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Description : Check out this medical presentation on Emergency Medical Services (EMS), which is titled "EMS Equipment Review", to know about the indications for use of a variety of EMS equipment used in the field.

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EMS Equipment Review March 2015 CE Condell Medical Center EMS System CE IDPH Site Code #107200E-1215 Prepared by: Sharon Hopkins, RN, BSN, EMT-P 1
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Objectives Upon successful completion of this module, the EMS provider will be able to: List indications for use of a variety of EMS equipment used in the field. Manage a group of peers in setting up and applying a variety of equipment used in the field. Evaluate the effectiveness of application of a variety of EMS equipment in a practical setting. 2
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Objectives cont’d Actively participate in review of selected Region X SOP’s as related to the topics presented. Actively participate in review of the process of transmission of 12 lead EKG’s using department specific equipment. Actively participate in reviewing the operation of your department monitor/defibrillator, pacing capacity, synchronized cardioversion and defibrillation at the paramedic level. 3
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Objectives cont’d Actively participate in HARE/Saeger traction application. Successfully complete the post quiz with a score of 80% or better. 4
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Equipment and Patient Interventions There comes responsibility when using equipment in the delivery of patient care. You need to: recognize what the problem is to know what to do be able to distinguish what the appropriate intervention(s) is/are understand how to properly apply and use the equipment chosen recognize when the intervention is working as well as not accomplishing the goal know what documentation must be done with each piece of equipment used in patient care be knowledgeable regarding the cleaning and returning to service for each piece of equipment 5
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Capnography Background A continuous, non-invasive monitoring tool Measures level of CO2 at end of exhalation Quantitative results provides a number Assesses respiratory status thru-out respiratory cycle Provides current, at the moment, breath-to-breath information on patient status Results measured as mmHg of CO2 Normal 35 – 45 mmHg 6
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Capnography Information Numeric value provides end tidal (end of breath) CO2 level Waveform is a picture representation of the CO2 value exhaled with each breath Airway status reflected in: ETCO2 value (mmHg) Waveform picture Respiratory rate 7
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Definitions Ventilation Process of breathing; eliminating CO2 from body Respiration Exchange of gasses at alveoli level Oxygenation Getting O2 to tissues; measured by pulse oximetry Diffusion Process by which gas moves between alveoli and pulmonary capillaries (gases move from area of high concentration to areas of low concentrations) 8
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Capnography Usefulness Provides information on how effectively the body is: Producing CO2 (metabolism) Transporting CO2 (perfusion) Exhaling CO2 (ventilations) Goal – attain/maintain CO2 levels 35 – 45 mmHg 9
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Capnography Usefulness cont’d Confirms and monitors advanced airway placement Indicates effectiveness of chest compressions Blood must circulate through lungs to off-load CO2 for it to be exhaled Levels expected to minimally be >10mmHg during CPR Indicates return of spontaneous circulation (ROSC) Sudden, sustained rise in levels toward 35-45 mmHg Allows early interventions to be started 10
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Capnography Usefulness cont’d Monitor asthma & COPD conditions and response to bronchodilator therapy Detect increased respiratory depression and hypoventilation Tiring accessory muscles Neuromuscular disease effect on respiratory center Change in level of consciousness – alcohol/drug overdose, head trauma, sedation/analgesia Seizure activity &/or post ictal period 11
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Capnography Waveform A-B – respiratory baseline B-C expiratory upslope C-D expiratory plateau D – end of exhalation point of measurement D-E – inspiratory downslope 12
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Capnography Waveforms Hypoventilation CO2 retained so values  Hyperventilation CO2 eliminated so values  13
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Capnography Waveforms Asthma attack or COPD Difficulty exhaling evidenced by slow, gradual upslope 14
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Capnography Waveforms Apnea or loss of advanced airway - flat line 15
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ETCO2 Detector End tidal (end of breath) CO2 detector Qualitative device Indicates presence/absence of detectable CO2 exhaled via pH sensitive paper Does not provide specific measurement of numeric value Color scale estimates CO2 level Able to change as detected levels change May take up to 6 breaths to wash enough CO2 out for proper measurement 16
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ETCO2 cont’d Gastric content or acidic drug contact on pH paper can affect accuracy of values detected When perfusion decreased (shock, arrest) ETCO2 reflects change in pulmonary blood flow and CO2 level Does not reflect ventilation status 17
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Altered CO2 Levels  CO2 level Shock, cardiac arrest, pulmonary embolism, bronchospasm, complete airway obstruction  CO2 level Hypoventilation, respiratory depression, hyperthermia 18
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CO2 Influence on Circulation  CO2 in blood (hypoventilation) Cerebral vasodilation  increase in intracranial pressure (ICP) due to increased blood flow to the brain  CO2 in blood (hyperventilation) Cerebral vasoconstriction  decrease in fresh blood flow to brain; decrease in levels of adequate oxygen and glucose negatively affect function of brain 19
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ETCO2 Result Interpretation Yellow – yes, CO2 is being detected in exhaled breath Tan – poor perfusion or ventilation status First evaluate placement of airway device Continue to trouble shoot Blue or purple – no CO2 being detected First evaluate placement of airway device Continue to trouble shoot 20
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Trouble Shooting Advanced Airway Placement – “DOPE” D – displacement of tube (i.e.: into esophagus) Chest rise and fall? Gastric sounds? Bilateral breath sounds? O – obstruction P – pneumothorax E – equipment failure Faulty cuff 21
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Esophageal Detector Device - EDD A modified bulb syringe Simple means of evaluating for missed endotracheal intubation Squeeze bulb, attach to end of endotracheal tube Bulb re-expands = tube in trachea Bulb does not re-expand or does so slowly – collapsing sides of esophagus onto tube preventing air from filling EDD – consider esophageal placement 22
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EDD cont’d Need to interrupt ventilations to use device Evaluate results of technique used with results of all other steps of confirmation – could be extenuating reason why you get false negatives 23
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Defibrillators Electrical capacitor that stores energy Biphasic defibrillators provide waveforms that use less DC energy than monophasic machines Energy flows in one direction and then reverses Therefore, possible decrease in tissue damage Survival rates increase if early CPR provided with prompt defibrillation attempt as soon as possible after collapse 24
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Defibrillation Early defibrillation critical to survival from sudden cardiac arrest Most frequent initial rhythm in arrest is VF Treatment for VF is defib (defibrillation) Probability of successful defibrillation diminishes over time VF deteriorates to asystole over time Check with your vendor to know your biphasic device’s recommended energy settings 25
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Ventricular Fibrillation as Presenting Rhythm Best chance of survival in public Early activation of EMS CPR initiated very soon after collapse Early application of AED or other defibrillation attempt Current passes though fibrillating heart to depolarize heart cells to allow them to uniformly repolarize Allows dominant pacemaker (SA node) to take over electrical control Goal – resume organized electrical activity 26
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Influences on Success of Defibrillation Time from onset of VF – shorter time  survival Condition of myocardium Less success in presence of hypoxia, acidosis, hypothermia, electrolyte imbalance, drug toxicity Pad size Larger pads felt to be more effective and cause less myocardial damage; should not overlap Ideal size for adults10-13 cm (4 -5 inches) Ideal size for peds 4.5 cm (roughly 3 inches) 27
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Influences cont’d Pad / skin interface Need to  the resistance Greater the resistance the less energy delivered to the heart and the greater the heat production at the skin surface Pad contact Max contact with skin; no air bubbles breaking contact; no pads touching or overlapping Avoiding placement of pads over bone Bone is poor conductor of electricity 28
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Pad Placement Operator Choice Anterior /posterior 1 pad over apex of heart, under left breast 1 pad under left scapula in line with anterior pad Anterior/anterior (apex) Anterior pad on right upper sternum just below clavicle Apex pad below left nipple in anterior axillary line over apex of heart 29
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Pad Placement cont’d DO NOT place pads Over sternum – bone poor conductor of electricity Over pacemaker or AICD – deflects energy; could damage the implanted device Place at least one inch away from device Over topical medication patches – deflects energy 30
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Defibrillation Indications VF, pulseless VT Contraindications Failure to demonstrate one of the above rhythms Asystole – defibrillation places a patient into asystole for the dominant pacemaker to take over PEA – electrical activity not a problem; needs mechanical response fixed 31
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Defibrillation Equipment Monitor/defibrillator Defibrillating pads Example: PadPro Defibrillation/pacing/cardioversion/monitoring electrodes Most come with conductive gel already applied in center of pad 32
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Defibrillation Safety CPR is performed just until the defibrillator is ready Confirm O2 not blowing across patient’s chest wall – hold away from the patient when not using the BVM Physically look all around (“nose to toes”) Clearly yell out “all clear” Deliver energy Immediately resume CPR 33
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Return of Spontaneous Circulation ROSC After 2 minutes of resumed CPR, evaluate the rhythm If an organized rhythm is viewed on the monitor, THEN check for a pulse If no pulse, rhythm is PEA Resume CPR Adult 1 and 2 man CPR 30:2 Infant and child 1 man CPR 30:2 Infant and child 2 man CPR 15:2 34
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Indications to Activate Cooling Protocol Post ROSC Presumed cardiac arrest NOT indicated for respiratory or traumatic arrest Remains unconscious and unresponsive ROSC present at least 5 minutes Systolic B/P >90 with or without pressor agent use (i.e.: Dopamine) Airway has been secured 35
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ROSC Contraindications Major head trauma or traumatic arrest Recent major surgery within past 14 days Systemic infection (i.e.: septic shock) Coma from other causes Active bleeding Isolated respiratory arrest Hypothermia (34o C/93.2o F) already present 36
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Induction of ROSC Place ice paks in the axilla, neck and groin Areas where blood vessels tend to be superficial Place ice pak over IV site If patient begins to shiver, contact Medical Control Anticipate order for Valium to stop the shivering Shivering will generate heat and therefore increase body temperature 37
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Vasopressor - Dopamine Stimulates alpha, beta, and dopaminergic receptors based on dose provided Starting dose 5mcg/kg/min IVPB up to 20 mcg/kg/min Take patient’s weight and drop last number Minus 2 from number left Left with rate to run IVPB in drops per minute Ex: 150 pounds; drop “0” 15 – 2 = 13 drops per minute 38
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Dopamine cont’d Dopaminergic effects at 2 mcg/kg/min Renal vasodilation to improve blood flow to kidneys Keep kidneys working, the body keeps working Beta effects 5 – 10 mcg/kg/min Increases strength of myocardial contraction – squeeze more blood out of ventricles Alpha effects at >20 mcg/kg/min Severe vasoconstriction that diminishes blood flow to all tissues 39
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AED (Automated External Defibrillator) Function AED’s will Analyze rhythms Deliver a shock if indicated Ventricular fibrillation (VF) Monomorphic and polymorphic VT if rate and R wave morphology exceed preset values Will not deliver a synchronized shock Can indicate loose electrodes / poor electrode contact 40
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AED Use in Pediatrics Pediatric attenuator used to deliver lower energy doses to children (built into cables with peds pads) 1-8 year old Use pediatric pads if available No attenuator (peds pads)available, use standard AED pads < 1 year old Manual defibrillator preferred If no manual defibrillator, use peds pads with attenuator No peds pads, use AED pads available 41
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AED Use With CPR Do NOT interrupt CPR to apply pads Apply pads while CPR in progress Do not touch patient during analysis phase Can provide compressions during charging phase No O2 flow across patient body during defibrillation attempt Call and look “ALL CLEAR” prior to each defibrillation attempt Immediately resume CPR 42
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Transition From AED To Defibrillator Upon arrival at scene, if AED ready to discharge, utilize AED Do not interrupt operation of device During 2 minutes of CPR, can switch from AED use to monitor/defibrillator Immediately resume CPR after delivery of each defibrillation attempt regardless of equipment used 43
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Synchronized Cardioversion A controlled form of defibrillation using a lower energy level that interrupts underlying reentrant pathway Used with organized rhythms and in presence of a pulse Monitor interprets QRS cycle and energy delivered during R wave Less vulnerable area of QRS Downslope of T wave is relative refractory area Minimal stimulant could generate rhythm into VF 44
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Indications Synchronized Cardioversion Unstable tachyarrhythmias SVT Rapid atrial fibrillation or flutter Hazard of breaking loose a blood clot in the atria and resulting in a stroke Ventricular tachycardia Note: polymorphic VT NOT likely to respond to synchronized cardioversion – no defined R wave 45
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Synchronized Cardioversion Procedure Apply pads Anterior/anterior or anterior/posterior position Sedate if possible This is a painful procedure! Versed 2 mg IVP/IO; repeated every 2 minutes; max 10 mg (desired effect – sedation!) Consider pain management Fentanyl 1 mcg/kg IVP/IN/IO; may repeat in 5 minutes to max of 200 mcg total dose 46
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Sync Procedure cont’d Activate “sync” button Verify R wave is being flagged/identified Choose energy setting starting at the lowest watt setting 100j, 200j, 300j, 360j Verify O2 not blowing across chest wall Look (nose to toes) and call “ALL CLEAR” Press and hold sync buttons until energy discharged Momentary delay waiting to identify the R wave 47
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Sync Procedure cont’d If synchronized cardioversion needs to be repeated, need to reset the “sync” button Safety that machine will default to defibrillation mode after every discharge of energy If VF occurs, verify sync mode is off and defibrillate patient without delay 48
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Transcutaneous Pacemaker - TCP Electrical cardiac pacing across the skin TCP is a painful non-invasive procedure so sedation will most likely be necessary Indications Symptomatic bradycardia Hypotensive Hypoperfusing Evaluate level of consciousness and B/P for most reliable indicators of patient condition/stability 49
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TCP Procedure Apply pads (-) over apex of heart, anterior chest wall (+) mid upper back below left scapula Set desired heart rate (80) Confirm sensitivity at auto/demand Begin mA current at 0 Turn pacer on 50
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TCP Procedure cont’d Slowly increase output until ventricular capture Spike followed by widened QRS Reassess vital signs and pain level Document settings – mA and rate Reassess need for sedation and analgesia Valium 2 mg IVP/IO over 2 minutes; repeat every 2 minutes until max of 10 mg total dose Fentanyl 1 mcg/kg IVP/IO/IN ; can repeat dose in 5 minutes with max total of 200 mcg 51
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Critical Thinking Skill and TCP In setting of acute MI, consider contacting Medical Control May want to decrease heart rate of TCP just enough to maintain perfusion Want to avoid increasing the work load on the heart by automatically selecting 80 as the heart rate Increasing work load on heart may increase the size of the infarction 52
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What would you do… You applied the TCP for a symptomatic bradycardia You had a paced rhythm You notice the following rhythm strip change – what is the rhythm and what would you do? Reassess patient; increase mA; consider need for CPR Failure to capture 53
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Defibrillation During Pacing Mode Check your device for specifics When in the pacing mode and the need to defibrillate occurs, for some models, you may have to turn off the pacing mode If pacing must be resumed, reset all levels 54
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12 Lead EKG’s A graphic recording of electrical activity in the heart Must evaluate the pulse to determine mechanical response Single lead (i.e.: lead II) evaluates cardiac rhythms 12 lead views can diagnose an acute MI Early interpretation of 12 lead EKG  early diagnosing  early reperfusion & restoring blood flow to ischemic tissues 55
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Acute MI Death of portion of heart muscle from prolonged deprivation of oxygenated blood Heart’s demand exceeds supply of oxygen over extended period of time Often associated with atherosclerosis process Location and size of infarct depends on vessel involved and site of obstruction Left ventricle most common site 56
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Evolution of Acute MI Ischemia – initial lack of oxygen ST depression can be reversible Injury to myocardial tissue ST elevation can be reversible Death/infarction Necrotic tissue can lead to scar formation Irreversible process Can leave a positive Q wave marker in leads affected 57
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58
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AMI Process Ring of ischemic tissue surrounds infarcted myocardium Collateral circulation may develop Ischemic area often site of arrhythmia development 59
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Complications of AMI Arrhythmia most common VF most lethal Most common cause of sudden death within one hour of onset of signs and symptoms Destruction of myocardial muscle mass can lead to CHF due to impairment of pumping capability Cardiogenic shock may develop if heart function is inefficient and inadequate Ventricular aneurysm can develop due to damaged wall of heart – can rupture causing instant death 60
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Patient Assessment Pain most common chief complaint Lasts more than 30 minutes Not relieved by rest or NTG Tired and weak most often complaint in elderly, long standing diabetic and women Determine responses to OPQRST assessment Activity at onset, provocation/palliation (worsens/improves), quality in their words, radiation, severity on 0 -10 scale, time of onset 61
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EMS Action Apply monitor Examine underlying rhythm – document rhythm Obtain 12 lead EKG Evaluate for ST segment elevation If elevation, in what group of leads? If depressed, look for reciprocal elevation Watch for development of arrhythmias 62
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Proper Placement EKG Chest Leads 63
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Groups of Acute MI by Leads 64
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Identifying Groups of ST Elevation 65
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Why Aspirin??? Inhibits platelets from aggregating/collecting at site of plaque rupture inside vessel wall Decreases morbidity and mortality rate Chewed to increase breakdown and absorption time of medication Patients on daily aspirin already have elevated and acceptable blood levels of aspirin – don’t have to supplement a dose if absolutely sure they took one today Always better to give full dose than to risk skipping any dose (just in case of skipped dose) 66
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12 Lead EKG Procedure Obtain rhythm strip Interpret, report and document rhythm Obtain 12 lead EKG Identified with patient age, sex, department name in preparation for transmission Review for ST elevation pattern Report to Medical Control what you see, then read word for word interpretation on 12 lead EKG printout 67
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12 Lead EKG Documentation Interpret the rhythm strip and document on patient care run report Document presence or absence of ST elevation If elevation, report and document in which leads Provide copy of rhythm strip and 12 lead EKG to ED secretary for placement on patient’s medical record 68
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CPAP Continuous positive airway pressure Effective therapy for acute CHF – pulmonary edema Can avert the need for intubation and mechanical ventilation if applied early enough Maintains constant pressure within the airway and through-out the respiratory cycle Keeps alveoli open and expanded Increases surface space for diffusion of gases 69
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CPAP cont’d Buys time for other therapies (i.e.: medications) to work Precaution Too much pressure can inhibit ventricular filling decreasing cardiac output B/P can drop 70
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CPAP Indications Stable pulmonary edema Alert; systolic B/P >90mmHg COPD with wheezing First contact Medical Control for orders For unstable pulmonary edema (altered mental status, systolic B/P <90 mmHg), contact Medical Control to discuss use of CPAP Reminder: all therapies used in pulmonary edema have potential to drop the B/P 71
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CPAP Contraindications Respiratory arrest or apnea Pneumothorax or trauma to chest wall Tracheostomy present Can’t get tight fit over trach stoma Actively vomiting 72
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CPAP Procedure Sit patient upright Assess and obtain baseline vital signs Begin O2 via non-rebreather mask while setting up equipment Administer first dose NTG Used as venodilator to decrease blood return to heart (decreases pre-load) 73
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CPAP Flow Safe II Procedure Assemble CPAP Flow Safe II Attach proximal end of O2 tubing with manometer to port in mask Attach distal end of tubing to O2 source Secure face mask snugly to patient’s face using head harness Adjust O2 flow – 13-14 lpm for 10 cm H2O Continue administration of medications 74
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CPAP Procedure cont’d Lasix 40 mg IVP (80mg if on med at home) as a diuretic If systolic B/P remains >90 mmHg Morphine 2 mg IVP slowly over 2 minutes May repeat 2 mg every 2 minutes as needed to max of 10 mg Used to decrease anxiety and for benefit of vasodilation If patient shows deterioration during CPAP treatment, remove CPAP, consider intubation, inform Medical Control 75
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CPAP Tidbits Be prepared to coach patient through first few minutes of CPAP use until positive effects begin Patient is already frightened Patient may feel suffocated with the mask on Exhaling against the resistance is tough at first    76
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HARE and Saeger Traction Indicated for isolated mid-femur fractures Reduces muscle spasm and therefore pain level Reduces risk of bones overriding Contraindications Open fracture Do not want to draw contamination into the wound Hip, knee, or pelvic fractures Increased risk of nervous or vascular complications 77
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Preparing for Traction Application Assess motor/sensory/circulation before and after splinting Can you move this/can you feel that? Mark pulses once found – easier to find the site on reassessment Compare to uninjured side Apply manual traction until mechanical traction in place 78
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HARE Application Measure and adjust splint Support distal end of splint on backboard Apply distal ankle hitch while maintaining manual traction Position traction under injured extremity Secure proximal end to groin area Apply hook to ankle hitch Replace manual traction with mechanical traction 79
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HARE Traction Adjust straps avoiding over the knee and over the injured site 80
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Saeger Traction Application Support leg and maintain gentle traction Use uninjured leg to measure and adjust splint length Place splint inside injure leg; padded bar snug against pelvis in groin (watch pressure areas!!!) Attach strap to thigh Attach padded hitch to foot and ankle Extend splint until correct tension obtained Apply elastic straps to secure leg to splint 81
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Saeger Splint Do not place straps over fracture site Release manual traction Reassess distal pulse, motor, and sensory 82
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Pain Control With Use of Traction Fentanyl 1 mcg/kg IVP/IN/IO May repeat same dose in 5 minutes Max total dose of 200 mcg As a CNS depressant, watch the respiratory status If respiratory depression occurs, begin to support ventilations via BVM 1 Breath every 5 – 6 seconds Document 10 -12 breaths per minute assisted Narcan 2 mg IVP/IN/IO can be used to reverse respiratory depression due to opioid use 83
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Cleaning of Traction Splints Rinse off gross contaminant Wet down all surfaces with Cavicide wipes Let device air dry Confirm all straps are accounted for and repackage device in preparation for next patient 84
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Combat Application Tourniquet - CAT Indications Uncontrollable hemorrhage when usual means have failed Contraindications Non-compressable site Equipment Tourniquet with attached rod 85
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CAT - Procedure Apply tourniquet proximal to bleeding site as distal as possible; preferably over bare skin Pull band very tight and securely fasten band back on itself Twist rod until bright red bleeding has stopped Or until distal pulses are eliminated Place rod inside clip; locking into place Secure straps over clip holding rod 86
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CAT – Potential Problems Inability to control bleeding Continue with direct pressure Prepare to apply a second CAT Apply QuikClot dressing if available Must be applied directly over wound site for impregnated material to be effective 87
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CAT – Documentation Pearls Reason CAT was applied Time and site of CAT application Results post intervention Consideration of administration of pain medication Fentanyl 1 mcg/kg IVP/IN/IO May repeat in 5 minutes, same dose Max 200 mcg total dosing 88
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Midazolam - Versed Potent, rapid onset, short acting benzodiazepine Onset 3-5 minutes Duration 20-30 minutes Used as sedative and hypnotic Has amnesic properties and reduces anxiety Amnesia of recent past (antegrade) useful to inhibit unpleasant reminders of procedures Low toxicity and high rate of effectiveness 89
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Indications for Versed Per Region X SOP’s Sedation prior to synchronized cardioversion Useful to maintain sedation post drug assisted intubation procedure Suppresses seizure activity IN route allows safer delivery method Decreases severe anxiety and apprehension 90
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Precautions With Versed Crosses placental barrier – could cause respiratory depression in newly born infant Elderly more sensitive to effects; metabolize med more slowly Toxicity increases when mixed with CNS depressants (alcohol, opioids like Fentanyl, tricyclic antidepressants) Toxicity may be higher in patients with COPD 91
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Side Effects of Versed Respiratory depression Drowsiness Hypotension When administering, have a BVM readily available Be prepared to assist respirations 1 breath every 5 – 6 seconds Document 10 – 12 breaths per minute assisted 92
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Fentanyl Synthetic opiate analgesic for pain control Shorter acting than morphine Onset immediate when administered IVP Peak effect 3 5 minutes Lasts 30 – 60 minutes Does not affect blood pressure like Morphine does 93
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Dosing For Fentanyl per Region X SOP’s Adult 1 mcg/kg IN/IVP/IO May repeat same dose in 5 minutes Max total dose 200 mcg Pediatrics 0.5 mcg/kg IVP/IN/IO May repeat same dose in 5 minutes Max total dose 200 mcg 94
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Precautions With Fentanyl Crosses the placental barrier – could cause respiratory depression in newly born infant Monitor respiratory rate, SpO2 levels, and level of consciousness Have BVM available to counteract potential respiratory depression 1 breath every 5 – 6 seconds Document 10 – 12 respirations per minute 95
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Cleaning of Equipment – After Every Patient Use In general, each piece of equipment in contact with a patient MUST be cleaned between each patient use Gross contaminant must be removed Surfaces need to remain wet and allowed to air dry All cables need to be wiped down (i.e.: EKG, B/P, pulse ox) Cables drag across contaminated surfaces A LOT!!! B/P cuffs need to be wiped down Pulse ox sensors need to be cleaned following manufacturer recommendations 96
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Department Review of Equipment Review set up of capnography monitoring Review operation of monitor/defibrillator for defibrillation, synchronized cardioversion, and TCP Review procedures for transmission of 12 lead EKG to receiving hospital In teams, apply the HARE or Saeger traction device to a peer 97
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Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013. Campbell, J., International Trauma Life Support for Emergency Care Providers. 7th Edition. Pearson. 2012. McDonald, J. ALS Skills Review. AAOS. Jones and Bartlett. 2009. Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010. Pediatric Education for Prehospital Professionals 3rd Edition. American Academy of Pediatrics. 2014. Region X SOP’s; IDPH Approved January 6, 2012. www.MARescue.com 98