EMT Review Package

Alexanuia Bamilton SmaitReview
EMT Review Package

Alexandra Hamilton

Smart Review

Topics:
1. Anatomy and Physiology
2. Vital Signs and History
3. Lifting and Moving Patients
4. Airway Management
5. CPR
6. Scene Size up
7. Initial and Ongoing Assessment
8. Trauma Assessment
9. Documentation
10. Communication
11. Bleeding and shock
12. Dressing and Bandaging
13. Musculoskeletal Injuries
14. Head and Spinal Injuries
15. Pharmacology
16. Respiratory Emergencies
17. Cardiac Emergencies
18. Diabetic and Altered Mental Status
19. Allergic Reactions
20. OBGYN
21. Infants and Children
22. Geriatrics
23. HAZMAT
24. Ambulance Operations
Anatomy and Physiology
Anatomy: study of the structure of form of living things
Physiology: normal functions of living organisms and their parts.

Knowledge of anatomy:
Accurate patient assessment
Locating body organs & systems
Quality patient care.

Anatomical Position: best described as a person standing, facing forward with his palms
facing forward
Medial: refers to a position closer to the midline
Lateral: refers to a position farther away from the midline
Proximal: nearer to the point of origin
Distal: farther from the point of origin
Anterior: nearer to/or at the front of the body
Posterior: nearer to or at the back of the body

Abdominal Quadrants:

Right Upper: liver, kidney, colon, pancreas &
gallbladder
Left Upper: liver, spleen, left kidney, stomach, colon,
pancreas
Right lower: right kidney, colon, small intestine, major
artery and vein to the right leg, ureter and appendix.
Left lower: left kidney, colon, small intestine, major
artery and vein to the left leg, ureter.

Supine
Someone in the supine position is lying on his or her back.

Prone
Someone in the prone position is lying face down

Right Lateral Recumbent
Patient is lying on their right side. *If injuries exist on left.

Left Lateral Recumbent (Recovery Position)
Patient is lying on their left side

Fowler's Position
Sitting straight up or leaning slightly back. Their legs may either be
straight or bent. 30-45 degree angle.
Trouble breathing = 90 degree.

Trendelenberg Position
Lying supine with their head slightly lower than their feet.
For patients that have lost a lot of fluid.

Body Systems

Musculoskeletal System: Gives body shape, protects vital organs and provides for body
movement

Skull and Facial Bones:
Skull: 22 bones: 8-Cranial 14-Facial

Spinal Column:
Spine: contains 33 bones called vertebrae
Five sections:
o Cervical (7)-base of skull to beginning of chest
o Thoracic (12)- contains intact spinal cord and
has ribs (12) attached.
o Lumbar (5)
o Sacral (5)
o Coccygeal (4)

Skeletal system: 206 bones.
Need to be able to identify:
Spine: Skull, mandible, cervical/thoracic/
lumbar/sacral/coccyx spine, ribs.
Arms: Hummers, radius, ulna, carpels, metacarpals, phalanges
Pelvis: ilium, ischium, pubis, acetabulum (ball joint of femur fits into pelvis)
*in elderly patients-broken hip could lead to death.
Legs: femur, tibia, fibula
Foot: tarsals, metatarsals, phalanges
Shoulder: scapula, clavicle (collarbone)

Joints:
Ball and Socket: pelvis
Hinge: knees and elbows
Capsule around joints in the shoulder, elbow, knee, hip and pelvis
Cartilage: keeps bones from grinding against each other.

Muscle:
Skeletal - voluntary.
o Attaches to bones.
o Responsible for movement/under conscious control
o Forms the major muscle mass of the body
o 700 skeletal muscles
Cardiac- involuntary
o Found in the heart
o Has its own blood supply (coronary arteries)
o Contracts on its own (automaticity) via electrical impulses
Smooth involuntary
o Found in gastrointestinal tract, urinary system, blood vessels
o Control the flow of materials through these structures.
o Carries our automatic muscular functions
o No conscious control (autonomic nervous system
o Responds to stimuli such as heat, cold and stretching.

Thoracic Cavity:

Respiratory System:
Stoke patients: lose ability to swallow. Epiglottis.
Trachea: does not have capacity to constrict or expand
Bronchi: left and right. (Left is a little bigger but shorter)
5 lobes in lung: (right: 3 / left: 2)
Bronchiole lead to Alveolus:
Alveolus are covered by capillary beds
Capillary beds: sight of diffusion of Oxygen and CO2 across the membrane.

Inhalation- air flows into lungs
o Diaphragm and intercostal muscles
contract
o Diaphragm moves downwards
o Ribs more upward and outward
o Size of chest cavity increases

Exhalation
o Diaphragm and intercostal muscles relax
o Diaphragm moves upwards
o Ribs move downward and inward
o Size of chest cavity decreases

Adequate Breathing: must be breathing adequately
o Normal Breathing Rates:
! Adults: 12-29 breaths/min
" Between 20-30 is not as good. Take closer look.
" Acidosis: condition of excessive acid in the body fluids
Fix it! Supplemental oxygen.
! Children: 15-30 breaths/min
! Infants: 25-50 breaths/min

Inadequate breathing: breathing effort
o Increased use of accessory muscles, especially in infants and children.
o Intercostal contraction: can see space in between ribs.
o Breathing fast:
! Indentation by clavicle# using extra muscles to get chest to
expand
o Pale or cyanotic (blue skin) assoc. with low oxygen content.
! Hypoxia parts of the body are deprived of oxygen.
o Cool, clammy skin
o Agonal respirations (occasional gasping, seen just before death)
! Nervous response, not ventilation.
o Signs of Acute Respiratory Distress: nasal flaring, pursed lips on
exhalation, coughing, crowing, high pitched bark, respiratory noise
(wheezing, rattling), chest tightness, excessive use of accessory
muscles, numbness tingling (hands and feet), impaired mentation,
unconsciousness (dizziness, restlessness, anxiety, confusion,
combativeness)

Pediatric Airway anatomy:
Child has smaller nose and mouth. More space is taken up by tongue. Childs
trachea is narrower. Cricoid cartilage is less rigid and less developed. Airway
structures are more easily obstructed.
Signs of Inadequate Breathing: nasal flaring, retractions, seesaw breathing,
diaphragmatic breathing.

Circulatory System: Heart, blood vessels and blood.

Vein: blood back to heart
Artery: blood away from heart to other parts of body.

Cardiac Conduction System:
Sinoatrial (SA) node: creates electrical impulses that are transmitted to other
parts of the heart.
Atrioventricular (AV) node: polarization and depolarization
Bundle of His

Heart:
Right Atrium: High in carbon dioxide, low in oxygen. Comes from vena cava.
Tricuspid Valve: One way valve to prevent backflow
Right Ventricle: Blood is pushed to the pulmonary artery
Pulmonary artery: takes blood from heart to lungs. Diffusion of oxygen coming in, and
carbon dioxide going out.
Pulmonary vein: from the lungs back to the heart. High oxygen conc. Low carbon dioxide
Left Atrium: High oxygen conc. Low carbon dioxide
Bicuspid valve: prevents backflow
Left Ventricle: pushed out through the aortic valve
Aorta: vein that pushes blood from heart to the rest of the
body.

Systolic: heart pumps blood out
Diastolic: heart is resting

* Blood moves back to heart by skeletal muscular
movement and 1-way valves.

Need to be able to recite: the
flow of a red blood cell
from right atrium to left
ventricle

Coronary arteries: come off
at root of Aorta.
3 big coronary arteries
o Left Anterior Descending (LAD): supplies blood to the front portion of
the heart and the septum (muscle in between ventricles)
o Circumflex (Circ): supplies the back (posterior) portion of the left
ventricle
o Right Coronary Artery (RCA): supplies the bottom portion of right
ventricle

Arch of Aorta:
Brachiocephalic artery: artery of medinisum that
supplies blood to right arm, head and neck.
o Right common carotid artery: supplies head
and neck with oxygenated blood
o Right subclavian artery:
Left common carotid artery: supplies head and neck
with oxygenated blood
Left subclavian artery: supplies blood to left arm

Blood Composition:
Red blood cells: give blood its color. Carries oxygen
to organs. Carry carbon dioxide away from organs.
White blood cells: provide defense against infection
and produces antibodies.

Pulses:
Carotid Pulse: under jaw, along trachea
Femoral Pulse: deep inside the groin.
Radial pulse: arm. Side of thumb
Brachial Pulse: underside of arm or elbow
Posterior Tibial Pulse: inside of ankle
Dorsalis Pedis Pulse: midway top of foot

Blood Pressure: pressure exerted by
circulating blood upon the walls of blood
vessels
Ideal: 120/80
*Blood pressure = [cardiac output (CO)] x [peripheral vascular resistance
(PVR)]
o Cardiac output= (heart rate) x (stroke volume)
Blood pressure = (heart rate) x (stroke volume) x (peripheral vascular
resistance)
o HR: # of heart beats per unit of time
o SV: volume of blood pumped from one ventricle of the heart with each
beat
o PVR: size of lumen (open space of blood vessels)
Pulse rate = if over 130 # could be losing blood ^

o Epinephrine: hormone and neurotransmitter
! Increasing induction through nervous system of heart
! Increases heart rate, constricts blood vessels, dilates air
passages and participates in the fight-or-flight response of the
sympathetic nervous system.

Perfusion: delivery of oxygen and other nutrients to the cells of all organ systems and the
removal of waste products. Hypoperfusion: lack of oxygen and nutrients

Nervous System-
Controls the voluntary and involuntary activity of the body. Consists of the brain, spinal
cord and nerves.

Central nervous system- controls all basic bodily functions and responds to external
changes

Peripheral Nervous System- provides a complete network of motor and sensory nerve
fibers connecting the central nervous system to the rest of the body
Sensory nerves carry information from the body to the brain and spinal cord
Motor nerves- carry information from the bran and spinal cord to the body
Autonomic nervous system: parallels spinal cord but is separately involved in
control of exocrine glands, blood vessels, viscera and external genitalia. Ex:
digestion and heart rate.

Digestive System:
Allows for food travel and breakdown. Main organs: stomach, large & small intestine

Mouth# salivary amylase breaks down carbohydrates. Saliva is added
o pH between 6.5 and 7.5.
Esophagus# food travels down the esophagus by peristalsis
Stomach # breaks things down. Referred to as chime.
o Gastric juice consists of enzymes such as pepsinogen(digest proteins)
Duodenum# first part of small intestine
o Chyme enters through a sphincter.
Pancreas # an exocrine gland by producing pancreatic juice, which empties
into the small intestine via a duct.
o Secretes insulin (from beta cells of isles of Langerhans)
Liver # produces bile (stored in gallbladder)
o Bile emulsifies fats (separates it into small droplets) so they can mix
with water and be acted upon by enzymes.
Spleen # plays a key role in bodys immune system.
Small intestine # site of most digestion. # Of villi (projections) that assist
with absorption. Approx. 15 feet of small intestine
o Peptidases complete the digestion of peptides to amino acids.
o Maltase completes the digestion of disaccharides
Large intestine # 95% of water is reabsorbed
o Appendix # beginning of large intestine. Role in body is unknown.

Abdominal Quadrants:

Note: anyone with a pelvic injury needs to be treated as a critical patient

Skin / Integumentary System: largest organ of the body
Protects the body from the environment and organisms.
o A barrier to keep out microorganisms, debris, and unwanted
chemicals. Underlying tissues and organs are protected from
environmental contact. This helps preserve the chemical balance of
body fluids and tissues.
Fluid retention
o Prevent water loss and stops environmental water from entering the
body.
Helps regulate body temperature
o Blood vessels in the skin can dilate (increase in diameter) to carry
more blood to the skin, allowing heat to radiate from the body. When
the body needs to conserve heat, these vessels constrict (decrease in
diameter) to prevent heat loss. The sweat glands found in the skin
produce perspiration, which will evaporate and help cool the body.
The fat that is part of the skin serves as a thermal insulator.
Sense heat, cold, touch, pressure and pain a lot of sensory nerves.
Excretion: Salts and excess water can be released through the skin.
Shock absorption: The skin and its layers of fat help protect the underlying
organs from minor impacts and pressures.

The skin has three major layers: the epidermis, dermis, and subcutaneous layer.
The outer layer of the skin is called the epidermis.
The layer of skin below the epidermis is the dermis, which is rich with blood
vessels, nerves, and specialized structures such as sweat glands, sebaceous
(oil) glands, and hair follicles. Specialized nerve endings are also found in the
dermis. They are involved with the senses of touch, cold, heat, and pain.
The layers of fat and soft tissue below the dermis are called the subcutaneous
layers. Shock absorption and insulation are major functions of this layer.

Burns:
1
st
degree skin
2
nd
degree- burns down into the capillary bed. Causes blisters.
3
rd
degree burn down to the nerves. Very black of waxy white.
4
th
degree- burn down to the muscles
5
th
degree- burn down to the bone
People with 2
nd
degree burn on greater than 15% of their body go to burn
centers.

Endocrine System:
Secretes chemicals that regulate body activities
and functions:
Insulin
Epinephrine

-Pineal gland: modulation of wake/sleep
patterns and seasonal functions.
-Hypothalamus: controls temperature control
-Thyroid: metabolism
-Parathyroid gland: calcium uptake
-Thymus gland: development of T cells
(immune system)
-Pancreas: produces insulin
-Kidney: eliminating and retention of body
fluids
-Adrenal glands: adrenaline
-Sexual glands: ovaries and testes
Vitals Signs and Sample History

Baseline Vital Signs: Outward signs of whats going on inside the body.
1
st
measurements you will take

Pulse: the number of beats per minute
o Count for 30 seconds and multiply by 2. (Minute pulse rate)
o Adults generally: 60-100/minute
! Tachycardia is pulse more than 100/minute
" Result from sympathetic discharge + more
! Bradycardia is pulse less than 60/minute
o Pulse quality: strong or week. Regular or irregular
o Carotid pulse: for patients that are unresponsive
o Brachial pulse: for babies
o Radial pulse: for patients that are awake

Respirations: single breath is considered to be the complete process of breathing in
followed by breathing out.
o Count for 30 seconds and multiply by 2
o Adults generally at rest is between 12 and 20 breaths/minute
o Keep in mind that age, sex, size, physical conditioning, and emotional state can
influence breathing rates.
o Quality: normal, shallow, labored, noisy (wheezing)

Skin: color, temperature and condition
o The blood vessels of the skin will receive less blood when a patient has lost a
significant amount of blood or the ability to adequately circulate blood
o Abnormal skin colors: Constriction of the blood vessels causes the skin to become
pale
! Pale: indicates poor circulation of blood. =Loss of blood
! Cyanotic: not getting enough oxygen to red blood cells
! Flushed: caused by exposure to heat
! Jaundiced: yellowish tint to the skin from liver abnormalities
! Mottling: a blotchy appearance in patients (esp. children) as a result of
shock
! If it is hard to tell skin color: check inside lower lip, inner eyelid or palm
of hand.
o Temperature: hot, cool and cold
! Feel the patients skin with the back of your hand
o Condition: wet or very dry.
! Can reveal problems with circulation

Pupils: responds to light
o Size: dilated or constricted
o Equality
o Reactivity: to light or nonreactive (fixed)
o Pupils that are dilated, constricted to pinpoint size, unequal in size or reactivity, or
nonreactive may indicate a variety of conditions including drug influence, head
injury, or eye injury.

Blood pressure: force of blood against blood vessels walls.
o Systolic: pressure created when the heart contracts and forces blood into the
arteries
! Normally systolic is usually no more than 120 mmHg.
" Hypertension: systolic greater than 140 mmHg
o Diastolic: the left ventricle relaxes and refills, the pressure remaining in the
arteries/ the heart at rest.
! Normally diastolic is normally 60-90 mmHg
" Hypertension: diastolic greater than 90 mmHg
o Adult females
! May be 8-10 mmHg lower than an adult male
! Hypertension considered at same level as in male adult.
o Child
! 1- 10 years old:
" (Childs age x 2) + 80 mmHg
! Child or adolescent older than age 10
" Minimum systolic of 90 mmHg

Auscultating Blood Pressure:
AuscultationWith auscultation the EMT will listen for the systolic and diastolic sounds
using a stethoscope.
o Avoid placing the BP cuff over clothing
o Palpate the brachial artery
o Deflate the cuff at about 2 mmHg per second. When you hear the first sound,
record the pressure (systolic). Continue releasing air. When you hear the last
sound, record the pressure (diastolic)
o Close the valve and pump until radial pulse is no longer felt. Note the number and
deflate the cuff. Position the stethoscope over the brachial artery and inflate the
cuff to 30 mmHg above the level where you previously stopped feeling the radial
pulse.

Palpating Blood Pressure: the EMT will feel for the return of the pulse with deflation of the cuff.
When the pulse returns, this becomes your systolic number.
Apply the cuff and inflate rapidly to 30 mmHg above the level where you can no longer
feel the radial pulse.
Slowly deflate the cuff. Note the pressure at which the radial pulse returns (systolic). You
will not be able to measure the diastolic pressure by palpation.

Noninvasive Blood Pressure Device: in ambulances.

Pulse Oximetry: measures oxygen circulating in the blood
Place sensor on nail bed. Algorithm will provide a reading as a percent of hemoglobin
saturated with oxygen
Results:
o 96100% = normal
o 9195% = mildly hypoxia
o 8690% = significant hypoxia
o < 85% = severe hypoxia
Precautions:
o Not accurate in shock or hypothermia:
! Not enough blood is flowing through the capillaries for the device to get
an accurate reading.
o False readings in carbon monoxide poisoning
o Movement and nail polish can cause inaccurate readings.
o Batteries must be in good condition.
Note: Do not withhold oxygen from a patient who may need it because the oximeter
reads normal.

Reassessment of Vital signs:
Stable patient (every 15 minutes)
Unstable patient (every 5 minutes)

SAMPLE History:
S : signs and symptoms
A : allergies
M : medications
P : pertinent past history
L : last oral intake
E : events leading to injury or illness

Signs and Symptoms:
A sign is objectivesomething you see, hear, feel, and smell when examining the
patient. Ex- vital signs.
A symptom is subjectivean indication you cannot observe but that the patient feels and
tells you about. Ex- chest pain, dizziness, and nausea.

Allergies: to medications, foods, and environment. Is there a medical tag?

Medications: prescription and over the counter. Current and recent
What medications are you currently taking or supposed to be taking (prescription, over-
the-counter, or recreational)?
Are you on birth-control pills? Or smoking? (Can cause blood clots)
Is there a medical identification tag with the names of medications on it? Do you take any
herbal supplements or medications?
Epocrates.com # application stating all medications and what it does.

Pertinent Past History:
Have you been having any medical problems?
Have you been feeling ill? Have you recently had any surgery or injuries?
Have you been seeing a doctor? What is your doctors name?
Should include medical, surgical, and trauma factors.

Last Oral Intake:
When did you last eat or drink? What did you eat or drink? Food or liquids can cause
symptoms or aggravate a medical condition.
Also, if a patient will need to go to surgery, the hospital staff must know when he last had
anything to eat or drink, since stomach contents can be vomited while a patient is under
anesthesia, which is a very dangerous occurrence.

Events leading to illness or injury:
What sequence of events led up to todays problem?
o For example, the patient passed out, then got into car crash versus got into car
crash and then passed out?

Interview Strategies:
Position yourself appropriately:
o So the patient can see your face and it is at a level close to that of the patients
face. This is especially important with children.
Identify yourself and reassure the patient:
o The patient knows he is in competent hands. Maintain eye contact with the patient
and state your name that you are an Emergency Medical Technician, and the
organization you represent.
Speak in a normal voice:
o When you ask a question, wait for a reply. Avoid inappropriate remarks like
Dont worry, and Everything is all right.
Use your patients name.
o For adults, use the appropriate Mr., Mrs., Miss, or Ms. unless they introduce
themselves by their first name.


Lifting and Moving Patients
Lifting Patients:

Lift safely with proper body mechanics.
Back injuries are a leading cause of long-term disability for EMTs.
Lifting Considerations:
o Consider the weight of object/patient.
o Communicate with partner.
o Identify the need for help before lifting.
o Have a plan.

Guidelines:
Use your legs to lift: not your back
Have feet positioned properly: They should be on a firm, level surface and positioned
shoulder-width apart.
Keep weight close to body: or as close as possible. This allows you to use your legs
rather than your back while lifting.
Lift without twisting: Attempts to make any other moves while you are lifting are a major
cause of injury.
Person at the head of the patient call the shots
Avoid reaching more than 1520 inches in front of your body.

Safe pushing and pulling:
Push rather than pull
Keep your back locked in and your knees bent
Keep weight close to your body
Keep the line of pull through the center of your body by bending your knees.
Avoid pushing or pulling overhead.
Keep elbows bent and arms close to sides.
If weight is below waist level, push or pull from a kneeling position.

Types of Moves:
Emergency Moves: Three situations#
Scene is hazardous:
o This may occur when there is uncontrolled traffic, fire or threat of fire, possible
explosions, electrical hazards, toxic gases, or radiation.
Life threatening condition requires move
o You may have to move a patient to a hard, flat surface to provide CPR, or you
may have to move a patient to reach life-threatening bleeding.
Patient must be moved to reach a critical patient
o When there are patients at the scene requiring care for life-threatening problems,
you may have to move another patient to access them.

Drags:
Clothes Drag: the patient is dragged by the clothes, the feet, the shoulders, or a blanket.
These moves are reserved only for emergencies, because they do not provide protection
for the neck and spine
Drag (headfirst): greatest danger is spine injury.
o Hands under armpits and hold onto forearms.
Firefighter carry
One-Rescuer Assist- arm over shoulder
Two-Rescuer Assist- arms over shoulders

Urgent Moves:
Scene factors cause a decline in patient condition
Treatment of patients condition requires a move
o Spinal precautions

Non-urgent moves:
Used when there is no threat to life
Use when patients condition allows for assessment and
care
Typically utilize a carrying device
Extremity Carry

Patient Carrying Devices:

Moving Patients to Carrying Devices:
Carrying device choice:
o What is the patients position? Is there a
suspected spinal cord injury?
Patient Positioning:
o Part of patient care plan
o Must not cause harm to patient
o Must be safe
Recovery Position:
o Turn patient on left side.
Position of Comfort
Shock Position

Transferring the patient to a hospital stretcher:
1. Position raised ambulance cot next to hospital stretcher.
o Hospital personnel then adjust stretcher (raise or lower the head) to receive
patient.
2. You and hospital personnel gather the sheet on either side of the patient and pull it taut in
order to transfer the patient securely.
3. Holding the gathered sheet at support points near patients shoulders, mid torso, hips, and
knees, you and hospital personnel slide patient in one motion onto hospital stretcher.
4. Make sure patient is centered on stretcher and stretcher rails are raised before turning him
over to emergency department staff.


Airway Management

Major concern: to make sure they have a patent, working airway at all times.
Without airway, within 3-4 minutes, everything will be bad

Anatomy:
Upper Airway:
Nose
Mouth
Pharynx
Oropharynx
Nasopharynx
Uvula
Epiglottis

Gastric content- high in acid.
When a patient loses consciousness, they lose control of the epiglottis, in which gastric
content could be thrown up and worse case, reach the bronchioles and destroy the
alveolus.

Lower Airway
Larynx (voice box)
Cricoid cartilage
Trachea- main windpipe
o Some degree of cilia
Carina
Bronchi (right and left main stem bronchus)
o Bronchioles
Lungs
Alveoli (alveolar sacs)

Lungs:
Right has 3 lobes / Left has 2 lobes
Covered by pleura
o The visceral pleura is the innermost covering of the lung.
o The parietal pleura is a thicker, more elastic layer that adheres to the
inner portion of the chest wall.
o Between the two layers is pleural space, a small space that is at
negative pressure
! space contains a small amount of serous fluid that acts as a
lubricant to reduce friction when the layers of the pleura rub
against each other during breathing.

Gas Exchange:
Oxygenation is the process by which the blood and the cells become saturated
with oxygen. This happens as a result of respiration, the process in which
fresh oxygen replaces waste carbon dioxide, a gas exchange that takes place
between the alveoli and the capillaries in the lungs, and also between the
capillaries and the cells throughout the body; this process is known as
diffusion.
Ventilation is the mechanical process of moving air in and out of the lungs.

Inhalation and Exhalation
Inhalation is an active process that requires energy expenditure due to
muscular contraction.
o Inhalation process: This action increases the size of the chest cavity,
creating negative pressure inside the chest cavity.
Exhalation is a passive process as the thorax and lungs recoil back to their
normal anatomic position.
o Exhalation process: This action decreases the size of the chest cavity,
creating positive pressure inside the chest cavity.

Inhalation- air flows into lungs
o Diaphragm and intercostal muscles contract
o Diaphragm moves downwards
o Ribs more upward and outward
o Size of chest cavity increases
Exhalation
o Diaphragm and intercostal muscles relax
o Diaphragm moves upwards
o Ribs move downwards and inwards
o Size of chest cavity decreases

Signs of Adequate Breathing
Look: adequate and equal expansion of both sides of the chest when the
patient inhales. Is there a chest rise or not?
Listen: For air entering and leaving the nose, mouth, and chest
Feel: For air moving out of the nose or mouth.

Normal Rates:
o Adult: 12-20 breaths/min
o Children: 15-30 breaths/min
o Infants: 25-50 breaths/min
Rhythm: regular or irregular
o Agonal respirations patient is unconscious, sounds like breathing but
no breathing.
Quality: with use of stethoscope
o Breath sounds: present and equal
o Minimal effort
Depth: chest expands adequately and equally

Signs of Inadequate Breathings
Hypoxia: Inadequate amount of oxygen being delivered to the cells, resulting
in an oxygen deficiency.
o can result from an occluded airway, inadequate breathing, inadequate
delivery of oxygen to the cells by the blood (hypoperfusion or shock),
inhalation of toxic gases (e.g., carbon monoxide), lung and airway
diseases (e.g., asthma, emphysema), drug overdose that suppresses the
respiratory center in the brain (e.g., morphine, heroin, and other
narcotics), stroke, injury to the chest or respiratory structures, and head
injury. There are, in addition, many more conditions or injuries that
may create a blockage to the airway or produce inadequate breathing
by depressing the respiratory centers in the brain, interfering with gas
exchange at the level of the alveoli, or restricting the movement of the
chest wall.
o Position: tripod # hands on legs to increase chest cavity.
o cyanosis : The patients skin, lips, tongue, ear lobes, or nail beds are
blue or gray.

Mild/moderate Hypoxia:
o Tachypnea rapid, shallow breathing
o Dyspnea- shortness of breath
o Tachycardia heart rate increases over 100
o Pale, cool, moist skin sympathetic discharge
o Hypertension increase in blood pressure.
o Restlessness
o Disorientation
o Headache
o Combative eliminate hypoxia first.

Severe hypoxia
o Tachypnea rapid shallow breathing
o Dyspnea shortness of breath
o Tachycardia (early) heart rate increases
! then bradycardia heart rate slows down
o Pale, cool skin sympathetic discharge
o Hypertension increase in blood pressure
o Drowsiness
o Confusion
o Altered mental status- combative
o Accessory muscle use to breath

Critical Findings: When the patients signs indicate inadequate breathing or
no breathing (respiratory failure or respiratory arrest), a life-threatening
condition exists and prompt action must be taken.
o Respiratory distress: Patient struggling to breath. Start ventilation.
o Respiratory failure: Oxygen intake not enough to support life
o Respiratory arrest: Breathing stops completely

Child vs. Adult Airway
Head is disproportionally larger than body.
Child has a larger tongue
high tendency for choking
Trachea: larynx narrows down.

Inadequate Breathing
o Infants and children: nasal flaring, see saw breathing and retractions
! Due to the lack of muscle development in the chest, the infants
count on the abdominal muscles and intercostal muscles to
assist in the breathing effort.

Opening the airway:
Goal is to establish and maintain a patent(clear and open) airway on EVERY
patient that you encounter. A patient without a patent airway will die

Child:
A towel behind the shoulder will help maintain an open airway.

Adult:
No suspected head/spine injury # head tilt maneuver
Suspected head/spine injury# jaw-thrust maneuver


Techniques of Artificial Ventilation
Mouth to mask
Two-person bag-valve mask
Flow-restricted, oxygen-powered ventilation device
One-person bag-valve mask

Mouth to mask:
16% oxygen concentration
attach oxygen to mask at 15 lpm (if available)
follow same steps as bag valve mask to obtain a seal
with mask
deliver each ventilation over 1 second, for every 5 seconds. (For all patients)
o 3 seconds for children

Bag-Valve Masks (Adult, Child and Infant)
Closed system.
Consists of an oxygen reservoir, ventilation
bag and exhalation port.
Mask is clear
Caution: adequate ventilation may require
disabling the pop-off valve if the bag-valve
mask unit is so equipped.
Method
o Select correct size mask. The top of
the mask shouldnt pass the bridge of the nose and the bottom
shouldnt pass the lower part of the chin.
o Position yourself behind the patients head.
o Hold the mask with your thumbs over the top half and your index and
middle fingers over the bottom half.
o Place the top of the mask over the patients nose and lower the bottom
half of the mask over the mouth and chin.
o If the mask has a large round cuff around the ventilation port, center
the port over the patients mouth.
o Use your ring and little fingers to lift the chin and maintain the head
tilt.
o Attach to oxygen at 15 liters per minute and have an assistant squeeze
the bag once every 5 seconds (3 seconds for a child or
infant).

Flow-Restricted, Oxygen-Powered Ventilation Device
40 liters per minute
uses oxygen under pressure to deliver artificial ventilations through
a mask placed over the patients face. This device is similar to the
traditional demand-valve resuscitator but includes newer features designed to
optimize ventilations and safeguard the patient.
pressure relief valve that opens at 60 cm water (audible alarm also sounds)
Use on adult patients only.

If there is NO chest rise
Reposition head
Check for seal at mask and absence of air leaks
Check for blockages in Bag Valve Mask or tubing
If chest still does not rise, try a pocket mask or manually triggered device

Positive Pressure Oxygen Percentage: very important
Pocket face mask
o Without O
2
16%
o With O
2
45%50%
Bag-valve mask (BVM)
o Without O
2
21%
o With O
2
and without reservoir 45%50%
o With O
2
and reservoir 90%100%
Flow-restricted oxygen-powered ventilation device (FROPVD)
o 100%

Ventilating through a Stoma or Tracheotomy Tube
Patients with stomas who are found to be in severe respiratory distress or
respiratory arrest frequently have thick secretions blocking the stoma. It is
recommended that you suction the stoma frequently in conjunction with Bag
Valve Mask-to-stoma ventilations.
Ventilating a stoma:
o Clear any secretions in stoma (most common problem).
o Place head in a neutral position.
o Choose a pediatric-size mask.
o Ventilate at age-appropriate rate.
If there is no chest rise:
o air escapes from the mouth and/or nose when ventilating via
stoma, consider sealing the stoma.
o Attempt artificial ventilation through the mouth and nose

Airway Adjuncts: Rules
Open airway manually first.
Ensure there is no gag reflex for oral airway, no possible skull fracture for
nasal airway.
o Do not attempt the use of a nasopharyngeal airway if there is evidence
of clear (cerebrospinal) fluid coming from the nose or ears. This may
indicate a skull fracture in the area where the airway would pass.
Maintain manual airway method even with airway in place.
Do not force tongue into pharynx.
Have suction available.
Remove adjunct if patient gags or regains consciousness.
Maintain infection control.

Oropharyngeal Airways (OPA)
An Oral Airway can help prevent the tongue from obstructing
the airway of an unresponsive patient without a gag reflex
Method:
o Measure for correct size.
o Open the mouth and insert the airway with tip towards
roof of the mouth.
o Insert airway along hard palate until you reach the soft palate, then
rotate180.

Nasopharyngeal Airways (NPA)
Method
o Select the correct size.
o Lubricate the airway.
o Insert the airway posteriorly.
! If it does not advance, try the other nostril.
Meant to go in the right nostril
Has to be lubricated before use.
Diameter: size of mid-section of pinky finger and size of nostril.
Caution: NPA cannot be used if patients has suspected basilar skull fracture.

Techniques of Suctioning
Purpose: To remove blood, other liquids, and food from the airway
If you hear gurgling, suction

Type of Suction Units:
Mounted on the ambulances. Run off of vacuum.
Battery powered portable. Must check that it is charged.
Oxygen powered nobody uses them anymore # eats oxygen.
Manual suction really good. Hand powered with a trigger.

Suction Catheters:
Hard - Useful for most secretions
Soft - Useful for nasopharynx and when hard catheter wont work/fit

Rules of Suctioning
Always use infection-control measures.
Suction for no more than 15 seconds at a time (fewer in children and infants).
o prolonged suctioning will cause hypoxia and death. If the patient
continues vomit longer than 15 seconds, you must still continue to
suction
o In short, suction quickly and efficiently for as short a time as possible.
Place tip of catheter where you want to begin suctioning, and suction on way
out.
Suctioning Technique
Inspect and test suction unit before you need it.
Position the patient and yourself properly.
Open the patients mouth while protecting your fingers.
Without suctioning, insert hard catheter to base of tongue.
If using a soft catheter, insert it only as far as the distance from the lips to the
earlobe or angle of the jaw.
Once tip of catheter is in the right place, apply suction, move tip, and remove
fluid in airway.

Supplemental Oxygen:

Conditions Requiring Oxygen :
Respiratory/cardiac arrest
Stroke
Shock
Blood loss/fractures
Many other conditions

Oxygen Cylinder: a seamless steel or lightweight alloy cylinder filled with oxygen under
pressure, equal to 2,000 to 2,200 pounds per square inch (psi) when the cylinders are full.
Pressure Gauge: pounds per square inch
Flow meter: 0 -25 m per minute
Sizes:
o D cylinder contains about 350 liters of oxygen.
o E cylinder contains about 625 liters of oxygen.
o M cylinder contains about 3,000 liters of oxygen.
! Fixed systems on ambulances (commonly called on-board
oxygen) include the M cylinder and larger cylinders:
o G cylinder contains about 5,300 liters of oxygen.
o H cylinder contains about 6,900 liters of oxygen.

Safety with Oxygen
Inspect before using.
Use nonsparking wrenches.
Store and maintain cylinders properly.
Do not drop cylinders or leave standing unsecured.
Do not smoke or use near open flame.
Stamp # indicates the test date of the tank.
o Every 5 years, cylinders need to be tested.
o Star present # testing can occur every 10 years.
o Plus sign (+) present # hold 10% more per square inch

Oxygen Delivery System: in a green tank
Aluminum (portable) or steel(in ambulance) cylinders.

Administering Oxygen
If the patient is not breathing, use artificial ventilations.
If the patient is breathing and needs supplemental oxygen, use:
o Nonrebreather mask
o Nasal cannula

Nonrebreather mask:
Can deliver up to 90% oxygen
Must fill bag before placing mask on patient
Use setting of 815 liters per minute
Adult, child, and pediatric sizes
Method:
o Explain procedures to patient and
attach tubing to regulator.
o Open valve, adjust flow meter, fill bag of nonrebreather mask.
o Place the mask on the patient and adjust the flow rate.
o Secure the tank.

Nasal Cannula:
Delivers low-concentration oxygen (2444%)
Useful for patients who do not tolerate mask
Use a setting of 26 lpm.

Supplemental Oxygen Percentage-
Non rebreather mask
o Without reservoir O
2
45%50%
o With reservoir 90100%
Nasal cannula
o 1lpm O
2
24% 2lpm 28%
o 3lpm O
2
32% 4lpm 36%
o 5lpm O
2
40% 6 -lpm 44%

Special Considerations
Facial Injuries:
many blood vessels in the face
make a seal so that there is no air leak
Can lead to two problems
o Severe swelling from blunt injury
o bleeding into the airway

Dentures:
Leave in place under ordinary circumstances; remove if they block airway.
If a partial plate becomes loose, leave it in place unless it causes a problem

Infants and Children:
Avoid excessive hyperextension when opening the airway.
Avoid excessive pressure when ventilating.
Gastric distention may be common.
Use properly sized BVM, nonrebreather, and suction equipment.

Oxygen Administration
Administer high concentration oxygen
First choice: non-rebreather mark at 12 LPM or greater so reservoir bag does
not collapse during inhalation. If reservoir bag collapses and does not refill,
increase to 15 LPM
Second Choice: Nasal cannula at 6 LPM

Pediatric Oxygen Administration
There is no contraindication to high concentration oxygen in pediatric patients
in pre-hospital setting
Administration of oxygen is best accomplished by allowing parent to hold the
face mask, if tolerated, 6-8 inches from childs face
Humidified oxygen is preferred.

CPR - Recap

Regardless of if EMT has arrived: start chest compressions
Chest compressions moves the blood around

6-10 mins # the brain will die due to lack of oxygen

Portable Defibrillator (AED)
Shock # caused a depolarization and slows down other activity of the heart
(electrical silence) so that the SA node will have an opportunity to fire.
o After it defibrillates: it will tell you to start chest compression
No shock indicated # check vitals
o Really good or really bad

BLS : Basic Life Support

Adult
Immediate recognition and activation of Emergency Response system
Early bystander CPR
Rapid of EMS
Effective Advanced Life Support
Integrated Post Cardiac Care

Pediatric
Prevention of arrest
Early bystander CPR
Rapid of EMS
Effective Advanced Life Support
Integrated Post Cardiac Care

CAB (not ABC)
Chest compressions # Airway # Breathing
Rescuers can start chest compression earlier.
Check victim for response and breathing
With CAB, the rescuer should activate emergency response system if patient is
unresponsive or barely breathing

Compression rate: at least 100/min

Training using a team approach
Rescuer 1: activates system
Rescuer 2: chest compression
Rescuer 3: Bag valve mask
Rescuer 4: setting up defibrillation

In order to help assure the airway is open
Find the Adams apple # half an inch below
Press down on tricoid cartilage (1
st
ring of trachea)

If within 10 seconds you dont feel a pulse, begin chest compressions
Manual defibrillators are preferred to AED for infant patients

Maximum output of AED: 200-300 joules. = 2000-3000 volts.

AED measures transthoracic energy (how much energy does it take to get from one pad
to another)

Critical elements of High Quality CPR
Start compressions within 10 seconds
Push hard and
Rate of at east 100 compression/min
Allow complete chest recoil
Minimize interruption (less than 10 seconds)
Efficient airways to make chest rise

Should be performed as a team
Mask the individual skills of CPR

CPR
1
st
step: check that the scene is safe = No water around
2
nd
step: check for response and breathing
3
rd
step: call for help
4
th
: check for pulse.
Adult and Child: carotid pulse
Infant: brachial pulse
5
th
: If there is no pulse, start chest compressions.
Push hard and fast and allow complete chest recoil after each compression.
Minimize interruptions
6
th
: Ventilate twice

One cycle consists of
chest compressions: 5 times
ventilations: 5 times

Chest Compressions:
1. Position yourself at victim side
2. Victim: supine on flat surface
3. Remove clothing from front of chest
4. Heal of one hand on center of bare chest
5. Heal of other hand on top
6. Shoulders right over your hand
7. Push hard and face
a. 2 inches/ 5 cm down
8. Rate of at least 100 compressions/min

Opening the airway and giving breaths:
Two-rescuer scenario: Bag Valve Mask
One rescuer scenario: Pocket mask
Pocket mask: place on patients face and seal mask.
o Breath hard and look for chest compression
o Each breath should be delivered over 1 second
o If you have time, insert airway adjunct.
Unresponsive and a Pulse # ventilations
Unresponsive and No pulse # 30 compressions and 2 ventilations

When do you stop CPR?
Someone comes and relieves you and starts doing CPR
Physician tells you to stop
Depended lividity (cells begin to break down#patient is dead) purple
undertone.
Patient wakes up
DNR order # must call and get permission to stop

Bag Valve Mask:
Dont pump forcefully: If too much air enters stomach # the patient may vomit

AED (automated external defibrillator)
Open case and turn on
AED will guide you
Adult (8+) and pediatric pads
Attach to bare chest
o Side of left nipple
o Below right collarbone
No one touch the victim when shock is given (pause CPR)
If no shock needs to be given: start chest compressions again

Circumstances
1. Water on chest# wipe chest and attach AED pads and move victim to dry area
2. Pacemakers/Automated defibrillator(surgically) # do not put pad over lump
a. Not going to hurt the device but if you place it over, the metal component
will accumulate some current.
3. Hair on chest# shave off or pull off hard (Removing chest hair) then attach pads
a. Do not set patients chest on fire
4. Get off the scene by 3
rd
defibrillation

Puberty: anyone from 1 to puberty is considered a child
Chest or underarm hair on males
Chest/breast development on females

Single rescuer
Compression to ventilation = 30:2
Hypoxia is a main reason why children go into cardiac arrest.
If arrest is sudden, learn the child, activate emergency response system, get
defibrillator and start compressions
Children: A single rescuer should perform 5 cycles of CPR before leaving to
activate the emergency response.
o Compression: 1/3 of the chest
! If child is under 1 year old use two fingers for compression
! Hands wrapper around and thumbs in center of chest
! Then ventilate

Two rescuer
Compression to Ventilation Ratio
Adult= 30:2
Child= 15:2

Pop off valve: given pressures so that you wont give more pressure than needed

Review of Infant Basic Life Support
Single rescuer
Check for responsiveness and breathing
If not breathing# shout for help
If others present# tell them to activate emergency response system and get
AED
Check for pulse# brachial pulse for 5 secs
30 compressions then 2 breaths

When another rescuer comes
compression to ventilation 15:2.

AED# can have appropriate adult and child shocks.
If you have an infant, but dont have pediatric pads.
Put a pad in front and pad in back between shoulder blades

Advanced Airway

Rescue Breathing: ventilations with chest compressions.
Ventilations every 6-8 seconds
1 breath every 3-5 seconds for children
Check pulse every 2 minutes

Choking: foreign items block airway
Signs: Clutch neck, cyanosis, coughing

Abdominal thrust: arms around patient. Find naval.
Quick forceful upwards thrust

Infant
Site and kneel with infant in lap
Infant prone on hand and support head and jaw with hand
5 back slaps between shoulder blades.
And then start chest compressions. 1 per second
Repeat back slaps and chest thrusts until object has removed.

Scene Size Up

Evaluate the scene for safety hazards
Yourself
Crew
Patients
Bystanders

Danger Zone: minimum of 50 feet around scene
Further if: fuel spill, fire, hazardous materials or downed power lines
Note:
o Do not enter unstable crash scenes.
o Managing patients at crash scenes or on roadways and highways place
the EMT at extreme risk of being struck by moving traffic.
o Take extra precautions at crime scenes, suspected crime scenes, and
scenes involving volatile crowd situations; wait for the arrival of
police or, if a scene turns threatening, retreat and wait for the police.
o Be sure to bring your portable radio with you when you leave the
ambulance so that you can contact dispatch or medical direction from
the scene for needed resources or advice.
o Call for help from the appropriate agenciespolice, fire department,
rescue squad, utility company, water rescue squad, hazmat team, or
otherif a scene is outside your area of training or expertise.
o Remove yourself if a scene turns hazardous.
Crash or Rescue Scenes
Toxic Substances or Hazmat
Unstable Surfaces: slopes, ice or water
Scene Violence: fighting, loud voices, alcohol/drug use, unusual silence, prior
experience.
Crime scenes and Violence: retreat to a position of safety, call for help, and
return only after police has secured the scene. Be sure to document the danger
and your actions.

Standard Precautions
Take the necessary Standard Precautions: Body Substance Isolation
Anticipate the need for Standard Precautions
Always have Standard Precaution equipment available: gloves, mask and eye
protection and gowns
Use appropriate equipment to prevent exposure

Mechanism of Injury vs. Nature of Illness
Determine the
Mechanisms of injury vs. nature of illness
o Mechanism of injury (MOI) determines that the patient is a trauma
patient
o Nature of illness (NOI) determines that the patient is a medical
patient.
Number of patients: quick count
o Each ambulance can carry 2 patients
o Badly hurt patient= 1 patient/ambulance
Need for additional resources

Mechanism of Injury - the physical event that caused the injury
Determined from patient, family, bystander and observation of the scene

Motor Vehicle Collision

o (Head On): Two types of injury patterns are likely: the up-and-over
pattern and the down-and-under pattern.

! Up and Over Pattern: the patient follows a pathway up and
over the steering wheel, commonly striking the head on the
windshield (especially when he was not wearing a seat belt),
causing head and neck injuries.
" Head leads + compression of cervical spine +
chest/abdomen impacts steering wheel (compression of
hollow and solid organs and shearing)

! Down and Under Pattern: the patients body follows a pathway
down and under the steering wheel, typically striking his knees
on the dash, causing knee, leg, and hip injuries.
" Force is transmitted to lower extremities(tibial and
femoral impact) + upper body rotates forward and
strikes dash or steering wheel.

o (Rear Impact): common causes of neck and head injuries
! the head remains still as the body is pushed violently forward
by the seat back(hyperextended), extending the neck backward,
then the body will stop and the head will push forward(hyper
flex)

o (Side Impact) or T-bone : have the most fatalities
! The head tends to remain still as the body is pushed laterally,
causing injuries to the neck
! The head, chest, abdomen, pelvis, and thighs may be struck
directly, causing skeletal and internal injuries.
o (Rotation Impact): involve cars that are struck, then went into a spin.
! a corner of the vehicle stops, the rest of the vehicle continues in
forward motion until energy is transformed
" Combination of front and lateral patterns

o (Rollover ): Rollover collisions frequently cause ejection of anyone
not wearing a seat belt
! multiple impacts at various angles
! unrestrained driver: partial or full ejection with direct impact
to ground/tree/outside the car.
" 75% of totally ejected occupants die. Risk of death is
6x greater for ejected occupants.

o Vehicle Interior: spider web on windshield, deformed windshield,
steering wheel, and vehicle deformity.

o Other Motorized Vehicles: motorcycles, all-terrain vehicles,
snowmobiles and jet-ski

Falls:
o Falls from heights of greater than three times the height of the patient
are usually considered severe.
o Consider
! Distance patient fell
! Part of body that struck surface
! Type of surface patient landed on
! Anything that interrupts/breaks the fall
! The force is also transmitted to adjoining parts of the body.
! When in doubt, assign the patient a high priority for rapid
packaging and prompt transport.

Penetrating Trauma
o Injury caused by an object that passes through the skin or other body
tissue
o These wounds are classified by the velocity, or speed, of the item that
caused the injury.
o Velocity: kinetic energy= mass x velocity^2
! Low velocity injuries are usually limited to the area that was
penetrated. (ex. Knife)
! Medium velocity wounds are usually caused by handguns and
shotguns. (ex. Handgun or shotgun)
! High velocity: bullets are propelled by a high-powered or
assault rifle.
o Body Region Penetrated
o Exit wounds
o Bullets: can cause damage in two ways
! Damage directly from the projectileThe bullet itself will
damage anything in its path. The path of the bullet once it is
inside the body is unpredictable since it may be deflected by
bone or other tissue onto a totally different course.
! Pressure-related damage, or cavitationThis means that the
velocity of the bullet as it enters the body creates a pressure
wave that causes a cavity considerably greater than the size of
the bullet. This cavity is temporary, but it may damage items in
its path

Blunt force Trauma: is injury caused by a blow that strikes the body but
does not penetrate the skin or other body tissues
o The energy from a blunt-force blow will travel through the body, often
causing serious injury to, even rupture of, internal organs and vessels.
The resulting compromise of body functions, hemorrhage, or spillage
of organ contents into the body cavity may have more severe
consequences for the patient than a penetrating injury.

Nature of Illness: finding out what is or what may be wrong with the patient.
Patient, when conscious and oriented, is a prime source of information about
his or her condition.
Family members or bystanders can also provide important information,
especially for the unconscious patient.
The scene. While you are sizing up the scene for safety, make note of other
factors that may be clues to the patients condition. You may observe
medications, of which you will make a mental note to examine later. You may
be struck by dangerous or unsanitary living conditions for this particular
patient.

Adequacy of Resources: is determining if you have sufficient resources to handle the
call.
Note: Number of Patients, Hazardous materials, Fire or rescue , Unusual
Situations
Call for assistance before beginning care
Triage procedures: to quickly assess all the patients and assign each a priority
for receiving emergency care or transportation to definitive care.

Initial Assessment

Components of Initial Assessment:
Form a general impression
Assess mental status
Assess airway
Assess breathing
Assess circulation
o (C-A-B) if unresponsive
Identify priority patients

Form A General Impression: is based on your immediate assessment of the
environment and the patients chief complaint and appearance # helps you to determine
how serious the patients condition is and to set priorities for care and transport.
Environment/scene clues
Chief complaint
Age
o Child or infant
o Adult
o Over 50s
Sex
Look/Listen/Smell: alcohol?
Obvious life threats: growing pool of blood?

Assess Mental Status - AVPU
Alert: Patients who are oriented to person, place, time, and day, or date are
considered alert and oriented
Verbal stimulus: A patient who is awake but confused or disoriented is
considered verbal
Painful stimulus: At a lower level of responsiveness, the patient will respond
only to painful stimuli, such as pinching
Unresponsive: the lowest and most serious mental status is unresponsiveness,
when the patient will not respond even to a painful stimulus.

Assess the Airway #
Is patient able to maintain his own airway?
If the patient is alert and talking clearly or crying loudly, the airway is open.
o Assist with ventilations
If the airway is not open or is endangered (patient is not alert, is supine, or is
breathing noisily),
o open the airway (jaw-thrust or head-tilt, chin-lift maneuver,
suctioning, or insertion of an oropharyngeal or nasopharyngeal
airway.)
o If the airway is blocked, perform clearance procedures.

If unable to, is patient a medical or trauma patient?
Medical Patients:
o Use head tilt, chin lift.
o Suction and insert oral or nasal airway adjunct.
Trauma Patients:
o Immobilize the head manually
o Use jaw thrust
o Suction and insert oral or nasal airway as necessary

Assess Breathing
If Breathing:
Inspect Chest (DCAP-BTLS)
o Deformities Contusions Abrasions - Punctures/Penetrations -
Burns - Tenderness - Lacerations - Swelling
Auscultate Chest (Breath Sounds): check with stethoscope

If not breathing

If he is not alert and his breathing rate is less than 8 or greater then 28
ventilations, ventilate with a BVM or Pocket Face Mask with 100% oxygen.
If the patient is alert and his breathing is adequate, but the rate is greater than
20 breaths per minute, give high-concentration oxygen by non-rebreather
mask.

AcronymOIPASS:
o OxygenNasal Cannula or Nonrebreather vs. BVM or Pocket Face
Mask
o InspectOpen the shirt and visualize and breathing obstructions in the
chest
o Palpatecheck for symmetrical chest rise with your hands
o AuscultateListen to lung sounds with a stethoscope bilateral
o SealAny holes in the chest with an occlusive dressing
o StabilizeAny flail segments in the chest with an bulky dressing

Assess Circulation: Pulse, Bleeding and Skin
Once any breathing problems are corrected, assess circulation.

VCR: Voids - CTC - Radial Pulse
VoidsCheck for major bleeding at the arches such as: the neck, waist, knees, and
ankles.
CTCColor, temp, condition of the skin
Radial pulseCheck for the presence and the quality of the radial pulse.

Pulse# between 60 - 100/min
o In adults and children, check radial pulse first or carotid pulse.
! Infants: check brachial pulse
o If no carotid pulse, start CPR and use AED as appropriate.
Skin: color, temperature and condition
o Colors: pink, pale, cyanotic, mottled
! Warm, pink, and dryindicating good circulation
! Pale and clammy (cool and moist)indicating poor circulation
! Dark-skinned, check the color of the lips or nail beds, which
should be pink.
! Cyanotic # deprived of oxygen
! Mottled- blotchy
o Condition: dry, wet, turgor
o Temperature
o Check capillary refill (for infants/children)

Identify Priority Patients
Poor general impression
Unresponsive patients
Responsive but not following commands
Difficulty breathing
Shock (hypoperfusion)
Complicated childbirth
Chest pain with systolic BP lower than 90
Uncontrolled bleeding
Severe pain anywhere # pay especial attention to older patients and diabetics

Which step is next?
Medical assessment
OR
Trauma Assessment

Ongoing Assessment

Steps of the Ongoing Assessment
Repeat initial assessment: to check for life-threatening problems
Reassess and record vital signs: comparing the results with the earlier baseline
measurements and any other vital signs measurements you may have taken
Repeat focused assessment
Check on treatment in progress: This may help you to evaluate the adequacy
of your interventions more objectively and to adjust them as necessary.
o Always do the following:
o Ensure adequacy of oxygen delivery and artificial ventilation.
o Ensure management of bleeding.
o Ensure adequacy of other interventions.

Ongoing assessment is done in the ambulance
Except in the case of mass casualties
Remember, life-threatening problems that were not present or were brought
under control during the initial assessment may develop or redevelop before
the patient reaches the hospital.

Reassessment
Stable: Every 15 minutes for a stable patient, such as a patient who is alert,
has vital signs in the normal range, and has no serious injury
Unstable Every 5 minutes for an unstable patient, such as a patient who has an
altered mental status, difficulty with airway, breathing, or circulation,
including severe blood loss, or a significant mechanism of injury
Note that a stable patient can quickly become an unstable patient.

Assessment of a Trauma Patient

Focused History and Physical Exam # based on initial assessment
May be called the secondary assessment or secondary survey.
This exam takes a somewhat different path for trauma vs. medical patients.

Physical Exam: is there a significant mechanism of injury
Two kinds of physical exam can be chosen for a trauma patient:
o Rapid trauma assessment (a rapid head-to-toe exam) followed by
prompt transport, or on-scene emergency care
o Focused trauma assessment (an exam that is focused on a specific
injury site) followed by on-scene emergency care

Significant Mechanism of Injury: the patient has a significant MOI, multiple injuries,
AMS, or critical initial assessment findings:
Mechanism of injury:
o Adult: ejection from vehicle, death in same passenger compartment,
fall of greater than 15 feet or 3 times the patients height, rollover of
vehicle, high-speed vehicle crash, unresponsive or altered mental
status, penetrating injury of head, chest or abdomen
o Infants and children: falls greater than 10ft, bicycle collision, vehicle
in medium speed collision
o Interior of Vehicle: deformities to a vehicles interior may show where
a person struck the surface and reveal and injury.
! Pay close attention to steering wheel, pedals, dashboard and
rear-view mirror and airbags
If significant mechanism of injury:
o Reconsider mechanism of injury
o Assess mental status
o Continue spine stabilization
o Perform a rapid trauma assessment

Rapid Trauma Assessment: DCAP-BTLS
D deformity
o Parts of the body that no longer have the normal shape
C contusions
o The medical term for bruise. The collection of blood under the skin
A abrasions or scrapes such as road rash
P punctures/penetrations
o Are holes in the body, frequently the result of gunshot wounds and
stab wounds.
B burns
o Be reddened, blistered, or charred-looking areas
T tenderness
o An area hurts when pressure is applied on it, as when it is palpated
L lacerations
o Cuts or open wounds that sometimes cause significant blood loss
S swelling
o Result of injured capillaries bleeding under the skin

Check: head # neck # chest # abdomen # pelvis # extremities # posterior

o Head: DCAP-BTLS + Crepitation:
! Crepitation: sound or feel of broken bones rubbing against each
other
! Run your gloved fingers through the patients hair and palpate
gently.

o Neck: DCAP-BTLS + Jugular Vein Distention and Crepitation
! Jugular vein distention is present when you can see the
patients neck veins bulging. # If they are bulging when the
patient is upright, it means that blood is backing up in the veins
because the heart is not pumping effectively
! After you assess the head and neck, size and apply a rigid
cervical spine immobilization collar.

o Chest: DCAP-BTLS + Crepitation + Breath sounds (presence and
equality)
! Paradoxical motion, or movement of part of the chest in the
opposite direction from the rest of the chest,
" It usually occurs when a segment of ribs has broken at
two ends and is floating free of the rest of the rib cage
(obvious during respiration, moving inward when the
lungs expand with air and outward when the lungs
empty)
! Breath sounds: check if present and equal

o Abdomen: DCAP-BTLS + Firmness and Distention
! Distention is another way of saying the abdomen appears larger
than normal. A distended abdomen could be a sign of internal
bleeding or fluid collecting in the abdominal cavity

o Pelvis: DCAP-BTLS (Compress gently)
! Check for bleeding
! priapism, a persistent erection of the penis that can result from
spinal cord injury or certain medical problems
! patient is awake, palpate the pelvis gently, stopping as soon as
the patient identifies pain in the pelvis.

o Extremities: DCAP-BTLS +Distal Pulse, Sensation, Motor
Function
! Is a pulse present
! Can the patient move his hands and feet,
! Does the patient have feeling in his hands and feet.

o Posterior: DCAP-BTLS
! Roll the patient onto his side as a unit and assess the posterior
body, inspecting and palpating for DCAP-BTLS in the area of
the spine and to the sides of the spine, the buttocks, and the
posterior extremities.
! Release back onto a long board

Significant Mechanism of Injury
Assess baseline vital signs
Obtain SAMPLE history
Make CUPS determination
o Critical (unconscious)
o Unstable
o Potentially unstable
o Stable
Consider requesting ALS
Reconsider transport decision

If No Significant Mechanism of Injury
Reconsider mechanism of injury
Determine chief complaint
Perform focused physical exam based on: chief complain and MOI

Vital Signs:
Respiration
Pulse
Skin color, temp, condition
Pupils
Blood pressure

SAMPLE history:
S- signs and symptoms
A- allergies
M- medications
P- pertinent past history
L last oral intake
E events leading to injury or illness

Rules of Assessment:
Explain to the patient what you are doing
Expose areas before assessing
Assume spinal injury

Detailed Physical Exam
Who needs a detailed physical exam?
Determined by the patients condition
After critical interventions for a patient with significant MOI
Occasionally for a patient with significant MOI
Rarely for a medical patient

Assess areas examined in rapid trauma assessment plus:
Face, ears, eyes, nose and mouth
o Eyes: DCAP-BTLS + Discoloration, unequal pupils, foreign bodies,
blood in anterior chamber
o Nose and mouth: DCAP-BTLS + discoloration. etc.
Throat: tracheal deviation
Neck: DCAP-BTLS + Crepitus
Abdomen: look, listen and feel for crepitus and paradoxical movement.
Reassess breath sounds, presence and equality.
Abdomen, Pelvis and extremities may have already been assessed during
rapid trauma assessment; if not yet done, assess these areas thoroughly.

Reassess Vital Signs: (this will be the 2
nd
time vitals are being done)
Respirations
Pulse
Skin color, temperature, condition
Pupils
Blood Pressure


Documentation

Pre-hospital Care Report (PCR): record of patient care, serves as a legal document,
provides information for administrative functions, aids education and research, and
contributes to quality improvement.

Functions:
Continuity of care: The report you write will become a part of the patients
permanent hospital record.
Legal document: may be used as evidence in a legal case
Quality improvement: become a valuable source for research on trends in
emergency medical care and a guide for continuing education and quality
improvement
Education
Billing Information: be used in preparing bills and in submitting records to
insurance companies.
Statistics
Research: researchers might be looking to discover + or - effects of certain
interventions at different stages of patient contact, others might be experts in
administration studying documentation in an effort to deliver services in a
more timely or cost-effective manner.

Type of Reports:
Written Reports: are those that have portions with narrative areas, areas to
record vital signs in written number form and check boxes
Computerized Reports: those that are completed by shading boxes to record
data; they are scanned for easy data storage and evaluation.
Pen-Based Computer and PDA: laptop computers or PDAs that allow the
EMT to enter information about a call directly into a database

PCR Data Set
Individual box in the prehospital care report is called a data element.
o Eg. Vital signs
U.S. DOT defines minimum elements/minimum data set for a PCR: to aid in
research across states. PCR can be broken down into several sections. The
sections include run data, patient data, check boxes and the narrative section.

Minimum Data:
Patient Information: EMTs initial contact with patient on arrival of scene,
following all interventions and on arrival at facility. This section contains
information about the patient, the patients condition throughout the call and
the care given to the patient.
o Chief complaint
o Level of consciousness (AVPU), mental status
o Systolic BP for patents more than 3 years of age
o Skin perfusion (capillary refill) for patients < 6 years of age
o Skin color and temp
o Pulse rate
o Resp rate and effort
Administrative Information
o Time of incident reported
o Time unit notified
o Time of arrival at patient
o Time unit left scene
o Time of arrival at destination
o Time of transfer of care

Data sections of the PCR:

Run Data:
includes agency name, unit number, date, times, run or call #, crew member
names, licensure levels and numbers.
Time recorded must be accurate.

Patient Data
Includes complaint, past medical history and vitals signs recorded

Treatment Given:
Stable patients vital signs should be taken every 15 minutes and an unstable
patients should be taken every 5 minutes.

Narrative: It provides space to write information about the patient that cannot fit into
fill-in blanks or check-off boxes.
Avoid conclusions # be objective
Include observations of the scene
Include pertinent negatives: which are examination findings that are negative
(things that are not true), but are important to note
o for example, if a patient has chest pain, you will ask that patient if he
has difficulty breathing. If the patient says he does not have difficulty
in breathing, that is an important piece of negative information.
Avoid slang and radio codes
Use only standard abbreviations
Use correct spelling
Write legibly
Unusual occurrences are documented on a separate Incident Report

Pre-hospital Care Report
Confidentiality:
o Regulated by the Health Insurance Portability and Accountability Act
(HIPAA)
o Completed reports must be kept in a locked box
Distribution of Copies
o Determined by local and state regulations
Falsification of PCR
o Leads to poor patient care
o May lead to revocation of certification/license: may also lead to the
suspension or revocation of your certification/license
o If an error in patient care occurs, document what did or didnt happen
! Note steps taken (if any) to correct the situation
Correction of Errors
o Draw single horizontal line through the error
o Write the correct information beside it
o Do not obliterate the error
o If an error is discovered after the form is submitted:
! Complete a Supplemental Report attached to PCR
" Use a different color of ink
" Correct error with a single line cross out
" Initial and date the correction
Patient Refusal: make sure you get consent.
o Competent adult patients may legally refuse treatment: age? Impaired
by alcohol/drugs? Mentally competent? Impaired by medical
condition?
o Patient must be informed of the consequences of refusing care
o Document all assessment findings
o Have patient AND witness sign refusal form
o Document attempts made to convince patient to go to hospital
o Document actions taken to protect patient after you leave
o Contact medical direction, if necessary

Special Documentation Issues

Special Reporting Situation
Multiple casualty incident (MCI)
o Insufficient time to fully complete a PCR
o Use local forms or tags on the scene: chief
complaint, vital signs, and treatment provided
is recorded on a triage tag that is attached to
the patient
o Follow local MCI plan for documentation
Infectious disease exposure
Injuries to self/other providers
Hazardous areas/scenes
Social service referrals
Child/elder abuse
Document unusual events
o These reports are not made a part of the patients record
Provide additional supplements to PCR
Follow local guidelines for confidentiality.

Enrichment
Alternative methods used for PCR charting
o SOAP: subjective-objective-assessment-plan
CHART: chief complain-history-assessment- Rx(treatment)- transport

Communications

The three types of EMS Communication
EMS Communication
Radio
Verbal reports: to convey information about your patient directly to the
hospital personnel who will be taking over his care
Interpersonal: are important in dealing with other EMTs, the patient, family
and bystanders, medical direction, and other members of the EMS system.

Radio Communication System:
Base station: A base station is a two-way radio at a fixed site such as a
hospital or dispatch center. The base station can serve as a dispatch and
coordination hub, and ideally is in contact with all other elements of the
system.
o base should be located on a suitable terrain, preferably a hill, and be in
proximity to the hospital that serves as a medical command center.
Two-way mobile radio
Portable radio: useful when you are out of your vehicle and must stay in
communication. Such portable units may also be used by medical direction
when they are stationed at a hospital that has no radio.
o Cell phones: transmit through the air instead of over wires so that the
phones can be transported and used over a wide area. Cell phones
allow EMS communications through an already established
commercial system. Cell phones are not always a solution to the
problem of radio communication because a cell phone needs to be able
to reach a cell tower or site.

Radio System Maintenance:
o Back up radio system in case of equipment failure
o Daily radio checks and batter charging
o Maintenance by qualified technicians

Radio system Components:
o Radio frequencies are assigned and licensed by the Federal
Communications Commission
o This is to prevent two or more agencies from trying to use the same
frequency and interfering with each others communications. There are
also strict rules about interfering with emergency radio traffic and
prohibiting profanities or offensive language

Communication Principles
Radio reports must be concise, organized and pertinent
Listen before transmitting
Press Push to Talk (PTT) button one second before speaking
Speak slowly and clearly with 2-3 inches from the microphone
Avoid slangs, codes and profanity
Do not give a patients name over the air: it is a violation of HIPAA
Consider using land line or cell phone for privacy
Provide objective information

Communication with Medical Direction and Dispatch

Reasons to communicate with dispatch:
Location of call and information
When en route to scene
Upon arrival at the scene
When en route to hospital
Request additional resources
Advice when at hospital
Advise when leaving hospital
Report unusual situations
Request assistance

Reasons to communicate with medical direction
Consultation
Obtain orders for medications/interventions

Medical Radio report:
Provides patient information to hospital
Allows hospital to prepare
A quality report paint a picture of the patient with words

Radio Report Content
Unit and level of provider
Estimated time of arrival
Patients age and sex (and race)
Chief complaint
Brief, pertinent history of present illness
Major past illness
Mental status
Vital signs
Pertinent findings of the physical exam
Emergency medical care given
Response to emergency medical care
Questions/orders from medical directions
o After receiving an order:
! Repeat the order back word-for-word
! Question orders that are unclear or appear to be inappropriate

Example: Arrival in approx. 8 minutes. 64-year-old male: Caucasian. Was
complaining of severe chest pains that have worsened. History of Diabetes
and takes insulin for that. Currently patient is awake, conscious and very
anxious. Blood Pressure is 110/70. Respiration: 20. Skin: cool and pale.

Verbal Communication: At the Hospital
Introduce the patient by name (if known)
Summarize information from the radio report
Provide any additional information and changes since radio report

Interpersonal Communication
Maintain eye contact: Make frequent eye contact. It shows interest and
attentiveness.
Positioning and Body Language: Position yourself at or below the patients
eye level and use a more open stance
Be honest
Use language that the patent can understand: slowly and clearly and explain
procedure before they are performed
Use the patients proper name.
Act and speak in a calm, confident manner.
Allow the patient enough time to answer each question and LISTEN
Be aware of disabilities that impair communication. Ex. mental disabilities.
Interpreters may be needed for language barriers
Visual or auditory deficits:
o For the visually impaired person, you will want to take extra effort to
explain anything that is happening that he cannot see.
o Elderly patients
Pediatric note: best to involve parents when communicating with a child

Bleeding and Shock

Circulatory System
Responsible for the distribution of blood
Components
o Heart: muscular organ that lies within the chest, behind the sternum.
! pump blood, which supplies oxygen and nutrients to the cells
of the body. To provide a sufficient supply of oxygen and
nutrients to all parts of the body, the heart must pump at an
adequate rate and rhythm.
o Blood
o Blood vessels:
! Arteries: carry oxygen-rich blood away from heart
" Except for pulmonary artery
" thick muscular wall that constricts and dilates
! veins: microscopically small and carry oxygen rich blood to
supply every cell
! capillaries: carry deoxygenated blood back to the heart
" less pressure than blood in artery

Taking the patients blood pressure is a means of measuring arterial pressure.
Where capillaries and body cells are in contact, a vital exchange takes place.
o Oxygen and nutrients are given up by the blood and pass through the
extremely thin capillary walls into the cells. At the same time, carbon
dioxide and other waste products given up by the cells pass through
the capillary walls and are taken up by the blood.
Veins have one-way valves that prevent the blood from flowing in the wrong
direction.

Hypo means low, so hypoperfusion means low perfusion.
inadequate perfusion of the bodys cells will eventually lead to the death of tissues and
organs.
Patient will start losing blood pressure


Function of the Blood:
Transportation: oxygenated and deoxygenated blood
o Blood carries inhaled oxygen from the lungs to the bodys cells, and it
carries carbon dioxide from the body cells back to the lungs where it is
then exhaled.
Nutrition: from intestines or storage tissues (such as fatty tissue, the liver, and
muscle cells) to the other body cells.
Excretion: carries waste products from the cells to organs, such as the kidneys,
that excrete (eliminate) them from the body.
Protection: antibodies and white blood cells, which help fight disease and
infection.
Regulation: Blood carries substances that control the functions of the body,
such as hormones, water, salt, enzymes, and chemicals. Blood also helps
regulate body temperature by carrying body heat to the lungs and skin surface
where it is dissipated.

Bleeding:
Classification: internal or external bleeding
Hemorrhage: severe bleeding, major cause of shock
Most sensitive:
o Brain: major nutrients are glucose and oxygen
o spinal cord
o kidneys

Classification
Arterial: Most difficult to control
o bright red, rich in oxygen
o high pressure. # blood spurts out
Venous: dark red(low in oxygen), maroon color
o Lower that atmospheric pressure
o Large veins may actually suck in debris or air bubbles
Capillary: minor and is easily controlled
o slow and oozing, low pressure
o clots spontaneously with minimal treatment

External Bleeding

The severity of the bleeding is somewhat dependent on the amount of blood
lost in relation to the physical size of the patient.

Patient assessment
Estimate amount of external blood lost
Triage (prioritize)
Predict potential shock
Control external blooding

Patient Care
1. Standard precautions.
2. Open airway.
3. Monitor respirations.
4. Ventilate if necessary.
5. Control bleeding.
Assess circulation by taking a radial pulse; assessing skin color, temperature,
and condition; and controlling external bleeding.

Controlling External Bleeding
Direct pressure and hemostatic gauze:
o Apply pressure to wound
o Hold pressure firmly.
o Bandage
o Dont remove dressing
Apply tourniquet:
o Device that closes off blood flow to and from an extremity
o Controls life-threatening bleeding
o Commonly used in military and tactical settings
o Direct pressure and elevation are usually successful
o Hemostatic gauze in areas where tourniquet is appropriate: trunk,
neck, head
o Use:
! Extremity injuries only
! Once applied, do not remove or loosen
! Material: 4in wide, 6-8 layers, cravats frequently used,
! never use narrow material such as rope or wire
o Application:
! Select site, no farther than two inches from wound.
" Should be between the wound and the heart
! Tighten to the point where bleeding is controlled
! Attach a notation to the patient: show other rescuers that it has
been used and the time of application
! Blood pressure cuff may be used, temporarily, as a tourniquet
to control life threatening arterial bleeding from an extremity
while a pressure dressed is applied. Inflate to approx. 150
mmHg.
! Contact medical direction
Alternative Bleeding
o pressure point is a site where a large artery lies close to the surface of
the body and directly over a bone
! four sites (two on each side) used as pressure points to control
profuse bleeding in extremities:
" the brachial arteries for bleeding from the upper
extremities,
" femoral arteries for bleeding from the lower extremities
o Splinting:
! Stabilization
! Various types:
" Inflatable splints, also called air splints, may be used to
control internal and external bleeding from an
extremity.
" Air splints are useful if there are several wounds to the
extremity or one that extends over the length of the
extremity. Air splints are most effective for venous and
capillary bleeding
! Not effective for arterial bleeds
! Maintains pressure

Special Situations
Head injuries: increased pressure within the skull, which forces fluid out of
the cranial cavity
o Fracture skull
o Bleeding or loss of cerebral spinal fluid from ears or note
o Do not attempt to stop bleeding: Doing so may increase the pressure in
the skull. Do not apply pressure to the ears or nose. Allow the drainage
to flow freely, using a gauze pad to collect it.
Nose bleed
o Epistaxis
o Direct trauma: Tiny capillaries in the nose may burst because of
increased blood pressure, sinus infection, or digital trauma (nose
picking)
o Increased blood pressure
o Patients at risk
o Controlling Nosebleeds:
! Have patent sit down and lean forward
! Apply or instruct patient to apply direct pressure
! Keep patient quiet and calm
! Position patient on side(recovery position) if unconscious.
Prepare to suction

Internal Bleeding
Damage to internal organs and large blood vessels:
o can result in loss of a large quantity of blood in a short period of time.
Blood loss cannot be seen
Sharp bone ends of a fractured femur can cause enough tissue and blood
vessel damage to cause shock (hypoperfusion)

Mechanism of:
Blunt Trauma
o Falls
o Motor vehicle/motorcycle crashes
o Auto-pedestrian collisions
o Blast injuries

Penetrating Trauma
o Gunshot wounds
o Stab wounds
o Impaled objects

Signs of Internal Bleeding
Injuries to surface of body
Bruising, pain, swelling or deformed extremities (especially in the chest and
abdomen)
Bleeding from mouth, rectum, vagina, etc.
Tender, rigid, or distended abdomen
Vomiting
Dark, tarry stools and bright red blood
o Red blood # new
o Dark blood # old
Signs and symptoms of shock

Patient Care
Maintain ABCs# airway, breathing, circulation
Administer high concentration oxygen via nonrebreather mark
Control external bleeding
Prompt transport


Shock:
the inability of the circulatory system to supply cells with oxygen and nutrients.

Hypoperfusion also causes the inadequate removal of waste products from
the cells.
Causes:
o Inability of heart to pump
o Decreased supply of blood
o Lack of integrity in blood vessels
o Failure of vessels to dilate and constrict.
Development
o Heart fails as a pump
o Blood volume is lost
o Blood vessels dilate

Classification of Shock
Compensated shock.
o increased heart rate (to increase blood flow) and increased respirations
(to increase oxygenation of the blood).
o Constriction of the peripheral circulation (to redirect blood to the vital
core organs)
o results in pale, cool skin and, in infants and children, increased
capillary refill time.
Decompensated shock.
o At the point when the body can no longer compensate for the low
blood volume or lack of perfusion, decompensated shock begins.
Irreversible.
o Cell damage occurs, especially in the liver and kidneys.
o Even if adequate vital signs can be restored, the patient may die days
later due to the failure of irreparably damaged organs
o Unable to maintain perfusion of vital organs

Types of Shock
Hypovolemic:
o uncontrolled bleeding or hemorrhage
! also may be caused by burns or crush injuries, where plasma is
lost
o Internal, external or combination
Cardiogenic
o Myocardial infarction or heart attack
o Inadequate pumping of blood
o Electrical system malfunctioning
o 50% change of living if at hospital
Neurogenic
o Uncontrolled dilation of blood vessels # increases the capacity of the
circulatory system to the point where the available blood can no longer
adequately fill it.
o Sepsis (massive infection) or an anaphylactic (severe allergic) reaction
may also cause neurogenic shock.
Obstructive
o Blocking blocks blood to heart (vena cava) from the heart
o Cardiac tamponade: compression of the heart that occurs when blood
or fluid builds up in the space between the myocardium (heart muscle)
and the pericardium (outer covering sac of the heart)
o Tension pneumothorax: progressive build-up of air within the pleural
space
o Pulmonary embolism: blockage of the main artery of the lung or one
of its branches by a substance that has travelled from elsewhere in the
body through the bloodstream
Signs and Symptoms
Restlessness, changes in mental status
Pale, cool, and clammy skin
Nausea and vomiting
Vital sign changes
o Pulse and respiration increase
o Blood pressure drops
o Inaccurate pulse oximetry
Other signs of shock include thirst, dilated pupils, and sometimes cyanosis
around the lips and nail beds.

Emergency Care for Shock:
Increasing the oxygen saturation of the blood will improve oxygen supply to the tissues.
You must also attempt to stop what is causing the shock, such as external bleeding, and
attempt to maintain perfusion. Remember that transportation is an intervention.
Maintain airway:
Oxygenation
Transport (intervention)
o Maximum time on scene ten minutes, unless extrication involved. This
time limit is often called the platinum ten minutes.

Pediatric notes
Efficient compensating mechanism:
o they can maintain a normal blood pressure until over half of their
blood volume is gone.
Blood pressure drops # serious
o they are already near death
Consider shock and treat early

Cultural considerations
Skin color: This is best evaluated where the outer layer is thinnest.
Fingernails and lips
Mouth: The color of the mucous membranes inside the mouth.
Eyelids: Note the color of the conjunctiva
Palms of hands and Soles of feet: Look for yellowish color or jaundice or
small round purplish spots called petechiae that are a result of capillary
bleeding.
Ask the family: Ask if the patients skin color is normal.

Trending Vital Signs
Elevated pulse
Elevated respiratory rates
Identifies patients condition
Unstable- vital signs taken every 5 minutes

Normal, Shock or Excited?
On Scene # ventilate, administer oxygen, compensated shock
o Pulse : 96 Weak/regular
o Respirations 8 and Shallow
o Skin Cool/moist
o BP 90/60
5 Minutes # ventilate, decompensated shock
o Pulse: 100 Weak/regular
o Skin Cool/moist
o B/P 82/56
10 Minutes #
o Pulse : 112 Weak/regular
o Skin Cool/moist
o B/P 74/50

Treatment of Shock:
Supine
Administer oxygen (airway management)
Control bleeding
Use PASG if necessary.
Elevate extremities 810 inches.
Prevent heat loss.
Transport rapidly.

Alternative Bleeding- Control Methods
Pneumatic Anti Shock Garment
o Systolic BP < 50 mmHg and signs of inadequate
perfusion, inflate all sections
o Systolic BP < 90 mmHg and signs of inadequate perfusion and
unstable pelvic fracture, inflate all sections
o Never inflate just the abdominal section
o Never apply PASG if bleeding is above level of the garment
o Never apply to children


Dressing and Bandaging

Dressing:
Material applied to a wound in an effort to control bleeding and prevent
further contamination
should be sterile, meaning that all microorganisms and spores that can grow
into active organisms have been killed. Dressings also should be aseptic,
meaning that all dirt and foreign debris have been removed
Occlusive dressing: used to form an airtight seal on open wounds
Aluminum foil or saran wrap
Pressure dressing: self adherent roller bandage wrapped rightly over dressing
Bandage: material used to hold a dressing in place

Do NOT:
Dont wrap anything around airway
Do not cover tips of fingers and toes
Do not bandage too tightly or loosely
Do not leave loose ends
Cover all edges of dressing

Types of bandaging
Used for ear or forehead

Joints roller gauze works well

Forearm:

Hand: figure 8

Shoulder(including blade), scapula and armpit

Pelvis- rollergauze works well

Dressing Open Wounds
Take standard precautions.
Expose wound: Cut away any clothing so the entire wound is exposed
Use sterile or very clean materials.
Cover entire wound.
Control bleeding.
Do not remove dressings once applied.

Two special problems occur when bandaging an extremity.
First, point pressure can occur if you bandage around a very small area.
o It is best to wrap a large area, ensuring a steady, uniform pressure.
o Apply the bandage from the smaller diameter of the limb to the larger
diameter (distal to proximal) to help ensure proper pressure and
contact.
Second, the joints have to be considered. You can bandage across a joint, but
do not bend the limb once the bandage is in place. To do so may restrict
circulation, loosen the dressing and bandage, or both.


Chest Injuries
Blunt trauma- blow to chest
o can fracture the ribs, the sternum, and the costal (rib) cartilages.
o Whole sections of the chest can collapse.
o the lungs and airway can be damaged and the great vessels (aorta and
venae cava) and the heart may be seriously injured.
Severe blunt trauma: damaging internal organs and impairing respiration
Penetrating objects: bullet, knives, steel rods
Compression motor vehicle collision

Closed chest injuries
Closed skin is not broken
Open- skin is broken
Flail chest- fracture of two or more consecutive ribs in two or more places
Paradoxical motion- opposite movement of flail verses chest cavity.

Patient Care- Flail chest
Perform initial assessment.
Administer oxygen; assist ventilations as needed.
Apply bulky dressing to stabilize flail segment.: tape should not encircle the
chest or interfere with chest expansion
o Ed says place hand over area and apply pressure # will stabilize
them.
Monitor respiratory rate and depth

Open Chest Injuries:
Sucking chest wound open to atmosphere
Signs of severe difficulty breathing
o Wound to the chest
o Characteristic sucking sound
o Gasping for air

Patient Care-Open Chest Wound
Maintain open airway.
Seal open chest wound
o Ed says: put hand over hole and release according to patient status
Apply occlusive dressing.
Administer high concentration oxygen
Treat shock.
Transport

Occlusive and Flutter Valves
involve taping the dressing in place, leaving a side or corner of the dressing
unsealed.
As the patient inhales, the dressing will seal the wound.
As the patient exhales, the free corner or edge will act as a flutter valve to
release air that is trapped in the chest cavity.

Management-Sucking Chest
Hand pressure
Reseal dressing: tape also may not stick well to bloody skin or to skin that is
sweaty from shock
Improvised occlusive dressing- IV bag or aluminum foil

Injuries within the chest cavity:
Pneumothorax: air enters the chest cavity, possibly collapsing the lung.
o The air can enter through an external wound or through a punctured
lung or both. Signs of shock will also be present.
o Air enters chest cavity # diminished or absent lung sounds # can
progress to a tension pneumothorax
Tension pneumothorax: trapped air builds up in the chest cavity and puts
pressure on the heart, great blood vessels, and the unaffected lung, reducing
cardiac output and the ability of the lungs to oxygenate the blood.
o Most often with closed chest injury after sealing a sucking chest
wound
o Lung punctured by broken ribs or other cause
o Air cannot escape and builds up in chest
o Jugular veins distend (unless blood volume is low)
o Reduces cardiac output
o Tracheal deviation
Hemothorax: caused when lacerations within the chest cavity are produced by
penetrating objects or fractured ribs
o Chest cavity fills with blood # caused by laceration within chest #
blood flows in and around lungs # signs of shock
Hemopneumothorax: combination of blood and air, usually producing the
same results: a collapsed lung and loss of blood leading to shock.
o blood will flow into the space around the lung# lung may collapse #
patient will experience a loss of blood and/or added pressure # shock
Traumatic asphyxia: result of crush injury/sudden severe compression to chest
o Sternum and ribs exert severe pressure exerted on heart and lungs
forcing blood out of right atrium into jugular veins in neck
o Blood vessels rupture # extensive bruising to face and neck
o Neck and face darker color (red, purple or blue)
o Bulging eyes, distended neck veins
Cardiac tamponade: injury to the heart causes blood to flow into the
surrounding pericardial sac
o The hearts unyielding sac fills with blood and compresses the
chambers of the heart to a point where they will no longer fill
adequately, backing up blood into the veins.
o Blood in pericardial sac # sac fills with blood # compresses
chambers of heart # blood backs up into veins
Signs: distended neck veins, weak pulses, low blood pressure and
decreasing pulse pressure
! Pulse pressure : systolic diastolic pressure
" Normal : 120-80 = 40
Aortic injury and dissection: inner layer of the wall of the aorta begins to tear.
Blood from the interior of the vessel leaks into the outer layers and eventually
causes a balloon-like protrusion (aneurysm).
o Damage to this large, high-pressure vessel causes massive, often fatal
bleeding. Penetrating trauma can cause direct damage to the aorta.
Blunt trauma, such as deceleration from a severe motor-vehicle
collision (e.g., head-on), can sever or tear the aorta.
o Largest artery in body # high pressure vessel # fatal bleeding #
blunt trauma # degeneration secondary to hypotension.
o Signs:
! tearing chest pain radiating to back and chest
! Differences in pulse and blood pressure between right and left
arms and legs
! Cardiac arrest

Patient Care- Chest Injuries
Maintain an open airway.
Administer high -low oxygen.
Follow local protocols.
Care for shock.
Transport as soon as possible.
Consider ALS intercept.

Critical Decision Making
Determining serious underlying problems
Not necessary to diagnose
Knowledge of signs and symptoms

Abdominal Injuries
Closed or open
Blunt trauma
Internal bleeding
Protruding organs(evisceration)

Signs and Symptoms- Abdominal
Pain, cramps, nausea
Weakness, thirst
Lacerations and punctures
Bruising, developing shock
o Shock may present with restlessness; pale, cool, and clammy skin;
rapid shallow breathing; a rapid pulse; and low blood pressure.
Coughing up or vomiting blood
o The vomitus may contain a substance that looks like coffee grounds
(partially digested blood).
o
Rigid and/or tender abdomen
Distended abdomen

Patient Care- Closed and Open
Stay alert for vomiting and keep airway open.
Patient supine with legs flexed to reduce pain by relaxing abdominal muscles.
Administer high-flow oxygen.
Care for shock.
Apply anti-shock garments.
Nothing by mouth.
Monitor vital signs.
Transport .

Additional Steps
Control external bleeding
Do not touch or try to replace any eviscerated or exposed organs
o Apply a sterile dressing moistened with sterile saline over the wound
site before you apply an occlusive dressing. Maintain warmth by
placing layers of bulky dressing or a lint-free towel over the occlusive
dressing
! Saline: 0.9% sodium chlorine dissolved in water
Do not remove impaled objects
o stabilize it with bulky dressings that are bandaged in place. Leave the
patients legs in the position in which you found them to avoid
muscular movement that may move the impaled object

Burns
may involve structures below the skin including muscles, bones, nerves, and
blood vessels.
.Burns can injure the eyes beyond repair. Respiratory system structures can be
damaged, producing airway obstruction due to tissue swelling, and even
respiratory failure and respiratory arrest.
When caring for a burn patient, always think beyond the burn. For example, a
medical emergency or accident may have led to the burn.
fire or burn may aggravate a medical condition or injury
o Someone trying to escape a fire may fall and suffer spinal damage and
fractures. The EMT should not only detect the burn but detect the
spinal damage and fractures as well.

Classification of Burns:
Agent or source
o Agent
! Chemical
! Electrical
! Thermal
o Source:
! Dry lime
! Alternating current
Depth
o Superficial (1st degree)
! Epidermis
! Reddening of skin
! Swelling
o Partial thickness (2nd degree)
! Through the dermis only
! Intense pain and blistering
o Full thickness (3rd degree)
! All layers damaged, including nerves
! Severe pain from 1st
and 2nd degree burns
Severity:
o Agent or source
o Body region involved
o Depth
o Extent
o Age
o Other illnesses or injuries

Area:
Rule of Nines
o Each major area represents 9% of body surface area.
Rule of Palm
o Palm of patients hand equals 1% body surface area.

leg 18% each
arm 9% each
Note: burns of airway, genitalia, hands, feet #go to burn center
Partial thickness burns of >30% body surface area # burn center


leg 14% each
arm 9% each
head- 18%

Pediatric Note:
Greater risks
BSA difference
Higher risk of shock
Severity differs in less than 5 years old
Consider child abuse

Geriatric Note
Minor to moderate in young adult = fatal for an aged person.
Tissue healing is lessened.
Time of healing is increased.
Consider other illnesses and injuries.
Moderate burns = critical when >55 years old.

Critical Burns
Burns with respiratory injury
Full-thickness burns >10% Body surface area
Partial-thickness burns >30% Body Surface Area
Burns with painful, swollen, or deformed extremity
Moderate burns in young or elderly
Burns to face, hands, or feet
Burns to genitalia
Burns encircling any body part (arm, chest, etc.)

Patient Carethermal burns
Dry sterile dressings
EMS medical directors decision
Considerations
o All partial and full thickness = dry dressing or burn sheet vs.
o Moist dressing for partial thickness burns less than 10% and dry for
more severe cases
Never apply ointments, sprays, or butter (which would trap the heat against
the burn site and have to be scraped off by the hospital staff). Do not break
blisters. Do not apply ice to any burn (it can cause tissue damage).

Patient Carechemical burns
Requires immediate care
Wash away chemical with water.
If chemical is dry, brush away.
Apply sterile dressing or burn sheet.
Treat for shock.
Transport.

Specific Chemicals:
Dry lime: do not wash with water-brush away
Carbolic acid (phenol) does not mix with water
Sulfuric acid # heat is produced when water is added
Hydrofluoric acid # flood with water
Inhaled vapors # give high concentration oxygen

Electrical Burns
Can cause severe damage to body
Entry and exit burns

cover up with dry sterile dressing

Musculoskeletal Injuries
Anatomy:
Bones are formed of dense connective tissue
Provide bodys framework
Support and protection
Production of red blood cells
Bones articulated into joints
Classified:
Long
Short
Flat
Irregular

Physiology
Bones provide framework.
Joints allow for bending.
Muscles allow for movement.
Cartilage provides flexibility.
Tendons connect muscle to bone.
Ligaments connect bone to bone.

Periosteum
Strong, white, fibrous material surrounding bone
Blood vessels and nerves pass through
Obvious when bone exposed
Impaled objects
Do not remove

Joints


Muscles: the tissues or fibers that cause movement of
body parts or organs
Skeletal
o Voluntary
o Gives body shape
o Connected to bones
o Tongue, pharynx
o Upper esophagus
Smooth
o Involuntary
o Walls of organs
o Digestive
Cardiac
o Walls of the heart

Cartilage: connective tissue that covers the outside of
the bone end (epiphysis) and acts as a surface for
articulation, allowing for smooth movement at joints.
Connective tissue outside of the bone
(epiphysis)
Surface for articulation
Smooth movement at joints
Less rigid
Forms flexible structures: ,
o Cartilage is less rigid than bone, forms or helps to form some of the
more flexible structures of the body
! Septum of nose
! External ear
! Trachea
! Connections between ribs and sternum

Tendons and Ligaments
Tendons
o Bands of connective tissue
o Binds muscles to
bones
o Power of movement
o MTB = muscle-tendon-bone
Ligaments
o Connective tissue
o Supports joints by attaching the
bone ends and allowing for a
stable range of motion.
o Connects bone to bone
o BLB = bone-ligament-bone.

Mechanism of Injury
Direct force: is a person being struck by an automobile, causing crushed tissue
and fractures.
o MVC
o Crushed tissue
o Fractures
Rotational forces: can cause stretching or tearing of muscles and ligaments, as
well as broken bones, such as occur when a ski digs into the snow while the
skiers body rotates.
o Football, basketball
o Soccer
Indirect force
o Falls from heights

Types of Injury
Fracture: Bones break
Dislocation: Joints come apart
Sprain: Stretching and tearing of ligaments
Strain: Overexertion of muscle

Patient Assessment

Assessment:
Pain and tenderness
Deformity or angulation
Grating or crepitus
Swelling
Bruising
Exposed bone ends
Joints locked in position
Nerve and blood vessel compromise

Fractures:
a !"#$%& %()*%+,)- ,./0*- is one in which the
skin is not bioken.
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skin has been bioken oi toin thiough fiom the
insiue by the injuieu bone oi fiom the outsiue by
something that has causeu a penetiating wounu
with associateu injuiy to the bone.
o An open injuiy is a seiious situation
because of the incieaseu likelihoou of
infection.

Patient Care

Injuries:
Initial assessment (ABCs)
Rapid trauma exam
Apply cervical collar
Splint
Apply dressing to wounds
Cold pack/elevate
Note:
For a low-priority (stable) patient, splint individual injuries before transport.
For a high-priority (unstable) patient, immobilize the whole body on a long
spine board, then load and go. If time and the patients condition permit,
you may be able to splint a specific injury en route.

Load and Go
Initial assessment reveals unstable patient.
Address ABCs.
Use long spine board.
Do not splint individual extremities.

Splinting
Immobilize adjacent joints and bone ends.
Decreases pain and movement
Prevents additional injuries such as nerves, arteries, veins, and muscles.
splinting minimizes the movement of disrupted joints and broken bone ends,
and it decreases the patients pain.
It can prevent a closed fracture from becoming an open fracturea much
more serious conditionand it can help to minimize blood loss. In the case of
the spine, splinting on a backboard prevents injury to the spinal cord and helps
to prevent permanent paralysis

Realignment:
Restores effective circulation
Splint may be ineffective otherwise.
Decreases circulatory compromise:
o If the extremity is not realigned, the chance of nerves, arteries, and
veins being compromised increases. When distal circulation is
compromised or shut down, tissues beyond the injury become starved
for oxygen and die.
Reduction in pain
o Pain is increased for only a moment during realignment under traction.
Pain is reduced by effective splinting.

General rule-realignment
Grasp distal extremity for support
Splint in position found
o Realign if extremity cyanotic or lacks pulse
Manual traction
o Resistance:
! Stop realignment and splint in position found.
o No resistance:
! Maintain traction until splint applied.
Generally, injured joints should be splinted in the position found unless the
distal extremity is cyanotic or lacks pulses. If so, an attempt should be made to
align the joint to a neutral anatomical position using gentle traction, provided
that no resistance is felt.

General rule- immobilization
Treat life-threatening problems first
Expose
Assess distal PMS before and after
Align long-bone to anatomical position
Choose method to be used
Do not push protruding bones
Immobilize both injury site and adjacent joints
Pad voids

Hazards of Splinting
First address life-threatening conditions.
Ensure airway, breathing, and circulation.
Method dictated by severity of patient.
Compression of nerves, blood vessels, and muscles
Inappropriate splinting:
o Cause further soft-tissue injury
o Cause open fracture to occur

Procedure-Splinting
Expose
Stabilize the injury site.
Assess pulses and circulation, motor function, and sensation.
Check for disability.
Realign if deformed or if the distal extremity is cyanotic or pulseless
Measure or adjust the splint.
Maintain manual stabilization or traction.
Apply and secure the splint.
Reassess PMS distal to the injury.

Traction Splint:
Indications
o Painful, swollen, deformed thigh with no joint or lower-leg pain
Amount of traction to pull
o 10% of patients body weight
o Do not exceed 15 pounds
Guidelines:
o Standard Precautions
o Manual stabilization and traction
o Assess PMS.
o Adjust splint to proper length.
o Apply proximal securing device (ischial strap).
o Apply distal securing device (ankle hitch).
o Apply mechanical traction.
o Position and secure support straps.
o Re-evaluate
o Secure torso and traction splint to long board.

SignsLower Extremity Injuries
Pain in pelvis, hips, groin, or back
Painful reaction when pressure applied to iliac crest
Inability to lift legs when supine
Lateral rotation (outward)
Unexplained pressure on bladder

Patient care-pelvic injuries
Limit patient movement.
Determine PMS function distally.
Straighten and stabilization lower limbs.
Apply pneumatic anti-shock garment (PASG) when B/P <90.
Immobilize on long spine board.
Reassess.
Provide oxygen and treat shock.
Transport.
Monitor vital signs.

Pelvic Wrap: wrap should be performed on patients who have pelvic
deformity or instability (movement upon palpation) whether or not signs of
shock are present.
o Pelvic deformity or instability
o Mechanism of injury indicates pelvic injury.
o Follow local protocols.

Hip dislocation: occurs when the head of the femur is pulled or pushed from its pelvic
socket. It is difficult to tell a hip dislocation from a fracture of the proximal (uppermost
portion of the) femur. Conscious patients will complain of intense pain with both types of
injury.
Patients who have had a surgical replacement of the hip joint are at increased
risk of hip dislocation. The hip can be dislocated either anteriorly or
posteriorly.

Signs and Symptoms-Hip dislocation
Anterior
o Lower limb rotated outward
o Hip flexed
Posterior
o Lower limb rotated inward
o Hip flexed
o Knee bent
o Foot may hang loose.

Patient CareHip
o Assess distal PMS.
o Apply long spine board
o Immobilize limb with pillows or blankets
o Secure patient
o Reassess distal PMS.
o Treat shock and provide oxygen.
o Transport.

Signs and SymptomsHip fracture
Localized pain (sometimes in the knee)
Sensitive to pressure laterally (greater trochanter)
Discolored tissues
Swelling
Unable to move limb
Unable to stand
Foot rotated outward
Injured limb appears shorter

Patient Care-Hip fracture
o Bind legs together
o Padded boards
o Apply PASG

Femoral Shaft Fracture
Pain
Open or closed fracture with deformity
Injured limb shortened

Patient Care-Femoral Shaft Fracture
o Control any bleeding by applying direct pressure .
o Manage the patient for shock .
o Assess distal PMS function.
o Apply a traction splint.
o Reassess distal PMS function.

Knee Injury
Pain and tenderness
Swelling and deformity with obvious swelling
The knee is a joint and not a single bone. Fractures can occur to the distal
femur, to the proximal tibia and fibula, and to the patella (kneecap).

Patient Care- Knee injury
o Assess distal PMS function.
o Padded board splints
o Pillow
o Immobilize with padded board splint.
o Pad the voids
o

Head and Spinal Injuries

Anatomy and Physiology
Human Body
Skeletal system
o Support
Protection
Nervous system
o Control of thought
o Sensations
o Motor function
Subsystems
o Central nervous system
o Peripheral nervous system

Central nervous system
Brain
Spinal cord

Peripheral Nervous system
the nerves that enter and exit the spinal cord between each pair of vertebrae
the 12 pairs of cranial nerves that travel from the brain without passing
through the spinal cord
all of the bodys other motor and sensory nerves.
o Messages from the body to the brain are carried by sensory nerves.
Messages from the brain to the muscles are carried by motor nerves.
These nerves control voluntary movements, or those we consciously
control such as running or grasping.
As the nerves exit the brain, prior to traveling down the spinal cord, they cross
over to the opposite side of the body. This is why an injury to the left side of
the brain may produce effects such as weakness or lack of sensation on the
right side of the body.

Autonomic Nervous system
Controls involuntary functions:
o heart beat, breathing, and control of diameter of vessels, sphincter
muscles, muscles controlling bladder and bowel and digestion.

Brain
Master organ
Receives and sends messages (which determines the bodys response)
Susceptible to injury
The brain is held within the skull. The spinal cord exits the base of the brain
and leaves the skull through a large hole where the spinal column is attached.
The brain is bathed in a fluid called cerebrospinal fluid (CSF). This fluid
also circulates down the spine around the spinal cord.
Dura matter - tough connective tissue that
covers brain
Arachnoid - lies underneath dura matter and
provides some added connective features.
Pia matter - interlining membrane and very
fragile.

Head
Skull (29)
o Cranium (8)
o Facial bones(14)
o Auditory bones (6)
o Hyoid bone (1)
Cranium: portion of the skull that
encloses the brain
o Forehead
o Top
o Back
o Upper sides of skull
Cranial Bones
o fused
Face
o Fused except for mandible
o 14 bones
o temporal bone
o temporomandibular joint
Upper Jaw
o Fused
o Maxillae: made of two fused
bones known as a maxilla.
Nasal
o Bridge
o 2 bones
o Cheek
o Malar
o Zygomatic
o Forms portion of orbits

Spine
33 vertebrae
o 7 cervical
o 12 thoracic
o 5 lumbar
o 5 sacral
o 4 coccygeal
spinous process
o bony bump
Every vertebra has a hollow space like the hole in a
donut. These hollow spaces form a channel that runs the
length of the spinal column and contains the spinal cord,
which is cushioned by the cerebrospinal fluid.

Injuries to the Head

Scalp:
Blood vessels = bleeds profusely
Control bleed
Dress and bandage
o Do not apply pressure if the injury site shows bone
fragments or depression of the bone or if the brain is
exposed. Instead, use a loose gauze dressing.
Caution when applying pressure
Skull
Cranium and facial fractures
Open or closed
o assume that there may be an open head injury
beneath any contusion or laceration of the scalp
Brain
Direct: to the brain can occur in open head injuries, with the
brain being lacerated, punctured, or bruised by the broken
bones or by foreign objects.
Indirect: the shock of impact on the skull is transferred to
the brain. Indirect injuries to the brain include concussions
and contusions.

Brain Injuries:
Concussion: when a person strikes his head in a fall, or is
struck by a blunt object, a certain amount of the force is
transferred through the skull to the brain. Usually there is no
detectable damage to the brain and the patient may or may
not become unconscious.
o Mild
o No detectable damage
o May or may not lose consciousness
o Headache
Contusion: caused by a collision or blow that causes the brain to hit the inside
of the skull, bounce off the opposite side, and then rebound to strike the first
side of the skull again.
o Occurs with closed head injuries
o Bruising on opposite side of blow
o Contrecoup bruising on the opposite side of the blow
o Coup bruising of the brain occurs on the side of blow
Laceration
o Cut
o Open head injury
o Caused by sharp, bony ridges
o Object penetrates cranium
Hematoma
o Collection of blood within tissue
o Named based on location in brain
o Subdural: a collection of blood between the brain and the dura
o Epidural : blood between the dura and the skull.
o Intracerebral: when blood pools within the brain.

Skull and Brain Injury- Signs
Visible bone fragments
Altered mental status
Deep laceration or severe bruise
Hematoma
Depression or deformity
Severe pain
Bruising behind ear (late sign)
Unequal pupils
Raccoon eyes (late sign)
Bleeding from ears and/or nose
CSF from ears and/or nose
Personality change
Increased BP and decreased pulse
Irregular breathing
Temperature increase
Blurred or multiple vision
Hearing impairment
Equilibrium problems
Projectile vomiting
Posturing
Paralysis or disability
Seizures
Deteriorating vitals

Patient Care
Stabilize C Spine
Evaluate breathing
Administer oxygen
Control bleeding
Keep patient at rest
Emotional support
Treat shock
Transport

Cranial Injuries: Impaled Objects # lengthy impaled object can make
transporting the patient impossible until the object is cut or shortened
Do not remove.
Stabilize in place.
Pad around object.
Use hacksaw if needed
Consult medical control.

Injuries to Face and Jaw
Fractures
Bone fragments: Bone fragments may lodge in the back of the
pharynx and cause airway obstruction. So may blood, blood clots, dislodged
teeth, or a separated palate.
Dislocations: mandible is subject to dislocation as well as to fracture
Airway management
Suction
Jaw thrust
Control bleeding
C spine precautions
Treat shock

Nontraumatic Brain Injuries
Caused by an internal brain event
Hemorrhage
Blood clot
Signs of nontraumatic (not caused by external trauma) brain injury
Same as those for a traumatic injury
No evidence of trauma
No mechanism of injury

Glasgow coma scale
EMS agencies use the GCS in addition to AVPU, for ongoing neurological assessment.
Some systems would immediately transport a patient with a score of 8 or less directly to
the trauma center if they are within 30 minutes transport time.

Eye Opening:
Spontaneous
Open your eyesnormal tone
Shout command if normal tone
unsuccessful
Note eye injuries.
Verbal Response
Oriented
o Who he is
o Where he is
o Day of the week
Confused
o Cannot answer questions
Inappropriate words
o Words do not fit situation
Incomprehensible sounds
o Mumbling
o Moans
o Groans
o No verbal response
Motor Response
Obeys command
o Carry out request
Localizes pain
o Apply pressure to nail bed
Withdraws
o Pulls away from pain
o Posturing in flexion
o Elbows flex
o Appearance of stiffness
Posturing in extension
o Legs and arms extend
o Internal rotation of shoulder and forearm
No motor response
WithdrawsNote if the elbow flexes, if the patient moves slowly, if there is the
appearance of stiffness, if he holds his forearm and hand against the body, or if the limbs
on one side of the body appear to be paralyzed (hemiplegic position).

Posturing
A) decorticate # sign of spinal reflex. Consciousness can still be salvaged.
Upper extremities in towards the body
B) decerebrate # cerebral cortex no longer intact (brain dead)
extended upper extremities and rotated outwards.

Injuries to the Spine

Mechanism of Injury to Upper Body

A simple rule of thumb is, if the mechanism of
injury exerts great force on the upper body or if
there is any soft-tissue damage to the head, face,
or neck due to trauma (such as from being thrown
against a dashboard), assume possible cervical-
spine injury. Any blunt trauma above the
clavicles may damage the cervical spine.

Patient Assessment-Spinal Injury
Paralysis: Most reliable
Pain without movement: Not always constant
Pain with movement: Dont ask patient to move
Tenderness along spine: Gentle palpation
Impaired breathing: Watch patient breathe
o If there is only a slight movement of the abdomen, with little or no
movement of the chest, it is safe to assume that the patient is breathing
with the diaphragm alone (diaphragmatic breathing)
o nerves that control the diaphragm are located high in the cervical area
(the third, fourth, and fifth cervical nerves) and are often unharmed,
but the intercostal (between-the-ribs) nerves that control the chest
muscles are often damaged in cervical and thoracic injuries.
Deformity: Remove clothes and check
Priapism: Persistent erection
Posturing: Motor-nerve pathway interrupted
Loss of bowel control
Loss of bladder control
Nerve impairment to extremities
Soft-tissue injuries
o Traumatic soft-tissue injuries to the head and neck may signal injury
of the cervical spine. Traumatic soft-tissue injuries to the shoulders,
back, or abdomen may signal injury of the thoracic or lumbar spine.
Traumatic soft-tissue injuries to the lower extremities may signal
injury of the lumbar or sacral spine.
Severe spinal shock: Failure of the nervous system
o (neurogenic shock) can be caused by the failure of the nervous system
to control the diameter of blood vessels. The pulse rate may be normal
because a message to speed up the heart may be prevented from
getting to the heart due to the cord injury.

Questions:
What happened?
Where does it hurt?
Does your neck or back hurt?
Can you move your hands and feet?
Can you feel me touching (fingers and toes)?
Do you feel pins and needles?

Strategiesresponsive patient
Mechanism of Injury
Bystander information
DCAP-BTLS
PMS
Palpation

Assessment:
Inspect DCAP-BTLS
Palpate for tenderness.
o Abdomen
o Chest wall
Assess extremities.
o Pulses
o Motor
o Sensation
Bystander information
o What happened?
o What did you see?

Patient Care-Spinal injury
Manual in-line stabilization
Assess ABCs.
Rapid trauma exam
Assess sensory and motor function.
Apply spinal immobilization device.
Oxygen
Reassess motor and function.

Cervical Spine Injuries in Perspective
2.4% blunt trauma patients experience some degree of musculoskeletal injury
to spine
approx. 20,000 spinal cord injuries a year in US
$1.25 million to care for a single patient with permanent SPI
15,000-20,000 SCI per year
higher in men between ages of 16 30
common causes: motor vehicle crashes, falls, etc.

Positive MOI- forces of impact suggest a potential spinal injury
His speed MVC
Falls greater than 3x body height
Axial loading
Violent situations near the spine : gun shots, stabbing
Sports injuries
o Infants 4 y.o. bones have not calcified efficiently.
o Elders with osteoporosis
Other high impact situations
Consideration to special persons population
o Pediatrics, geriatrics, history of Downs, spinal bifata, etc.

Normal Procedure-Immobilization
Head and neck manually stabilized
C collar applied after assessment
Secure to short spine board or extrication vest.
o Extrication vest: Flexible piece of equipment useful for immobilizing
patients with possible injury to the cervical spine. It can be used when
the patient is found in a bucket seat, in a short compact car seat, in a
seat with a contoured back, or in a confined space.
! KED
! Kansas Backboard
! XP-1
! LSP Halfback Vest

Technique-Rapid Extrication
Bring the patients head into a neutral in-line position. This is best achieved
from behind or to the side of the patient.
Perform an initial assessment and rapid trauma assessment; then, apply a
cervical spine immobilization collar.
Support the patients thorax. Rotate the patient until his back is facing the
open car door. Bring the patients legs and feet up onto the car seat.
Bring the board in line with the patient and against the buttocks. Stabilize the
cot under the board. Begin to lower the patient onto the board.

Logroll and Immobilization
Establish and maintain in-line stabilization. Apply a rigid cervical spine
immobilization collar.
Place a long spine board parallel to the patient. If possible, pad the voids
under the head and torso.
Three rescuers kneel at the patients side opposite the board, leaving space to
roll the patient toward them.
Secure the patient to the board with straps. Loosely tie the wrists together.
Using a head/cervical immobilizer, secure the patients head to the spine
board.
Transfer the patient and the spine board as a unit. Secure the patient and the
spine board to cot.

Other options
Another option for securing the patient is using an X strap method that
secures the torso to the backboard. Also apply one strap at the hip, one above
the knee, and one below the knee.
Blanket rolls and tape can also be used to secure the head of the patient to the
backboard

Pediatric Note
6 years old or younger: When immobilizing a 6-year-old or younger child,
provide padding beneath the shoulder blades to compensate for the large head.
Pad from shoulders to toes as needed to establish a neutral position.
Padding beneath shoulder blades
Pad from shoulders to toes
Practice immobilization with adult equipment.

Helmet Removal
Injuries
Face
Neck
Spine
Airway management
Resuscitation

Indication-helmet in place
Helmet is snug
No impending airway or breathing problems
No resuscitation needed
Removal would cause
further injury
Immobilization can be done with it in place
No interference with airway and breathing assessment

Removal or Helmet
Interferes with assessment
Airway and breathing
issues
Improperly fitted
Interferes with immobilization
Cardiac arrest
Per Medical Direction
Pharmacology

Pharmacology study of drugs their sources, characteristics, effects, etc.
Usually refer to them as medicines or medications, because the public often
thinks of drugs as illegal drugs
EMT-Bs carry some medications, and can assist the patient take some of their
prescribed medications.

Medications EMTs can Administered (carried on ambulance)
Routinely carried:
o Activated charcoal
o Oral glucose
o Oxygen
o Baby aspirin
May be carried
o Albuterol mini0nebulizer
o Epi-pen

Medications EMTs can assist with
Prescribed inhaler (patients)
Nebulized albuterol (can be carried on ambulance w/NYSDOH approval)
Nitroglycerin (patient's)
Epi-pen (epinephrine)

Definitions
Pre prescribed medications# are those that are prescribed for a specific
patient prior to the emergency

Medication Names
Generic: the name listed in the US pharmacopoeia a governmental publication
listing of all drugs in the US.
o Name assigned to a drug before it becomes officially listed. Usually a
simple form of the chemical name
! Ex: nitroglycerin, epinephrine.
Trade: brand name is the name a manufacturer uses in marketing the drug
o Ex. Epinephrine = adrenalin

Actions: the desired effects a drug has on the patient and/or his body systems
ExampleNitroglycerin
o Dilation of coronary arteries and subsequent increase of blood flow
and oxygen to the heart muscle
o Causes general dilation of systemic arteries, causing a drop in blood
pressure

Indications for use
The indication for a drugs use includes the most common uses of the drug in
treating a specific illness
Specific signs, symptoms or circumstances under which it is appropriate to
administer the drug to a patient.

Contraindications
Situation in which a drug should not be used because it may cause harm to the
patient or offer no effect in improving the patients condition or illness
Example Nitroglycerin
o Should not be given if the patient has a low blood pressure, because
nitroglycerin, in dilating the arteries can cause a drop in systolic blood
pressure
o Should not be given if the patient has taken any erectile dysfunction
medication in the last 72 hours.

Side Effects - Any actions of a drug other than those desired
Some side effects may be predictable
Ex: nitroglycerin
o Hypotension, headache and pulse rate changes

Dose: how much of a drug should be given
Usually given in milligrams

Routes of Administration- Route by which a drug is administered affects the rate that
the medication enters the blood stream and arrives at its target organ.
Oral or swallowed
Sublingual or dissolved under the tongue
Inhaled, or breathed into the lungs, usually in tiny aerosol particles as from an
inhaler or as a gas such as oxygen
Injected, through skin
Absorption through the skin

Various Forms
Suspensions # such as activated charcoal suspension or liquid-char
Gels or paste # such as glucose to treat hypoglycemic
Tablets or Spray # such as nitroglycerin tablets or spray.
Gases

When do you give medication?
Scene size up
Initial assessment
Sample history (OPQRST)
Focused physical/vital signs
Medication administration
On going assessment
o Evaluate response to treatment
*give oxygen in initial assessment

Administration Procedure
Five Rights of medication administration
o Right patient
o Right medication
o Right dose
o Right route
o Right time (timing; expiration date)

Bronchodilators

Bronchodilator Inhalers actions
Dilates (enlarges) bronchioles, reducing airway resistance
Ventolin or proventil (albuterol)
Bronkosol or bronkometer (isoetharine)
Alupent or metaprel (metaproternol)

Indications
Patient exhibits signs and symptoms of a respiratory emergency (asthma)
Patient has physician-prescribed hand held nebulizer

Contraindications
Patient is unable to use device (not alert)
Inhaler is not prescribed for the patient
Patient has already taken maximum prescribed dose prior to EMT-Bs arrival
Patient cannot hold nebulizer

Medical form
Hand held metered close inhaler
o Note: assure inhaler is at room temperature or warmer, and shake it up
a little

Side effects: increased pulse rate, tremors and nervousness

Nebulized Albuterol
Age range: 1year to 65 years
Patient must be experiencing an exacerbation of their previously diagnosed
asthma
2.5 mg unit dose
administered nebulized albuterol
o Standing Order! you do not need permission from hospital
! you can give 3 doses (5-10 minute intervals
! Contact medical control for further doses.
reassess patient: vital signs
o you should not hear wheezing

Epinephrine Auto-Injections
(Patients Own or Carried on Ambulance with NYSDOH approval)

dilates the bronchioles

Indications:
Patient indicated signs of severe allergic reaction including either respiratory
distress or shock (hypoperfusion)
Medication is prescribed for the patient by a physician
Administer as Standing Order, once, when assisting with patients own Epi.
If patients own epinephrine is not available or expired, contact Medical
Control for order to administer EMS Epinephrine.

Contraindications
there are no contraindications when used in a life-threatening anaphylaxis
in cases of an allergic reaction, as opposed to anaphylaxis, the patient should
be able to participate in the decision and delivery of epinephrine.

Side effects
Increased heart rate
Pallor
Dizziness
Chest pain
Headache
Nausea/vomiting
Excitability, anxiety.

Doses
Adult-one adult auto injector (0.3mg)
Infant and Child one infant/child auto injector (0.15mg)

Reassessment Strategies:
Continue focused assessment of airway, breathing and circulatory status
If patients condition continues to worsen (decreasing mental stat, increased
breathing difficulty, decreasing BP)
Meet ALS ASAP
Obtain medication direction for an additional dose of epinephrine
Treat for shock
Prepare to initiate basic life suppose procedures (CPR/AED)

Hypoglycemia low blood sugar
Use a glucose supplement

Indications:
patients with altered mental status with a history of diabetes controlled by
medications

Contraindications:
Decreased level of consciousness
Cannot swallow or protect own airway

Side effects:
None when given properly

Dosage:
(1 tube) 30 grams

Vital Signs
Assure S/S of AMS and Hx of diabetes
o Assure that patient is conscious an can swallow and can protect own
airway

Ingestion of Toxic Substances

Causes
Self inflicted (adults)
Accidental (pediatrics)

Signs and Symptoms
Nausea
Vomiting
Diarrhea
Abdominal pain
Burns around the mouth
Unusual breath odors
Difficulty breathing

Initial assessment
History:
o What substance?
o When?
o How much?
o Over what time?
o Patient interventions?
o Weight of patient?
o Vital sings

Treatment: Activated charcoal
Acidose, instachar, superchar, liquidchar

Action:
binds to certain toxins and prevents absorption

Contraindictions:
ingestion of acids or alkalines

Side effects:
Nausea/vomiting
Black stools

Form:
pre mixed in water in plastic container of 12.5 Gm or 25 Gm
Dosage:
1Gm/Kg of body weight
adult 25-50 Gm

Administration
Shake container vigorously for at least 30 seconds. Repeat shaking if ingestion
of activated charcoal takes longer than 10 minutes
Persuasion
Fill empty container with water after administration and have patient drink
contents to assure proper dosing
Do not delay transport

Documentation Requirements
All assisted administration of medications must be documented on PCR
Comments section
o name of medication, dosage, route, time administered, response to
medication, EMT# of technician who assisted with administration
Treatment section
o Check medication administered
o Write the word assisted
PCR distribution
o White copy- retained by EMS
o Yellow copy- retained by EMS agency
o Pink Copy- left for patient at hospital

Respiratory Emergencies

Anatomy Review


Pediatric Anatomy
Airway structure differences
Larger tongue
The mouth and nose, in children, are smaller than those in adults and are more
easily obstructed by even small objects, blood, or swelling. The tongue
Smaller more flexible trachea: Because the head of an infant or young child is
quite large relative to the body, it is necessary to place a folded towel or
similar item about one inch thick under the shoulders to keep the trachea
aligned and open
cricoid cartilage is less developed and much less rigid. Therefore, the
maneuver of pressing on the cricoid cartilage to help in placing a tube into the
trachea, often used on adults, is not appropriate for an infant or child, since it
can depress the soft cartilage and result in obstruction.
Abdominal breaths

Reasons for Breathing
InspirationThe active process that uses the contraction of several muscles to
increase the size of the chest cavity is called inspiration. The intercostal (rib)
muscles and the diaphragm contract. The diaphragm lowers and the ribs move
upward and outward. The expanding size of the chest cavity causes air to flow
into the lungs. Another term for inspiration is inhalation.
ExpirationA passive process, expiration, involves the relaxation of the rib
muscles and diaphragm. The ribs move downward and inward, while the
diaphragm rises. This movement causes the chest cavity to decrease in size
and causes air to flow out of the lungs. Another term for expiration is
exhalation.

Process of Breathing
Inspiration
Diaphragm and intercostal (rib) muscles contract.
Diaphragm moves downward.
Ribs move upward and outward, expanding chest cavity size.
Larger chest size allows air to flow into lungs.
Exhalation
Diaphragm rises.
Ribs move downward and inward, decreasing chest cavity size.
Smaller chest size allows air to flow out of lungs.

Adequate Breathing
Adequate breathing falls within certain ranges that are considered normal. The patient
will not appear to be in distress. Adequate breathing is breathing that is sufficient to
support life.
RateRates of breathing that are considered normal vary by age.
o adult, a normal rate is 1220 breaths per minute.
o child, it is 1530 breaths per minute.
o infant, it is 2550 breaths per minute.
RhythmNormal breathing rhythm will usually be regular. Breaths will be
taken at regular intervals and will last for about the same length of time.
QualityBreath sounds, when auscultated with a stethoscope, will normally
be present and equal when the lungs are compared to each other.
o both sides should move equally and adequately
o The depth of the respirations must be adequate.
Skin color normal
Normal mental status
Evaluate rate, rhythm, and quality

Inadequate breathing
Inadequate breathing is breathing that is not sufficient to support life. If left untreated,
this condition will surely lead to death.
Ratea breathing rate that is out of the normal ranges.
o Very slow breaths and very rapid breaths
o Agonal respirations (dying respirations) are sporadic, irregular breaths
o They are shallow and gasping with only a few breaths per minute.
Rhythm irregular.
o However, rhythm is not an absolute indicator of adequate or
inadequate breathing.
QualityWhen breathing is inadequate, breath sounds may be diminished or
absent.
o The depth of respirations (tidal volume) will be inadequate or shallow.
o Chest expansion may be inadequate or unequal and respiratory effort
increased.
o the use of accessory muscles (muscles other than the diaphragm and
the intercostal muscles, such as the muscles of the neck and abdomen)
in breathing.

Inadequate Breathing in Pediatrics
Most prominent signs:
Nasal flaring
Grunting
Retractions and see-saw breathing
you may observe a slight increase in pulse early, but soon the pulse will drop
significantly. A low (or bradycardic) pulse in infants and small children in the
setting of a respiratory emergency usually means trouble
Leading killer of children
Rapid deterioration and crashing of these patients rapid treatment and
assessment is critical!

Evaluation of Breathing
Frequent chief complaint. May also complain of chest tightness, anxiety, or restlessness
Do not rely completely on patients perception, but rather on full patient
assessment.
May be a chronic problem or an acute onset
Signs:
o Increased or decreased pulse rate
o Pale, cyanotic skin
o Noisy breathing (gurgling, snoring,
wheezing, etc.)
o Accessory muscle use
o Change in mental status
o Flared nostrils, pursed lips
o Positioning (tripod)

Respiratory Rate and Rhythm and Quality
Rate:
o Normal rates:
! Adult: 1220/min.
! Child: 1530/min.
! Infant: 2550/min.
o Critical finding:
! Very slow or very fast rates
Rhythm
o Breaths taken at regular intervals
o Breaths last for approximately same length of time
o May be influenced by talking, coughing, etc.
o Critical finding:
! Irregular (not an absolute indicator)
Quality
o Measure by watching for equal chest rise.
o Measure by feeling chest wall for equal expansion during inspiration.
o Listen with stethoscope for abnormal noises.
o Critical findings:
! Shallow or gasping
! Noisy lung sounds
! Unequal expansion
! Accessory muscle use
! Pale, cyanotic, or clammy skin

Pulse Oximetry
oximeter reading in a normal, healthy person is typically 96 to 100 percent.
o 91 to 95 percent indicates hypoxia,
o 86 to 90 percent indicates significant hypoxia
o 85 percent or less indicate severe hypoxia.

Causes of Respiratory Distress
May be result of an acute problem
o Trauma (chest injuries, head injuries)
o Medical condition (heart attack, allergic reaction)
o Other conditions (drowning, vomiting)
o Anxiety, stress
Respiratory condition
o COPD
! Chronic bronchitis
! Emphysema
Asthma

Chronic Obstructive Pulmonary Disease (COPD)
Includes emphysema, chronic bronchitis, and black lung
Generally affects older patients
Affects patient continuously
Causes include cigarette smoking, chemical exposure, and pollution

Chronic Bronchitis: involves inflammation, swelling, and thickening of the lining of the
bronchi and bronchioles and excessive mucus production.
Inflamed and swollen bronchioles and thick mucus restricts airflow to the
alveoli
o Causing respiratory distress and possible hypoxia.
Recurrent infections leave scar tissue that further narrows the airway.

Signs:
o Typically overweight
o Chronic cyanotic complexion
(Chronic bronchitis patients are
often called blue bloaters.)
o Difficulty in breathing, but less prominent than with
emphysema
o Coarse rhonchi usually heard upon auscultation of the lungs
o Vigorous productive cough with sputum (material that is coughed up)
o Wheezes and, possibly, crackles at the bases of the lungs

Emphysema: the lung tissue loses its elasticity, the alveoli become distended with
trapped air, and the walls of the alveoli are destroyed.
Breakdown of alveolar walls
Reduced surface area for exchange of oxygen and carbon dioxide
Reduced elasticity of lungs
Distal airways also involved have a greatly increased
airway resistance.

Signs:
o Thin, barrel chest appearance
o Coughing, but with little sputum
! (Material that is coughed up)
o Prolonged exhalation
o Diminished breath sounds
o Wheezing and rhonchi (rattles) on auscultation
o Pursed-lip breathing
o Extreme difficulty of breathing on minimal
exertion
o Pink complexion (Emphysema patients are often called pink
puffers.)
o Tachypnoeabreathing rate usually greater than 20 per minute at rest
o Tripod position
o May be on home oxygen

Asthma: Episodic disease with the narrowing of bronchioles and overproduction of
mucus
Typically one-directional, allows air into lungs but requires forceful
exhalation (wheezing)
Episodic # a disease that only affects the patient at irregular intervals).
The small bronchioles that lead to air sacs of lungs become narrowed due to
muscle contractions that make up airway. PLUS there is an overproduction of
thick mucus.
o The combined effects of the contractions and the mucus cause the
small passages to practically close down, severely restricting air flow
Causes:
o Allergic reactions to something inhaled, swallowed, or injected into
the body
o Pollutants
o Exercise and stress

Lung Sounds
Stridor: caused by a blockage in the throat or larynx (voice box), and it is
typically heard when the patient inhales.
Rhonchi: snoring or rattling noises heard upon auscultation.
o Can indicate obstruction by thick secretions of mucus.
o Often heard in chronic bronchitis, emphysema, aspiration, and
pneumonia.
Crackles: bubbly, popping sounds heard upon inhalation.
o Associated with fluid that has surrounded or filled the alveoli or small
bronchioles.
o Crackles may indicate pulmonary edema or pneumonia.
o Fine: Crackles are intermittent popping sounds.
o Coarse: crackles are lower pitched and longer in duration than fine
crackles.
Wheezes: high-pitched musical sound heard upon inhalation and exhalation.
o Usually due to swelling or spasms along the lower airway.
o But is common in asthma and sometimes in chronic obstructive lung
diseases such as emphysema and chronic bronchitis.

Artificial Ventilation
Pocket face mask with supplemental oxygen
Two-rescuer bag-valve mask with supplemental oxygen
One-rescuer bag-valve mask with supplemental oxygen
Flow-restricted, oxygen-powered ventilation device (FROPVD)
Ensure chest rise and fall.
Rate of 12 breaths per minute for adults
o 20 breaths per minute for children
Monitor for a return to normal pulse rate and improved skin color.

BVM
BVM with reservoir and 15 lpm of oxygen# patient receives 90100% of
oxygen
BVM without reservoir and 15 lpm of oxygen # patient receives 4550% of
oxygen.
BVM without oxygen # patient received 21% of oxygen.

Nasal Cannula
1 lpm24 percent
2 lpm28 percent
3 lpm32 percent
4 lpm36 percent
5 lpm40 percent
6 lpm44 percent

Supplemental Breathing
Provide for patients with adequate respirations.
Deliver oxygen through
o Nonrebreather mask (12 to 15 liters per minute)
o Nasal cannula (2 to 6 liters per minute).
Carefully monitor to ensure that ventilations are adequate.

Patient Interview
Conduct after initiation of oxygen therapy.
Use OPQRST and SAMPLE as guides for questions.
o OOnset. When did it begin?
o PProvocation. What were you doing when this came on?
o QQuality. Can you describe the feeling you have?
o RRadiation. Does the feeling seem to spread to any other part of
your body? Do you have pain or discomfort anywhere else in your
body?
o SSeverity. On a scale of 1 to 10, how bad is your breathing trouble?
! (10 is worst, 1 is best.)
o TTime. How long have you had this feeling?
If patient has difficulty breathing, use family/friends to help with answers.
Medications that the patient takes may influence treatment options.

Prescribed Inhaler
Inhalers contain a drug that dilates, or enlarges, the air passages, making breathing easier.
Medication name:
o Generic: albuterol, isoetharine, etc.
o Trade: Proventil, Ventolin, Alupent, etc.
Act immediately in an emergency to reverse airway constriction
o E.g. Ventolin, Proventil, albuterol.
Not for use in emergencies; used daily to help reduce inflammation and
prevent attacks
o Beclomethasone, Advair # should not be used to reverse an acute
attack or in the event of breathing difficulty.
Indications:
Signs/symptoms of breathing difficulty
Prescribed by physician
Specific authorization by medical direction
Patient must meet all criteria.

Contraindications:
Inability of patient to use device
Inhaler not prescribed
No permission from medical direction
Patient has used maximum dose

Medication form:
Metered-dose inhaler

Dosage:
Number of inhalations based on physician order

Actions:
Beta agonist
Dilates bronchioles
Reduces airway resistance

Side effects:
Increased pulse rate
Tremors
Nervousness

Note:
Check the expiration date.
Make sure the patient is alert and able to use device.
Be sure inhaler is at room temperature or warmer.
Determine if patient has already used inhaler and the number of times it has
been used.

Step by Step Instructions
1. This permission from medical direction may be by phone/radio or by standing order,
depending on your local protocols.
2. Check the medication to assure it is for the patient, it is the correct medication for the
problem, and that it has not expired.
3. Shake the inhaler vigorously for at least 30 seconds.
4. Instruct the patient to then exhale slowly through pursed lips.
5. Instruct the patient to inhale deeply, and, as they do so, depress the canister.
6. Remove inhaler and instruct the patient to hold their breath for 10 seconds
a. (or as long as possible).
7. Replace the oxygen to the patient. Reassess the breathing status and vital signs.

Spacer devices make the exact timing necessary to use an inhaler less critical.
The inhaler is activated into the spacer device (sometimes called an
Aerochamber). The medication stays airborne inside the chamber and can
then be inhaled directly into the lungs.

Small-Volume Nebulizer
The medications used in metered-dose inhalers can also be administered by
small-volume nebulizer (SVN).
produces a continuous flow of aerosolized medication that can be taken in
during multiple breaths over several minutes, giving the patient a greater
exposure to the medication.

Cardiac Emergencies

The human heart is a muscular organ located in the center of the thoracic cavity.
The heart has four chambers: two upper chambers called atria and two lower
chambers called ventricles. The atria both contract at the same time. When
they contract, blood is forced into the hearts lower chambers, the ventricles.
Both ventricles contract simultaneously to pump the blood out of the heart.
one-way valve to prevent blood in the ventricle from being forced back up
into the atrium when the ventricle contracts.
o The pulmonary artery has a one-way valve so that blood in the artery
does not return to the right ventricle.
o The aorta also has a one-way valve to prevent backflow to the left
ventricle.

Four Chambers of the heart
Right atrium.
The venae cava (the superior vena cava and the inferior vena cava) are the
two large veins that return blood to the heart. The right atrium receives this
blood and, upon contraction, sends it to the right ventricle.
Tricuspid valve# prevents backflow

Right ventricle.
The right ventricle receives blood from the chamber above it, the right atrium.
When the right ventricle contracts, it pumps this blood out to the lungs via the
pulmonary arteries.
o Tricuspid will close from added pressure (preventing backflow)
blood is very low in oxygen and is carrying waste carbon dioxide that was
picked up as the blood circulated through the body. While this blood is in the
lungs, the carbon dioxide is excreted (taken out of the blood and when the
person exhales, carried out of the body), and oxygen is obtained (taken into
the blood from air the person has inhaled). The oxygen-rich blood is now
returned to the left atrium via the pulmonary veins.

Left atrium.
The left atrium receives the oxygen-rich blood from the lungs. When it
contracts, it sends this blood to the left ventricle.
o Bicuspid valve

Left ventricle.
The left ventricle receives oxygen-rich blood from the chamber above it, the
left atrium. When it contracts, it pumps this blood into the aorta, the bodys
largest artery, for distribution to the entire body.
o Since the blood must reach all parts of the body, the left ventricle is
the most muscular and strongest part of the heart.

Cardiac Conduction System: The contraction, or beating, of the heart is an automatic,
involuntary process.).
Regulation of rate, rhythm, and force of heartbeat comes, in part, from the
cardiac control centers of the brain. Nerve impulses from these centers are
sent to the pacemaker and conduction system of the heart. These nerve
impulses and chemicals (epinephrine, for example) released into the blood
control the hearts rate and strength of contractions.

The Conduction System
Sinoatrial node
Site of impulse formation
Internodal tracts provide impulse transmission across
both atria and also to the AV node
Intrinsic rate 60100 bpm
Atrioventricular node
Temporarily slows impulse before it reaches the
ventricles
Bundle of His
Connects the AV node to the bundle branches
Right and left bundle branches
Transmit the impulse from the AV node to each of the two ventricles
Purkinje fibers
Terminal portion of the conduction system that provides the electrical impulse
to the contractile cells of the ventricles
This allows organized contraction of the ventricles.
Intrinsic rate less than 20 bpm

Coronary Arteries
branch off from the aorta and supply the heart muscle with blood. Although
the heart has blood constantly moving through it, it receives its own blood
supply from the coronary arteries.
Damage or blockage to these arteries usually results in chest
pain.
Important to note are the coronary arteries, which are the first arteries to arise
from the aorta, and provide perfusion to the myocardium.
Partial or full occlusion of these arteries is what precipitates cardiovascular
compromise in patients.
When the heart does not receive a constant supply of oxygenated blood, cells
begin to malfunction or cease to function.

Vessels of Circulation: Blood vessels are described by their function, location, and
whether they carry blood away from or to the heart.
Artery: vessel that carries blood away from the heart
o Arteries begin with large vessels, like the aorta. They gradually branch
to smaller and smaller vessels.
! The smallest branch of an artery is called an arteriole.
Capillaries are tiny blood vessels found throughout the body
o where gases, nutrients, and waste products are exchanged between the
bodys cells and the bloodstream. From the capillaries the blood
begins its return journey to the heart by entering the smallest veins.
! these small veins are called a venule.
Vein: vessel that carries the blood from the capillaries back to the heart is
called
o . From the venules, the veins get gradually larger, eventually reaching
the venae cava.

Cardiac Compromise : is a blanket term that refers to any
kind of problem with the heart.

Atherosclerosis is a build-up of fatty deposits on the inner walls of arteries.
This build-up causes a narrowing of the inner vessel diameter, restricting the
flow of blood.
o Fats and other particles combine to form this deposit, known as
plaque. As time passes, calcium can be deposited at the site of the
plaque, causing the area to harden.
Arteriosclerosis is a stiffening or hardening of the artery wall resulting from
calcium deposits. Often called hardening of the arteries, this condition
causes the vessel to lose its elasticity, changing blood flow and
increasing blood pressure.
Aneurysm: from weakened sections in the arterial walls. Each weak
spot that begins to dilate (balloon)
o weakened section of an artery bursts, there can be rapid, life-
threatening internal bleeding.
o Tissues beyond the rupture can be damaged because the
oxygenated blood they need is escaping and not reaching them.
o If a major artery ruptures, death from shock can occur very quickly.
When an artery in the brain ruptures, a severe form of stroke occurs.
The severity is dependent on the site of the stroke and the amount of
blood loss.

Causes of Cardiac Compromise
Electrical Malfunctions of the Heart: generally result in a dysrhythmia, an
irregular, or absent heart rhythm
o Bradycardia : Less than 60 beats per minute
o Tachycardia : Greater than 100 beats per minute
o No pulse :Cardiac arrest
Mechanical Malfunctions of the Heart
o can lead to cardiac arrest, shock, pulmonary edema or congestive heart
failure.
o A lack of oxygen has caused the death of a portion of the myocardium.
The dead area can no longer contract and pump. If a large enough area
of the heart dies, the pumping action of the whole heart will be
affected.
Angina pectoris means, literally, a pain in the chest.
o narrowed the arteries that supply the heart. During times
of exertion or stress, the heart works harder. The portion
of the myocardium supplied by the narrowed artery
becomes starved for oxygen. When the myocardium is
deprived of oxygen, chest painangina pectorisis the
most frequent result. This pain is sometimes called an
angina attack.
acute myocardial infarction (AMI): portion of the
myocardium (heart muscle) dies as a result of oxygen starvation
o AMI is brought on by the narrowing or occlusion of the
coronary artery that supplies the region with blood.
Rarely, the interruption of blood flow to the
myocardium may be due to the rupturing of a coronary
artery (aneurysm).
2#.3%$),4% 5%6*) 76,"0*%8 left ventiicle cannot effectively pump
o The signs anu symptoms:
! Naikeu oi seveie uyspnea (shoitness of bieath)
! Tachycaiuia (iapiu heait iate gieatei than 1uu bpm)
! Bifficulty bieathing when supine (oithopnea)
! Suuuenly waking at night with uyspnea (paioxysmal
noctuinal uyspnea)
! Fatigue on any type of exeition
! Anxiety
! Tachypnea (iapiu iespiiatoiy iate)
! Biaphoiesis (sweating)
! 0piight position with legs, feet, aims, anu hanus uangling
! Cool, clammy, pale skin
! Chest uiscomfoit
! Cyanosis
! Agitation anu iestlessness uue to the hypoxia
! Euema (swelling) to the ankles, feet, anu hanus
! Ciackles anu possibly wheezes on auscultation
! Becieaseu Sp02 ieauing
! Signs anu symptoms of pulmonaiy euema
! Bloou piessuie may be noimal, elevateu, oi low
! Bistenueu neck veinsjugulai venous uistension (}vB)
(late)
! Bistenueu anu soft, spongy abuomen


Signs and Symptoms of Cardiac Compromise
Difficulty breathing (dyspnea)
Nausea, vomiting
Anxiety/feeling of impending doom
The elderly, diabetics, and female patients may not experience chest pain or
discomfort in cardiac compromise. Weakness and difficulty breathing are
more common symptoms.
Cool, pale skin
Dizziness
Sweating
Abnormal heart rates
Tachycardiafaster than 100 bpm
Bradycardiaslower than 60 bpm
Abnormal blood pressures

Automated External Defibrillation # only if theyre pulseless
Many EMS systems have resuscitated patients with AEDS (automated external
defibrillators)
The highest survival rates occur in systems with strong links in the chain of survival
Extremely accurate

Types of AEDs:
Semi automatic/shock advisory
o Computer in AED analyzes rhythm and advises EMT to deliver shock
Fully automatic
o EMT turns on power and attached to patient; shock delivered
automatically if needed
Monophasic:
o sends single shock (energy current) from one pad to the other
Biphasic:
o sends shock in both directions, measures resistance and adjusts energy
o Causes less damage to heart muscle

Inappropriate Shock
Very rarely does the AED computer make a mistake
AED related errors are almost always human error due to
o Touching the patient during analysis
o Not stopping the ambulance to analyze rhythm

Shockable Rhythm
AEDs will shock two rhythms
o Ventricular fibrillation
! Up to 50% of cardiac arrest patients
o Ventricular tachycardia

Shock or Compression First?
When the response time is greater than 4 to 5 minutes, it is appropriate to do 2 minutes of
CPR (about 5 cycles) prior to analyzing and administering the first shock.
It is appropriate to re-prime the pump by doing CPR for 2 minutes. If you come on the
scene and a citizen or other provider is already doing high-quality compressions, you can
count that effort toward the first 2 minutes and proceed with applying the AED.

Witnessed arrest
Do not delay defibrillation to perform CPR.
Defibrillation is the top priority!
Unwitnessed arrest
Do not delay CPR to perform defibrillation.
CPR is the top priority!

Call ALS because paramedics can do a better job by inserting IVs, getting
medication.etc.

Additional Safety Consideration
Water
o Dry patients chest. Remove from wet environment
Metal
o Ensure no one is touching any metal that the patient is in contact with
Medication patch
o If patch is visible on chest, remove it with gloved hands before
delivering shock

Diabetic Emergencies & Altered Mental Status

Diabetes Mellitus: The condition brought about by decreased insulin production, or the
inability of the body cells to use insulin properly (which prevents the bodys cells from
taking the simple sugar called glucose from the bloodstream)
Insulin allows sugar to pass from the bloodstream to the bodys cells
o Glucose, a form of sugar, is the bodys
basic source of energy. The sugars that a
person eats are converted into glucose,
which is then absorbed into the
bloodstream.
o To enter the cells, insulin, a hormone
produced by the pancreas, must be present.
Without insulin, the cells can be surrounded
by glucose but still starve for this sugar.

Noimal ulucose Regulation

Biabetes is tieateu with injections oi oial meuication

9-1% : &,6;%)%$: also iefeiieu to as insulin-uepenuent uiabetes mellitus (IBBN),
since these patients aie iequiieu to inject insulin to iegulate theii bloou glucose
levels.
patient's pancieas usually uoes not seciete any insulin.
o most commonly unuei the age of 4u
o The patients aie typically lean fiom weight loss. Theii bloou
glucose levels aie extiemely high if untieateu.

9-1% :: &,6;%)%$: also iefeiieu to as non-insulin-uepenuent uiabetes mellitus
(NIBBN)
patients usually uo not have to inject insulin.
iegulate theii uiet anu exeicise anu take oial uiugs to help the pancieas
seciete moie insulin oi to make the insulin that is secieteu moie effective
in facilitating movement of glucose into the cells.

<,6;%),! =+%*3%.!,%$

Hypoglycemia: (low blood sugar) a life-threatening emergency for people with diabetes.
Causes:
o After taking too much insulin
o Vomiting # no food going in
o After unusual amount of exercise
o Reduced sugar intake caused by not eating
Signs and Symptoms:
o Rapid onset
o Intoxicated appearance, staggering, slurred speech, unconsciousness
o Cold, clammy skin
o Rapid heart rate
o Seizures (severe cases)
o Unusual or bizarre behavior
o Anxiety
o Refusal to cooperate or combativeness

Hyperglycemia : (high blood sugar) is a slow-onset condition from decreased insulin
levels in people with diabetes.
Causes:
o Forgotten or insufficient insulin dose
o Infection
o Stress
o Increased dietary intake
Signs and Symptoms
o Slow onset
o Nausea/vomiting
o Acetone odor on breath
o Increased urination/hunger/thirst

Distinguishing the Difference
Hypoglycemia:
o Rapid onset
o Skin is cold, pale, moist, or clammy.
o No breath odors
Hyperglycemia:
o Slow onset
o Skin is warm, red, or dry.
o Acetone odor on breath
o Increased urination/hunger/ thirst
o Abdominal cramps

Assessing Diabetic Emergencies
Perform initial assessment
o ABCs
! Maintain airway.
! Administer oxygen.
Perform focused history and physical exam.
o When and how did it start?
o How long did it last?
o Complaints of other symptoms?
o Any trauma involved?
o Any medical alert tags?
o Has the patient seized?
o Fever?
o Interruptions in episode?
Get SAMPLE history.
o Note any medical alert tags.
If the patient has a history of diabetes:
o When did patient last eat?
o Any medications? Last taken?
o Any other illnesses?
o Can the patient swallow?
Take baseline vital signs.
Give oral glucose if all of these conditions are met:
o History of diabetes
o Altered mental status
o Patient can swallow
If patient becomes unconscious, stop glucose administration immediately and
secure the airway!
If no improvement, consult medical direction.
If patient is not awake enough to
swallow:
o Secure airway.
o Administer oxygen.
o Position appropriately.
o Request ALS and transport.

Blood Glucose Meters
80120 mg/dl Normal
6080 mg/dl Moderate hypoglycemia
Below 50 mg/dl Severe hypoglycemia
Above 120 mg/dl Hyperglycemia
Question results that are inconsistent with patients condition.

Using Blood Glucose Meter and Test Strip
Prepare the device including a test strip and lancet.
Use an alcohol prep to cleanse the patients finger.
After allowing the alcohol to dry, use the lancet to perform a
finger stick on the patient. Wipe away the first drop of blood
that appears.
Apply the blood to the test strip.
The blood glucose meter analyzes the sample and provides a
readingusually in less than a minute.

Causes of Inaccurate Readings:
Meter not calibrated
Low batteries in meter
Improperly stored or expired test strip
Insufficient blood on test strip

Administration of Oral Glucose
Squeeze glucose onto tongue depressor
Insert Tongue Depressor between the Patients Cheek and Gum

Indications:
Ability to swallow

Contraindications:
Unconsciousness
Diabetic who has not taken insulin for days
Inability to swallow

Dosage: one tube
Actions: Increases blood sugar
Side effects:
None when given properly
May be aspirated if given to patient without gag reflex

Reassessment strategies:
If patient seizes or loses consciousness, remove tongue depressor and secure
airway.

Altered Mental Status

Causes:
Hypoglycemia
Poisoning (including alcohol and drugs)
Infection
Head trauma
Hypoxia

Emergency Care:
Secure airway.
Ventilate and suction as needed.
Transport.
Evaluate potential causes.

Seizures
Sudden change in sensation, behavior, or movement caused by irregular electrical activity
of the brain

Causes:
Toxin: Drug or alcohol use, abuse, or withdrawal
Brain tumor
Congenital brain defects
Trauma: Head injuries can cause seizures, as can scars formed at the site of
previous brain injuries.
Infection/fever: Swelling or inflammation of the brain caused by an infection
can cause seizures.
o (#1 cause in pediatric patients 6 months to 3 years old)
Metabolic: Seizures can be caused by irregularities in the patients body
chemistry (metabolism).
Epilepsy
Stroke
Hypoglycemia
Eclampsia (complication of pregnancy)
Hypoxia: lack of oxygen
Heat stroke

Information to Obtain
What was the patient doing before the seizure?
What movements were exhibited?
Loss of bladder or bowel control?
What did the patient do after the seizure?
Length of episode?

Emergency Care:
Place patient on floor.
Position patient on side.
Loosen restrictive clothing.
Remove harmful objects.
Protect patient from injury; do not hold patient still or place anything in
mouth.

After seizure subsides:
o Protect airway with positioning and suction.
o If cyanotic, ventilate with oxygen.
o Treat injuries.
o Transport.

Simple Partial Seizure: there is tingling, stiffening, or jerking in just one part of the
body.

Complex Partial Seizure: also called psychomotor or temporal lobe, characterized by
abnormal behavior that varies widely from person to person.

Generalized Seizure: In a tonic-clonic (also called grand mal) seizure, there is often no
aura or other warning. This type of seizure is characterized by unconsciousness and major
motor activity. Convulsion usually lasts only a few minutes and has three distinct phases:
Tonic phase. The body becomes rigid, stiffening for no more than 30 seconds.
Breathing may stop, the patient may bite his tongue (rare), and bowel and
bladder control could be lost.
Clonic phase. The body jerks about violently, usually for no more than 1 or 2
minutes (some can last 5 minutes). The patient may foam at the mouth and
drool. His face and lips often become cyanotic.
Postictal phase. This begins when convulsions stop. The patient may regain
consciousness immediately and enter a state of drowsiness and confusion, or
he may remain unconscious for several hours. Headache is common.

Absence Seizures: brief(usually only 1 to 10 seconds) There is no dramatic motor
activity and the person usually does not slump or fall. Instead there is a temporary loss of
concentration or awareness.
A child may suffer several hundred absence seizures a day, severely
interfering with his ability to pay attention and do well in school

Status Epilepticus: A life-threatening condition in which the patient has two or more
convulsive seizures without regaining consciousness or lasting more than 5 minutes
Emergency Care:
o Secure the airway.
o Ventilate with 100% oxygen.
o Request ALS.
o Transport immediately.

Stoke
Death or injury of brain tissue that is deprived of oxygen
Caused by a blockage (ischemic) or bleeding (hemorrhagic) of a blood vessel in
the brain
ischemic stroke : caused by blockage of an artery that supplies blood to
part of the brain or bleeding from a ruptured blood vessel in the brain.
It can occur when a clot or embolism occludes an artery or as the
result of atherosclerosis.
hemorrhagic stoke: caused by bleeding into the brain is called.
result of longstanding high blood pressure (hypertension). It also
can occur when a weak area of an artery (an aneurysm) bulges out
and eventually ruptures, forcing the brain into a smaller than usual
space within the skull.
Signs and Symptoms
Intoxicated appearance, slurred speech, unconsciousness
Severe headache, vision changes
One-sided weakness on body
Confusion
Loss of bladder/bowel control
Unequal pupils
High blood pressure

Transient Ischemic Attack (ITA): Mini-stroke
Signs and symptoms of a stroke
Often resolved before EMS arrival
Symptoms resolve without treatment in less than 24 hours
Significant risk of having a full stroke

Treatment:
Prompt transport is critical.
Identify potential stroke patients and notify the hospital.
Maintain airway; administer oxygen.

Cincinnati Prehospital Stroke Scale:
1. Have patient attempt to smile.
2. Have patient attempt to hold arms straight in front of her for 10 seconds.
o A normal response is for the patient to move both arms at the same
time.
o An abnormal response is for one arm to drift down or not move
at all.
3. Evaluate patients speech.
o like slurred speech, the wrong words, or no speech at all.

Presence of any one sign indicated 72% probability of stroke
Presence of all three signs indicates an 85% probability of stoke

Dizziness and Syncope
Syncope is a brief loss of consciousness.
It can occur at any age; more common in elderly.
It may be an indicator of a serious medical problem.

Causes:
Hypovolemia: or low fluid/blood volume, can cause dizziness or syncope
when the patient attempts to sit up or stand.
o Trauma
o Dehydration
Metabolic: something is wrong w/ the brain or the structures near it
o Hypoglycemia
o Stroke
o Seizure
Environmental/toxicological: imbalances can lead to alterations in
consciousness.
o Alcohol/drugs
o Carbon monoxide
o Panic/anxiety
Cardiovascular
o Fast or slow heart rates
! A dysrhythmia that results in the heart beating extremely fast (a
tachycardia) can lead to either dizziness or syncope.
o Electrical system disturbance
o Vagus nerve stimulation

Assessment
Obtain a SAMPLE history.
Ask about onset time, activities.
Length of episode?
Any previous episodes?

Treatments
Any medications for this condition?
Any nausea/vomiting/bowel changes?
Administer high-concentration oxygen.
Loosen restrictive clothing.
Lay patient flat and elevate legs (if no suspected spinal injury).
Treat any associated injuries.
Request ALS and transport.

Allergic Reactions

Identifications
Identification of an allergic reaction
Mild allergic reaction versus anaphylaxis
Treatment of an allergic reaction
Identification of candidates for epinephrine auto-injection
Documentation of findings and treatment

Allergic Reaction:
An exaggerated reaction of the human bodys immune system to any foreign substance

Allergen: Something that causes an allergic reaction

Anaphylaxis:
A life-threatening allergic reaction that causes shock (hypoperfusion) and airway
swelling
Referred to as anaphylactic shock

Auto-Injection:
Epinephrine carried by individuals who are subject to severe allergic reactions
Spring-loaded needle and syringe with a single dose of epinephrine
Automatically releases and injects the medication through the skin when the
device is pressed firmly against the body

Epinephrine: A hormone produced by the body that constricts blood vessels and dilates
respiratory passages

Causes of Allergic Reactions: insect stings, plants, medications, foods, etc.

Signs and Symptoms:
Skin:
o Itching
o Hives
o Flushing
o Swelling
o Warm
Respiratory:
o Tightness in throat
o Rapid breathing
o Cough
o Labored breathing
o Hoarseness
o Stridor

Generalized Findings:
Cardiac
o Increased heart rate
o Decreased heart rate
Itchy, watery eyes
Headache
Runny nose
Sense of impending doom

Signs and Symptoms of Shock
Flushed, dry, clammy, or pale skin
Nausea or vomiting
Changes in vital signs (pulse, respirations, blood pressure)

Mild allergic reaction or Anaphylaxis
Perform initial assessment.
Perform focused history and physical exam.
Look for itching, hives, respiratory distress, or signs of hypoperfusion.
Assess baseline vitals and get SAMPLE history.

Treatment
Manage airway and breathing.
High-concentration oxygen by Nonrebreather
Positive pressure ventilations
Consider assisting with epinephrine auto-injector IF:
Signs and symptoms of shock are present.
Patient is prescribed auto-injectorconsult medical direction.
No auto-injector availablerapid transport or call for ALS intercept.

Epinephrine Auto Injection (Epi pen)
Self-administered Epinephrine :prescribed by physician.
Authorization: administer or help patient

When to Administer:
Respiratory distress
Signs and symptoms of shock (hypoperfusion)
Signs of allergic reaction
Physician has prescribed epinephrine to patient
Medical direction authorizes epinephrine

Dosage:
Adult: one auto-injector
Child: one pediatric auto-injector

What to look for:
Injector prescribed for THIS patient?
Expiration date
Liquid cloudy or discolored?
Give epinephrine ONLY to patients that have been prescribed auto-injectors

Procedure:
Check liquid to make sure it is clear.
Remove cap.
Press injector firmly against patients thigh
o (outside of thigh, midway between waist and knee).
Not necessary to remove clothing prior to administration
Follow your local protocols.

Action of Epinephrine:
Dilates bronchioles:
Constricts blood vessels.

Protocol
Has to be a severe allergic reactions, either respiratory distress or shock
Medication is prescribed for the patient by a physician
Medical direction authorizes use for this patient

Side Effects:
Increased heart rate
Pallor and dizziness
Chest pain
Headache, excitability, and anxiety
Nausea and vomiting

Reassessment Strategies:
If patients condition WORSENS:
o Consult medical direction.
o Treat for shock.
o Be prepared to use CPR/AED.
If patients condition IMPROVES:
o Continue oxygen.
o Treat for shock (hypoperfusion).

OBGYN
Care of the mother before delivery

Anatomy:
Fetus-developing baby
Uterus-a muscular organ also called the womb
Cervix- the neck of the uterus
Vagina- canal
Placenta- attached to the wall of the uterus and is composed of maternal and
fetal tissues

Blood from the fetus is sent through blood vessels in the umbilical cord to the placenta
where the blood picks up nourishment from the mother, then returns through the
umbilical cord to the fetus body. The fetus is enclosed and protected within a thin,
membranous bag of waters known as the amniotic sac.
Amniotic fluid serves as a cushion. As the child develops, child ingests some
amniotic fluid.

Stages of Pregnancy
1st trimester (1st3rd months)
o Fetus is being formed
2nd trimester (5th month)
o Uterus grows rapidly, reaching the umbilicus
3rd trimester (7th month)
o Uterus now reaches the epigastrium

Types of Presentation
Cephalic # normal, head first birth
Breech # buttocks or both feet deliver first

Stages of Labor

The first stage of labor is also called the dilation period. Picture the uterus as a long-
neck bottle. In order to expel the contents, the neck of the bottle must be stretched to the
size of a wide-mouth jar. Before the cervix can fully dilate, the long neck of the cervix
must be shortened and thinned (this process is called effacement) to the wide-mouth-jar
shape.

A and B) beginning of contractions to full cervical dilation.
Cervix expands until head can pass through
c)baby enters birth canal and is born
d) delivery of the placenta

Labor Pains:
Ache in lower backs
Pain in lower abdomen, with increased intensity
Regular intervals
o Lasting from 30 seconds to 1 minute
o Occurring at 2-3 minute intervals

Delivery

Equipment:
Surgical gloves, scissors
Towels, sheets, baby blanket
Gauze pads
Sanitary napkins
Towel or plastic bag
Sterile disposable gloves, eye wear

Pre-delivery Evaluation
Name, age, due date?
First pregnancy?
Contractions or pain? Onset?
Bleeding or discharge?
o meconium staining: Fluid that is greenish or brownish-yellow in color
may be an indication of maternal or fetal distress during labor
Crowning? (do you see the babys head?)

Evaluation of Labor Pains
Contraction time, or durationthe time from the beginning of contraction to
when the uterus relaxes (from start to end).
Contraction interval, or frequencythe time from the start of one contraction
to the beginning of the next (from start to start).
o When contractions last 30 seconds to 1 minute and are 2 to 3 minutes
apart, delivery of the baby may be imminent.
Feel the urge to move bowels
Feel the need to push
Rock hard abdomen

Transport Decision
Based on assessment
o Birth imminent if contractions less than 2 minutes apart
o crowning
Numbers of prior births
Distance to hospital
Note: make sure shes on her left side with pillows
o Baby and mother must be in same ambulance

Supine hypotensive syndrome
Dizziness and drop in blood pressure
Referred to as vena cava compression syndrome
Decreased blood return leads to drop in blood pressure and shock

Treatment of hypotension
Transport on left side: counteract or avoid the possible drop in blood pressure,
all third-trimester patients should be transported on their left side
Pillow or rolled blanket behind back should be placed behind the back to
maintain proper positioning.

Preparing for Delivery
Patient privacy
Position mother on bed, floor, or ambulance
stretcher
Remove clothing
Position your assistant
Position equipment near patient (OB
kit #
If you are not in a private room and
transfer to the ambulance is not
practical (crowning is present), ask
bystanders to leave
There is a high probability of
splashing blood and other body fluids
during delivery. Have the mother lie
with knees drawn up and spread apart

Delivering the Baby
Encourage her to relax between contractions.
Continue to time her contractions from the beginning of one contraction to the
beginning of the next.
Keep someone at the mothers head to provide support, and monitor vital
signs, and be alert for vomiting.
If no one is on hand to help, be alert for vomiting and check vital signs
between contractions.

Normal Delivery:
Position your gloved hands at the mothers vaginal opening when the babys
head starts to appear. Do not touch the area around vagina except to assist
with delivery.
Place one hand below the babys head as it delivers.
o Spread your fingers evenly, remembering that the skull contains soft
spots, or fontanelles.
If the amniotic sac has not broken by the time the babys
head is delivered, use your finger to puncture the membrane.
Do not pull on baby

Checking for Umbilical Cord
Once the head delivers, check to see if the umbilical cord is wrapped
around the babys neck. Tell the mother not to push while you check.
Then gently loosen the cord if necessary.
If the cord is wrapped around the babys neck, try to place
two fingers under the cord at the back of the babys neck. Bring the cord
forward, over the babys upper shoulder and head.
o If you cannot loosen or slip the cord over the babys head, the baby
cannot be delivered.
So immediately clamp the cord in two places using the clamps provided in the
obstetric kit. Gently unwrap the ends of the cord from around the babys neck,
and then proceed with the delivery.

Delivery Steps: babys coming out
Check airway. Most babies are born face down and then rotate to the right or
left. Support the babys head. Continue to support the head with one hand and,
with the other hand, wipe the mouth and nose with sterile gauze pads. Use the
rubber bulb syringe to suction the babys mouth, then the nose. Compress
the syringe BEFORE placing it in the babys mouth.
The upper shoulder (usually with some delay) will deliver next, followed
quickly by the lower shoulder. (assist with upper shoulders)
Support the trunk
Support the torso and legs
Note: Remember that newborns are very slippery. Once the feet are delivered,
lay the baby on his side with his head slightly lower than his body

Delivery Steps: Once the feet are delivered, lay the baby on his side with his head
slightly lower than his body.
Wipe blood and mucus from nose and mouth
Suction again
Warmth is critical (can rub the back)
Wrap baby in warm towel, head lower than trunk

Post Delivery
Try to keep the baby on the same level as mother
Wait for umbilical cord to stop pulsating
Clamp and cut umbilical cord
Note exact time of birth

Cutting the Umbilical Cord
Infant warm
Sterile clamps or umbilical tape
1st clamp 3 inches from mother
2nd clamp 7 inches from baby
Cut between clamps

Care of the newly born

-within the first 30 seconds the baby you start to cry
-babies may appear cyanotic at first but will pink up within 30 seconds
if not, follow blow by blow enriched oxygen
if not, then bag mask ventilation
if not working, Chest compressions


Assessmentnewly born
Breathing, heart rate, crying, movement, skin color
Pulse greater than 100 bpm
o If less than 60, begin CPR
Vigorous crying
Moving extremities
Blue coloration hands and feet ONLY
Reassess after 5 minutes: these signs should still be apparent, with breathing
becoming more relaxed. The blue coloration may or may not disappear, but it
should not spread to other parts of the body

Resuscitation-Newly Born
Warmth and clear airway
Suction (using bulb syringe)
Establish breathing
Assess heart rate, respirations and color

Respirations
Newborn should begin breathing within 30 seconds
Provide only small puffs of air if using mouth to mask
Rate of 40 to 60 breaths per minute
Adequate respirations and a pulse rate greater than 100 per minute
Supplemental oxygen

Heart Rate
Heart rate less than 100 beats per minute
o Ventilate at a rate of 40 to 60 per minute
o 1 every 3 seconds
Heart rate is less than 60 beats per minute
o Initiate chest compressions
Rate of 120 compressions per minute
3:1 ratio of compressions to respirations
90 compressions and 30 ventilations per minute

Stimulation
Gentle but vigorous rubbing of the babys back
It is not uncommon for this blue color to remain for the first few minutes

Cultural considerations
Be sensitive to various ethnic, cultural, and religious groups regarding child
birth
If possible, allow time for family to respond to birth

Care of the Mother After Delivery

Delivery of the Placenta: The third stage of labor is the delivery of the placenta with its
umbilical cord section, membranes of the amniotic sac, and some of the tissues lining the
uterus.
Labor pains
Lengthening of cord, which indicates the placenta, has separated from the
uterus.
Process may take longer than 30 minutes
Transport can be delayed
Observe for delivery of placenta
When placenta delivers, place in plastic bag for transport to hospital
o Place in a container and label
In most cases, the placenta will be expelled within a few minutes after the
baby is

Control Vaginal Bleeding
Place sanitary napkin over vagina. (Do not place anything in the vagina)
Position mothers legs lowered and together. Elevate her feet.
Massage the uterus
o Feel the mothers abdomen until you note a grapefruit-sized object.
This is her uterus. Rub this area lightly with a circular motion. It
should contract and become firm, and bleeding should diminish.
The mother may want to nurse the baby.
Treat torn perineum as a wound.

Childbirth Complications
Breech presentation
Prolapsed cord
Limb presentation
Multiple births
Premature birth
Meconium

Breech Presentation:
Most common abnormal delivery
Buttocks first or both legs first
Increased risk of prolapsed cord
Possible meconium staining

Patient Care:
Transport rapidly.
Never attempt to pull legs.
Provide high-flow oxygen.
Position mother in head-down position.
If body delivers, support it.
Provide care for baby, cord, mother, and placenta.

Prolapsed Cord: After the amniotic sac ruptures, the umbilical cord, rather than the
head, may be the first part presenting at the vaginal opening.
Position mother head down and buttocks raised using, gravity to lessen
pressure on the birth canal.
Provide high-concentration oxygen.
Check for pulses and wrap cord. (keep it warm)
Insert several fingers into vagina to
push up on babys head.
Transport.

Limb Presentation
Limb protrudes from vagina
Commonly a foot or arm
Cannot be delivered in prehospital
Rapid transport essential for survival

Assessment
look for crowning
arm or leg or both
shoulder and arm

Patient Care
Keep baby off cord
Transport mother
Mother in head down position
High flow oxygen
For a limb presentation, do not try to pull on the limb or replace the limb into
the vagina. Do not place your gloved hand into the vagina, unless there is a
prolapsed cord.

Multiple Births
More than one baby born during single delivery
Twins not considered complication
Call for assistance: you should have enough personnel and equipment to be
prepared for multiple resuscitations.

Assessment
Mother should be aware.
Abdomen appears unusually large.
Multiple contractions

Patient Care
Clamp of tie cord of 1
st
baby before the 2
nd
baby is born
2
nd
baby either before of after placenta
provide care

Premature Birth
Infant weights less than 5-1/2 lbs. (2.5 kgs)
Born before 37th week
Assessment
o Full term vs. premature
o Head is larger

Patient Care
Keep baby warm: Premature infants are at great risk of developing
hypothermia. Once breathing, the baby should be dried and wrapped snugly in
a warm blanket.
Keep airway clear
Provide ventilations, as needed
Watch for umbilical cord bleeding
o Examine the cut end of the cord carefully. If there is any sign of
bleeding, even the slightest, apply another clamp or tie closer to the
babys body.
Provide oxygen
Avoid contamination
Transport in warm ambulance

Meconium: earliest stools of an infant. Problem if child is covered in it.
Results from fetus defecating
Sign of fetal or maternal distress
Assessment
Amniotic fluid greenish or brownish-yellow
Risk for respiratory problems

Patient Care
Reduce risk of aspiration.
o (do not stimulate the infant before suctioning the oropharynx)
Suction mouth then nose.
Maintain open airway.
Provide ventilations and/or chest compressions.
Transport.

Emergencies in Pregnancy
Pre birth bleeding
Ectopic pregnancy
Seizures
Miscarriage and abortion
Trauma
stillbirths

Placenta previa
Placenta in abnormal position
Tearing of placenta
May occur in 3
rd
trimester
Life threatening to mother and baby

Abruptio Placentae
Placenta separates from uterine wall
Partial or complete
Life threatening
May occur in 3
rd
trimester
This is extremely painful
o Complaint of abdominal pain

Ruptured Uterus
As the uterus enlarges throughout pregnancy, the uterine wall becomes
extremely thin and is prone to spontaneous or traumatic rupture

Signs and Symptoms
Main sign-profuse bleeding
Associated abdominal pain
Shock
Rapid heartbeat may indicate significant blood loss.

Patient CareExcessive Bleeding
Signs of shock high concentration of oxygen
Sanitary napkin over vagina
Save tissue.

Ectopic Pregnancy
Normal pregnancyegg divides in the oviduct (fallopian tube)
Ectopic pregnancyegg implanted outside the uterus
o May be on the outside of fallopian tube or abdominal cavity
Acute abdominal pain
Vaginal bleeding
Rapid and weak pulse (later sign)
Low blood pressure (a very late sign)

Patient Care
consider the need for immediate transport
position the patient for shock
care for shock
nothing by mouth

Infants and Children

Developmental Characteristics
Newborns # birth-1 year
Toddlers # 1-3 years
Preschool # 2-6 years
School aged # 6-12 years
Adolescents # 12-18 years

Behavioral Traits

Newborns and Infants
birth # 1 year
Tolerate parental separation poorly
Exhibit minimal anxiety over presence of strangers
Accept undressing but want to feel warm
Can track movement visually (follows movement with eyes)
Do not tolerate oxygen masks
Have a parent hold the infant during the physical exam
Keep hands and tools warm
Observe breathing from a distance
Examine the head last
Listen to lungs (before child is upset)

1-3 years
Do not tolerate parental separation
Do not like to be touched
May perceive illness as punishment
Sensitive about modesty.
Easily frightened (i.e., by needles)
Have a parent hold the child during the physical exam.
Explain that the child was not bad.
If clothing is removed, replace it.
Try to examine the head last.
Explain what you do in advancebut use a childs terms.

Preschool (3-6 years)
Do not tolerate parental separation
Do not like to be touched
Sensitive about modesty (do not like their bodies exposed)
May perceive illness as punishment
Tend to fear blood, pain, and permanent injury or disfigurement.
Have a parent hold the child during the physical exam.
If clothing is removed, replace it.
Be calm, reassuring, and respectful.
Explain what you do in advance.
Allow the child to give the history.

School age (6-12 years)
Cooperative, but expect to have opinions heard
Sensitive about modesty (do not like their bodies exposed)
Tend to fear blood, pain, and permanent injury or disfigurement
Allow the child to give the history.
Explain as you examine.
Respect the childs modesty.

Adolescent (12-18 years)
Expect to be treated as adults
Generally act as though indestructible
May fear lasting disfigurement
Variable emotional and physical development may produce some insecurity
about self-image
Try to respect the emerging adult, yet reassure the remaining child.
Explain as you examine.
Respect the young adults modesty and need for privacy.

Anatomical Differences

Airway Differences
Small airways are more easily blocked.
Child's tongue is larger.
Infants are nose-breathers.
o Suctioning nasopharynx improves breathing significantly.
The trachea (windpipe) is softer and more flexible in infants and children.
The trachea is narrower and is easily obstructed by swelling or foreign
objects.
The chest wall is softer, and infants and children tend to depend more on their
diaphragms for breathing
Put childs head in neutral position, not hyperextended.
Children can compensate (breathe faster/harder) for a while, then get worse
rapidly.

Head
Bigger, softer: A childs head is proportionately larger and heavier than an
adults until about the age of 4
Infants and small children have disproportionately larger heads (until about
age 4). Note the effect of padding.
Fontanelles (soft spots) exist until about 1218 months old.
o Sunken fontanelles may indicate dehydration.
o Bulging fontanelles may indicate crying or head injury

Chest and Abdomen
Increased elasticity of chest
Primarily abdominal breathers (infants primarily nose-breathers)
Less protection than adults for internal organs

Body Surface
Larger in proportion to body mass making child more prone to heat loss
Increased risk of hypothermia
Burn injuries calculated differently

Blood Volume: the blood volume of a pediatric patient is less than the blood volume of
an adult.
A newborn does not have enough blood to fill a 12-ounce soda can, and an 8-
year-old has only about 2 liters of blood.
Therefore, a blood loss that might be considered moderate in an adult can be
life threatening for a child.

Assessment
Two methods:
Pediatric Assessment Triangle (PAT)
OR
Step-by-Step Assessment

Pediatric Assessment Triangle
is a method of pediatric assessment from two viewpoints.
from the doorway.
o Observe appearance:
! Mental status
! Body position/muscle tone
o Observe breathing effort.
o Observe circulation (skin color).
hands on - Provide interventions and assess for any further concerns.
o Appearance
o Breathing
o Circulation

Step by Step Assessment

General impression
Observe:
o Quality of cry or speech
o Emotional state
o Response to your presence
o Tone and body position
o Mental status
o Effort of breathing
o Skin color
Observe interaction with environment and parents:
o Normal behavior for age?
o Playing or moving around?
o Attentive?
o Eye contact?
o Recognize and respond to parents?

Initial Assessment
Airway # open? Adequate? Any steps needed to ensure it remains open?
Breathing
o Chest expansion and symmetry
o Effort of breathing
o Nasal flaring
o Retractions
o Rate
Respirations
o Look for crowing or noisy respirations, wheezing, stridor or grunting,
and equal expansion
o Rate

Approach to Evaluation
Assess circulation:
Pulse
o For assessment, check the radial pulse in a child, the brachial pulse in
an infant. For basic life support, check the carotid pulse in a child, the
brachial or femoral pulse in an infant In infants and children 5 years
old or younger
Capillary refill
Skin color, temperature, condition

Identify Priority Patients
Poor general impression
Unresponsive
Compromised airway (inadequate breathing)
Shock
Uncontrolled bleeding

Focused History
Child may be only source use simple yes/no questions
Use parents/guardians for information if possible

Detailed physical exam
Generally, start at trunk and evaluate head last
Alter order of steps to fit situation
Avoid making child more anxious

Ongoing assessment
Reassess interventions.
Reassess ABCs.
Reassess vital signs.
Continuous reassessment is key!

Technique of Pediatric Care

Opening the Airway: Use Head-Tilt, Chin-Lift Without Hyperextension

Suctioning:
Ensure small enough catheter.
Do not insert too deeply.
Suction as briefly as possible.

Sings of Partial Airway Obstruction
Stridor, crowing or noisy respirations
Retractions on inspiration
Pink mucous membranes and nail beds
Alert

Treating Partial Airway obstruction
Place in position of comfort
Administer high conc oxygen
Transport without agitating

Complete Airway Obstruction
No crying or speech
Initial difficulty breathing that worsens
Cough becomes week and ineffective
Altered mental status, unconsciousness

Clearing foreign body objects
Infants # back blows and chest thrusts
Children# abdominal thrusts

Oral Airways
Use correct size
Use tongue depressor to hold tongue down
Insert right side up

Nasal Airways
Use proper size
Do not use if facial or head trauma exists
Insertion technique same as for adult

Oxygen Therapy
Nonrebeather
Blow by technique # hold tubing 2 inches from face or insert tubing into
paper cup
o Not Styrofoam
Artificial Ventilation
o Use proper size mask and bag
o If trauma involved, use jaw thrust
o If unable to maintain mask seal with one hand, use two
Mouth to mouth ventilations
Bag valve mask
o Squeeze bag slowly/evenly until chest rises
o If under 8 years old, ventilate 20 times a minute
o If over 8 years old, ventilate 10-12 times a minute

Shock (hypoperfusion)
Causes:
o Diarrhea, vomiting, dehydration
o Trauma and blood loss
o Infection
o Abdominal injuries
Uncommon causes
o Allergic reactions
o Poisoning
o Cardiac problems
Signs
o Rapid breathing
o Pale cool clammy skin
o Weak/absent peripheral pulses
o Delayed capillary refill
o Decreased urine output
o Changes in mental status
o Lack of tears when crying

Treating Shock
Maintain airway & administer high-concentration oxygen.
Ventilate as needed.
Control bleeding.
Elevate legs.
Keep warm.
Transport.

Common Medical Problems

Respirator Emergencies
Upper airway obstruction : Stridor on inspiration
Lower airway disease: Wheezing and respiratory effort on exhalation OR
rapid breathing without stridor

Early Respiratory Distress
Nasal flaring
Stridor, wheezing
Retractions
o Between ribs (intercostal)
o Above clavicles (supraclavicular)
o Below ribs (subcostal)
Respiratory rate >60
Cyanosis
Decreased muscle tone
Excessive use of accessory muscles

Respiratory Arrest
Little or no muscle tone
Unconsciousness
Slow/absent pulse

Respiratory Emergencies
High-concentration oxygen
Ventilate if respiratory distress severe:
o Altered mental status
o Cyanosis not improving with oxygen
o Poor muscle tone
o Respiratory arrest

Croup
Viral inflammation of trachea and larynx
Usually affects ages 6 months to 4 years
Onset typically at night
Seal-like barking cough
Signs of respiratory distress

Treatment of Croup
Place in position of comfort.
Cool air may provide relief.
Transport.

Epiglottis
A life-threatening emergency!
Bacterial inflammation of epiglottis
Usually affects ages 3 to 7
Sudden onset of high fever
Tripod positioning
Painful swallowing and respiratory distress

Treatment of Epiglottis
Place in position of comfort.
Transport immediately.
Do not increase childs anxiety.
Do not place anything in patients mouth.

Fever
Variety of causes
Goal is to cool without causing hypothermia.
Be prepared for seizures.

Emergency Care of fever
Remove clothing.
Avoid hypothermia.
Transport.
If protocols allow:
o Cover with soaked towels.
o Allow small sips of water

Seizures
Should be considered life-threatening in children
May be brief or prolonged
May cause injuries
Causes:
o Fever
o Infection
o Poisoning
o Hypoglycemia
o Trauma
o Hypoxia
o Idiopathic (unknown cause)

Assessing seizures:
Has child had seizures before?
If yes, was this a typical seizure?
Anti-seizure medication taken?
Any fever?

Treatment of Seizures
Establish airway.
Position on left side if no spinal trauma.
Have suction ready.
Administer oxygen. Ventilate if needed.
Transport.

Altered Mental Status
Causes:
Hypoglycemia
Poisoning
Post-seizure
Infection
Head trauma
Hypoxia
Shock

Emergency Care of altered mental status
Establish airway.
Ventilate and suction as needed.
Consider spinal precautions.
Transport.

Poisoning: Emergency Care

Conscious patient
Contact medical direction.
Give activated charcoal as directed.
Administer oxygen.
Transport and monitor patient.

Unconscious patient
Rule out trauma.
Establish airway.
Administer oxygen; ventilate as needed.
Transport.
Contact medical direction.

Drowning: means that a patient has been submerged in water and has suffered either a
cardiac or a respiratory arrest.
If heart and respiratory function are not restored, it is a drowning. However, if the patient
has a return of pulse and/or breathing, even temporarily, it is a near-drowning.
Patients who have been submerged in cold water have been revived 30 minutes or more
after submersion
Ventilation is top priority.
Consider possibilities of trauma, hypothermia, and drug ingestion.
Transport.

Sudden Infant Death Syndrome
Sudden death without identifiable cause in infant <1 year old. Cause is not well
understood. Most common time of discovery is early morning.

Emergency Care:
Try to resuscitate unless rigor mortis is present.
Avoid comments that blame parents.
Expect parents to feel remorse and guilt.

Trauma

Blunt trauma
Motor vehicle crashes:
o Unrestrained passenger (neck and head injuries)
o Restrained passenger (abdominal and lower spine injuries)
Motor vehicle impacts
o Struck while riding bicycle (head, abdominal, spinal injuries)
o Pedestrian struck by vehicle (head, abdominal and femurs injuries)
Falls from height : neck and head injuries
Diving into shallow water : head and neck injuries
Sports injuries
Child abuse

Specific types of injuries:
Head (common injury area)
o Airway maintenance critical
o Can result in respiratory arrest
o Nausea and vomiting very common
Chest
o Childrens ribs less rigid and more pliable
o Result in injury to internal organs without external wounds
Abdomen
o More common injured in children than adults
o May be subtle and difficult to detect
o Air in stomach may cause gastric distention or impede breathing
Extremities
o Managed the same as for adults

Trauma: other considerations
Pneumatic anti shock garment
o Use only if:
! Child fits garment
! Trauma with hypoperfushion and pelvic instability
! Do not inflate abdominal compartment
Burns
o Cover with sterile dressing
o Follow local protocol with regard to transport to burn center

Child abuse and neglect
Abuse: improper or excessive action so as to injure or cause arm
Child abuse can take several different forms, often occurring in combination.
These forms include:
o Psychological (emotional) abuse
o Neglect: Giving insufficient attention or respect to someone who has a
claim to that attention
o Physical abuse
o Sexual abuse

Signs of abuse
Physical abuse and sexual abuse are the forms of child abuse EMT is most
likely to suspect.
EMT must be aware of condition in order to recognize it.
Multiple bruises in different stages of healing
o Slap marks, bruises, abrasions, lacerations, and incisions of all sizes
and with shapes matching the item used.
Injury not consistent with mechanism described
Injury matches item used to cause it
Fresh burns
Parents seem not to care as much as they should
Conflicting stories
Child afraid to describe how injury occurred

Signs of neglect
Lack of adult supervision
Child appears malnourished
Unsafe living environment
Untreated chronic illness

Handling abuse and neglect
Head injuries are most lethal.
o Shaken baby syndrome: Closed head injuries occur to many infants
and small children who have been severely shaken.
! Indications: bulging fontanelle due to increased intracranial
pressure from the bleeding of torn blood vessels in the brain,
unconsciousness,
Abdominal injuries include ruptured spleens, livers and lungs lacerated by
broken ribs, internal bleeding from blunt trauma and punching, and lacerated
and avulsed genitalia.
Bite marks may be present showing the teeth size and pattern of the adult
mouth.
Burn marks that are small and round from cigarettes; glove or stocking
burn marks from dipping in hot water; burns on buttocks and legs (creases
behind the knees and at the thighs are protected when flexed); and
demarcation burns in the shape of an iron, stove burner, or other hot utensil
are frequently found.
Do not accuse anyone in the field.
Required reporting: follow state laws and protocol and document objective
information

Infants and Children with Special Needs

Children with special needs
Premature infants with lung disease
Infants and children with heart disease
Infants and children with neurological disease
Children with chronic disease or altered function from birth

Technologically Dependent Children (High tech kids)
Tracheostomy tube: tubes that have been placed into the childs trachea to
create an open airway
o Complications: Obstruction, Bleeding, Air leak, Dislodged tube,
Infection
o Managing Tracheostomy Tube
! Maintain open airway.
! Suction.
! Maintain a position of comfort.
! Transport.
Central intravenous lines
o IVs that are very long
! Tip in vein near heart
o Complications:
! Cracked line
! Infection
! Clotting off
! Bleeding
o Care: If bleeding is present, apply pressure. Transport.
Gastrostomy tubes: Tube placed directly into stomach for child who usually
cannot be fed by mouth
Shunts: Tube running from brain to abdomen to drain excess cerebrospinal
fluid
o Should the shunt malfunction, pressure inside the skull will rise,
causing an altered mental status.
o An altered mental status may also be caused by an infection. These
patients are prone to respiratory arrest.

Provider Response

EMTs frequently feel anxiety about treating children because they:
Lack experience
Fear failure
Identify with their own children

To reduce anxiety about treating children:
Remember that most adult care is similar for children.
Practice with children playing the patient and use proper-sized equipment on
them.

Understanding Geriatric Patients

Patients Age 65+
Neatly half have bone/joint disorders
A third have high blood pressure and heart disease
! are hearing impaired
1/10 have diabetes and/or visual impairments
most take multiple medications
more than half of patients age over 85 live alone or with a spouse
this number is even greater in the 65 to 74 range
o only 5% live in nursing homes
1 out of every 8 people is over age 65

Communication with Geriatric Patients
May have vision deterioration
Possible hearing loss
Difficult speech pattern
o Dentures
o Previous medical problems
Dont assume
o Confusion is normal for any patient
o Aging does not mean impaired thinking ability

Assessing Geriatric patients
Physical hazards that could produce injuries?
Environment well ordered?
Are meds organized and current?
Food half eaten? Surroundings sanitary?
Temp of home?

General Impression
Level of distress?
Body position
Medical equipment: oxygen tank, hospital bed?
Mental status: normal baseline?

Focused and Sample History
May have long medical history or none at all
May have multiple medications or none at all
May have little knowledge of their condition or know it very well

Assess ABCs
Airward and breathing may be affected by
o Stiffness in neck
o Dentures (can cause blockage)
Arthritis/circulation may be affected by irregular heart rate

Use Special Consideration
Be gentle, esp. if skin appears thin and fragile
Listen patiently
Protect patients modesty
Take extra time to pad or cushion unusual body curves.

Common complaints of elderly patients

Pharmacology:
Elderly use far more medication than other age groups
May lose track if they have taken them
Expensive; may not take regularly
Drug patient interactions
Drug-drug interactions
o may act differently on each patients
o may interact with each other

Shortness of Breath
May or may not have chest pain
o Asthma, emphysema, heart failure, myocardial infarction
Chest pain
May or may not have shortness of breath
o Angina, myocardial infarction, aortic aneurysm, pneumonia(4
th
leading
cause of death in the elderly)

Other complaints
Abdominal pain: may be aneurysm or bowel obstruction
Weakness/malaise: may be sign of underlying problem
Depression/suicidal behavior: elderly males most successful of all age groups

Additional Concerns
25% of hospital admissions for falls result in death
o impact on lifestyle can be devastating
o circumstances of falls are often linked to serious disorders
many elderly fear hospitalization
o loss of control over own circumstances
o separation from loved ones
o high costs can wipe out resources
o consider the possibility that an elderly patient might understate
medical complaints.

Elder Abuse and Neglect
Physical: overtly hitting, pushing, shoving, ignoring physical needs
Psychological: threats, insults, silent treatment
Financial: exploitation for resources

HAZMAT

Hazardous material: common
Any substance (gas, liquid, or solid) capable of creating harm to people,
property and the environment

DOT:
DOT utilizes 8 hazardous classes, some which contain subcategories called
classifications, and a 9
th
covering other regulated materials.
DOT includes in its regulations hazardous substances and wastes as an ORM-
E both of which are regulated by the EPA.
Class 1: explosives (blasting agents_
Flammable gas (compressed gas)
Flammable liquid (combustible liquid)
Flammable solids (w/wet)
Oxidizer (organic peroxide)
Poison/toxic inhalation

Risk Assessment
The danger of injury, damage or loss will occur
Somebody or something likely to cause injury, damage or loss
The statistical chance of danger from something, especially from the failure if
an engineered system,

Safety Precautions
Park upwind, uphill
Keep a safe distance. keep people away from the area
Avoid contact with material
Do not enter hazmat scene
Removal of non ambulatory patients done by trained personnel

HAZMAT zones:
Cold zone:
o The area contains the command post and such other support functions
as are deemed necessary to control the incident. Clean zone or support
zone
Buffer zone/warm zone
o The area where personnel and equipment for decontamination and hot
zone takes place. It includes control points for the access corridor and
thus assists in reducing the spread of contamination
o Also referred to as decontamination-contamination reduction corridor
or limited access zone
o Decontamination involves volumes and volumes of water
Hot zone:
o Area immediately surrounding a hazardous materials incident. It
should extend far enough to prevent adverse effects from the
hazardous materials released. This zone is also referred to as the
Exclusion Zone

Levels of Protection
Level A: highest level of respiratory, skin , eye and mucous membrane
protection. Fully encapsulated, vapor-tight, chemical resistant suit, boots,
inner outer gloves, coveralls, hardhat and SCBA
Level B: highest level of respiratory but with a lesser degree of skin, eye and
mucous membrane protection. Primarily a splash hazard
Level C: airborne contaminates are known, APR can be used and where skin,
eye , mucous membrane contact is unlikely Splash protection
Level D: work uniforms, shoes, no respiratory protection required

Treat/Transport Contaminated Patients
All patients/emergency personnel operating in the hot/warm zones are
considered contaminated
All patients/emergency personnel undergo decontamination prior to entering
the ambulance
The hospital may decide to decontaminate the patients a second time

Hazardous Materials
A placard and an orange panel
Reference Book
NFPA 704 Diamond System: fixed facilities
o Blue: health hazard
o Red: fire hazard
o Yellow: reactivity
o White: protective equipment

Emergency Response Guide Book
The Yellow sections list hazardous materials in numerical order by placard
number. It can be used to find the appropriate GUIDE NUMBER
Blue sections list hazardous materials in alphabetical order. It can be used to
find the appropriate GUIDE number
o Products highlighted in Green have special isolation/evacuation
information
Orange section consists of numbered guides that lists the materials
potential hazards: health, fire/explosion, public safety, and emergency
response.

HAZMAT Scene Size up:
Dispatch information
Scene survey
Incident command report/briefing
Confirm the nature of the call/emergency
Operational time frame
Manpower and emergency
Additional resources needed
Start TRIAGE
Initial assessment
Priority

Avoiding the Product
EMS operates in the cold zone
Deals with non contaminated patients or patients that have been put through
the decontamination process
Keep the vehicle in a ready condition

Response to HAZMAT releases
This plan is for emergency response operations for releases of, or substantial
threats of releases of hazardous substances.
EMS defines hazardous substances as: flammable liquids/solids, explosives,
gases, and oxidizers.
Recognition/Anticipation: hazardous materials can be found in every
household (chemical storage areas, paint and hardware stores, pool supply
businesses, agricultural/gardening facilities, sewage treatment and waste
disposal centers, power companies, radiation treatment centers, fuel/oil
storage areas)
In addition to labels, placards, warning signs or the presence of suspicious
containers, EMS teams must also include the presence of certain patient
complaints as possible indicators. This may include but not limited to
complaints such as nausea, vomiting, dyspnea, headache, dizziness, syncope,
profuse diaphoresis, burns, altered mental status.

INCIDENT COMMAND
A management system designed to provide a structured process of coordinating
emergency response resources at situations involving
Fires
Hazardous materials
Multiple casualty incidents
Rescue operations

Unified Command: used to coordinate resources of multiple types of services in a given
jurisdiction
Fire
Ems
Police
Government agencies
Commonly implemented for more incident responses

Singular Command: used to coordinate resources of a single type of service in a given
jurisdiction
Ems response with limited or no other services involvement
Example: multiple victims of food poisoning at a wedding reception

Incident Command System:
When is the ICS implemented?
When more than two ambulances are needed at a scene
When multiple emergency services are needed at a scene
All HAZMAT responses
All mass casualty incidents

Role of the EMS Incident Commander:
Location: incident command post
Radio ID: EMS command
Reports to: Incident Commander in Unified Command model
Duties: manages overall EMS response to incident
o Administrative function (does not provide hands-on care)

EMS Incident Commander
Establishes and functions in the EMS sector of the Incident Command Post
Coordinates actions of all EMS personnel
Serves as liaison to Fire/police/rescue agencies
Assesses incident to determine manpower/equipment/supply needs
Determines the number of causalities

Designate EMS Operations Officers
Triage officer:
o Location: incident site
o Radio ID: triage
o Reports to: EMS command
o Duties: initiates triage
! Determines accurate number of victims
! Establishes a triage/treatment area with the following
considerations: sheltered, access to ambulance transportation,
establish access control, personnel
! Two states of triage: field triage and second triage in treatment
area
Staging officer
Treatment officer
Transportation officer
Communications officer
Safety officer
EMS command assistant

Triage Categories
Priority One (P-1 Tx, red tag)
o Treatable life threatening injuries: airway, breathing, severe bleeding,
altered mental status, severe burns, shock, severe medical conditions
o RED tag
Priority Two (P-2 Tx, Yellow Tag)
o Serious, but not life threatening
! Burns without airway involvement
! Major or multiple musculoskeletal injuries
! Back injuries without spinal cord damage
Priority Three (P-3 Tx, Green Tag)
o Walking wounded
! Minor musculoskeletal injuries
! Minor soft tissue injuries

Field Triage: START (Simple Triage and Rapid Treatment
Is victim walking?
Yes # green tag
No # check respiratory status
Respirations Present?
No: position airway
o Respirations adequate? Less than 10/min
! Yes # red
! No # black
Yes
o > 30/min # red tag
o >10/min and <30/min # assess hemodynamic status
Hemodynamic status adequate? Carotid pulse?
No # black tag
Yes
o Radial pulse absent. Capillary refill > 2 seconds. Skin-cool and moist
! # red tag
o Radial pulse present. Capillary refill < 2 seconds. Skin is warm dry
and pink
! # assess mental status
Mental Status Adequate?
No: unresponsive, disoriented, fails to follow simple commands # red
Yes (alert and oriented, follows simple commands) # Green tag

Role of Staging Officer
Ensures that all vehicles re properly positioned to allow for immediate egress
Ensures that all vehicle drives remain with vehicle
Directs vehicle slow as requested by transportation officer
Maintains documentation of victims

Communications Officer:
Establishes communicated area at the command post
Contact area receiving hospitals and determine bed availability, forward this
info to transportation officer

Transfer of Command
Must be done each time a new individual assumes Incident Command position
A verbal report must be given by the outgoing commander to the incoming
commander
Transfer of command is completed with a radio message to all units indicating
a transfer of command
o EMS command to all units
! Command has been transferred from MLSS M9 to County
EMS 1

Putting it all together
First In unit responsibilities
o Scene size up
! Scene safety and hazards
! Number of victims
! Perform START
o Do not treat patients during the size up
o Determine need to implement incident command system (paramedic)
! Rule of thumb
" >2 ambulances needed at scene
6 green tag patients
4 yellow tag
2 red tag
o Assume position of EMS command until ambulance service officer
arrives at scene, at which time command is transferred from the EMT
to the officer.
o Upon arrival of subsequent EMS units, EMS command appoints
officers

Pitfalls of ICS
Communications: unnecessary chatter and freq overload
Mobile ICS officers: too many cooks
Lack of personnel: need for rehab, knowing ones limitations
Free lancing

Ambulance Operations

Phases of the Ambulance Call
Preparation for the call
Dispatch and responding
Transferring patient to the ambulance
Transporting the patient
Terminating the call

Preparation for the Call
Check equipment
o Mechanical/fluids
o Walk-around
o Communication
o Treatment supplies
o Safety equipment
o Other supplies

Mechanical/Fluids: Follow your agencys checklist through a careful
mechanical inspection
o Under hoot check
o Starts
o Streers
o Stops
o Stays running
Walk around: Start the engine. Turn on the lighting equipment.
o New body damage
o Fluid leaks
o Tire wear
o Warning equipment
Communications: radio equipment and your warning equipment are vital to
your patients safety
o Dispatch
o Handheld
o Medical direction
Treatment supplies
o Suction
o Oxygen/resuscitation
o Carrying devices
o Defibrillation
Safety Equipment
o Standard precautions equipment
o Binoculars
o Scene wear
Other Supplies
o Carry-in kits
o Maps/GPS
o Personal gear
Ensure cleanliness
o Carry in gear
o Ambulance interior and exterior

Dispatch and Response
Central access (911)
24 hour availability
trained personnel (EMDs)

Information
o Nature of call
o Name, location, callback number
o Location of patient
o Number of patients and severity
o Special problems
Procedures: notify dispatch when responding
Personnel available for response:
o At least one EMT in patient compartment (minimum staffing)
o Two EMTs preferred

En Route to Call
Driving the ambulance: emergency vehicle operations course recommended.
o course mandated in some areas.
o Good operators and tolerate other drivers
o Mentally and physically fit
o Emotions under control and able to perform under stress
o Wear safety belts (both driver and passengers)
o Be familiar with vehicle
o Be alert to road and weather conditions
o Do not operate under the influence or when fatigued
o Use caution when using emergency lights/siren
o Select appropriate route
o Maintain safe following distance

Driving Hazards:
o Intersections # most common accident type
o Use caution with escorts and multiple-vehicle responses
! Motorists dont expect second emergency vehicle
Other Procedures
o Obtain additional info from dispatch
o Assign personnel specific duties
o Assess equipment needs

Arrival at the Scene
Parking the ambulance
o Park uphill from leaking hazards
o Park 100 feet from wreckage
o Set parking brake and utilize warning lights
o Avoid parking were exit will be hampered.
Procedures
o Notify dispatch
o Size up the scene: safety, body substance isolation and the # of
patients.

On Scene
Actions
o Stay organized
o Move rapidly and efficiently toward goal of transportation

Transferring Patient to Ambulance
Procedures
o Prepare patient for transport
o Complete critical interventions
o Check dressings and splints
o Select proper moving device and secure patient

Transporting Patient
Notify dispatch
Continue ongoing assessment
Notify receiving facility
Reassure patient
Prepare for any changes

At Receiving Facility
o Notify uispatch
o 0se caution backing into facility
! 0se a "spottei" whenevei possible
Patient Tiansfei at Facility
o Pioviue veibal anu wiitten iepoits to staff
o Ensuie tiansfei of caie to hospital peisonnel

9%*+,.6),.3 )5% 26""
Notify uispatch
Piepaie foi the next call
Restock equipment
Refuel unit
Complete anu file iepoit
Complete cleaning anu uisinfection

>,* ?%&,!6" @1%*6),#.$
0tilizing Aii Neuical Seivices
Neuical ieasons
0peiationaliescue ieasons
Know local piotocols

Belicoptei Lanuing Zone
Requiies 1uu' x 1uu' aiea
Less than 8 uegiee slope
Fiee of wiies, tiees, people anu loose objects
Nevei shine light at pilot

Bangei Aiea:
Ciouch while appioaching to stay
well below moving iotois.
Appioach fiom uownhill siue

Appioach to Belicoptei:
Follow uiiections of ciew
Ciew will uiiect patient loauing
Stay cleai of tail iotoi
No smoking, tiaffic, vehicles within 1uu' of
helicoptei

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