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Basic emt skills manual

SOUTHWEST TENNESSEE
COMMUNITY COLLEGE
DEPARTMENT
EMERGENCY MEDICAL SCIENCES
H. WAID RAY
SKILLS MANUAL
17th Edition
Caring for the sick and injured has always been a demanding and oftentimes precarious profession. Early prehospital care in Tennessee usually consisted of funeral homes placing a sick or injured person in the back of a hearse and driving at a breakneck speed to the closest hospital. Fortunately, patients today receive far better professional care from highly-trained, highly-skilled providers. The goal of this manual is to provide you with the psychomotor skills and attendant facts necessary to save lives, reduce morbidity and give the "far better professional care" mentioned above. This manual is not a magic lantern illuminating the correct methodology for managing each and every illness or injury. Rather it is a suggested method of performing skills that, when mastered, provide the foundation for becoming a competent prehospital care provider. Always remember that the psychomotor skills described in this manual are useless without a sound and broad fund of basic knowledge from which to draw. Significant recognition must be given to the National Registry of Emergency Medical Technicians (NREMT) whose original skills sheets this manual is based upon. H. Waid Ray Basic EMT Skills Manual H. Waid Ray, 17th Edition Basic EMT Skills Manual H. Waid Ray, 17th Edition Basic EMT Skills Manual H. Waid Ray, 17th Edition
Description:
• Oxygen is the most important emergency drug and is required by the body to facilitate the breakdown of glucose into usable forms of energy. Oxygen is odorless, colorless, and tasteless. • Administration increases arterial oxygen tension which increases the oxygen saturation available for hemoglobin.
Indications:
• Respiratory emergencies. • Cardiac arrest.
Contraindications:
• NONE in the emergency setting.
Precautions:
• Patients with COPD may experience apnea. These patient's chemo-receptors no longer influence breathing as they have converted to an oxygen-based (hypoxic) drive to breathe. • Do not withhold oxygen from any patient who truly needs it. • Prolonged administration of high flow oxygen to newborn infants can result in eye • Cardiac Arrest – as close as possible to 100% FiO2 (BVM), NOT TO EXCEED
99% SaO2.
• Hypoxia – as close as possible to 100% FiO2 (BVM or 15 LPM / NRB), NOT TO
EXCEED 99% SaO2.
• Chest Pain – as close as possible to 100 % FiO2 (15 LPM / NRB), NOT TO
EXCEED 99% SaO2.
1. For severe respiratory distress, 100% FiO2 or as close as possible (15 LPM / NRB), NOT TO EXCEED 99% SaO2 while closely monitoring
respiratory rate and depth.
2. For normal or minimal respiratory distress, 2-6 LPM via BNC IF patient cannot tolerate a NRB mask, NOT TO EXCEED 99% SaO2 while closely
monitoring respiratory rate and depth.
• In all instances, be prepared to ventilate and intubate with a double lumen Page 1 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Oxygen Tank Set-Up and
This station is designed to test your ability to correctly assemble the equipment needed to administer supplemental oxygen in the pre-hospital setting. This is an isolated skills test. You will be required to assemble an oxygen tank and a regulator and administer oxygen to a patient using a non-rebreather mask. At this point you will be instructed to discontinue oxygen administration by the non-rebreather mask and start oxygen administration using a nasal cannula because the patient cannot tolerate the mask. Once you have initiated oxygen administration using a nasal cannula, you will be instructed to discontinue oxygen administration completely. You may use only the equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions? Page 2 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Oxygen Tank Set-Up and Administration
Possible Awarded Take or verbalize standard precautions Assemble the regulator to the tank Check tank pressure Attach non-rebreather mask to oxygen Prefill reservoir Adjust liter flow to 12 liters per minute or greater Apply and adjust the mask to the patient's face Note: The medical director now orders you to apply a nasal cannula to the patient
Attach nasal cannula to oxygen
Adjust liter flow to six (6) liters per minute or less Apply nasal cannula to the patient Note: The medical director now orders you to discontinue oxygen therapy
Remove the nasal cannula from the patient
Shut off the regulator Relieve the pressure within the regulator Critical Criteria  Did not take, or verbalize, standard precautions  Did not assemble the tank and regulator without leaks  Did not prefill the reservoir bag  Did not adjust the device to the correct liter flow for the non-rebreather mask (12 liters per minute  Did not adjust the device to the correct liter flow for the nasal cannula (6 liters per minute or less)  Any other action or inaction causing patient harm or unnecessary pain Page 3 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Ventilation Skills – Pocket
This station is designed to test your ability to ventilate a patient with supplemental oxygen using a mouth-to-mask technique. This is an isolated skills test. You may assume that mouth-to-barrier device ventilation is in progress and that the patient has a central pulse. The only patient management required is ventilator support using a mouth-to-mask technique with supplemental oxygen. You must ventilate the patient for at least 30 seconds. You will be evaluated on the appropriateness of ventilatory volumes. You may use any equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions? Page 4 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Ventilation Skills – Pocket Mask
Take or verbalize standard precautions Connect one-way valve to mask Open patient's airway or confirm patient's airway is open (manually or with adjunct) Establishes and maintains a proper mask to face seal Ventilate the patient at the proper volume and rate (800-1200 ml per breath/10-20 breaths per minute) Connect the mask to high concentration of oxygen Adjust flow rate to at least 15 liters per minute Continue ventilation of the patient at the proper volume and rate (800-1200 ml per breath/10-20 breaths per minute) Note: The examiner must witness ventilations for at least 30 seconds
Critical Criteria  Did not take, or verbalize, standard precautions  Did not adjust liter flow to at least 15 liters per minute  Did not provide proper volume per breath (more than 2 ventilations per minute were below 800 ml)  Did not ventilate the patient at a rate a 10-20 breaths per minute  Did not allow for complete exhalation  Any other action or inaction causing patient harm or unnecessary pain Page 5 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Ventilation Skills – Bag-
Valve-Mask (BVM)

This station is designed to test your ability to ventilate a patient using a bag-valve-mask.
As you enter the station you will find an apneic patient with a palpable central pulse.
There are no bystanders and artificial ventilation has not been initiated. The only patient
management required is airway management and ventilatory support. You must initially
ventilate the patient for a minimum of 30 seconds. You will be evaluated on the
appropriateness of ventilator volumes. I will then inform you that a second rescuer has
arrived and will instruct you that you must control the airway and the mask seal while the
second rescuer provides ventilation. You may use only the equipment available in this
room. You have five (5) minutes to complete this station. Do you have any questions?
General Considerations:
• Gastric distention - Increase inspiratory times to deliver the necessary tidal volume at low peak inspiratory pressures. If possible, apply cricoid pressure or the Sellick Maneuver (requires additional rescuer) to reduce air inflow to the stomach. • Low ventilatory volume - Squeeze the bag with your free hand against your leg or side to expel additional volume. With two rescuers, use two hands to seal the mask to the patient's face and a second rescuer to squeeze the bag with both hands. The two-rescuer technique is preferred. If available, incorporate the use of an automatic transport ventilator to provide adequate tidal volume while sealing mask with both hands. If difficulty exists in providing a leak proof seal to the face, resort to using the mouth-to-mask method. • Observe for vomitus and be prepared to suction. • ALWAYS reassess the patient's ABC's, skin color, LOC and record. Page 6 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Ventilation Skills – Bag-Valve-Mask (BVM)
Take or verbalize standard precautions Verbalize opening the airway Verbalize inserting an oral airway Select appropriately sized mask Create a proper mask-to-face seal Ventilate patient at no less than 800 ml volume (The examiner must witness for at least 30 seconds)
Connect reservoir and oxygen
Adjust liter flow to 15 liters/minute or greater Note:A second EMT arrives to ventilate the patient while you control
the mask and the airway
Verbalize re-opening the airway
Creates a proper mask-to-face seal Instruct assistant to resume ventilation at proper volume per breath (The examiner must witness for at least 30 seconds)
Critical Criteria  Did not take, or verbalize, standard precautions  Did not immediately ventilate the patient  Interrupted ventilations for more than 20 seconds  Did not provide high concentration of oxygen  Did not provide, or direct assistant to provide, proper volume/breath (more than two (2) ventilations per minute are below 800 ml)  Did not allow adequate exhalation  Any other action or inaction causing patient harm or unnecessary pain Page 7 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Oro/Nasopharyngeal
Airways and Suctioning
This station is designed to test your ability to properly measure, insert and remove oropharyngeal and nasopharyngeal airway adjuncts as well as suction a patient's upper airway. This is an isolated skills test comprised of three separate skills. You may use any equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions? OROPHARYNGEAL (ORAL) AIRWAY
• An inadequate airway, or • Patient with loss of consciousness, without a gag reflex, or not breathing, and • Need for prolonged artificial ventilation.
Contraindications:
• Conscious or semiconscious patient with an intact gag reflex (the adjunct could cause vomiting or spasm of the vocal cords). • Inability to introduce the adjunct into the oropharynx secondary to massive
Risk & Complications:
• Stimulation of gag reflex may increase risk of vomiting, aspiration, or laryngospasm. Be prepared to suction. • If the chosen adjunct is TOO SHORT, the tip may displace the tongue into oropharynx obstructing the airway or the adjunct will not advance far enough to lift tongue. • If the chosen adjunct is TOO LONG, the tip may push the epiglottis over the glottic opening or induce laryngospasm. • If the only choice is between an adjunct that is too long and an adjunct that is too short, choose the adjunct that is TOO LONG. Measure from the corner of the patient's lips to the bottom of the patient's ear lobe or angle of jaw and mark the adjunct. Follow proper insertion techniques to the mark and secure the adjunct to prevent it from advancing further. NASOPHARYNGEAL (NASAL) AIRWAY
• A conscious patient with an intact gag reflex. • An inadequate airway due to a relaxed tongue. • A patient with decreased level of consciousness who cannot tolerate the oropharyngeal adjunct. • Trismus, preventing oropharyngeal adjunct insertion. • Massive trauma to lower jaw, preventing insertion of an oropharyngeal adjunct.
Contraindications:
• Nasopharyngeal adjuncts should not be used in suspected basilar skull fractures or severe nasal injuries. Page 8 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Risk & Complications:
• Inserting a nasopharyngeal adjunct too far or using a nasopharyngeal adjunct that is too long may stimulate the gag reflex and may cause vomiting and aspiration or laryngospasm. • Always have suction prepared prior to insertion. • If the chosen nasopharyngeal adjunct is TOO SHORT, it may not advance far enough to create an adequate airway. • If the chosen nasopharyngeal adjunct is TOO LONG, the tip may push the epiglottis over the glottic opening or induce laryngospasm • If the only choice is between a nasopharyngeal adjunct that is too long and a nasopharyngeal adjunct that is too short, choose the adjunct that is TOO LONG. Measure from the tip of the earlobe to the tip of the nostril and mark the adjunct. Follow proper insertion techniques to the mark and secure the adjunct to prevent the adjunct from advancing further. • Even if the adjunct is generously lubricated, the nasal passages may still suffer trauma secondary to insertion. Be prepared for epistaxis (nose bleed). Page 9 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Oro/Nasopharyngeal Airways and Suctioning
Possible Awarded OROPHARYNGEAL AIRWAY
Take or verbalize standard precautions Select appropriately sized airway Insert airway without pushing the tongue posteriorly Note: The patient is gagging and becoming conscious
Remove the oropharyngeal airway
SUCTIONING
Note: The patient requires suctioning
Turn on/prepare suction device
Assure presence of mechanical suction Insert the suction tip without suction Apply suction to the oropharynx/nasopharynx NASOPHARYNGEAL AIRWAY
Note: The patient now requires a nasopharyngeal airway
Select appropriately sized airway
Verbalize lubrication of the nasal airway Fully inserts the airway with the bevel facing toward the septum Critical Criteria  Did not take, or verbalize, standard precautions  Did not obtain a patent airway with the oropharyngeal airway  Did not obtain a patent airway with the nasopharyngeal airway  Did not demonstrate an acceptable suction technique  Any other action or inaction causing patient harm or unnecessary pain Page 10 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Pulse Oximetry
This station is designed to test your ability to correctly apply, monitor and interpret pulse oximetry. This is an isolated skills test. You will be required to correctly apply a pulse oximeter and then verbalize its monitoring and how to interpret the data it provides. You may use only the equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions? Page 11 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Pulse Oximetry
Possible Awarded Take or verbalize standard precautions Retrieve pulse oximeter and check batteries Assess patient's fingernails for polish or false nails and remove if necessary Verbalize normal values (96 – 100%) and describe treatment: Non rebreather mask at 12-15 LPM or nasal cannula at 4 – 6 LPM if patient cannot tolerate a mask and based on patient's chief complaint Verbalize mild hypoxia values (91 – 95%) and describe treatment: Immediate need to increase the FiO2; Non rebreather mask at 12 – 15 LPM; consider use of CPAP if available Verbalize moderate hypoxia values (86 – 90%) and describe treatment: Immediate need to increase the FiO2; consider possible loss of airway patency; Non rebreather mask at 12 – 15 LPM; consider airway adjunct and bag-valve-mask at 15 LPM; consider use of CPAP if available Verbalize severe hypoxia values (<86%) and describe treatment: assist ventilations with adjunct and bag-valve-mask at 15 LPM; request ALS intercept if appropriate; consider use of CPAP if available Critical Criteria  Did not take, or verbalize, standard precautions  Did not check for nail polish or false nails  Did not remove nail polish or false nails if present  Did not correctly recite any pulse oximetry values and treatment Page 12 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Table of Autonomic Effects
STRUCTURE OR ACTIVITY
SYMPATHETIC EFFECT
Circulatory System
Rate and Force of Heart Beat Heart and Skeletal Muscle Vessels Skin and Visceral Muscle Vessels Respiratory System
Rate and Depth of Breathing Digestive System
Digestive Secretions Renal System
Integumentary System
Pilomotor Muscles Page 13 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Bronchiodilator - Albuterol
(Proventil, Ventolin, Bronkosol, Alupent, Metaprel, etc)

Description:

• A commonly prescribed bronchodilator in pre-hospital care, Albuterol is administered with either a small volume nebulizer ("nebulizer") or a metered dose inhaler ("MDI").
Actions:
• Albuterol causes bronchodilation with minimal side effects and reduces airway resistance with approximately five hours duration.
Indications:
• Bronchial asthma or signs and symptoms of respiratory distress. • Reversible bronchospasm associated with chronic bronchitis and cases of • Third drug for anaphylaxis.
Contraindications:
• Patients with a known hypersensitivity to Albuterol.
Precautions:
• Palpitations, anxiety, nausea, and dizziness may be seen. • Monitor vital signs. • Use caution when administering to patients with a history of cardiovascular disease or hypertension. Nebulizer:
Adult: 2.5 mg of the drug placed in 3 ml of normal saline for inhalation and administered by a nebulizer running at the flow rate established in the nebulizer's manufacturer's recommendations until an appropriate mist is achieved (usually about six liters per minute). Shake the MDI vigorously several times and administer to the patient upon deep inhalation. The patient should hold their breath as long as comfortably possible (at least 10 seconds or more) to assure more effective distribution of the medication. • Inhalation only. Page 14 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Inhaler: Assist with
Patient's Own Device

This station is designed to test your ability to correctly assist a patient in taking their
inhaled medications using a metered dose inhaler (MDI) in the pre-hospital setting. This
is an isolated skills test. You will be required to assemble and administer medications to
a patient using an MDI. Once you have demonstrated your ability to safely administer
MDI medication, you will be instructed to discontinue the therapy completely. You may
use only the equipment available in this room. You have five (5) minutes to complete this
station. Do you have any questions?
Indications:
• Bronchial asthma and/or bronchospasm in emphysema and chronic bronchitis.
Contraindications:
• Usually none.
General Considerations:
• The contents of the MDI are under pressure: 1. Do not puncture. 2. Do not use or store near heat or open flames. 3. Exposure to temperatures above 120 degrees Fahrenheit may cause 4. Never throw container into fire or incinerator. • When not in use, keep the cap on the MDI's mouthpiece. • When not in use, store the MDI between 59 degrees and 86 degrees Fahrenheit. • Failure to use the MDI within the recommended temperature range may result in improper dosing. • Infant and Child Considerations: 1. Use of hand held inhalers is very common in children. 2. Retractions are more commonly seen in children than adults. 3. Cyanosis is a late finding in children. 4. In some children, frequent coughing may be present rather than wheezing. Page 15 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Inhaler: Assist with Patient's Own Device
Possible Awarded Take or verbalize standard precautions Apply high flow oxygen Assess vital signs Determine patient allergies and previous doses Obtain order to administer medication Note: The medical director orders you assist the patient with one "puff" of MDI Ventolin
Assemble MDI and extension tube (if available)
Check medication for correct medication, concentration, expiration date, etc. Instruct patient Remove high flow oxygen Allow patient to complete treatment, coaching as necessary Reapply high flow oxygen Reassess vital signs and determine subjective improvement Critical Criteria  Did not take, or verbalize, standard precautions  Did not check medication  Administered incorrect dosage  Did not reassess patient  Did not reapply high flow oxygen  Any other action or inaction causing patient harm or unnecessary pain Page 16 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Nebulizer: Assist with
Patient's Own Device

This station is designed to test your ability to correctly assemble the equipment needed
to administer nebulized medications in the pre-hospital setting. This is an isolated skills
test. You will be required to assemble and administer medications to a patient using an
oxygen-driven nebulizer. Once you have demonstrated your ability to safely administer
nebulized medication, you will be instructed to discontinue the therapy completely. You
may use only the equipment available in this room. You have five (5) minutes to
complete this station. Do you have any questions?
Indications:
• Bronchial asthma and/or bronchospasm in emphysema and chronic bronchitis.
Contraindications:
• Usually none. Page 17 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Nebulizer: Assist with Patient's Own Device
Possible Awarded Take or verbalize standard precautions Verbalize indications for nebulized therapy in the pre-hospital setting a. Signs and symptoms of respiratory emergency b. Bronchospasm due to allergens Gain medical control permission Assemble appropriate equipment a. medication (pre-mix) b. handheld nebulizer with t-piece c. mouthpiece d. oxygen with tubing Calmly reassure the patient and explain the procedure to the patient Determine the correct medication, expiration date, medication clarity and medication dosage Attach the T-piece, mouth piece and 150mm flextube Connect the oxygen tubing to the oxygen regulator, set the liter flow to 6 LPM and connect the other end of the tube to the nebulizer Position the patient in full fowlers for maximum chest expansion Advise the patient to hold the nebulizer upright and to close his/her lips around the mouthpiece Encourage the patient to inhale and to hold his/her breath for several seconds before exhaling Administer half of the medication, then pause and assess the patient's vital signs for adverse reactions If the vital signs remain essentially unchanged, administer the remaining half of the medication while continually monitoring the vital signs Return the patient to 12-15 LPM of oxygen via non-rebreathing mask Transport the patient to the appropriate hospital (if not already enroute) Continually monitor the patient Contact Medical Control, advise patient's condition and request further orders Document the procedure appropriately Critical Criteria  Did not take, or verbalize, standard precautions  Did not gain medical control permission  Did not determine the correct medication, expiration date, medication clarity and medication  Did not assess vital signs for adverse reactions  Any other action or inaction causing patient harm or unnecessary pain Page 18 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Normal Vital Signs
80/46 (+ or - 16 systolic, 16 diastolic) 89/60 (+ or - 24 systolic, 16 diastolic) 96/66 (+ or - 24 systolic, 16 diastolic) 98/64 (+ or - 24 systolic, 16 diastolic) 100/68 (+ or - 24 systolic, 16 diastolic) 99/66 (+ or - 24 systolic, 16 diastolic) 94/56 (+ or - 16 systolic, 16 diastolic) 100/56 (+ or - 16 systolic, 16 diastolic) 106/58 (+ or - 16 systolic, 16 diastolic) 108/58 (+ or - 16 systolic, 16 diastolic) 112/58 (+ or - 18 systolic, 16 diastolic) 114/60 (+ or - 18 systolic, 16 diastolic) 116/60 (+ or - 18 systolic, 16 diastolic) 118/60 (+ or - 18 systolic, 16 diastolic) 130/80 (+ or - 14 systolic, 24 diastolic) Page 19 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Vital Signs and Patient History
Take-Home Assignment
Name:

1) Solicit the assistance of any five cooperative classmates, friends and/or family
2) On each volunteer, assess the a) pulse including rate and quality; b) respirations including rate and quality; c) auscultated blood pressure; d) skin color, temperature, and moisture; e) pupils; and f) find the following pulses: i) Carotid, ii) Brachial, iii) Radial, iv) Femoral, v) Posterior tibialis (posterior tib), and vi) Dorsalis pedis (pedal). 3) Record the name, date, time taken, age, sex, race and vital signs of each volunteer below and be prepared to turn in your findings next class meeting. Page 20 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Patient Assessment Memory Prompts
Isolation
(Standard Precautions) Scene size-up including SINHS (Safety, Injury/Illness, Number of Patients,
Initial including IRCABCP (Impression, Responsiveness, Complaint,
Airway, Breathing, Circulation, Priority) Focused/Rapid including HEVIT (History, Exam, Vitals, Interventions,
Detailed assessment
Ongoing including FIV (Focused, Initial, Vitals [repeat each])
Page 21 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Medical Assessment
This station is designed to test your ability to perform a patient assessment of a patient with a chief complaint of a medical nature and "voice-treat" all conditions discovered. You must conduct your assessment as you would in the field including communicating with your patient. You may remove the patient's clothing down to shorts or swimsuit if you feel it is necessary. As you conduct your assessment, you should state everything you are assessing. Clinical information not obtainable by visual or physical inspection will be given to you after you demonstrate how you would normally gain that information. You may assume that you have two EMTs working with you and that they are correctly carrying out the verbal treatments you indicate. You have (10) minutes to complete this skill station. Do you have any questions? Page 22 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Medical Assessment
Take or verbalize standard precautions SCENE SIZE-UP
Determine the scene is safe
Determine the mechanism of injury/nature of illness Determine the number of patients Request additional help if necessary Consider stabilization of spine INITIAL ASSESSMENT
Verbalize general impression of the patient
Determine responsiveness/level of consciousness Determine chief complaint/apparent life threats Assess airway and breathing Initiate appropriate oxygen therapy Assure adequate ventilation Assess/control major bleeding Assess circulation Assess skin (color, temperature and condition) Identify priority patients/make transport decision FOCUSED HISTORY AND PHYSICAL EXAMINATION/RAPID ASSESSMENT
Signs and symptoms (Assess history of present illness)
How do you feel? Medical problem? General or local Past pertinent history Last oral intake Event(s) leading to present illness (rule out trauma) Perform focused physical examination (assess affected body part/system or, if indicated, complete rapid assessment) Vitals (obtain baseline vital signs) Interventions (obtain medical direction or verbalize standing order for medication interventions and verbalize proper additional intervention/treatment) Transport (re-evaluate transport decision) Verbalize the consideration for completing a detailed physical examination ONGOING ASSESSMENT (verbalize)
Repeat initial assessment
Repeat vital signs Repeat focused assessment regarding patient complaint or injuries Critical Criteria  Did not take, or verbalize, standard precautions when necessary  Did not determine scene safety  Did not obtain medical direction or verbalize standing orders for medical interventions  Did not provide high concentration of oxygen  Did not find or manage problems associated with airway, breathing, hemorrhage or shock (hypoperfusion)  Did not differentiate patient's need for transportation versus continued assessment at the scene  Did detailed or focused history/physical examination before assessing the airway, breathing and circulation  Did not ask questions about the present illness  Administered a dangerous or inappropriate intervention  Any other action or inaction causing patient harm or unnecessary pain Page 23 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Trauma Assessment
This station is designed to test your ability to perform a patient assessment of a victim of multi-systems trauma and "voice-treat" all conditions and injuries discovered. You must conduct your assessment as you would in the field including communicating with your patient. You may remove the patient's clothing down to shorts or swimsuit if you feel it is necessary. As you conduct your assessment, you should state everything you are assessing. Clinical information not obtainable by visual or physical inspection will be given to you after you demonstrate how you would normally, gain that information. You may assume that you have two EMTs working with you and that they are correctly carrying out the verbal treatments you indicate. You have (10) ten minutes to complete this skill station. Do you have any questions? Page 24 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Trauma Assessment
Take or verbalize standard precautions Scene Size-Up
Determine the scene is safe
Determine the mechanism of injury Determine the number of patients Request additional help if necessary Consider stabilization of spine Initial Assessment
Verbalize general impression of the patient
Determine responsiveness/level of consciousness Determine chief complaint/apparent life threats Initiate appropriate oxygen therapy Assess airway and breathing Assure adequate ventilation Injury management Assess/control major bleeding Assess circulation Assess skin (color, temperature and condition) Identify priority patients/make transport decision Focused History And Physical Examination/Rapid Trauma Assessment
Select appropriate assessment (focused or rapid assessment)
Obtain, or direct assistant to obtain, baseline vital signs Obtain S.A.M.P.L.E. history Interventions
Transport
Detailed Physical Examination
Inspect and palpate the scalp and ears Assess the facial areas including oral and nasal areas Inspect and palpate the neck Assess for tracheal deviation Assess the chest Assess the abdomen Assess the abdomen/pelvis Assess the pelvis Verbalize assessment of genitalia/perineum as needed 1 point for each extremity IF includes inspection, palpation, and Assess the extremities assessment of motor, sensory and circulatory function Assess the posterior Manage secondary injuries and wounds appropriately Verbalize re-assessment of the vital signs Critical Criteria  Did not take or verbalize standard precautions  Did not determine scene safety  Did not assess for spinal protection  Did not provide for spinal protection when indicated  Did not provide high concentration of oxygen  Did not find, or manage, problems associated with airway, breathing, hemorrhage or shock: (hypoperfusion)  Did not differentiate patient's need for transportation versus continued assessment at the scene  Did other detailed physical examination before assessing the airway, breathing and circulation  Did not transport patient within (10) minute time limit  Any other action or inaction causing patient harm or unnecessary pain Page 25 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Direct

This station is designed to test your ability to control hemorrhage. This is a scenario
based testing station. As you progress through the scenario, you will be given various
signs and symptoms appropriate for the patient's condition. You will be required to
manage the patient based on these signs and symptoms. A scenario will be read aloud
to you and you will be given an opportunity to ask clarifying questions about the
scenario, however, you will not receive answers to any questions about the actual steps
of the procedures to be performed. You may use any of the supplies and equipment
available in this room. You have ten (10) minutes to complete this skill station. Do you
have any questions?
General Considerations:
 Treat to Prevent Shock (hypoperfusion). • Use standard precautions. • Maintain airway/artificial ventilation and apply high flow oxygen. • Control any external bleeding using numerous stacked, sterile dressings (approximately two to three inches in height). • If signs of shock (hypoperfusion) are present and the lower abdomen is tender and pelvic injury is suspected, apply and inflate PASG if approved by medical control. • Elevate the lower extremities approximately 8 to 12 inches (Trendelenburg position). If the patient has serious injuries to the pelvis, lower extremities, head, chest, abdomen, or neck, elevate the spine board. • Splint any suspected bone or joint injuries. • Prevent loss of body heat by covering the patient with a blanket and placing a blanket under the patient. • Initiate a volume-replacing IV on the patient at an appropriate infusion rate. • Immediately transport and perform on-going assessment. Page 26 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Direct Pressure
Take or verbalize standard precautions Apply direct pressure to the wound using numerous stacked, sterile dressings (approximately two to three inches in height)
Note: The bleeding is now controlled
Bandage the wound using Kerlix, triangular bandages, tape or some other
appropriate form of bandaging Critical Criteria  Did not take, or verbalize, standard precautions  Did not control hemorrhage using correct procedures in a timely manner  Any other action or inaction causing patient harm or unnecessary pain Page 27 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Tourniquet
Note: Direct pressure has failed to control bleeding
Instruct a second rescuer to continue applying direct pressure Immediately apply a tourniquet proximal to the wound tightened until the first of bleeding being controlled or the pulse distal to the tourniquet being lost
Note: The bleeding is now controlled
Bandage the wound using fresh, numerous stacked sterile dressings
(approximately two to three inches in height) Note: The patient is now showing signs and symptoms indicative of hypoperfusion
Properly position the patient
Apply high concentration oxygen Initiate steps to prevent heat loss from the patient Indicate the need for immediate transport Critical Criteria  Did not control hemorrhage in a timely manner  Did not apply high concentration of oxygen  Did not indicate a need for immediate transportation  Any other action or inaction causing patient harm or unnecessary pain Page 28 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Amputation

This station is designed to test your ability to control hemorrhage by application of a
specialized bandage. This is a scenario based testing station. As you progress through
the scenario, you will be given various signs and symptoms appropriate for the patient's
condition. You will be required to manage the patient based on these signs and
symptoms. A scenario will be read aloud to you and you will be given an opportunity to
ask clarifying questions about the scenario, however, you will not receive answers to any
questions about the actual steps of the procedures to be performed. You may use any of
the supplies and equipment available in this room. You have ten (10) minutes to
complete this skill station. Do you have any questions?
Upper Extremity Elevation Guidelines:
• Amputation - elbow at 45 degrees. Page 29 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Amputation
Take or verbalize standard precautions Apply direct pressure to the wound using numerous stacked, sterile dressings Note: The bleeding is now controlled
Apply roller gauze using "boxing glove" analogy
Apply roller gauze using "figure eight" analogy Apply roller gauze to forearm/leg Apply sling elevating extremity Apply at least one swathe Note: Candidate may verbalize the following steps
Find the amputated part
Remove any large, adherent debris Irrigate with sterile normal saline Wrap the amputated part with sterile gauze moistened with sterile saline and place in a plastic bag Place first plastic bag in second plastic bag with cooling agent Critical Criteria  Did not take, or verbalize, standard precautions  Applied a tourniquet before attempting other methods of bleeding control  Did not apply roller gauze correctly  Did not sling or swathe or slung at inappropriate angle  Failed to describe proper care of amputated part  Any other action or inaction causing patient harm or unnecessary pain Page 30 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Eye Irrigation and
Bandaging
This station is designed to test your ability to properly irrigate, dress and bandage an eyeball wound. You are required to treat only the specific, isolated injury to the eye. The scene size-up and initial assessment have been completed and during the focused assessment an avulsed eye was detected. Ongoing assessment of the patient's airway, breathing, and central circulation is not necessary. You may use any equipment available in this room. You have five (5) minutes to complete this skill station. Do you have any questions? Page 31 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Eye Irrigation and Bandaging
Take or verbalize standard precautions Maintain cervical immobilization, if necessary Control bleeding as appropriate without applying pressure to globe of eye Retrieve at least one (1) liter bottle of sterile normal saline Irrigate eye from medial to lateral for at least five to ten minutes Apply 4x4 dressings in ring around globe Apply 4x4 dressings moistened with sterile normal saline over globe Apply 4x4 dressings moistened with sterile normal saline in cup Apply roller gauze to stabilize cup over globe Cover uninjured eye Critical Criteria  Did not take, or verbalize, standard precautions  Failed to irrigate with sterile normal saline  Failed to irrigate from medial to lateral  Failed to apply dressings in appropriate manner  Did not apply roller gauze correctly  Failed to cover uninjured eye  Any other action or inaction causing patient harm or unnecessary pain Page 32 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Head Bandage

This station is designed to test your ability to properly dress and bandage a soft tissue
injury to the head. You are required to treat only the specific, isolated injury to the head.
The scene size-up and initial assessment have been completed and during the focused
assessment an extruded eye was detected. Ongoing assessment of the patient's airway,
breathing, and central circulation is not necessary. You may use any equipment
available in this room. You have five (5) minutes to complete this skill station. Do you
have any questions?
General Considerations:
• Apply direct pressure to wound to control bleeding only if depressed skull fracture is not suspected. • Control bleeding from the edges of wounds by direct pressure. Page 33 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Head Bandage
Take or verbalize standard precautions Maintain cervical immobilization, if necessary Control bleeding as appropriate without applying pressure to the wound Apply numerous stacked, sterile 4x4 dressings over the wound Apply roller gauze, cravat or other bandage to stabilize dressings over the wound WITHOUT applying pressure to skull Critical Criteria  Did not take, or verbalize, standard precautions  Failed to apply dressings in appropriate manner  Did not apply roller gauze, cravat or other bandage correctly  Applied pressure to skull  Any other action or inaction causing patient harm or unnecessary pain Page 34 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Impaled Objects

This station is designed to test your ability to properly dress and bandage an impaled
object. You are required to treat only the specific, isolated injury. The scene size-up and
initial assessment have been completed and an impaled object was detected during the
focused assessment. Ongoing assessment of the patient's airway, breathing, and central
circulation is not necessary. You may use any equipment available in this room. You
have five (5) minutes to complete this skill station. Do you have any questions?
General Considerations:
• Pressure may be used around the wound to aid in bleeding control. • Do not wrap bandaging over the impaled object. • The impaled object may be removed ONLY if the airway is compromised. Page 35 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Impaled Objects
Take or verbalize standard precautions Control bleeding as appropriate Apply numerous stacked, sterile dressings 4x4 dressings around the impaled object Note: An occlusive dressing must be applied first if the impaled object
is in the chest
Apply numerous stacked multiple trauma dressings around impaled object
Apply roller gauze, cravat or other bandage to stabilize multiple trauma dressings around impaled object securing it in three planes Critical Criteria  Did not take, or verbalize, standard precautions  Failed to apply dressings in appropriate manner  Did not apply roller gauze, cravat or other bandage correctly  Failed to apply occlusive dressing to impaled object in chest  Any other action or inaction causing patient harm or unnecessary pain Page 36 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Long Bone Injuries

This station is designed to test your ability to properly immobilize a closed, non-
angulated long bone injury. You are required to treat only the specific, isolated injury to
the extremity. The scene size-up and initial assessment have been completed and
during the focused assessment a closed, non-angulated injury of the (radius-ulna, hip,
tibia-fibula) was detected. Ongoing assessment of the patient's airway, breathing, and
central circulation is not necessary. You may use any equipment available in this room.
You have five (5) minutes to complete this skill station. Do you have any questions?
General Considerations:
• Swathes should not be in contact with a suspected fracture site. • Knots should be tied in void areas and padded as needed. • Utilize at least two swathes for better immobilization. • Legs should be tied together to prevent movement. • Gently move uninjured leg to injured leg. • Place padding between the legs.
Upper Extremity Elevation Guidelines:
• Radius-Ulna – elbow at 60 degrees. • Humerus - elbow at 90 degrees. • Clavicle - elbow at 90 degrees. Page 37 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Board Immobilization – Hip
Possible Awarded Take or verbalize standard precautions Direct application of manual stabilization of the injury Assess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Measure the splint
Apply the splint Immobilize the joint above the injury site Immobilize the joint below the injury site Secure the entire injured extremity Immobilize the foot in the position of function Reassess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Critical Criteria  Grossly moves the injured extremity  Did not immobilize the joint above and the joint below the injury site  Did not reassess motor, sensory and circulatory function in the injured extremity before and after  Any other action or inaction causing patient harm or unnecessary pain Page 38 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Board Immobilization – Radius/Ulna
Possible Awarded Take or verbalize standard precautions Direct application of manual stabilization of the injury Assess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Measure the splint
Apply the splint Immobilize the joint above the injury site Immobilize the joint below the injury site Secure the entire injured extremity Immobilize the hand in the position of function Reassess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Critical Criteria  Grossly moves the injured extremity  Did not immobilize the joint above and the joint below the injury site  Did not reassess motor, sensory and circulatory function in the injured extremity before and after  Any other action or inaction causing patient harm or unnecessary pain Page 39 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Board Immobilization – Tibia/Fibula
Possible Awarded Take or verbalize standard precautions Direct application of manual stabilization of the injury Assess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Measure the splint
Apply the splint Immobilize the joint above the injury site Immobilize the joint below the injury site Secure the entire injured extremity Immobilize the foot in the position of function Reassess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Critical Criteria  Grossly moves the injured extremity  Did not immobilize the joint above and the joint below the injury site  Did not reassess motor, sensory and circulatory function in the injured extremity before and after  Any other action or inaction causing patient harm or unnecessary pain Page 40 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Flail Chest
This station is designed to test your ability to properly immobilize a flail chest. You are required to treat only the specific, isolated injury. The scene size-up and initial assessment have been completed and during the focused assessment a flail chest was detected. Ongoing assessment of the patient's airway, breathing, and central circulation is not necessary. You may use any equipment available in this room. You have five (5) minutes to complete this skill station. Do you have any questions? Page 41 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Flail Chest
Take or verbalize standard precautions Apply high flow oxygen Cover flail segment with bulky dressings Apply roller gauze, cravats or other bandage to stabilize dressing over flail segment Position patient in semi-fowler's position unless suspicion of cervical injury Critical Criteria  Did not take, or verbalize, standard precautions  Failed to apply bulky dressings in appropriate manner  Did not apply roller gauze, cravat or other bandage correctly  Failed to properly position patient  Any other action or inaction causing patient harm or unnecessary pain Page 42 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Foot/Ankle Injury
This station is designed to test your ability to properly immobilize a closed, non-angulated foot/ankle injury. You are required to treat only the specific, isolated injury to the extremity. The scene size-up and initial assessment have been completed and during the focused assessment a closed, non-angulated injury of the (foot, ankle) was detected. Ongoing assessment of the patient's airway, breathing, and central circulation is not necessary. You may use any equipment available in this room. You have five (5) minutes to complete this skill station. Do you have any questions? Page 43 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Foot/Ankle Injury
Possible Awarded Take or verbalize standard precautions Assess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Select the proper splinting material
Immobilize the site of the injury Immobilize the foot in the position of function Reassess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Critical Criteria  Grossly moves the injured extremity  Did not immobilize the joint above and, if possible, the joint below the injury site  Did not reassess motor, sensory and circulatory function in the injured extremity before and after  Any other action or inaction causing patient harm or unnecessary pain Page 44 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Joint Injury Management
This station is designed to test your ability to properly immobilize a non-complicated knee injury. You are required to treat only the specific, isolated injury to the knee. The scene size-up and initial assessment have been accomplished on the victim and during the focused assessment a knee injury was detected. Ongoing assessment of the patient's airway, breathing and central circulation is not necessary. You may use any equipment available in this room. You have five (5) minutes to complete this skill station. Do you have any questions? Page 45 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Joint Injury Management
Possible Awarded Take or verbalize standard precautions Direct application of manual stabilization of the knee injury Assess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Select the proper splinting material
Immobilize the site of the injury Immobilize the bone above the injured joint Immobilize the bone below the injured joint Reassess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Critical Criteria  Did not support the joint so that the joint did not bear distal weight  Did not immobilize the bone above and below the injured site  Did not reassess motor, sensory and circulatory function in the injured extremity before and after  Any other action or inaction causing patient harm or unnecessary pain Page 46 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition PASG Fact Sheet

Other Name:
• Also known as MAST trousers.
Indications:

• Isolated fractures of legs without evidence of other internal injuries. • Pelvic instability.
Contraindications:
• Pulmonary edema as evidenced by rales and/or rhonchi. • Uncontrolled bleeding.
Cautious Use:
• Chest trauma, particularly penetrating trauma. • Abdominal aortic aneurysm. • Head injuries, particularly closed head injuries.
Modified Use (Do NOT Inflate the Abdominal Compartment):
• Pregnancy. • Abdominal evisceration. • Impaled objects in the abdomen. • If an impaled object is in a leg, do not inflate that leg or the abdominal compartment.
Application:
• Remove as much clothing as possible and belt buckles, keys, etc. • For trauma patients, use either of the following: 1. Scoop stretcher, or 2. Log roll. • The suit is properly seated when positioned at the groin and the lowest anterior rib. • Inflate only until fracture is stabilized increasing the systolic pressure no more than ten • The person checking the blood pressure during inflation should palpate a systolic pressure at least every five to ten pumps. • Close all three stop cocks and tape shut. • Don't remove pump after inflation; bundle between patient legs.
Altitude and Temperature:
• Suit pressure increases as altitude and temperature increase. • Suit pressure decreases as altitude and temperature decrease. Page 47 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: PASG – Splint

This station is designed to test your ability to splint using PASG. This is a scenario
based testing station. As you progress through the scenario, you will be given various
signs and symptoms appropriate for the patient's condition. You will be required to
manage the patient based on these signs and symptoms. A scenario will be read aloud
to you and you will be given an opportunity to ask clarifying questions about the
scenario, however you will not receive answers to any questions about the actual steps
of the procedures to be performed. You may use any of the supplies and equipment
available in this room. You have ten (10) minutes to complete this skill station. Do you
have any questions?
General Considerations:
• Local protocols may determine the use of PASG. • The pressure inside the suit is not being monitored. • Never increase the systolic pressure more than 10 points. • The proper size PASG should be used on pediatric patients. • PASG alone will not serve as a traction device. • PASG, used with a long spine board, is the preferred treatment for pelvic • When used with traction splints: The traction splint is to be applied first, applying traction and securing leg straps. Then apply the trousers over the traction splint. Inflate the trousers in the appropriate sequence. • The PASG device must be cleaned with mild soap and water and allowed to air- dry after each use. • DO NOT USE BLEACH. • DO NOT DRY IN DIRECT SUNLIGHT. Page 48 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition PASG – Splint
Take or verbalize standard precautions Assess pulse rate and blood pressure Remove clothing and/or any objects that may cause pressure points Apply PASG to patient using appropriate method Enclose patient in PASG suit appropriately Connect hoses and open all stopcocks Inflate PASG appropriately Close all stopcocks and verbalize taping Reassess pulse rate and blood pressure Note: The candidate verbalizes application for splinting purposes.
Verbalizes appropriate method of application
Verbalizes appropriate inflation criteria Critical Criteria  Did not take, or verbalize, standard precautions  Did not correctly apply PASG either by technique or nature of illness  Increased systolic pressure more than 10 points  Did not verbalize any required information correctly  Any other action or inaction causing patient harm or unnecessary Page 49 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Sling and Swathe
This station is designed to test your ability to properly immobilize a non-complicated humerus injury. You are required to treat only the specific, isolated injury to the humerus. The scene size-up and initial assessment have been accomplished on the victim and during the focused assessment, a humerus injury was detected. Ongoing assessment of the patient's airway, breathing and central circulation is not necessary. You may use any equipment available in this room. You have five (5) minutes to complete this skill station. Do you have any questions? Page 50 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Sling and Swathe
Possible Awarded Take or verbalize standard precautions Direct application of manual stabilization of the humerus injury Assess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Select the proper splinting material
Immobilize the site of the injury Immobilize the bone above the injured joint Immobilize the bone below the injured joint Reassess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal
Critical Criteria  Did not support the joint so that the joint did not bear distal weight  Did not immobilize the bone above and below the injured site  Did not reassess motor, sensory and circulatory function in the injured extremity before and after  Any other action or inaction causing patient harm or unnecessary pain Page 51 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Traction Splinting

This station is designed to test your ability to properly immobilize a mid-shaft femur injury
with a traction splint. You will have an EMT assistant to help you in the application of the
device by applying manual traction when directed to do so. You are required to treat only
the specific, isolated injury to the femur. The scene size-up and initial assessment have
been accomplished on the victim and during the focused assessment a mid-shaft femur
deformity was detected. Ongoing assessment of the patient's airway, breathing, and
central circulation is not necessary. You may use any equipment available in this room.
You have ten (10) minutes to complete this skill station. Do you have any questions?
Indications:
• Painful, swollen, deformed mid-thigh with no joint or lower leg injury.
Contraindications:
• Injury is to the knee; • Injury is within one or two inches of the knee; • Injury to the hip; • Injury to the pelvis; • Partial amputation or avulsion with bone separation, distal limb is connected only by marginal tissue; or • Lower leg or ankle injury.
General Considerations:
• During immobilization of an open femur, care should be taken to avoid pulling the bone ends back onto the skin. Stop traction when the bone ends just begin to move.
Use with PASG Device:
• The traction splint is applied first, applying proper mechanical traction and securing the leg straps. Then apply the PASG over the traction splint and inflate the trousers. Page 52 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Traction Splint
Possible Awarded Take or verbalize standard precautions Direct application of manual stabilization of the injured leg Assess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal.
Prepare/adjust splint to the proper length
Direct the application of manual traction Position the splint under the injured leg Apply the proximal securing device (e.g. ischial strap) Apply the distal securing device (e.g. ankle hitch) Apply mechanical traction Position/secure the support straps Re-evaluate the proximal/distal securing devices Reassess motor, sensory and circulatory function in the injured extremity Note: Motor, sensory and circulatory function are present and normal.
Note: The examiner asks the candidate how he/she would prepare the patient for transportation.
Verbalize securing the torso to the long board to immobilize the hip
Verbalize securing the splint to the long board to prevent movement of the splint Critical Criteria  Loss of traction at any point after it was applied  Did not reassess motor, sensory and circulatory function in the injured extremity before and after  The foot was excessively rotated or extended after splint was applied  Did not secure the ischial strap before pulling mechanical traction  Final Immobilization failed to support the femur or prevent rotation of the injured leg  Secured the leg to the splint before applying mechanical traction  Any other action or inaction causing patient harm or unnecessary pain Note: If the leg is elevated at all, manual traction must be applied before elevating the leg. The ankle hitch may be applied before elevating the leg and used to provide manual traction. Page 53 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition The Maine Protocol
The Maine Protocol is a methodology of assessing patients for potential spinal injuries and excluding those patients who most likely do not need spinal immobilization. Four separate criteria are evaluated: 1) Mechanism of injury; 2) Pain and/or tenderness along the spine; 3) Motor and sensory criteria; and 4) Patient reliability. • Mechanism of Injury – Not every violent or traumatic event creates a spinal injury. Most low-speed, non-violent crashes do not generate enough energy to prompt spinal injuries (i.e. twisted ankle). Accordingly, if the mechanism of injury seen demonstrates high velocity or high energy, only then should the EMT become overly concerned with spinal stabilization (i.e. high-speed rollover; falls from heights; etc.). • Spinal Assessment – It is rare that spinal injuries do not prompt some form of pain or discomfort. The pain is either continuous, upon patient movement, or upon palpation. Accordingly, a reliable patient with no pain probably has no spinal injury. However, make certain to follow the entire algorithm before making this determination. • Motor and Sensory Examination – Injuries to the spinal cord almost always cause some form of distal neurological manifestation. This can be evidenced by outright paralysis or perhaps tingling in the extremities. The motor function is tested by using the "push" and "pull" technique on the feet. On the upper extremities, the patient's fingers are tested by pushing on the dorsal surface and checking to see if the patient can mount counterforce. Also, the patient's fingers are spread apart and the EMT checks to see if the patient can resist squeezing the index and ring fingers together. • Patient Reliability – Patients who have altered mental status for any reason cannot be relied upon to properly respond to pain or to accurately participate in the motor and sensory examination. Accordingly any patient with altered mental status for any reason (e.g. brain injury, alcohol or drug consumption, postictal status, distracting injuries) should be treated as if they have a spinal injury. In order to be considered reliable, a patient must have the four "C's" in place: conscious, cooperative, calm and clean (i.e. sober). The chart on the following page graphically illustrates the flow of the algorithm and should be used in conjunction with the information on this page. Page 54 of 73


Basic EMT Skills Manual H. Waid Ray, 17th Edition The Maine Protocol - Flow Chart
Page 55 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Clam Shell Device

This station is designed to rest your ability to provide spinal immobilization on a patient
using a clam shell immobilization device. You and an EMT assistant arrive on the scene
of an automobile crash. The scene is safe and there is only one patient. The assistant
EMT has completed the initial assessment and no critical condition requiring intervention
was found. For the purpose of this station, the patient's vital signs remain stable. You are
required to treat the specific, isolated problem of an unstable spine using a clam shell
immobilization device. You are responsible for the direction and subsequent actions of
the EMT assistant. Transferring and immobilizing the patient to the long backboard
should be accomplished verbally. You have ten (10) minutes to complete this skill
station. Do you have any questions?
General Considerations:
• This device does not effectively complete the spinal immobilization process. • Patient must be moved and secured to a long spine board to provide adequate spinal immobilization. • Groin straps will need to be released once patient is moved to a long spine • Rapid extrication methods are performed instead of using this device if at any time: 1. There is an immediate danger to the patient (fire, explosion, etc.), or 2. The initial assessment indicates a condition (profound hypoperfusion) that requires immediate intervention that cannot be accomplished in the vehicle. Page 56 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Clam Shell Device
Take or verbalize standard precautions Direct assistant to gently move the head to the neutral in-line position Direct assistant to maintain manual immobilization of the head Reassess motor, sensory and circulatory function in each extremity Apply appropriately sized extrication collar Insert device correctly (top first) Seat device in Axilla Connect middle chest strap Connect groin straps Connect bottom torso strap Connect top chest strap Reassess breathing Secure feet, knees & hands Secure head to board, padding if necessary Recheck connections Reassess motor, sensory and circulatory function in each extremity Reassess airway & breathing Verbalize moving the patient to a long board Verbalize slowly releasing groin straps Critical Criteria  Did not immediately direct, or take, manual immobilization of the head  Released, or ordered release of, manual immobilization before it was maintained mechanically  Patient manipulated, or moved excessively, causing potential spinal compromise  Device moved excessively up, down, left or right on the patient's torso  Head immobilization allows for excessive movement  Torso fixation inhibits chest rise, resulting in respiratory compromise  Upon completion of immobilization, head is not in the neutral position  Did not assess motor, sensory and circulatory function in each extremity after voicing immobilization to the long board  Immobilized head to the board before securing the torso  Any other action or inaction causing patient harm or unnecessary pain Note: If an XP-1 device is used instead of a KED, the shoulder straps are connected at the same time as the top chest strap and failure to connect them at that time is a critical error (meets Critical Criteria). Page 57 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Long Spine Board

This station is designed to test your ability to provide spinal immobilization on a patient
using a long spine board immobilization device. You arrive on the scene with an EMT
assistant. The assistant EMT has completed the scene size-up as well as the initial
assessment and no critical condition was found which would require intervention. For the
purpose of this testing station, the patient's vital signs remain stable. You are required to
treat the specific problem of an unstable spine using a long spine board immobilization
device. When moving the patient to the device, you should use the help of the assistant
EMT and the evaluator. The assistant EMT should control the head and cervical spine of
the patient while you and the evaluator move the patient to the immobilization device.
You are responsible for the direction and subsequent action of the EMT assistant and
the evaluator. You may use any equipment available in this room. You have ten (10)
minutes to complete this skill station. Do you have any questions?
General Considerations:
• When neutral position of the head cannot be safely attained, immobilize the head in the position found. • If the board is too short for the patient, always ensure that the head, neck, and spine are centered on the board properly. The feet and lower legs may extend past the end of the board if necessary. • If a chinstrap is used, make sure the patient can open their mouth to prevent aspiration should vomiting occur. Page 58 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Long Spine Board
Possible Awarded Takes, or verbalizes, standard precautions Direct assistant to gently move the head to the neutral in-line position Directs assistant to maintain manual immobilization of the head Reassesses motor, sensory and circulatory function in each extremity Applies appropriately sized extrication collar Positions the immobilization device appropriately Directs movement of the patient onto the device without compromising the integrity of the spine Applies padding to voids between the torso and the board as necessary Immobilizes the patient's torso to the device Evaluates and pads behind the patient's head as necessary Immobilizes the patient's head to the device Secures the patient's legs to the device Secures the patient's arms to the device Reassesses motor, sensory and circulatory function in each extremity Critical Criteria  Did not immediately direct, or take, manual immobilization of the head  Released, or ordered release of, manual immobilization before it was maintained mechanically  Patient manipulated, or moved excessively, causing potential spinal compromise  Patient moves excessively up, down, left or right on the patient's torso  Head immobilization allows for excessive movement  Upon completion of immobilization, head is not in the neutral position  Did not assess motor, sensory and circulatory function in each extremity after immobilization to the  Immobilized head to the board before securing the torso  Any other action or inaction causing patient harm or unnecessary pain Page 59 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Electrical Anatomy of the Heart
An electrical impulse is generated in a small piece of tissue known as the Sino-Atrial (SA) node. The SA node routinely generates this electrical impulse about 80 to 100 times per minute. The SA node can be influenced to increase and decrease the rate at which it generates this impulse. Once generated, the electrical impulse can travel in the nerves of the heart at approximately 120 meters per second (270 miles per hour). Therefore, the electrical impulses, unless slowed or stopped, can travel the full distance of the heart in milliseconds. The impulse travels into the Atria via the Interatrial tracts and downward into the lower chambers of the heart via the Internodal tracts. The impulses into the Atria terminate in nerve cells called Purkinje fibers and cause a simultaneous contraction of the atrial muscle fibers. The impulse that travels downward into the lower chambers next reaches a piece of tissue known as the Atrio-Ventricular (AV) node. The impulse is then delayed for a fraction of a second. The delay is necessary because of the speed at which the impulse travels through the nerve fibers of the heart. If the impulse were not delayed, the Atria and Ventricles would contract at essentially the same time impeding blood flow through the heart. If the AV node does not receive a signal from the SA node, it will eventually generate an impulse of its own. The impulse continues its travel downward through bundles of nerve tissue known as the Right and Left Bundle Branches. The impulse finally terminates in nerve cells called Purkinje fibers which cause a simultaneous contraction of the Ventricular muscle fibers. If no impulse is received from the SA or AV nodes, the Purkinje fibers will initiate their own impulse. Page 60 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Cardiac Arrest
Management (CPR/AED)
This station is designed to test your ability to coordinate CPR, administer defibrillation to a patient using an Automated External Defibrillator (AED) and provide advance airway management. You should conduct yourself as if this were a real patient. You have five (5) minutes to complete this station. Do you have any questions? Page 61 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Cardiac Arrest Management (CPR/AED)
Possible Awarded Assessment
Take or verbalize standard precautions
Briefly question the first responder about arrest events Direct the first responder to stop CPR Verify absence of spontaneous pulse Note: Examiner states "No pulse"
Direct resumption of CPR
Turn on AED power Attach AED to patient at proper points Direct first responder to stop CPR and ensure all individuals are clear of patient Initiate analysis of the patient's heart rhythm Verify absence of spontaneous pulse Note: Examiner states "No pulse"
Transition
Direct resumption of CPR for two minutes
Gather additional information about arrest event Confirm effectiveness of CPR (check central pulse during and between compressions; auscultate breath sounds)
Integration
Insert airway adjunct
Ventilate of direct ventilation of the patient Attach high flow oxygen Assure CPR continues without unnecessary or prolonged interruption Re-evaluate patient in approximately two minutes Repeat defibrillator sequence Verify absence of spontaneous pulse Transportation
Verbalizes emergency transportation of the patient
Critical Criteria  Did not take, or verbalize, standard precautions  Did not evaluate the need for immediate use of the AED  Did not direct initiation/resumption of ventilations/compressions at appropriate times  Did not assure all individuals were clear of patient before analyzing/delivering each shock  Did not operate the AED properly (inability to deliver shocks)  Prevented the AED from delivering indicated shocks  Any other action or inaction causing patient harm or unnecessary pain Page 62 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Nitroglycerin (NTG)
(NitroStat, NitroDur, NitroBid)

Description:
• Used in the management of chest pain associated with both angina and acute myocardial infarction.
Actions:
• Nitroglycerin is a rapid smooth-muscle relaxant that causes decreased cardiac • Nitroglycerin dilates both arteries and veins and causes venous pooling of blood. • Nitroglycerin causes vasodilation of coronary arteries, thus increasing perfusion of ischemic myocardium. • Pain relief occurs within 2 minutes and therapeutic effects can be observed up to 30 minutes later.
Indications:
• Chest pain associated with angina pectoris. • Chest pain associated with acute myocardial infarction.
Contraindications:
• Nitroglycerin is contraindicated in patients with increased intracranial pressure • Hypotension or blood pressure below 100 mmHg systolic, hypovolemia, aortic stenosis, right ventricle infarction, and severe bradycardia or tachycardia. • Recent use (within 24 hours) of Viagra, Cialis or other similar medication.
Precautions:
• May induce headaches from vasodilation of cerebral vessels. • Patients may build up a tolerance. • Nitroglycerin deteriorates rapidly once the bottle is opened. • Ensure the bottle is resealed immediately after obtaining the dose. • Ensure the nitroglycerin is current and fresh. • Protect the nitroglycerin from light. • One tablet (0.4 mg) sub-lingual. • The dose may be repeated every 5 minutes to a maximum of 3 dosages. • Sublingual, making sure the patient does not swallow the tablet. • Also available in patches, sprays and ointment. • Ointment/paste: 1. Dosage is 1 - 2 inches of paste (6 - 12 mg) topically applied in a 4 inch circle on the chest. Page 63 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Nitroglycerin Spray
(Nitrolingual Spray) / (Antianginal)

Description:
• Used in the management of chest pain associated with both angina and acute myocardial infarction. The nitroglycerin spray is an aerosol preparation which delivers exactly 0.4 mg in each spray with a peak effect in 2 to 4 minutes.
Actions:
• Nitroglycerin is a rapid smooth-muscle relaxant that causes decreased cardiac • Nitroglycerin dilates both arteries and veins and causes venous pooling of blood. • Nitroglycerin causes vasodilation of coronary arteries, thus increasing perfusion of ischemic myocardium. • Pain relief occurs within 2 minutes and therapeutic effects can be observed up to 30 minutes later.
Indications:
• Chest pain associated with angina pectoris. • Chest pain associated with acute myocardial infarction. • Acute pulmonary edema.
Contraindications:
• NTG is contraindicated in patients with increased intracranial pressure. • Hypotension or blood pressure below 100 mmHg systolic, hypovolemia, aortic stenosis, right ventricle infarction, and severe bradycardia or tachycardia. • Recent use (within 24 hours) of Viagra, Cialis or other similar medication.
Precautions:
• May induce headaches from vasodilation of cerebral vessels. • Patients may develop a tolerance. • Wipe the container's cap with an alcohol prep to reduce contamination.
Dosage/Route:
• 1 spray (0.4 mg) sublingual. • No more than three (3) doses in 15 minutes. • The spray should not be inhaled. • Also available in tablets, patches, and ointment. • Ointment/paste: 1. Dosage is 1 - 2 inches of paste (6 - 12 mg) topically applied in a 4 inch circle on the chest. Page 64 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Aspirin (ASA)
(Bayer, St. Josephs)

Description:
• Thrombolytic.
Actions:
• Blocks formation of Thromboxane A2 which causes platelets to aggregate and arteries to constrict. • Reduces overall mortality from acute myocardial infarction (AMI). • Reduces additional infarction. • Reduces strokes.
Indications:
• Therapy for all patients with new pain suggestive of AMI.
Contraindications:
• Patients with acute ulcer disease, gastrointestinal disease or bleeding disorders. • Patients experiencing asthma attack. • If the patient has already had one or more aspirin prior to arrival. • Known hypersensitivity to aspirin.
Precautions:
• For patients with a history of asthma, be sure to verify any known tolerance of aspirin before administration. • Doses higher than recommended can interfere with prostacyclin production and
Side Effects:
• Sweating (usually at higher doses). • Nausea (usually at higher doses). • Hypotension (usually at higher doses). • Gastrointestinal bleeding (usually at higher doses). • 160 mg to 325 mg as soon as possible. • Patients should chew one aspirin and take one by mouth. Page 65 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Cardiac Pain Management
(NTG/ASA)
This station is designed to test your ability to administer typical cardiac medications to a patient experiencing chest pain. You should conduct yourself as if this were a real patient. You should assume that I am the actual patient and may ask me any questions you would normally ask a patient in this situation. You have five (5) minutes to properly administer the medications to the patient. Do you have any questions? Page 66 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Cardiac Pain Management (NTG/ASA)
Possible Awarded Take or verbalize standard precautions Verbalizes indication for chest pain therapy in the pre-hospital setting • Signs & symptoms of angina • Signs & symptoms of myocardial infarction Contacts medical control for permission to commence therapy Assembles appropriate equipment • High-flow oxygen with non-rebreathing mask • • Chewable aspirin Calmly reassure and explain procedure to patient Place patient on high-flow oxygen Determine baseline vital signs (systolic B/P must be > 90 mm Hg) Note: Some medical directors require a systolic > 100 mm HG
Ensures correct medication, expiration date and medication dosage
Correctly administers the prescribed nitroglycerin • 1/150 grain (0.4 mg) sublingually, 1 every 5 minutes to a total of 3 tablets; OR • 0.4 mg metered aerosol spray, may be repeated twice every 5 minutes; OR • 2 inches of 2% nitroglycerin ointment may be applied over a 2 to 4 inch area. Observes for side-effects • Headache (most common) Hypotension (most serious) • Treats hypotension with Trendelenburg positioning Assesses effectiveness of interventions Administers the prescribed aspirin • 80 mg Aspirin, chewed • 80 mg Aspirin, swallowed Observes for side effects • Increased bleeding time Assesses the effectiveness of the intervention Reassures and calms the patient Re-evaluates and assesses vital signs for adverse reactions Continually monitors patient Contacts medical control, advises patient condition and request further orders Documents procedure appropriately Critical Criteria  Did not take, or verbalize, standard precautions  Did not place the patient on high-flow oxygen  Did not assess baseline vital signs  Did not determine the correct medication, expiration date and medication dosage  Did not correctly administer the prescribed nitroglycerin  Did not administer the prescribed aspirin  Any other action or inaction causing patient harm or unnecessary pain Page 67 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Oral Glucose

Description:
• Provides sugar for patients who have low blood sugar levels as determined by blood glucometer. Glucose is the principal energy source utilized by the brain and other tissues.
Actions:
• Rapid absorption of glucose by the cells in treatment of hypoglycemia.
Indications:
• Known hypoglycemia patient with symptoms of hypoglycemia and ability to
Contraindications:
• May be detrimental to patients experiencing cerebral ischemia and/or hemorrhage since D50W may increase the cranial bleeding.
Precautions:
• Use extreme caution with disoriented patients so as to ensure the medication is not aspirated into the lungs. • One (1) tube. • If the first dose is ineffective, a second dose may be administered after 5 – 10 Page 68 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Hypoglycemia
Management (Oral Glucose)
This station is designed to test your ability to administer oral medication to correct hypoglycemia. You should assume that I am the actual patient and may ask me any questions you would normally ask a patient in this situation. You have three (3) minutes to properly administer oral glucose to the patient. Do you have any questions? Page 69 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Hypoglycemia Management (Oral Glucose)
Possible Awarded Take or verbalize standard precautions Assess hypoglycemia (<60 mg/dl) by blood glucometry Assures patient meets all three criteria for oral glucose administration: 1)altered mental status, 2) history of diabetes, and 3) ability to swallow Obtain order from medical control Assure suction is available and ready for use If possible, have patient squeeze glucose into own mouth and swallow If patient is too confused for self-administration, squeeze small quantities of glucose between patient's gums and cheeks, massaging lightly externally Monitor airway carefully and immediately suction patient if necessary Reassess blood glucometry Verbalize need to observe patient for desired effect/adverse side effects Critical Criteria  Failed to assess blood glucose level  Failed to assure patient meets all three criteria for oral glucose  Failed to monitor airway or suction if indicated  Failed to reassess blood glucose  Any other action or inaction causing patient harm or unnecessary pain Page 70 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Epinephrine 1:1,000

Description:
• The drug of choice for the emergency treatment of severe allergic reactions (anaphylaxis) due to insect stings or bites, foods, drugs, and other allergens.
Actions:
• A potent catecholamine which mimics the responses of the sympathetic nervous system and constricts blood vessels to improve blood pressure. Reduces leakage from blood vessels, relaxes smooth muscles in the bronchioles, alleviates wheezing and dyspnea and stimulates the heartbeat. • Halts additional swelling and hives and may reduce swelling and hives to some
Indications:
• Severe, systemic allergic reactions. • The medication must be prescribed to the patient or the EMT must obtain on-line orders or have a standing order from medical control.
Contraindications:
• There are no contraindications to the use of epinephrine in a life-threatening allergic reaction.
Precautions:
• Epinephrine may precipitate angina or myocardial infarction in susceptible • Common side effects include anxiety, chest pain, palpitations, tachycardia, headache, pallor, dizziness, nausea and vomiting. • The adult dose is 0.3 mg of a 1:1,000 solution. An adult auto-injector contains a • The pediatric dose is 0.15 mg of a 1:1,000 solution. A pediatric auto-injector contains a 0.15 mg dose. • Consider repeating the dose after 5 – 10 minutes if the patient exhibits no significant improvement. Epinephrine acts quickly and is quickly used by the body; therefore, a repeat dosage may be necessary after 15 – 20 minutes. Medical control must be contacted prior to administering any additional doses. • Subcutaneous Injection via an autoinjector. Page 71 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Instructions to the Candidate: Epinephrine Autoinjector
This station is designed to test your ability to correctly assemble the equipment needed to administer subcutaneous epinephrine in the pre-hospital setting using a patient-prescribed autoinjector. This is an isolated skills test. You will be required to assemble the necessary equipment and administer the medication to a patient using an autoinjector. You may use only the equipment available in this room. You have five (5) minutes to complete this station. Do you have any questions? Page 72 of 73 Basic EMT Skills Manual H. Waid Ray, 17th Edition Epinephrine Autoinjector
Possible Awarded Take or verbalize standard precautions Apply high flow oxygen Assess vital signs Obtain order to administer medication if necessary Note: The medical director orders you administer .3 mg of 1:1,000 Epinephrine by autoinjector
Assemble supplies
Check medication for correct medication, concentration, expiration date, etc. Remove gray cap from end of injector as indicated on side of injector Select appropriate general injection site (thigh or shoulder) Explain procedure to patient, including possible side effects Select specific site Check injector to see if it is cocked Place black tip firmly against site as indicated on side of pen and push hard until you hear or feel injector function holding injector against site for a minimum of ten (10) seconds Remove needle and massage area with alcohol prep WITHOUT recapping needle after injection Dispose of contaminated needle and syringe in sharps container Cover injection site with bandage Critical Criteria  Did not take, or verbalize, standard precautions  Did not check medication  Failed to use sterile technique  Administered incorrect dosage  Recapped or failed to properly dispose of syringe  Did not reassess patient  Any other action or inaction causing patient harm or unnecessary pain Page 73 of 73

Source: http://faculty.southwest.tn.edu/wray/documents/SkillsManual.pdf

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PRODUCT TECHNICAL DOSSIER TRIBULUS TERRESTRIS EXTRACT 95% SAPONINS Product Code: P20046 Raw Material Full Name: Tribulus Terrestris Extract 95% Saponins Raw Material Full Botanical/Chemical/Latin/Trade Name/Synonyms: Tribulus Terrestris L This material is Food Grade Assay (by UV): Min 95.0% Saponins Ratio of Material: Approx. 10:1 Solubility in Water: 40-50% Soluble in Water Solubility in Alcohol: The Solubility of this product in 75-80% Alcohol 80% Particle Size: 100% pass through 80 Mesh Bulk Density: 40g/ml – 60g/ml Loss on Drying: Max 5% Ash: Max 5.0%

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