Patient Treatment and Transport Study Guide for the EMT Test

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General Information

Treatment may begin at the scene and will continue throughout the transport, as necessary. The nature of the emergency will dictate the steps you take and when/where you take them. Questions about patient treatment and transport make up between 20% and 24% of the EMT test.

Transfer of the Patient

Transfer of the patient from where they are found to the ambulance can require specialized equipment. Ultimately, the patient needs to be safely secured to the stretcher in the ambulance. When to begin transfer can be a dynamic process, requiring interaction between assessment and treatment.

To achieve successful patient transfer, EMTs must understand proper lifting techniques, communication skills, and equipment use to protect both the patient and themselves from injury. A well-executed transfer promotes patient comfort, supports ongoing assessment, and sets the foundation for high-quality care throughout the transport process. Patient transfer also carries over after transport; patients must then be moved from the ambulance stretcher to the hospital bed. This secondary hospital transfer is equally as important and requires the same focus on proper technique and skill as the initial transfer.

Respiratory Management

Respiratory management is a fundamental responsibility of EMTs, focusing on recognizing and correcting life-threatening airway and breathing problems. Effective management includes assessing airway patency, monitoring respiratory effort, and providing interventions such as oxygen therapy, suctioning, and basic airway adjuncts. Quick identification of inadequate ventilation and timely care helps EMTs ensure that patients maintain adequate oxygenation and prevent further deterioration during the prehospital phase.

Airway Opening

When a patient is unresponsive, it is essential to maintain an open airway. Obstruction of the airway due to the tongue falling to the back of the throat is common in unconscious patients. EMTs must quickly recognize airway obstruction and use techniques such as the head-tilt-chin-lift or jaw-thrust maneuver to establish patency. Proper airway opening helps ensure oxygen can reach the lungs and prevents further compromise, making it a critical first step in managing any patient with respiratory compromise.

Maneuvers

Patients should be placed in the supine position if the situation allows, as this position is most effective for opening the airway. There are several methods for opening a patient’s airway. It’s important to assess the situation and the patient’s condition before choosing a technique. Using the wrong method could result in further injury to the patient.

Head Tilt-Chin Lift

The head-tilt-chin-lift is the preferred technique for opening a patient’s airway. The technique is performed by gently lifting the patient’s mandible up while simultaneously pressing down on the forehead. Using a head tilt-chin lift places the patient in the sniffing position, which is preferred for manual ventilation and if intubation is needed.

Jaw Thrust

A jaw thrust is an alternative way to open the airway and should be used in patients who have a suspected spine or neck injury. The jaw thrust technique involves moving the jaw upward by placing your fingers behind the angles of the jaw and gently lifting.

Opening Mouth

Opening the airway using either a jaw thrust or a head tilt-chin lift will not necessarily result in the patient opening their mouth. If the patient’s mouth does not open naturally, you need to open it to ensure effective ventilation. Open the patient’s mouth by using your thumb and index finger. Push the lower teeth down with your thumb while pushing the upper teeth upward with your index finger.

Suctioning

Secretions, such as mucus, blood, and vomit, can block a patient’s airway and need to be suctioned out of the mouth and possibly the nose. Suctioning is also often necessary before intubation to visualize the vocal cords. In some instances, it will be obvious that a patient needs to be suctioned, such as when you see large amounts of blood or vomit. In other cases, you may hear gurgling noises coming from the patient’s mouth, which also indicates suctioning is needed.

Equipment

Suctioning equipment may include a fixed, mounted suction unit inside the rig or a portable suction device. Either device provides vacuum pressure to remove secretions. A suction catheter should be selected based on the patient’s needs. There are two main types of suction catheters: a rigid tip catheter called a Yankauer, for suctioning in the mouth, and a soft tip flexible catheter, sometimes referred to as a French catheter, for suctioning the nose, trachea, stomas, and liquid secretions in the mouth.

Techniques

Make sure you have gathered the needed equipment, including the type of suction catheter you intend to use. Turn on the suction device and make sure it is set at 300 mmHg. Measure the catheter for the correct depth by measuring from the corner of the patient’s mouth to the edge of their earlobe or the angle of the jaw. Place the tip of the catheter in the patient’s mouth to the depth measured. Apply suction as you are withdrawing the catheter from the patient’s mouth. Limit suction time to 15 seconds in adults, 10 seconds in children, and 5 seconds in infants.

Here are some terms to know:

  • Yankauer—This is a rigid, curved suction catheter commonly used by EMTs to clear the upper airway of secretions, blood, or vomit.

  • French catheter—This is also known as a soft suction catheter, a flexible tube used to remove secretions from the airway when more delicate or precise suctioning is needed. Its thin, malleable design makes it more ideal for suctioning the nose, in or around airway adjuncts, or in the back of the throat, and it is most ideal for pediatric patients.

Airway Adjuncts

Airway adjuncts are used to keep a patient’s airway open. They work by preventing the tongue from blocking the airway. There are two types of airway adjuncts: an oropharyngeal and nasopharyngeal airway. Before selecting which airway adjunct is appropriate, it is essential to assess your patient and determine his or her level of consciousness. It is also critical to use the correct size airway device for your patient.

Oropharyngeal

An oral airway is inserted into the mouth to prevent the tongue from relaxing and blocking the airway. It can be used in patients who are breathing and those who require manual ventilation. It should only be used in patients who are unresponsive and do not have an intact gag reflex.

Nasopharyngeal

A nasal airway can also be used to maintain a patent airway. It is usually better tolerated in patients who have an intact gag reflex. It can also be used in patients who have an altered level of consciousness and may not be able to protect their airway.

Maintaining the Airway

If your patients do not have a suspected spinal injury, consider placing them in the recovery position to maintain their airway. The recovery position involves rolling the body onto one side, extending the lower arm, and placing the upper hand under the cheek. This position helps prevent the tongue from blocking the airway and also decreases the risk of aspiration if the patient vomits.

Advanced Airway Monitoring

Some patients may need an advanced airway when basic airway measures are not enough to support ventilation. An endotracheal tube or ET tube, is placed into the trachea by an appropriately trained provider to help secure the airway. After placement, waveform capnography is used to help confirm and monitor ET tube position. It measures exhaled carbon dioxide over time. EMTs can continue monitoring chest rise, breathing, oxygen saturation, and overall patient condition.

Supplemental Oxygen

Supplemental oxygen is needed in patients who are hypoxic. Hypoxia can lead to symptoms including shortness of breath, confusion, and bluish skin and nail beds. Supplemental oxygen should also be used when manually ventilating a patient.

Supplemental Oxygen Indications

When oxygen is needed, EMTs should adjust the amount of oxygen delivered based on the patient’s condition, work of breathing, and pulse oximetry reading. For many patients that receive oxygen, the goal is to keep SpO2 should be 95% to 99%. If the patient continues to show signs of distress even with a high saturation reading, continue reassessing breathing status and consider whether a higher support device or assisted ventilation is needed.

Oxygen Sources and Their Use

Different devices can be used to deliver supplemental oxygen, including cylinders and liquid oxygen. Cylinders come in different sizes, with the D and M cylinders being the most commonly used. Liquid oxygen is typically not used in the field but may be available for patients to use at home.

Equipment

In addition to an oxygen delivery device, if you are using an oxygen cylinder, you need to have a pressure regulator. A pressure regulator decreases the pressure of oxygen being released to a safe level of 40 psi to 70 psi. A flowmeter, which allows you to deliver a specific liter flow, is also needed. Many newer regulators incorporate a flow meter, which allows you to dial in a liter flow.

Procedures

When administering oxygen to a patient, you must inspect the cylinder and remove the seal. The cylinder also needs to be cracked, which involves opening and closing the valve with a tank key (wrench).

Attach the regulator and flowmeter to the tank according to the pin system design. When you select the oxygen delivery device (mask or nasal cannula), attach it to the flowmeter/regulator’s nipple. Turn the flowmeter to the desired liters per minute.

Hazards

Oxygen will not spontaneously burn, but it can support combustion. Be aware of the environment in which oxygen is used. Oxygen should not be used near flames or sparks, such as a fireplace or a lit cigarette. It’s also important not to leave a cylinder standing or leaning against a wall. Place the cylinder down unless it is in an oxygen cart. Oxygen toxicity is also a consideration when administering supplemental oxygen. Damage to cellular tissue can occur if blood oxygen levels become too high. However, it is critical not to deprive a hypoxic patient of oxygen due to fears of oxygen toxicity.

Here are some terms to know:

  • pressure regulators—essential devices used to safely control the high-pressure oxygen stored in cylinders, reducing the oxygen to a usable and consistent working pressure for patient care

  • flowmeter—device attached to an oxygen regulator that allows EMTs to control the exact rate at which oxygen is delivered to the patient

  • oxygen toxicity—harmful effects that can occur when a patient is exposed to excessively high concentrations of oxygen for prolonged periods

Delivery Equipment

Supplemental oxygen in the prehospital setting is usually delivered through a nasal cannula, non-rebreather mask, or a bag-valve mask. A non-rebreather should be set at 10 to 15 liters per minute and can deliver approximately 95 percent oxygen. It should be used in patients who are breathing on their own but are suspected of being hypoxic. A nasal cannula can be used at flow rates of 1 to 6 liters per minute and may be appropriate for patients who do not tolerate a mask. A cannula can deliver about 24 to 44 percent oxygen. A bag-valve mask should also be used to deliver oxygen in patients who require ventilatory assistance. Flows should be set at 15 liters per minute and can deliver close to 100 percent oxygen.

Here are some terms to know:

  • non-rebreather—high-concentration oxygen delivery device used for patients showing signs of significant hypoxia or respiratory distress

  • nasal cannula—low-flow oxygen delivery device used for patients who need supplemental oxygen but do not require high concentrations

  • partial rebreathing mask—oxygen delivery device that allows the patient to inhale a mixture of oxygen from a reservoir bag and some of their exhaled air

  • bag-valve mask—high-concentration oxygen delivery device designed to provide nearly 100 percent oxygen to patients in severe respiratory distress or hypoxia

  • Venturi mask —oxygen delivery device that provides precise, controlled oxygen concentrations to patients who require specific oxygen levels, using color-coded adaptors to mix oxygen with room air at a fixed ratio

Artificial and Assisted Ventilation

In instances when your patient is apneic or not breathing adequately, you need to provide assisted ventilation. Assisted ventilation can be provided with a bag-valve mask, a continuous positive airway pressure (CPAP) machine, or a mechanical ventilator.

Here are some terms to know:

  • mechanical ventilation—This involves the use of a device to assist or completely take over a patient’s breathing when they are unable to breathe adequately on their own.

  • gastric distention—This occurs when air unintentionally enters the stomach during artificial ventilation, causing it to expand. This expansion increases the risk of vomiting and aspiration, and it can make ventilation less effective by putting pressure on the diaphragm.

  • passive ventilation—This is a method of assisting a patient’s breathing without actively forcing air into the lungs, relying instead on the patient’s own respiratory effort.

Continuous Positive Airway Pressure (CPAP)

CPAP is a noninvasive ventilation method that delivers continuous positive airway pressure to keep the patient’s airway open and improve oxygenation. EMTs commonly use CPAP for patients experiencing respiratory distress from conditions like congestive heart failure or COPD. By preventing airway collapse and reducing the work of breathing, CPAP can stabilize patients and improve gas exchange without the need for intubation.

CPAP can be used to deliver continuous positive pressure to the lungs. It should only be used in spontaneously breathing patients. CPAP can improve tidal volumes and oxygenation while decreasing the work of breathing.

Here are some terms to know:

  • BiPAP—This stands for bilevel positive airway pressure, a noninvasive ventilation device that provides two levels of pressure: higher pressure during inhalation to assist breathing and lower pressure during exhalation to make breathing easier.

  • compliance—This is the ability of the lungs and chest wall to expand during inhalation. High compliance means the lungs expand easily, while low compliance indicates stiffness or resistance (making breathing more difficult).

Special Respiratory Issues

You may encounter special situations that require respiratory airway management methods that are different from what is listed above.

Stomas

A stoma is an opening made in the skin midline in the neck. It is typically used to insert a tracheostomy tube (trach tube), but the stoma itself can also be an independent airway without a trach tube. Since the upper airway is bypassed, humidification should be administered to the stoma to prevent mucus plugs from developing. If delivering oxygen to a patient with a stoma, use a tracheostomy mask. If you need to ventilate a patient manually and he or she has a trach tube, attach the bag-valve mask to the trach tube to ventilate. In patients who have only a stoma, a child’s mask can be connected to the bag and placed over the stoma to ventilate.

Here is a term to know:

  • tracheostomy—surgically created opening in the neck directly into the trachea to provide an airway

Other Emergency Respiratory Care

Respiratory emergencies may require other types of treatment. Be sure you thoroughly understand the procedures and indications for use of these types of respiratory emergency equipment.

Metered-Dose Inhaler

Metered-dose inhalers are small spray canisters, which can be used to deliver respiratory medications to the lungs. Bronchodilators, which open the airways, as well as steroids that decrease inflammation, can be administered via a metered-dose inhaler.

Small-Volume Nebulizer

A small-volume nebulizer can also be used to deliver respiratory medication as a fine mist that the patient inhales. The most common medication delivered in a small-volume nebulizer is albuterol, which is a bronchodilator used to treat conditions such as asthma and COPD.

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