this is an emergency airway device, you do not need permission from Medical Control. If it is indicated, do it!
The QuickTrach is to be used only when other means of establishing an airway in the emergency situation are impossible, or totally ineffective. Causes of upper airway obstruction include epiglottitis, fractured larynx, foreign body aspiration, airway burns, laryngeal edema, laryngospasms, and massive facial trauma. No paramedic may utilize this device until after successful completion of the Skill Evaluation.
Indications for use of the QuickTrach:

1. Complete airway obstruction not manageable with other airway techniques or devices.

2. Partial airway obstruction which is impeding oxygenation, or which is likely to progress (e.g., laryngeal

edema or spasm), and which is not manageable with other airway techniques or devices.


Equipment required to place and ventilate with the QuickTrach:

1. Betadine wipe

2. PerTrach Needle and Syringe

3. Bag-valve-mask

4. Oxygen

5. Attached securing device


Potential complications of QuickTrach placement:

1. Bleeding

2. Puncture of the posterior tracheal wall, with esophageal insertion

3. Mainstem bronchus intubation


Methods of tube confirmation:

1. CO2 Detector for patients who have a pulse.

2. Pulse oximetry

3. Esophageal detector device (EDD) for patients with no pulse.

4. Bilateral breath sounds - Many people have died following this method of detection.

5. Fogging of the tube.


Revised 01/07 – 5

PROTOCOL SKILL EVALUATION

SUBJECT: QuickTrach Cricothyrotomy

Combined Adult and Pediatric Evaluation
NAME____________________________ DATE________________________________
LEVEL: _____Paramedic


STEPS

1ST Testing

Comments


2ND Testing

Comments


  1. List the indications for use of the QuickTrach.

*Do not use on patient under 3 years of age.







B. List the equipment required to place & ventilate with the QuickTrach.







C. List the potential complications with the use of the QuickTrach.







  1. Assemble Equipment and prep patient with Betadine.










E. Place the patient in a supine position. Assure stable positioning of the neck and hyperextend the neck. (unless cervical spine injury suspected)







F. Secure larynx laterally between thumb and forefinger. Find the cricothyroid ligament (in the midline between the thyroid cartilage and the cricoid cartilage). This is the puncture site.







G. Firmly hold device and puncture cricothyroid ligament at a 90 degree angle.







H. After puncturing the cricothyroid ligament, check the entry of the needle into the trachea by aspirating air through the syringe. If air is present, needle is within trachea.







I. Now, change the angle of insertion to 60 degrees (from the head) and advance the device forward into the trachea to the level of the stopper. The stopper reduces the risk of over-insertion of the needle into the posterior wall of the trachea.







J. Remove stopper. After the stopper is removed, be careful not to advance the device further with the needle still attached.







K. Hold the needle and syringe firmly and slide only the plastic cannula along the needle into the trachea until the flange rests on the neck. Carefully remove the needle and syringe.







L. Secure the connecting tube to the 15mm connection and connect the other end to the BVM with supplemental oxygen. Ventilate and use confirmation methods.








CAUTIONS:

  1. Do not use on patient under 3 years of age.

  2. To determine when to use a Pediatric 2.0mm it is suggested that a patient needing a 4.0 - 6.5 ETT is appropriate for the Pediatric Quicktrach. The Adult 4.0mm would be based on a 6.5 ETT or >.


Electronic Capnography: End Tidal CO2 Monitors with Waveforms
For Departments that opt to purchase EtCO2 Monitors with waveforms, the following can be utilized to familiarize personnel with the process of reading these monitors.


Key Terms
PaCO2
Partial pressure of CO2 in arterial blood.

EtCO2
End-tidal carbon dioxide: measurement of the concentration of CO2 at the end of exhalation.

Capnometry
Measurement and numerical display of CO2 concentration at the patient’s airway.




Capnography
Measurement and waveform display of CO2 concentration at the patient’s airway.

Capnogram
Waveform display of CO2 throughout respiration.

a-ADCO2
Difference between EtCO2 and PaCO2 normally 2-5 mmHg.

Anatomic Dead Space
The portion of inhaled gases that fills the conducting airways and never reaches the alveolar membrane to participate in gas exchange







A Normal Capnogram

The diagram below shows the shape of a normal capnogram.





A-B: A near zero baseline—Exhalation of CO2-free gas contained in dead space.
B-C: Rapid, sharp rise—Exhalation of mixed dead space and alveolar gas.
C-D: Alveolar plateau—Exhalation of mostly alveolar gas.
D: End-tidal value— Peak CO2 concentration—normally at the end of exhalation.
D-E: Rapid, sharp downstroke—Inhalation



Abnormal Capnograms

Sudden loss of EtCO2 to zero or near zero



Possible causes:
Airway disconnection
Dislodged ET tube/esophageal intubation
Totally obstructed/kinked ET tube
Complete ventilator malfunction









Sustained low EtCO2 with good alveolar plateau



Possible causes:
Hyperventilation
Hypothermia
Sedation, anesthesia
Dead space ventilation



Sustained low EtCO2 without alveolar plateau



Possible causes:
Incomplete exhalation
Partially kinked ET tube
Brochospasm
Mucous plugging
Poor sampling techniques









Elevated EtCO2 with good alveolar plateau



Possible causes:
Inadequate minute ventilation/hypoventilation
Respiratory-depressant drugs
Hyperthermia, pain, shivering



Gradually increasing EtCO2



Possible causes:
Hypoventilation
Rising body temperature/malignant hyperthermia
Increased metabolism
Partial airway obstruction
Absorption of CO2 from exogenous source









Exponential decrease in EtCO2



Possible causes:
Cardiopulmonary arrest
Pulmonary embolism
Sudden hypotension; massive blood loss
Cardiopulmonary bypass



Sudden decrease in EtCO2 to low non-zero value



Possible Causes:
Leak in the airway system
ET tube in hypopharynx
Poorly fitting anesthetic mask
Partial airway obstruction
Partial disconnect from ventilator circuit










Rise in Baseline and EtCO2



Possible causes:
Defective exhalation valve
Rebreathing of previously exhaled CO2
Exhausted CO2 absorber



Spontaneous breathing during mechanical ventilation

Spontaneous breathing efforts may be evident on the CO2 waveform display. The patient on the top demonstrates poorer quality spontaneous breathing effort than the patient on the bottom.






Optional Skill

Acquisition & Transmission of 12-Lead ECG


Scope of Practice

EMT-Basic and Intermediate



















Indications

Patient ≥ 25 y/o










Suspected Cardiac/AMI Chest Pain or other signs/symptoms










of AMI or any non-trauma cardiac event including:










Respiratory Distress










Syncope










Diaphoresis










Weakness










Post-arrest



















Contra-Indications

Chest pain from trauma










Pleuritic chest pain



















Complications

There are no patient-related complications to this procedure













Yes

No

Procedure

Takes or verbalizes appropriate BSI precautions

 

 




Explain the procedure to the patient

 

 




Prepare equipment

 

 




Prepare the patient: expose chest, prep the skin (dry and shave if necessary)




 




Apply electrodes

 

 




Enter patient's age and identifiers (such as name, dob)

 

 




Instruct the patient to lie as still as possible during acquisition

 

 




Acquire ECG

 

 




Transmit to the receiving Emergency Department

 

 




During report (radio/phone), inform them of method of delivery used (fax, receiving station, e/mail, etc).

 

 













Notes

When possible, acquire the 12-Lead ECG prior to moving the patient







Always follow the Manufacturer's recommendations







Paramedic Study Guide: 12 Lead EKGs
by David N. Gerstner, EMT-P

Expectations for Paramedics Performing 12-Lead EKGs
To perform 12-Lead EKGs in the field, you should be able to meet the following objectives:

Be able to place 4 Limb Leads and 6 Precordial Leads within 90 Seconds

Limb Leads at proximal or distal limbs

Precordial Leads placed precisely, with no deviation, and with zero errors

Be able to discuss when to acquire 12-Lead EKGs

Be able to list issues relating to hospital care:

Notify if you or machine suspect Acute MI

Please note: if the LP-12 reads it as “MI, age indeterminate,” this is less likely to be acute. You should still notify and treat appropriately, but tell the hospital what it says.

List documentation required on the EKG Strip

Rapid transport

Deliver EKG to ER physician!

Understand need to note on chart and EKG if non-standard position (heart moves when patient sits up)

Understand use of negative complex in aVR as “test” for lead placement

Artifact, and what to do about it

Be able to recognize the EKG findings which indicate an AMI

Be able to localize the MI by the EKG findings

Be able to recognize the MI “mimics” on the EKG

Be able to list, from memory, which leads are “anterior leads,” which are “inferior leads,” which are “lateral leads,” and which are the “septal leads.”

Be able to explain the significance of the lead groupings listed above.





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