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NANCY CAROLINES EMERGENCY CARE IN THE

STREETS, SIXTH EDITION
Errata Sheet
p. 1.17: Changed definition of Prospective Research to read: Research
that defines a clear problem prior to gathering data.
p. 2.7: Changed definition of fight-or-flight syndrome: shunting blood
away from the gastrointestinal tract, and increasing blood flow to the
cerebrum and skeletal muscles.
p. 7.12 Edit under Sympathetic Nervous System: The nerve fibers
that release norepinephrine are referred to as adrenergic nerve fibers.
p. 7.26 Edit to definition of neuromuscular blocking agents: . . . affect
the somatic (motor) nervous system by inducing paralysis.
Edit following term nondepolarizing neuromuscular blocking agents: All
neuromuscular blocking agents bind to the somatic ACh receptors at
the neuromuscular junction.
p. 7.27 Edit to Beta-1 receptors: Increase the heart rate, cause
cardiac muscle to contract, strengthen cardiac contraction, produce
automaticity, and trigger cardiac electrical conduction.
p. 8.4 Deleted the sentence: Sodium is also a major component of the
circulating buffer, sodium bicarbonate (NaHCO3).
p. 8.5 Edit under Chloride: Chloride concentration is a primary
determinant of stomach pH.
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Edit under Osmosis: Changed (eg, a cell wall) to (eg, a cell

membrane)
p. 8.6 Figure 8-5 caption should read: Skin tenting is a sign of
dehydration.
p. 8.7 Under Isotonic Solutions: Changed (concentration of sodium)
to (concentration of solute)
p. 8.8 Third sentence: patients receiving dialysis because dialysis
therapy dehydrates the cells. Deleted the rest of the paragraph.
p. 8.20 and 8.21 Reworked Skill Drill 8-3 (based on comments from
Hopes customer at Huron): Removed Step 3 and altered language to
accommodate.
p. 11.10 Clarified the explanation of minute alveolar volume:
It is important to understand the concepts of minute volume (VM) and
minute alveolar volume (VA). Minute volume is simply the amount of
air that moves in and out of the respiratory tract per minute; it is
determined by multiplying the tidal volume by the respiratory rate (VM
= VT RR). Minute alveolar volume (VA) is the amount of air that
actually reaches the alveoli per minute and participates in gas
exchange; it is determined by multiplying the tidal volume (minus dead
space volume) by the respiratory rate. For example:
500 mL (VT) 150 mL (VD) 16 breaths/min = 5,600 mL (VA)

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Minute volume will increase if the tidal volume, respiratory rate, or

both, increases. Conversely, minute volume will decrease if the tidal
volume, respiratory rate, or both, decreases. As the respirations
become faster, however, they typically become more shallow (reduced
tidal volume). When respirations are too rapid and too shallow, the
inhaled air may reach only the anatomic dead space before it is
promptly exhaled, resulting in decreased minute alveolar volume.
Table 11-1 demonstrates how tidal volume and respiratory rate
can influence a patients minute alveolar volume and, therefore,
overall breathing adequacy. This information will prove useful for
assessing a patients breathing adequacy and identifying patients who
require assisted ventilation.

p. 11.11 Replaced current Table 11-1 with the following:

Table 11-1

How Tidal Volume and Respiratory Rate

Affect Minute Alveolar Volume
Example 1: Normal tidal volume and respiratory rate
(500 mL [VT] 150 mL [VD]) 16 breaths/min = 5,600 mL (VA) Good!
Example 2: Reduced tidal volume and a normal respiratory rate
(250 mL [VT] 150 mL [VD]) 14 breaths/min = 1,400 mL (VA) Not
good!
Example 3: Reduced tidal volume and a slow respiratory rate
(350 mL [VT] 150 mL [VD]) 6 breaths/min = 1,200 mL (VA) Not
good!
Example 4: Reduced tidal volume and a fast respiratory rate
(200 mL [VT] 150 mL [VD]) 40 breaths/min = 2,000 mL (VA) Not
good!
p. 11.45 Replaced the section on automatic transport ventilators
(pages 11.45-11.46) with the following:
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Automatic Transport Ventilators

The automatic transport ventilator (ATV) is basically a FROPVD
attached to a control box in which the variables of ventilationtidal
volume and respiratory ratecan be set, thus allowing accurate
regulation of a patients minute volume (Figure 11-37). The ATV is
used for intubated patients who need extended periods of ventilation.
Most ATVs are small and compact. The mechanical simplicity,
durability, and portability of the ATV make it a valuable prehospital
ventilation device. It frees up your hands to tend to other non-airwayrelated tasks.
The respiratory rate on the ATV is usually set at the midpoint or
average for the patients age. Tidal volume is usually set between 6
and 7 mL/kg, but can be adjusted based on the patients chest rise and
clinical response.
Like the FROPVD, the ATV is dependent on an oxygen source. It
also has a pressure relief valve, which can lead to unrecognized
hypoventilation in patients with poor lung compliance (eg, COPD, CHF),
increased airway resistance (eg, asthma), or airway obstruction. Table
11-10 describes the steps for using an ATV.

p. 11.45 Replaced text on Automated Transport Ventilators.

Automatic Transport Ventilators
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The automatic transport ventilator (ATV) is basically a FROPVD

attached to a control box in which the variables of ventilationtidal
volume and respiratory ratecan be set, thus allowing accurate
regulation of a patients minute volume (Figure 11-37). The ATV is
used for intubated patients who need extended periods of ventilation.
Most ATVs are small and compact. The mechanical simplicity,
durability, and portability of the ATV make it a valuable prehospital
ventilation device. It frees up your hands to tend to other non-airwayrelated tasks.
The respiratory rate on the ATV is usually set at the midpoint or
average for the patients age. Tidal volume is usually set between 6
and 7 mL/kg, but can be adjusted based on the patients chest rise and
clinical response.

p. 11.46 Added section on Continuous Positive Airway Pressure.

Continuous Positive Airway Pressure
Continuous positive airway pressure (CPAP) delivers positive pressure
to the airways of a spontaneously breathing patient during the
respiratory cycle. With CPAP, the patient exhales against positive
pressure (positive end-expiratory pressure [PEEP]); this prevents
atelectasis, forces fluid from the alveoli, and improves pulmonary
respiration. CPAP is an effective treatment for patients with pulmonary
edema (ie, CHF), and has been shown to reduce the need for
intubation when used in conjunction with drug therapy. CPAP has also
proven useful for patients with acute bronchospasm (ie, asthma) and
obstructive lung disease.
CPAP is delivered through a tight-fitting face mask that is
attached to an oxygen source; the amount of PEEP can be adjusted
between 2.5 and 10 cm H2O. Patient anxiety is common during initial
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CPAP therapy; coaching and reassurance are often needed to facilitate

compliance. After applying the CPAP device, observe for signs of
clinical improvement, which include decreased work of breathing,
increased ease in speaking, decreases in respiratory and heart rate,
and increased SaO2.

p. 11.53 Figure 11-46 caption should read: A straight (Miller) blade with
three additional size blades shown.
p. 11.93 Although the spelling of the term butrophenones is used in
many places, we changed to the more common spelling:
butryrophenones
Under Barbiturates, deleted as primary induction agents.
p. 13.40 Added an explanation of Babinski reflex: Babinski reflex occurs
when the great toe flexes and the others fan out. The presence of this
reflex in adults indicates neurological injury.
p. 19.18 Control of External Bleeding We revised this language
slightly to reflect the new National Registry Skill Sheet on Bleeding
Control, which recommends use of a tourniquet
Control of External Bleeding
External bleeding is bleeding that can be seen coming from a wound
when the integrity of the skin has been violated. Bleeding can be
characterized according to the type of blood vessel that has been
damaged. Arterial bleeding occurs in spurts, and the blood is usually
bright red because of the fully saturated hemoglobin. Venous bleeding
is more likely to be slow and steady, and the color of the blood is
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darker because it is relatively deoxygenated. In reality, most open

wounds show a combination of arterial and venous bleeding. Capillary
bleeding is characterized by a slow, even flow of bright or dark red
blood and is present in minor injuries, such as abrasions or superficial
lacerations.
Five methods are used in the field to control external bleeding: direct
pressure, elevation, pressure point control, immobilization, and a
tourniquet.
Direct Pressure
Application of pressure over a bleeding wound stops blood from flowing
into the damaged vessels, allowing the platelets to seal the vascular
walls.
If possible, use a sterile dressing to exert pressure, and then use your
gloved hand to apply pressure over the bleeding site. The steps for
controlling bleeding are:
1.

Apply a dry, sterile dressing over the entire wound. Apply

pressure to the dressing with your gloved hand (Step 1).

2.

Maintain the pressure, and secure the dressing with a roller

bandage (Step 2).

3.

If bleeding continues or recurs, leave the original dressing

in place. Apply a second dressing on top of the first, and secure it with
another roller bandage (Step 3).
4.

Splint the extremity to stabilize the injury, even if there is

no suspected fracture, which helps to minimize movement, further

control the bleeding, and keep the dressing in place (Step 4).
To maintain pressure, apply a pressure dressing over the site. On an
extremity, one effective way of maintaining uniform pressure on a
bleeding site is to apply an air splint over the dressed wound. If one or
both of the lower extremities are bleeding, you can use the PASG to
apply pressure, as discussed in Chapter 18. Maintain pressure over the
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bleeding site until the bleeding stops or until the patient reaches the
hospital and other personnel take responsibility for care.
Some commercially available pressure dressings allow for
simultaneous dressing of the wound and application of pressure. If one
of these products is not available, standard dressing material may be
used in conjunction with triangular bandages to create localized
pressure. This type of dressing will often allow you to focus on other
tasks while pressure is applied. Always assess distal circulation before
and after you apply a pressure dressing. Adjust the dressing as needed
in case of a complication, such as loss of distal pulse, diminished
sensation, or change in skin color and temperature distal to the
dressing.
Elevation
In cases of venous bleeding from an extremity, the rate of bleeding can
be substantially slowed by elevating the extremity above the level of
the heart. This measure alone will not control bleeding, but it may be
helpful in conjunction with other measures, such as direct pressure.
Pressure Point Control
When direct pressure is not sufficient to control bleeding or when the
same artery is associated with a number of bleeding points, pressure
point control may help slow the bleeding. The artery chosen must be
fairly superficial and overlie a hard structure against which it can be
compressed. Three pressure points are typically used: (1) the temporal
artery, which overlies the temporal bone of the skull and is used to
control bleeding from the scalp; (2) the brachial artery, which overlies
the humerus and is used to control bleeding from the forearm; and (3)
the femoral artery, which can be compressed against the pelvis and is
used to control bleeding from the leg.

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Recent studies have brought into question the effectiveness of using

pressure points in severe hemorrhage. It is acceptable, if allowed by
protocol and local policy, to move directly to the use of a tourniquet
without attempting pressure point control. If a tourniquet is deemed
necessary, it should be applied quickly and not released in the
prehospital setting.
Immobilization
Any movement of an extremity, even an uninjured extremity, promotes
blood flow within that extremity. When the extremity is also injured,
motion may disrupt the clotting process and lacerate more blood
vessels. It follows that preventing motion of an injured extremity will
have the opposite effects. Advise the patient to make every effort to
minimize movement. If that is not possible and conditions warrant,
apply a splint to prevent motion.
An air splint or padded board works well to keep an upper or lower
extremity immobilized. Use of an air splint gives a double benefit
splinting and direct pressure. Remember to assess distal pulses, motor
function, and sensation distal to the splint before and after application.
Tourniquet
In the civilian setting, it is rarely necessary to use a tourniquet for
control of external hemorrhage. Bleeding control can almost always be
achieved by one or more of the four methods already described.
Furthermore, use of a tourniquet has been associated with potential
hazards, including damage to nerves and blood vessels and, when the
tourniquet is in place for an extended period, loss of the distal
extremity. A tourniquet applied too loosely, by contrast, may increase
bleeding if it occludes venous return without hampering arterial
outflow.
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In military settings, application of a tourniquet would occur more often

owing to the nature of injuries experienced during battle. In addition,
rapid transport to a medical facility is typically more difficult on the
battlefield than in civilian situations. In such a scenario, a tourniquet
may be lifesaving, particularly in patients with a traumatic partial
amputation of a limb.
p. 21.32 and 28.12: Standardized values for normal ICP at 0 to 10.
p. 29.12: Changed normal blood glucose from 70-120 mg/dL to 80-120
mg/dL.
p. 23.19 Deleted Figure 23-16A because it shows sealing a sucking
chest wound on all four sides.
p. 27.22 Deleted text to The resistance against which the ventricle
contracts . . .
p. 27.36 First two paragraphs under Management of Left-Sided
Heart Failure: We replaced this text with information about CPAP as
an effective treatment.
p. 27.89 Definition of P wave: changed ventricles to atria.
p. 28.22 Under Administration of Dextrose/Glucose: Fifth line
down, changed hyperglycemia to hypoglycemia.
p. 29.13 Directly above Hyperglycemia and Diabetic Ketoacidosis,
added the following paragraph: If vascular access is not available,
glucagon, 1 mg by intramuscular injection, should be given.

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p. 32.13 Replaced sentence in first column about priapism with the

following: Priapisma sustained, painful penile erectioncan be
caused by conditions such as spinal injury and the use of erectile
dysfunction drugs (eg, Viagra, Levitra, Cialis).
p. 33.8 Table 33-1: Removed under Drug Examples, Narcotic:
Ambien and secobarbital
p. 33.14 Changed caption of Figure 33.7 to read: Drugs such as nasal
decongestants and diet pills stimulate the sympathetic nervous system
and can be detrimental to patients with an underlying cardiovascular
disease.
p. 33.19 Fifth bullet in left column; added: and for patients who are
dependent on benzodiazepines because it will precipitate seizures.
p. 33.22 Last full paragraph in right column replaced with new
information about cyanide poisoning treatment (administering amyl
nitrite, sodium nitrite, and sodium thiosulfate).
p. 34.7 Under Leukemia; edited sentence starting with Leukemia can
cause anemia . . .. Now reads: Leukemia can cause anemia and
thrombocytopenia (decrease in platelets). Leukemia can also cause
overproduction of some specific types of white blood cells, resulting in
overall white cell counts that are extremely high (severe leukocytosis).
In Chapters 38 and 39, we standardized definitions for parity and
gravidity The medical term for any pregnancy is gravid or gravidity;
the term for delivery of an infant is parity.

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p. 39.34 Fourth bullet from the bottom, left column: Added word
Ectopic before pregnancy.
p. 41.18 Replaced Figure 41-12: Equipment too large for infant in
original image.
p. 50.15 In section Corrosives: Acids and Bases: high and low
are reversed throughout this section (ie, acids have a low pH and bases
have a high pH).
M.3 Equation in upper right; changed to: total amount of fluid to be
administered (in mL) drop factor*
M.5 Changed Amyl Nitrate and Sodium Nitrate to Amyl Nitrite and
Sodium Nitrite
M.9 Flumazenil, Contraindications: Added benzodiazepine
dependence
M.10 Glucagon, Mechanism of Action: Changed first line to read:
Increases blood glucose level by stimulating glycogenolysis.
M.14 Nalaxone Hydrochloride (Narcan), Mechanism of Action:
Changed second line to read: reverse respiratory depression
secondary to opiate drugs

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