TRANSITION SERIES
Topics for the Advanced EMT
CHAPTER
49
Advanced Skills for the
AEMT
Objectives
• Address the clinical application, use,
and interpretation of capnometry.
• Review the indications, site selection,
and procedure for intraosseous
cannulation in children.
• Learn the process of establishing a
saline lock.
• Learn the six rights of medication
administration.
Objectives (cont’d)
• Administration methods by container
type:
– Glass ampule
– Single dose vial
– Multi dose vial
– Non-constituted drug vial
– Prefilled syringe
– IV piggyback
Introduction
• Given the provision of EMS in many
states, it is now being recognized that
the Advanced EMT can assist their
paramedic partners with many
advanced life support skills that are
utilized during patient care and
management.
Introduction (cont’d)
• No EMS provider can function without
appropriate medical direction.
– EMS system must have:
 Medical control
 Treatment protocols
 Quality assurance
Capnometry
• End-tidal carbon dioxide (ETCO2)
monitoring is a noninvasive method of
measuring the level of carbon dioxide
(CO2) in an exhaled breath.
Colorimetric end-tidal CO2 detector.
Pleasanton, CA)
(Reprinted by permission of Nellcor Puritan Bennett LLC,
Capnometry (cont’d)
• Capnometry: measurement of expired
CO2 typically provides a numeric
display of the partial pressure of CO2
(in torr/mmHg)
• Capnography: graphic
recording/display of the capnometry
reading over time.
Capnometry (cont’d)
• Capnograph: device that measures
expired CO2 levels.
• Capnogram: visual representation of
the expired CO2 waveform.
Normal capnogram. AB = Phase I: late inspiration, early expiration (no CO2).
BC = Phase II: appearance of CO2 in exhaled gas. CD = Phase III: plateau
(constant CO2). D = highest point (ETCO2). DE = Phase IV: rapid descent
during inspiration. EA = respiratory pause.
Capnometry (cont’d)
• Factors that influence carbon dioxide
levels:
– Changes in ventilation
– Changes in perfusion
– Changes in metabolic activity
Spontaneously breathing patient with a sampling line for CO2 measurement.
Intraosseous Access
• Involves the insertion of a rigid needle
into the medullary cavity of the bone.
– Long bones
– Sternum
• IO access is indicated in emergency
situations in which an IV is required but
not obtainable, or presumed difficult,
such as cardiac arrest or trauma.
Intraosseous Access (IO)
• Advanced EMT may use intraosseous
(IO) cannulation in children when
appropriate
EZ-IO device with needles
Intraosseous Access (cont’d)
• Any solution or drug that can be given
intravenously can be administered by
the intraosseous route.
• Medications and fluids given IV or IO
reach the central circulation in a similar
concentration and in the same amount
of time.
Intraosseous Access (cont’d)
• EZ-IO® is a small battery-powered drill
that places the needle into the bone.
Intraosseous Access (cont’d)
• Three needle sizes based on patient
size
– 15mm pink hub
– 25mm blue hub
– 45mm yellow hub
• 5mm mark on the needle should be
visible above the skin.
Selecting the appropriately sized EZ-IO needle.
Intraosseous Access (cont’d)
• Common sites for intraosseous
insertion
– Proximal tibia
– Distal tibia
– Proximal humerus
IO needle insertion sites depend on the device being used and include the
proximal tibia.
IO needle insertion sites depend on the device being used and include the
medial malleolus of the distal tibia.
IO needle insertion sites depend on the device being used and include the
humeral head.
Intraosseous Access (cont’d)
• Determine the need for IO access and
employ Standard Precautions.
• Assemble and check all equipment.
• Position the patient as appropriate for
the intended insertion site.
• Locate the access site and indentify all
the landmarks.
• Cleanse the site with alcohol or
Betadine.
Intraosseous Access (cont’d)
• Perform the puncture using the device
manufacturer’s instructions.
• Remove the trocar, attach the syringe,
and attempt to aspirate bone marrow.
Intraosseous Access (cont’d)
• Attach IV administration and/or
extension set if required and set fluid
flow.
• Secure the needle at the insertion site
with bulky dressings or commercial
device.
Heparin/Saline Lock
• The Advanced EMT may wish to
establish intravenous access but not
administer fluids.
• Placement involves insertion of the IV
catheter into a peripheral vein.
• A device with a short tube and clamp is
flushed with heparin or saline and
attached to the IV catheter then
secured.
Heparin/Saline Lock (cont’d)
• IV catheter
• Heparin lock or saline lock
• Syringe with 3-5cc of sterile saline or
commercial saline injection device
• Tape or commercial securing device
Heparin/Saline Lock (cont’d)
• Venous blood drawing equipment
• Tourniquet
• Antiseptic swab (alcohol, Betadine,
etc.)
A heparin or saline lock regulates IV flow and decreases the risk of accidental
fluid overload or electrolyte derangement.
Heparin/Saline Lock (cont’d)
Use Standard Precautions.
Prepare the heparin/saline lock.
Select the venipuncture site.
Place the tourniquet proximal to the
site.
• Cleanse the site.
• Insert the catheter as described for a
traditional IV.
•
•
•
•
Heparin/Saline Lock (cont’d)
• Slide the catheter into the vein.
• Carefully remove the metal stylet and
dispose of it properly.
• Remove the tourniquet.
• Attach the lock device to the IV
catheter.
• Inject 2-3 cc of sterile saline into the
lock.
• Secure the device.
Preparation of Medications
• As an Advanced EMT, your EMS system
may allow you to prepare medications
for your paramedic partner for
administration.
• Such situations include but are not
limited to cardiac arrest, rapid
sequence induction, and complicated
myocardial infarction.
Preparation of Medications (cont’d)
• “Six rights” of drug administration
– Right
– Right
– Right
– Right
– Right
– Right
person
drug
dose
time
route
documentation
Preparation of Medications (cont’d)
• Medication label
– Name of the medication
– Expiration date
– Total dose
– Drug concentration
Preparation of Medications (cont’d)
• Ampule
– Breakable glass container with a coneshaped thin-neck top that is broken off
to retrieve the medication.
– Usually ranges from 1-5 cc of solution.
– Solution is usually retrieved with a
syringe and filter needle.
Glass ampules
Preparation of Medications (cont’d)
• Vials
– Single or multi-dose.
– Plastic or glass container.
– Self-sealing hub at the top.
– Medication is packaged in a vacuum.
– Solution is retrieved with a syringe and
needle.
Glass medication vials with self-sealing rubber tops
Preparation of Medications (cont’d)
• Nonconstituted vial
– Used when a drug has a short shelf life or
is unstable in a liquid form.
– Packaged with powder drug vial and liquid
mixing solution vial.
– The dilution solution is injected into the
powder medication with a syringe and
needle.
– Once dissolved the medication is withdrawn
for administration.
The nonconstituted drug vial actually consists of two vials, one containing a
powdered medication and one containing a liquid mixing solution.
Preparation of Medications (cont’d)
• Prefilled Syringe
– Syringe of medication that does not
need to be drawn from another source.
– Two components
 Drug cartridge (glass or plastic)
 Plunger
– Usually contains standard doses to
prevent medication errors.
Preparation of Medications (cont’d)
• IV infusion/piggyback
– Deliver a steady, continual dose of
medication through an existing IV line.
– Can be used for loading and
maintenance doses.
– Piggybacked into the primary IV line.
– The Advanced EMT can prepare the IV
infusion for delivery, however, the
paramedic must establish the drip rate.
IV piggyback medication. (© Scott Metcalfe)
Preparation of Medications (cont’d)
• IV infusion/piggyback (continued)
– When preparing an IV piggyback
infusion, the Advanced EMT should
ensure the medication is properly
labeled.
 Name of the medication (generic and
trade names)
 Total amount of the drug mixed in the
bag
Preparation of Medications (cont’d)
• IV infusion/piggyback (continued)
– When preparing an IV piggyback
infusion, the Advanced EMT should
ensure the medication is properly
labeled
 Concentration (amount of drug per mL)
 Expiration date
Summary
• Assisting with medication
administration is a fundamental skill
and assisting your paramedic partner
can save precious time.
• It is the Advanced EMT’s responsibility
to be familiar with all equipment and
techniques so they can be employed
safely and efficiently.