Fall 2011 EMT Lectures

6/28/2011
1
Copyright 2012 by Pearson Education, Inc.
All rights reserved.
Emergency Care, Twelfth Edition
Limmer OKeefe Dickinson
Introduction to Emergency Introduction to Emergency
Medical Care Medical Care
11
OBJECTIVES OBJECTIVES
1.1 Define key terms introduced in this chapter. Slides
16-18, 2627, 4244
1.2 Give an overview of the historical events leading to
the development of modern emergency medical
services (EMS). Slides 1013, 19
1.3 Describe the importance of each of the National
Highway Traffic Safety Administration standards for
assessing EMS systems. Slides 1418
1.4 Describe the components of an EMS system that
must be in place for a patient to receive emergency
medical care. Slides 2127
continued
1.5 Compare and contrast the training and
responsibilities of EMRs, EMTs, AEMTs, and
Paramedics. Slides 2833
1.6 Explain each of the specific areas of responsibility for
the EMT. Slides 2829, 3133
1.7 Give examples of the physical and personality traits
that are desirable for EMTs. Slides 3439
1.8 Describe various job settings that may be available to
EMTs. Slide 40
1.9 Describe the purpose of the National Registry of
Emergency Medical Technicians. Slide 41
continued
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1.10 Explain the purpose of quality improvement
programs in EMS programs. Slides 4243
1.11 Explain EMTs role in the quality improvement
process. Slides 4243
1.12 Explain medical direction as it relates to EMS
systems. Slide 44
1.13 List ways in which research may influence EMT
practice. Slide 45
continued
1.14 Give examples of how EMS providers can play a
role in public health. Slide 46
1.15 Given scenarios, decide how an EMT may
demonstrate professional behavior. Slides 29, 32
33, 47
MULTIMEDIA
Slide 19 The Long and Winding Road of Ambulance
Service Video
Slide 48 Emergency Medical Services for Children
Video
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The chain of human resources that forms
the EMS system
How the public activates the EMS system
Your roles and responsibilities as an EMT
The process of EMS quality improvement
(QI)
CORE CONCEPTS
Topics Topics
The Emergency Medical Services System
Components of the EMS System
The Emergency Medical The Emergency Medical
Services System Services System
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How It Began How It Began
1790sNapoleonic Wars
Civil War
World War IVolunteer ambulance corps
Korea/VietnamMASH-type units and
helicopter transport from battlefield
continued
(Bettmann/CORBIS.)
How It Began How It Began
Non-military ambulance services began
operating in early 1900s in U.S.
Often operated by hospitals, fire
departments, or funeral homes
No requirements or standards for
equipment, crew training, or ambulance
design
You call, we haul, thats all!
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Development of Todays EMS Development of Todays EMS
1966Department of Transportation
charged with developing EMS standards
1970Founding of National Registry of
EMTs (NREMT)
1973National Emergency Medical
Service Systems Act (NEMSSA)
NHTSA Standards NHTSA Standards
for EMS Systems for EMS Systems
1. Regulation and Policy
Each state establishes laws, policies, and
regulations
2. Resource Management
Centralized coordination of emergency
treatment and transport resources
continued
3. Human Resources and Training
Assure EMS personnel are trained and
certified to minimum standard by qualified
instructors
4. Transportation
Provide safe, reliable transportationground,
air, or other means
continued
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5. Facilities
Must be transported to closest appropriate
facility
6. Communications
Universal access number (911), dispatch to
ambulance, ambulance to ambulance,
ambulance to hospital, hospital to hospital
continued
7. Trauma Systems
Develop trauma triage, transport, and
treatment protocols
8. Evaluation
Establish program for assessing and
improving quality of care provided (QI, QA,
TQM)
continued
9. Public Information and Education
Educate public about role of EMS, increase
public awareness, participate in injury
prevention programs
10.Medical Direction
Medical director oversees, is accountable for
EMS personnel within system
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Click here to view a video on the topic of the history of EMS.
Back to Directory
The Long and Winding The Long and Winding
Road of Ambulance Service Video Road of Ambulance Service Video
Components Components
of the EMS System of the EMS System
Emergency Department/Hospital
Doctors, nurses, allied health personnel
continued
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Other specialized
care facilities
Trauma centers
Burn centers
Stroke centers
Cardiac centers
Labor and delivery/
pediatrics
Poison control
Think About It Think About It
What medical services are available in
your community?
How important is it that EMS personnel
know the capabilities of community
medical facilities?
What are the possible consequences of
transporting a patient to a facility not
equipped to handle the problem?
Chain of Human Chain of Human
Resources in EMS System Resources in EMS System
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Accessing EMS System Accessing EMS System
911 telephone access
Available in most but not all areas
Enhanced 911
Provides caller number and location for
landline phones
Cell phones
Newer models may provide location in some
areas
Emergency Emergency
Medical Dispatchers Medical Dispatchers
Can provide instructions to callers on how
to provide emergency care until EMS
personnel arrive
EMD certification required in some
jurisdictions
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Critical Decision Making Critical Decision Making
Critical decision making is very important
in EMS
Information must be gathered, patients
assessed, and determination made on
treatment and transport options
Decisions often time-critical
Examples of Critical Decisions Examples of Critical Decisions
Is it better to take patient to closest
hospital or to one farther away but more
appropriate for the condition?
Is patient stable enough for further
evaluation on scene, or should patient be
transported immediately?
Will this treatment make patient better or
worse?
Levels of EMS Training Levels of EMS Training
Emergency Medical Responder (formerly
First Responder)
Emergency Medical Technician (formerly
EMT Basic)
Advanced EMT (formerly EMT
Intermediate)
Paramedic (formerly EMT Paramedic)
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Roles and Roles and
Responsibilities of EMTs Responsibilities of EMTs
Personal safety
Safety of crew, patient, and bystanders
Patient assessment
Patient care
Lifting and moving
Transport
Transfer of care
Patient advocacy
How would it impact elderly patient if
transported to the hospital without glasses,
hearing aid, or dentures?
On a routine call, would taking the time to
gather these items have a negative effect
on the patients care?
How about assuring the home is secure
and locked before leaving?
continued
Could the concept of patient advocacy
also extend to the community (fall
prevention programs for elderly, poisoning
awareness, pool and water safety
programs for children)?
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Physical Traits Physical Traits
of a Good EMT of a Good EMT
Ability to lift and carry equipment and
patients
Good eyesight (distance and reading) and
color vision
Good communication skills (oral and
written)
Personal Traits Personal Traits
Pleasant
Sincere
Cooperative
Resourceful
continued
Self starter
Emotionally stable
Able to lead
Neat and clean
continued
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Good moral character
Respectful of others
Control of personal habits
Control of conversation
Able to communicate
properly
Able to listen to others
Nonjudgmental and fair
Education Education
Maintain up-to-date knowledge and skills
Read EMS magazines; join EMS
organizations
Refresher courses for recertification
Continuing education to supplement
original training
continued
Education Education
Conferences, seminars, lectures, classes,
videos, and demonstrations
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Job Opportunities Job Opportunities
Ambulance
services
Fire departments
Medical facilities
Rural/wilderness
teams
Industrial settings
National Registry National Registry
of EMTs (NREMT) of EMTs (NREMT)
Registration for EMRs, EMTs, AEMTs, and
paramedics who successfully complete
NREMT examinations
May help in reciprocity (transferring to
another state or region)
Considered favorably when applying for
employment
Quality Improvement Quality Improvement
Continuous self-review to identify areas for
improvement
Develop plans to address areas
continued
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Quality Improvement Quality Improvement
Everyone in organization has a role
Prepare careful documentation
Involved in quality process
Get feedback from patients, hospital staff
Maintain equipment
Continuing education
Medical Direction Medical Direction
Medical Director: ultimate responsibility for
patient care aspects of EMS system
All patient care performed under direction
of Medical Director
Oversees training; develops treatment
protocols
Off-line medical control (standing orders)
On-line medical control
Research Research
Vitally important; more needed in EMS
field
Care should be based on evidence-based
research rather than tradition
Goal is improving patient outcomes
Form a hypothesis, review literature,
evaluate evidence, and adopt practice if
evidence supports it
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EMS Role in Public Health EMS Role in Public Health
Injury prevention for
geriatric patients and
youth
Blood pressure clinics
File of life
Public vaccination
programs
Disease surveillance
How will you refresh your knowledge and
stay current once you are out of the
classroom?
What qualities would you like to see in an
EMT who is caring for you? How can you
come closer to being this kind of EMT?
Emergency Medical Emergency Medical
Services for Children Video Services for Children Video
Click here to view a video on the topic of emergency medical services
for children.
Back to Directory
6/28/2011
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Chapter Review
Chapter Review Chapter Review
EMS system includes 911 or other
emergency access system, dispatchers,
EMTs, hospital emergency department,
physicians, nurses, physicians assistants,
and other health professionals.
EMTs responsibilities include safety;
patient assessment and care; lifting,
moving, and transporting patients; transfer
of care; and patient advocacy.
continued
EMT must have certain personal traits to
ensure the ability to do the job.
Education, quality improvement
procedures, and medical direction are all
essential to maintaining high standards of
EMS care.
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Remember Remember
EMS dates back to Napoleonic times.
Modern EMS standards come from
1960s1970s and National Emergency
Medical Service Systems Act (NEMSSA).
There is a chain of human resources
involved in EMS. Critical decisions are
made by each member of the chain.
continued
Remember Remember
There are certain personal and physical
traits that help you to be a successful EMS
provider.
An EMS provider should actively pursue
opportunities to improve personal
knowledge and abilities as well as the
units overall quality.
Questions to Consider Questions to Consider
What innovation was introduced in the
Korean and Vietnam wars that is now
common in many EMS systems?
What are the four levels of EMS
providers?
Requesting orders from a physician by
radio is an example of what kind of
medical control?
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Critical Thinking Critical Thinking
Your patient is hesitant to go to the
hospital because she is worried about her
dog. What can you do to assist in this
situation? What part of your role as an
EMT is this an example of?
Please visit Resource Central on
www.bradybooks.com to view
additional resources for this text.
11
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1720, 2426, 34, 4147, 5253, 5960
2.2 Describe health habits that promote physical and
mental well-being. Slide 15
2.3 Given an example of a patient care situation,
determine the appropriate personal protective
equipment to prevent exposure to infectious
disease. Slides 1720, 2426
continued
2.4 Describe proper procedures for hand washing and
using alcohol-based hand cleaners. Slides 2123
2.5 Discuss the health concerns related to exposure to
hepatitis B, hepatitis C, tuberculosis, and AIDS.
Slides 2830
2.6 Access the Centers for Disease Control website to
obtain the latest information on diseases of concern
to EMS providers. Slides 3233
continued
2.7 Explain the essential provisions of OSHA, the CDC,
and the Ryan White CARE Act as they relate to
infection control in EMS. Slides 3237
2.8 Describe the indications for use of an N-95 or HEPA
respirator. Slide 26
2.9 Describe the purpose of the tuberculin skin test
(TST). Slide 38
continued
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2.10 Give examples of common stressors in EMS work.
Slides 4748
2.11 Describe the stages of the stress response system,
including the effect of each stage on the body.
Slides 4243
2.12 Differentiate between acute, delayed, and
cumulative stress reactions. Slides 4446
2.13 List lifestyle changes that can be used to manage
stress. Slide 51
continued
2.14 Explain the purpose of critical incident stress
management (CISM). Slides 5253
2.15 Given a scenario, recognize a patients or family
members reaction to death and dying. Slides 5455
2.16 Given a scenario involving death or dying, use
effective techniques for interacting with the patient
and family members. Slide 56
continued
2.17 List indications of the potential for danger to yourself
or others at the scene of an EMS call. Slide 59
2.18 Outline proper responses to incidents including
hazardous materials incidents, terrorist incidents,
rescue operations, and violence. Slides 6064
2.19 Given a scenario of an emergency response
involving a safety threat, describe actions you
should take to protect yourself and other EMS.
Slides 6164
continued
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2.20 Identify with the feelings of a patient who has a
communicable disease. Slides 2832
2.21 Promote the importance of safety on EMS calls.
Slides 5864
MULTIMEDIA
Slide 39 AIDS: Etiology and Pathophysiology Video
CORE CONCEPTS
Standard Precautions, or how to protect
yourself from transmitted diseases
The kinds of stress caused by involvement
in EMS and how they can affect you, your
fellow EMTs, and your family and friends
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CORE CONCEPTS
The impact that dying patients have on
you and others
How to identify potential hazards and
maintain scene safety
Topics Topics
Well-Being
Personal Protection
Diseases of Concern
Emotion and Stress
Scene Safety
Well Well--Being Being
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Importance of Well Importance of Well--Being Being
Keeping yourself prepared for demands
and risks of EMT is very important
If unable to function for any reason,
patients will not get needed care
Maintaining Well Maintaining Well--Being Being
Maintain solid personal relationships
Exercise
Sleep
Eat right
Limit alcohol and caffeine intake
Have regular checkups and keep up-to-
date on vaccines
Personal Protection Personal Protection
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Standard Precautions Standard Precautions
Standard precautions include steps to
protect self from infectious material
Scene size-up and protocols provide
information on precautions to take
Refer to local protocols for wearing
personal protective equipment
When in doubt, wear it!
Personal Protective Equipment Personal Protective Equipment
Personal Protective Personal Protective
Equipment: Gloves Equipment: Gloves
Always have gloves on your person when
responding
May need to change gloves during call if
they become torn or when treating multiple
patients
Due to latex allergies, many providers are
now switching to non-latex gloves
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Personal Protective Equipment: Personal Protective Equipment:
Gloves and Arm Covers Gloves and Arm Covers
Hand Washing Hand Washing
Hand washing is still important even if
gloves were worn during patient care
Remove jewelry and watch
Use soap and rub hands vigorously
Rinse well
Pat hands dry
continued
continued
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Alcohol-based hand sanitizers can be
used if soap and water are not available
Follow up with hand washing as soon as
possible
Eye Protection Eye Protection
Use if at risk from splashes
Eye and Face Protection Eye and Face Protection
Use when at risk from splashes or
spraying fluids
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Masks and Gowns Masks and Gowns
NIOSH-approved HEPA (High Efficiency
Particulate Air) mask meeting N95
standard
May also wear gown to protect clothing
Diseases of Concern Diseases of Concern
Hepatitis B and C Hepatitis B and C
Hardy, infectious viral disease affecting the
liver
Can live on surfaces in dried blood for
several days
Hepatitis B (HBV) deadly; killed hundreds
of health care workers each year before
vaccine available
Hepatitis C (no vaccine yet) poses same
risk
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Tuberculosis (TB) Tuberculosis (TB)
Often infects lungs
Can be highly contagious
Can be spread through air
Consider precautions with any patient
having productive cough
HIV/AIDS HIV/AIDS
HIV: attacks immune system, leaving
patient unable to fight off infection
AIDS: set of conditions that can result from
HIV infection
Lower risk for health care workers than
hepatitis or TB
Contact with blood usual route of infection
Emerging Conditions Emerging Conditions
and Diseases and Diseases
West Nile Virus
Spread by mosquitoes
Flu-like symptoms (mild cases); infection of
brain and meninges (severe cases)
Severe Acute Respiratory Syndrome
(SARS)
Spread through respiratory droplets
Fever, dry cough, difficulty breathing
continued
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Emerging Conditions Emerging Conditions
and Diseases and Diseases
Influenza
Around for hundreds of years
1918 pandemic killed 30-50 million worldwide
Avian flu
Found in poultry; can affect humans
Swine (H1N1) flu
Caused widespread illness and panic
Infection Control and the Law Infection Control and the Law
EMS personnel, other health care workers
at high risk of coming in contact with
infectious diseases
Guidelines for workplace safety developed
by OSHA and other federal, state, and
local agencies
Occupational Exposure Occupational Exposure
Control Plan Control Plan
OSHA standard on bloodborne pathogens
(1992) requires infection control be joint
responsibility of employer and employee
EMS agencies provide training, protective
equipment, and vaccinations to employees
Employees participate in infection
exposure control plan
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Occupational Exposure Occupational Exposure
Control Plan Content Control Plan Content
Adequate education and training
Hepatitis B vaccination
Personal protective equipment
Methods of control
Housekeeping
Labeling of containers
Post-exposure evaluation, follow-up
Ryan White CARE Act Ryan White CARE Act
Allows EMS providers to seek to
determine if exposure to infectious disease
has occurred
Agencys Infection Control Officer gathers
facts about exposures
continued
Ryan White CARE Act Ryan White CARE Act
Officer notifies EMS provider of exposure
Agency refers EMS provider to health care
professional for evaluation and follow-up
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Immunizations Immunizations
Immunizations for hepatitis B, other
infectious diseases should be available
through agency
Regular TB testing may also be required
Local system protocols vary
AIDS: Etiology and AIDS: Etiology and
Pathophysiology Video Pathophysiology Video
Click here to view a video on the subject of AIDS.
Back to Directory
Emotion and Stress Emotion and Stress
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Stress Stress
Stress inevitable in EMS profession
Recognizing signs of stress and
developing strategies to deal with stress
are very important to EMS career
Stages of Stress Stages of Stress
First stage: Alarm reaction (fight or flight)
Second stage: Resistance (coping)
Third stage: Exhaustion (loss of ability to
resist or adapt to the stressor)
Acute Stress Reaction Acute Stress Reaction
Often linked to catastrophe
Occurs in EMTs and patients
Signs and symptoms develop soon after
incident
Physical, cognitive, emotional, and
behavioral symptoms
continued
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Acute Stress Reaction Acute Stress Reaction
Normal reactions to extraordinary situation
May require immediate intervention from
physician or mental health professional
Delayed Stress Reaction Delayed Stress Reaction
Post-traumatic stress disorder (PTSD)
Signs and symptoms not evident until long
after incident
Delay makes dealing with reaction much
harderpatient may not recognize what is
causing problem
Requires intervention by mental health
professional
Cumulative Stress Reaction Cumulative Stress Reaction
Results from years of sustained low-level
stressors
Early signs: vague anxiety, emotional
exhaustion
Progresses to physical complaints, loss of
emotional control, depression
May present as severe withdrawal or
suicidal thoughts requiring long-term
psychological intervention
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Causes of Stress Causes of Stress
Multiple casualty
incident (MCI)
Call involving
infants or children
Severe injury
continued
Causes of Stress Causes of Stress
Abuse and neglect
Death of a co-worker
Work-related issues involving family and
loved ones
Signs and Symptoms of Stress Signs and Symptoms of Stress
Irritability
Inability to concentrate
Lack of interest in activities
Changes in sleep patterns/nightmares
Changes in appetite
Guilt
Isolation
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If your partner is beginning to show signs
of stress, what should you do?
What possible risk could there be to your
partner, you, or a patient if stress is left
unresolved?
Do you have an obligation to act to help
your partner?
Ways of Dealing with Stress Ways of Dealing with Stress
Healthy diet
Exercise
Devote time to relaxing away from work
Change shift or location for lighter call
volume, different call types, more family
time
Critical Incident Critical Incident
Stress Management Stress Management
Comprehensive system
Includes education and resources to
prevent stress
Ways to deal with
stress appropriately
when it occurs
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Critical Incident Critical Incident
Stress Debriefing (CISD) Stress Debriefing (CISD)
Designed to help responders defuse
after incident
Team of trained peer counselors and
mental health professionals meet with
rescuers and health care providers
involved in major incident
Helps responders deal with stress
Death and Dying Death and Dying
Dont usually see dead people except at
funeral
Dont normally see person die
Often most difficult part of job
Dealing with family may be more difficult
Emotional Stages Emotional Stages
of Death and Dying of Death and Dying
Denial (Not me!)
Anger (Why me?)
Bargaining (Okay, but first let me)
Depression (Okay, but I havent)
Acceptance (Okay, Im not afraid.)
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Dealing with Dealing with
Patients and Family Patients and Family
Think of how you want to be treated
Recognize patients needs
Be tolerant of angry reactions from patient
or family
Listen empathetically
Do not falsely reassurebe honest
Offer as much comfort as you can
Scene Safety Scene Safety
EMS not usually a dangerous profession
Being aware of potential dangers always a
priority
Determining scene safety will be the most
important decision on any call
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Potential Safety Potential Safety
Threats at Scene Threats at Scene
Hazardous materials incidents
Terrorist incidents
Rescue operations
Violence
Weapons
Staging Staging
If not safe to approach scene, stop in a
secure area away from scene
Wait until cleared to enter by appropriate
authorities
Response to Danger: Plan Response to Danger: Plan
Wear safe clothing
Prepare your equipment
Carry portable radio whenever possible
Decide on safety roles
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Response to Danger: Observe Response to Danger: Observe
Survey scene on approach
Dont announce arrivalturn off lights and
siren
Drive few feet past residence so you can
see front and sides
continued
Response to Danger: Observe Response to Danger: Observe
Violence
Alcohol or drug use
Weapons
Family members
Bystanders
Perpetrators
Pets
React to Danger: Three Rs React to Danger: Three Rs
Retreat
Radio
Reevaluate
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Chapter Review
Your well-being is important.
Safety and Standard Precautions are
important decisions you will make at least
once at each scene.
Protect yourself from violence and scene
hazards.
Protect yourself from disease.
continued
Stress may be an immediate reaction from
a call or cumulative from life and EMS.
Seek help.
Treat people under stress fairly and
compassionately.
continued
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You will see death and reactions to death.
Each is personal to those involved.
Emotional stages of death and dying are
denial, anger, bargaining, depression, and
acceptance.
Remember Remember
Scenes are dynamic and can change in an
instant.
Assessment of scene safety is an ongoing
process.
Dont be so focused on the patient that
you lose perception of what is happening
around you.
What precautions must I take if I am
dealing with a patient who has an open
wound?
What can I do to help deal with stress?
A patient who refuses to believe she has a
terminal disease is in what stage of
dealing with it?
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You are called to an unknown emergency
at a tavern. As you approach the scene,
you see a man lying supine in the parking
lot, apparently bleeding profusely. Two
other men are scuffling, and one seems to
have a gun. What actions must you take?
11
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911, 14, 1617, 27, 31, 33, 4245, 50
3.2 Describe the factors that you must consider before
lifting any patient. Slides 1114
3.3 Use principles of proper body mechanics when
lifting and moving patients and other heavy objects.
Slides 1214, 17
continued
3.4 Demonstrate the power lift and power grip when
lifting a patient-carrying device. Slide 14
3.5 Follow principles of good body mechanics when
reaching, pushing, and pulling. Slides 1517
3.6 Give examples of situations that require emergency,
urgent, and non-urgent patient moves. Slides 19,
26, 29
continued
3.7 Demonstrate emergency, urgent, and non-urgent
moves. Slides 2025, 2729
3.8 Given several scenarios, select the best patient
lifting and moving devices for each situation. Slides
3140
3.9 Demonstrate proper use of patient lifting and
carrying devices. Slides 3140
continued
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3.10 Differentiate between devices to be used to lift and
carry patients with and without suspected spinal
injuries. Slides 4145
3.11 Identify with the feelings of a patient EMS personnel
are lifting or carrying. Slides 41, 4648
MULTIMEDIA MULTIMEDIA
Slide 17 Body Mechanics During Moving and
Transferring Video
Slide 50 Prehospital Lifting of Patients Video
How using body mechanics to lift and
move patients can help prevent injury
When it is proper to move a patient, and
how to do so safely
The various devices used to immobilize,
move, and carry patients
CORE CONCEPTS
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Topics Topics
Protecting Yourself: Body Mechanics
Protecting Your Patient: Emergency,
Urgent, and Non-Urgent Moves
Protecting Yourself: Body Protecting Yourself: Body
Mechanics Mechanics
Protecting Yourself: Protecting Yourself:
Body Mechanics Body Mechanics
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Before Beginning the Lift Before Beginning the Lift
Estimate weight
Know own limitations
Plan and communicate with partner
Rules for Lifting Rules for Lifting
Position feet properly
Use legs
Never turn or twist
Do not compensate when lifting with one
hand
continued
Rules for Lifting Rules for Lifting
Keep weight as
close to your body
as possible
Whenever possible,
use stair chair
when carrying
patient on stairs
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Power Lift and Power Grip Power Lift and Power Grip
Reaching Reaching
Keep back in locked-in position
Avoid twisting while reaching
Avoid reaching more than 1520 inches in
front of body
Avoid prolonged reaching when strenuous
effort is required
Pushing or Pulling Pushing or Pulling
Push, dont pull
Back locked in
Line of pull through center of body
Weight close to body
When weight is below waist, use kneeling
position
Avoid pushing or pulling overhead
Elbows bent, arms close to sides
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Body Mechanics During Body Mechanics During
Moving and Transferring Video Moving and Transferring Video
Click here to view a video on the subject of body mechanics during
moving and transferring patients.
Back to Directory
Protecting Your Patient: Protecting Your Patient:
Emergency, Urgent, and Non Emergency, Urgent, and Non--
Urgent Moves Urgent Moves
Emergency Move Situations Emergency Move Situations
Hazardous scene
Repositioning required to care for life-
threatening conditions
Must reach other patients
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Emergency Move: Emergency Move:
Clothes Drag Clothes Drag
Head First Drag Head First Drag
Firefighters Drag Firefighters Drag
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Firefighters Carry Firefighters Carry
One One--Rescuer Assist Rescuer Assist
Two Two--Rescuer Assist Rescuer Assist
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Urgent Moves Urgent Moves
Required treatment can be performed only
if patient is moved
Patients condition deteriorating
Performed with precautions for spinal
injury
Urgent Move: Urgent Move:
Onto Long Spine Board Onto Long Spine Board
Used if immediate threat to life and
suspicion of spine injury
Patient supine, log-roll onto side
Place spine board next to body; log-roll
onto board
Lift onto stretcher
Secure to stretcher; load into ambulance
Urgent Move: Urgent Move:
Rapid Extrication Rapid Extrication
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Non Non--Urgent Move Urgent Move
Patient stable
No immediate life threat
Patient can be assessed, treated, and
moved in normal way
Take all required precautions not to
aggravate existing conditions
Patient Patient--Carrying Devices Carrying Devices
Wheeled Ambulance Stretcher Wheeled Ambulance Stretcher
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Power Stretcher Power Stretcher
Bariatric Stretcher Bariatric Stretcher
Stair Chair Stair Chair
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Short Spine Board Short Spine Board
Vest Vest--Type Extrication Device Type Extrication Device
Scoop Stretcher Scoop Stretcher
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Basket Stretcher Basket Stretcher
Flexible Stretcher Flexible Stretcher
Vacuum Mattress Vacuum Mattress
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How do you choose the appropriate
patient-carrying device?
Moving Patients Moving Patients
With Suspected Spinal Injury With Suspected Spinal Injury
Immobilize head, neck, and spine before
move
Without Suspected Spinal Injury Without Suspected Spinal Injury
Extremity lift
Used to carry
patient to stretcher
or stair chair
Can be used to lift
patient from
ground or from
sitting position
continued
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Direct ground lift
Lifting from ground to stretcher
continued
Draw sheet method (shown)
Direct carry method
Recovery Position Recovery Position
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Position of Comfort Position of Comfort
Positioning for Shock Positioning for Shock
Place patients believed to be in shock in
supine position
Do not lower head
Do not elevate legs
Transferring the Transferring the
Patient to a Hospital Stretcher Patient to a Hospital Stretcher
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Prehospital Lifting Prehospital Lifting
of Patients Video of Patients Video
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patients.
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Lifting and moving patients requires
planning, proper equipment, and careful
attention to body mechanics to prevent
injury to patient and yourself.
Emergency moves may aggravate spine
injuries and, therefore, are reserved for
life-threatening situations.
continued
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Urgent moves are used when the patient
must be moved quickly but there is time to
provide quick, temporary spinal
stabilization.
Non-urgent moves are normal ways of
moving a patient to a stretcher after
performing a complete on-scene
assessment.
Remember Remember
Proper lifting technique is important
wellness strategy.
Biomechanics and rules of lifting help
prevent injuries associated with lifting.
Many different patient-carrying devices
exist. Choose the correct device based
upon particular patient and needs of
particular movement.
continued
Remember Remember
Use proper technique to move patients
onto patient-carrying devices and position
them for transport based upon their
condition.
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Why are body mechanics so important
when lifting and moving patients?
Why is using the appropriate patient-
carrying device an important
consideration?
When would an emergency move be
necessary?
In what ways can proper positioning help a
patients condition?
You arrive at a vehicle crash and find an
elderly driver slumped over the wheel.
Upon examination you determine the
patient is in respiratory arrest, but not
trapped in the vehicle. Which move would
be appropriate for this patient?
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11
1112, 14, 1622, 24, 2632, 3435, 39
4.2 Describe your scope of practice as an EMT. Slides
1112
4.3 Differentiate between scope of practice and
standard of care. Slide 12
4.4 Given a variety of scenarios, determine which type
of patient consent applies. Slides 1619
continued
4.5 Given a variety of ethical dilemmas, discuss the
issues that must be considered in each situation.
Slides 13, 30
4.6 Explain legal and ethical considerations in situations
where patients refuse care. Slides 2023
4.7 Discuss the EMTs obligations with respect to
advance directives, including do not resuscitate
orders. Slide 24
continued
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4.8 Given a variety of scenarios, identify circumstances
that may allow a claim of negligence to be
established. Slides 2730
4.9 Explain the purpose of Good Samaritan laws. Slide
30
4.10 Identify situations that would constitute a breach of
patient confidentiality. Slide 32
continued
Objectives
continued
4.11 Identify situations that would constitute libel or
slander. Slide 32
4.12 Recognize medical identification devices and organ
donor status. Slides 3334
4.13 List items that may be considered evidence at a
crime scene. Slide 39
4.14 Describe ways in which you can minimize your
impact on evidence while meeting your obligations
to care for your patient. Slides 36, 38
4.15 Recognize situations that may legally require
reporting to authorities. Slide 39
4.16 Given a scenario involving an ethical challenge,
decide the most appropriate response for an EMT.
Slides 22, 4546
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Slide 14 Legal Issues in Healthcare Video
The scope of practice of an EMT
How a patient may consent to or refuse
emergency care
The legal concepts of negligence, torts,
and abandonment
What it means to have a duty to act
The responsibilities of an EMT at a crime
scene
CORE CONCEPTS
Topics Topics
Scope of Practice
Patient Consent and Refusal
Other Legal Issues
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Scope of Practice Scope of Practice
Scope of Practice Scope of Practice
Regulations and ethical considerations
that define extent or limits of job duties
May include skills and procedures
Determined by national, state, local laws,
statutes, and protocols
Standard of Care Standard of Care
Care expected from EMT with similar
training for patient in a similar situation
Meeting standard of care reduces risk of
legal action
Scope of practice: what you can do
Standard of care: how you should do it
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Ethics Ethics
Morals or standards governing actions
Not always required by law
Golden Rule standard
Very important in EMS
Good ethical behaviorwhat you do when
no one is looking
Legal Issues Legal Issues
in Health Care Video in Health Care Video
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Patient Consent and Refusal Patient Consent and Refusal
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Patient Consent Patient Consent
Permission from patient to assess, treat,
and transport
Expressed consent
Must be informed
Implied consent
Assumed consent
Follow local laws and protocols
Consent for Children Consent for Children
Minors not permitted to provide consent
for treatment
Obtain from parent or legal guardian
Possible exceptions (check local law)
In loco parentis
Emancipated minors
Life-threatening illness or injury
Minors who have children
Minors serving in armed forces
Consent for Consent for
Mentally Incompetent Adults Mentally Incompetent Adults
Adult patients incapable of informed
decisions about care
State and local laws and protocols permit
transport of such patients under implied
consent
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Involuntary Transportation Involuntary Transportation
Patient considered threat to self or others
Court order
Usually requires decision by mental health
professional or police officer
If patient restrained, must not risk legal
liability
Refusal of Care Refusal of Care
Patient may refuse care or transport
Legally able to consent
Mentally competent and oriented
Fully informed of risks
Sign release form
Despite all precautions, EMT may still be
held liable
If in Doubt About Refusal If in Doubt About Refusal
Discuss decision with patient
Ensure patient understands risks
Consult medical direction
Ask to contact family member
Contact law enforcement
Listen to patient to determine why refusing
care
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What are the risks of beginning treatment
and/or transport without getting consent
from the patient?
What if the patient refuses to sign the
refusal of care form?
Things to Things to
Consider During Refusal Consider During Refusal
Have witnesses to refusal
Inform patient that if changes mind, can
call back
If possible have friend or relative remain
with patient
Document, document, document
Advance Directives Advance Directives
Legal document expressing patients
wishes if patient unable to speak for self
Do not resuscitate order (DNR)
Living will
Health care proxy
Does not prevent EMT from providing
comfort measures
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Other Legal Issues Other Legal Issues
Duty to Act Duty to Act
Obligation to provide care
While on duty, EMT obligated to provide
care if no threat to safety
Duty to act not always clear
Off duty
On duty, out of jurisdiction
Follow local laws and protocols
Follow own conscience
Negligence Negligence
Something was not done, or was done
incorrectly
Must prove:
EMT had duty to act
Breach of dutyEMT failed to provide
standard of care expected or failed to act
Proximate causationpatient suffered harm
because of EMT action or inaction
continued
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Negligence Negligence
Negligent EMT may be required to pay
damages
Res ipsa loquitur (the thing speaks for
itself): legal concept important in
negligence cases
Abandonment Abandonment
Once care initiated, may not be
discontinued until transferred to medical
personnel of equal or greater training
Failure to do so may constitute
abandonment
Good Samaritan Laws Good Samaritan Laws
Grant immunity from liability if person acts
in good faith within level of training
Rarely applies to on-duty personnel
May not cover EMTs in some situations
Does not protect persons from gross
negligence or violations of law
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You arrive on the scene of a patient in
cardiac arrest. The family says she has a
DNR, but dont know where it is. How
should you handle this?
You are off duty and arrive on the scene of
a vehicle crash. Police and EMS have not
yet arrived. Are you legally obligated to
stop and render aid?
Confidentiality Confidentiality
Information on patients history, condition,
treatment considered confidential
Can be shared with other health care
personnel as part of patients continuing
care
Otherwise must be obtained through
subpoena
Medical Identification Devices Medical Identification Devices
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Organ Donor Organ Donor
Person with completed legal document
allowing donation of organs and tissues in
event of death
May be identified by family members,
donor card, drivers license
Receiving hospital and/or medical
direction should be advised per protocol
Safe Haven Laws Safe Haven Laws
Allow person to drop an infant or child at
any fire, police, or EMS station
States have different guidelines for ages of
children included
Protect children who may otherwise be
abandoned or harmed by parents unwilling
or unable to care for them
Crime Scenes Crime Scenes
Location where crime
was committed or
anywhere evidence may
be found
Once police have made
scene safe, EMTs
priority is patient care
Know what evidence is
Take steps to preserve
evidence
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Examples of Evidence Examples of Evidence
Condition of scene
Patient
Fingerprints and footprints
Microscopic evidence
Evidence Preservation Evidence Preservation
Remember what you touch
Minimize impact on scene
Work with police
If patient transported on your stretcher,
stretcher sheet may be valuable source of
evidence
Document thoroughly
Mandatory Mandatory
Reporting Guidelines Reporting Guidelines
Child, elderly, or domestic abuse
Sexual assault
Stab/gunshot wounds
Animal attacks
Check local laws and protocols
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Medical, legal, ethical issues part of every
EMS call.
Morals are how a person expresses
beliefs of right and wrong.
Consent may be expressed or implied
continued
If a competent patient refuses care or
transport, you should make every effort to
persuade him, but you cannot force him to
accept care or go to the hospital.
Negligence is failing to act properly when
you have a duty to act.
continued
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Abandonment is leaving a patient after you
have initiated care and before you have
transferred the patient to a person with
equal or higher training.
Remember Remember
EMTs must use good judgment and
decision-making skills when dealing with
patient consent and refusal.
Avoiding negligence implies using good
judgment; critical thinking is an essential
component for avoiding liability.
continued
Remember Remember
EMTs hold responsibility for patients
protected health information; exercising
care when dealing with this information is
a legal and ethical obligation.
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Define scope of practice, negligence, duty
to act, abandonment, and confidentiality.
What steps must you take when a patient
refuses care or transportation?
What types of evidence may be found at a
crime scene? How should you act to
preserve evidence?
You respond to a motor vehicle crash and
find a seriously injured patient. He has no
pulse and you are about to begin CPR
when someone says, Dont do that! Hes
got cancer and a DNR! No one has the
DNR at the scene. Do you start CPR and
transport the patient?
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11
12, 20, 31, 41, 48, 6573
5.2 Describe the importance of the proper use of
medical terminology. Slides 12, 1617
5.3 Apply definitions of common prefixes, suffixes, and
roots to determine the meaning of medical terms.
Slides 1215
continued
continued
5.4 Recognize the meaning of acronyms and
abbreviations commonly used in EMS. Slide 16
5.5 Give examples of when it is better to use a common
or lay term to describe something than it is to use a
medical term. Slide 17
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5.6 Use anatomical terms of position and direction to
describe the location of body structures and position
of the body. Slides 2229
5.7 Utilize topographical anatomical landmarks as
points of reference. Slide 24
continued
continued
5.8 Describe the structures and functions of each of the
following body systems: musculoskeletal,
respiratory, cardiovascular, nervous, digestive,
integumentary, endocrine, renal, and male and
female reproductive. Slides 3173
5.9 Given a series of models or diagrams, label the
anatomical structures of each of the following body
systems: skeletal, respiratory, cardiovascular,
nervous, skin, endocrine, renal/urinary, and male
and female reproductive. Slides 3238, 41, 4952,
6566, 6870, 7273
continued
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5.10 Describe differences in the respiratory anatomy of
children as compared to adults. Slides 47
5.11 Apply understanding of anatomy and physiology to
explain the function of the life support chain. Slide
20
Slide 17 Medical Term Components Video
Slide 18 Terms Involved With Medical Specialties Video
Medical terminology and how terms are
constructed
Directional terms
Positional terms
The structure and function of major body
systems
CORE CONCEPTS
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Topics Topics
Medical Terminology
Anatomy and Physiology
Anatomical Terms
Body Systems
Medical Terminology Medical Terminology
Components of Medical Terms Components of Medical Terms
Words made from parts
Root: pnea, arthr
Root with combining form: therm-o + meter =
thermometer
Prefix: dys-pnea, tachy-pnea
Suffix: arthr-itis, hemophil-iac
Compounds of two or more words:
smallpox
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Word Component Example Word Component Example
tachy (fast) cardia (heart)
tachycardia (fast heart rate)
hemo (blood) thorax (chest)
hemothorax (blood in chest cavity)
cardio
(heart)
ology
(study of)
ist
(specialist)
cardiologist
(doctor specializing in cardiac care)
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Acronyms and Abbreviations Acronyms and Abbreviations
Acronym: abbreviation made up of initials
that can be pronounced as a word
CPAP (see-pap): Continuous Positive Airway
Pressure
Abbreviation: letters or symbols used in
place of words or phrases
DNR: Do Not Resuscitate
Medical Term Medical Term
Components Video Components Video
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Terms Involved Terms Involved
With Medical Specialties Video With Medical Specialties Video
Click here to view a video on the topic of terms involved with medical
specialties.
Back to Directory
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Anatomy and Physiology Anatomy and Physiology
Anatomystudy of body structure
Physiologystudy of body function
Anatomical Terms Anatomical Terms
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Anatomical Position Anatomical Position
Facing forward,
hands at sides, palms
facing forward
Anatomical Planes Anatomical Planes
Abdominal Quadrants Abdominal Quadrants
Horizontal and vertical
lines through navel
Right upper quadrant
(RUQ)
Left upper quadrant
(LUQ)
Right lower quadrant
(RLQ)
Left lower quadrant (LLQ)
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Positional Terms Positional TermsSupine Supine
Positional Terms Positional TermsProne Prone
Positional Terms Positional Terms
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Fowler/Semi Fowler/Semi--Fowler Position Fowler Position
Trendelenburg Position Trendelenburg Position
Body Systems Body Systems
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Musculoskeletal System Musculoskeletal System
Gives body shape
Protects body organs
Allows for movement
Skeletal System Skeletal System
Extends into all
parts of body
Consists of skull
and spine, ribs and
sternum, shoulders
and upper
extremities, pelvis
and lower
extremities
Skull Skull
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Spinal Column Spinal Column
Thoracic Cavity Thoracic Cavity
Pelvis Pelvis
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Lower Extremities Lower Extremities
Upper Extremities Upper Extremities
Joints Joints
Ball-and-socket joint Hinge joint
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Muscle Muscle
Voluntary (skeletal)
Involuntary
(smooth)
Cardiac
Respiratory System Respiratory System
Brings in oxygen via inhalation
Excretes carbon dioxide via exhalation
Respiratory Physiology Respiratory Physiology
Inhalation (active process)
Diaphragm and intercostal muscles contract;
diaphragm moves downward
Negative pressure pulls air into lungs
Exhalation (passive process)
Diaphragm and intercostal muscles relax
Positive pressure pushes air out of lungs
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Inhalation Inhalation
Exhalation Exhalation
Ventilation and Respiration Ventilation and Respiration
Ventilation: movement of gases to and
from alveoli
Respiration: exchange of gases between
cells and bloodstream
continued
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Ventilation and Respiration Ventilation and Respiration
Oxygenated blood travels from lungs to
heart, then is pumped to rest of the body
At capillary level, oxygen (O
2
) is
exchanged with cells for waste carbon
dioxide (CO
2
)
Deoxygenated blood returns to the heart,
then to lungs to exchange waste CO
2
for
O
2
Pediatric Differences: Pediatric Differences:
Cardiovascular System Cardiovascular System
Heart
Blood
Circulatory system
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Heart Heart
Conduction System Conduction System
Coronary Arteries Coronary Arteries
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Circulation of the Blood Circulation of the Blood
Composition of the Blood Composition of the Blood
Plasma
More than half of bloods volume
Red blood cells
RBCs, erythrocytes, red corpuscles
White blood cells
WBCs, leukocytes, white corpuscles
Platelets
Help with clotting
Pulse Pulse
Wave of blood flowing down an artery
when the left ventricle contracts
Can be felt when an artery is near the
surface of the skin and over a bone
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Peripheral and Central Pulses Peripheral and Central Pulses
Peripheral (outer parts of body)
Radial
Brachial
Posterior tibial
Dorsalis pedis
Central (core of body)
Carotid
Femoral
Central Pulses Central Pulses
Pulses near the center or core of the body
Carotid
Femoral
Carotid pulse should be used to determine
pulselessness rather than a peripheral
pulse
Carotid Pulse Carotid Pulse
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Brachial Pulse Brachial Pulse
Radial Pulse Radial Pulse
Femoral Pulse Femoral Pulse
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Dorsalis Pedis Pulse Dorsalis Pedis Pulse
Blood Pressure Blood Pressure
Pressure inside
arteries
Systolic (upper
reading)arterial
pressure when left
ventricle contracts
Diastolic (lower
reading)pressure
when left ventricle
refills
Perfusion Perfusion
Adequate circulation of blood and
exchange of oxygen and waste products
Hypoperfusion (shock): when flow
becomes inadequate
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How is the function of the respiratory
system related to the function of the
circulatory system?
Central Nervous System Central Nervous System
Brain
Spinal cord
Peripheral Nervous System Peripheral Nervous System
Sensory
Messages from
body to brain
Motor
Messages from
brain to body
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Digestive System Digestive System
Integumentary Integumentary
System SystemFunctions Functions
Integumentary System Integumentary SystemLayers Layers
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Endocrine System Endocrine System
Renal System Renal System
Helps body regulate fluid levels,
chemicals, and pH levels
Kidneys
Bladder
Ureters
Urethra
Male Reproductive System Male Reproductive System
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Female Reproductive System Female Reproductive System
continued
Medicine has a language of its own. You
will frequently communicate with medical
professionals who speak this language.
Medical terms generally consist of a root
with a prefix and/or suffix.
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Your knowledge of the anatomy, or
structure, and the functions, or physiology,
of the body will be important in allowing
you to assess your patient and
communicate your findings with other EMS
personnel and hospital staff accurately
and efficiently.
continued
Major body systems with which you should
be familiar are musculoskeletal,
respiratory, cardiovascular, nervous,
digestive, integumentary, endocrine, renal,
and reproductive.
Remember Remember
Medical terminology is the language of
health care. Roots, prefixes, and suffixes
can lend clues to the meaning of many
terms.
Understanding anatomy and physiology is
like reviewing the owners manual for the
body.
continued
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Remember Remember
Anatomical terminology brings precision
and accuracy to descriptions.
Understanding an overview and the basic
function of body systems will improve both
assessment and treatment of patients.
Is my use of medical terms accurate and
descriptive?
Can I identify critical organs and structures
that reside in an area where a patient has
a complaint or traumatic injury?
You respond to a teenage boy who has
taken a hard fall from his dirt bike. He has
a deep gash on the outside of his left arm
halfway between shoulder and elbow and
another on the inside of his right arm just
above the wrist. His left leg is bent at a
funny angle about halfway between hip
and knee.
continued
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When you cut away his pants leg, you see
a bone sticking out of a wound on the front
side. How will you describe your patients
injuries over the radio to the hospital staff?
11
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11, 15, 17, 26, 27, 31, 33, 37, 4042, 44, 45, 51, 58
6.2 Describe the basic roles and structures of body
cells. Slides 1320
6.3 Describe the roles of water, glucose, and oxygen in
the cell. Slides 1418
continued
continued
6.4 Describe conditions that can threaten
cardiopulmonary function. Slides 2630, 3334, 37,
4244
6.5 Explain how impaired cardiopulmonary function
affects the body. Slides 2630, 3334, 37, 4244
6.6 Discuss the mechanisms the body uses to
compensate for impaired cardiopulmonary function.
Slides 31, 37, 42
6.7 Explain the pathophysiology of shock. Slide 45
6.8 Identify signs and symptoms that indicate the body
is attempting to compensate for impaired
cardiopulmonary function. Slide 46
6.9 Describe ways in which the bodys fluid balance can
become disrupted. Slide 50
continued
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6.10 Recognize indications that the bodys fluid balance
has been disrupted. Slide 51
6.11 Describe ways in which the nervous system may be
impaired. Slide 52
6.12 Recognize indications that the nervous system may
be impaired. Slide 53
continued
6.13 Describe the effects on the body of endocrine
dysfunction, digestive system dysfunction, and
immune system dysfunction. Slides 55, 5758
Slide 20 Cell Structure Video
Slide 47 Transport of Carbon Dioxide Animation
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The cell, cellular metabolism, and results
of the alteration of cellular metabolism
The respiratory system and the
importance of oxygenation and ventilation
The cardiovascular system and the
movement of blood
CORE CONCEPTS
continued
The principles of perfusion, hypoperfusion,
and shock
Disrupted physiology of major body
systems
CORE CONCEPTS
Topics Topics
The Cell
The Cardiopulmonary System
Pathophysiology of Other Systems
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Introduction to Pathophysiology Introduction to Pathophysiology
Study of how disease processes affect
function of body
Understanding helps you recognize
changes patient is going through due to
illness or injury
The Cell The Cell
Structure of the Cell Structure of the Cell
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ATP ATP
Mitochondria convert glucose and other
nutrients into adenosine triphosphate
(ATP)
ATPfuel for cell functions
Without ATP many of the cells specialized
structures cannot function
Water and the Cell Water and the Cell
Cells need the correct balance of water
inside and outside
Too little water: cell dehydrated and dies
Too much water: cell systems dont work
properly
Water also affects levels of electrolytes
Impacts electrical functions
Draw an analogy between cell metabolism
and how a refinery turns crude oil into
gasoline for use in automobiles.
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Oxygen and the Cell Oxygen and the Cell
Aerobic metabolismcellular functions
using oxygen
Anaerobic metabolismcellular functions
not using oxygen
Creates much less energy and much more
waste
Body becomes acidic, impairing many body
functions
continued
Oxygen and the Cell Oxygen and the Cell
Cell Membrane Cell Membrane
Many diseases alter the permeability of
membrane
Negatively impacts membranes ability to
transfer fluids, electrolytes, and other
substances in and out
Also allows toxins to enter cell
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Cell Structure Video Cell Structure Video
Click here to view a video on the subject of cell structure.
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The Cardiopulmonary System The Cardiopulmonary System
Cardiopulmonary System Cardiopulmonary System
Respiratory and cardiovascular systems
work together
Bring oxygen into body
Distribute to cells
Remove waste products
Any breakdown can result in system
failure
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Airway Airway
continued
Airway Airway
continued
Airway Airway
Must have an open (patent) airway for
system to function
Upper airway obstructions are common
Caused by foreign bodies, infection, and
trauma
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The Lungs The Lungs
Part of lower airway
Tidal volumevolume of air moving in and
out during each breath cycle
Tidal volume x respiratory rate = minute
volume
Amount of air moved in and out of lungs in
one minute
continued
The Lungs The Lungs
Any change in tidal volume or respiratory
rate reduces minute volume
Respiratory dysfunction occurs any time
something interferes with minute volume
Disruption of Disruption of
Respiratory Control Respiratory Control
Respirations controlled in brain by the
medulla oblongata
Any event impacting function of the
medulla oblongata can affect minute
volume
Infection, drugs, toxins, trauma
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Disruption of Pressure Disruption of Pressure
If wall of thorax is compromised
(punctures, rib fractures), ability to inhale
and exhale is impacted and minute volume
is reduced
Air or blood accumulating in chest (pleural
space) also compromises respiration
Disruption of Lung Tissue Disruption of Lung Tissue
Trauma or medical problems can
compromise the ability of alveoli to
exchange gases
Less O
2
gets in, less CO
2
gets out
Can result in low oxygen levels (hypoxia)
and high carbon dioxide levels
(hypercapnia)
Respiratory Compensation Respiratory Compensation
Body attempts to compensate for changes
Chemoreceptors detect changing O
2
and
CO
2
levels
Brain stimulates respiratory system to
increase rate and/or tidal volume
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The Blood The Blood
Four parts
Plasma (liquid)
Red blood cells (contain oxygen-carrying
hemoglobin)
White blood cells (fight infection)
Platelets (form clots)
continued
The Blood The Blood
Plasma oncotic pressureproteins in
plasma attract water away from cells and
into bloodstream
Hydrostatic pressurewater pushed back
out of bloodstream
Problems with these proteins can cause
an imbalance
Blood Dysfunction Blood Dysfunction
Less blood (hypovolemia), less gas
exchange
Fewer red blood cells (anemia), less gas
exchange
Fewer water-retaining proteins, less
volume
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Blood Vessels Blood Vessels
continued
Take oxygenated blood from lungs via
heart to capillaries
Where gas exchange takes place
(between cells and capillaries)
Return blood to lungs via heart for gas
exchange (between capillaries and alveoli)
continued
Need adequate pressure to make cycle
work
Pressure controlled by changing diameter
of blood vessels
Stretch receptors monitor pressure
Pressure can be increased or decreased
depending on situation
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Blood Vessel Dysfunction Blood Vessel Dysfunction
Loss of tone
Vessels lose ability to constrict and dilate
Pressure drops
Causes: trauma, infection, allergic reaction
continued
Permeability
Capillaries leak
fluid out their walls
Caused by severe
infection (sepsis)
and certain
diseases
continued
Systemic vascular resistance (SVR)
pressure inside vessels
Various conditions lead to abnormal
constriction of vessels, leading to
dangerously high pressures (hypertension)
Major risk factor in stroke and heart
disease
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The Heart The Heart
Pump with stroke volume (output) of about
60 ml blood per contraction
Stroke volume is based on:
Preloadamount of blood returning to heart
Contractilityhow hard heart squeezes
Afterloadpressure in vessels (SVR)
Cardiac Output Cardiac Output
Stroke volume x beats per minute =
cardiac output
Slowing heart rate or decreasing stroke
volume reduces cardiac output
Rapid heart rates reduce cardiac output
Inadequate time for heart to refill between
contractions
Heart Dysfunction Heart Dysfunction
Mechanical problems
Physical trauma
Squeezing forces
Cell death (heart attack)
Electrical problems
Damage to hearts ability to regulate rate
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V/Q Match V/Q Match
Entire cardiopulmonary system must work
together to maintain life
Must be a balance between ventilation (V)
and perfusion (Q) for system to work
properly
Any breakdown in system impacts ratio
causing possible life-threatening situation
Shock Shock
Perfusionregular delivery of oxygen and
nutrients to cells and removal of waste
products
Hypoperfusionbreakdown in system
Can result in death of patient
Recognizing Compensation Recognizing Compensation
When problems arise, body attempts to
compensate
Signs of compensation:
Increased heart rate
Increased respiratory rate
Dilated pupils
Pale, cool, clammy skin
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Transport of Transport of
Carbon Dioxide Animation Carbon Dioxide Animation
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carbon dioxide.
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Pathophysiology of Other Pathophysiology of Other
Systems Systems
Fluid Balance Fluid Balance
Body is 60% water
Intracellular (70%)
Intravascular (5%)
Interstitial (25%)
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Fluid Regulation Fluid Regulation
Brain controls thirst
Kidneys control elimination of fluid
Blood plasma proteins pull fluid into the
bloodstream
Cell membrane and capillary permeability
regulate flow in and out
Fluid Disruption Fluid Disruption
Fluid loss (dehydration)
Decrease in total water volume
Fluid distribution
Water not getting to where its needed
Edema
Too much water in some parts of the body
Nervous System Nervous System
Brain and spinal cord are well-protected by
skull and spine
Covered by several protective layers
(meninges) and a layer of shock-absorbing
fluid (cerebrospinal fluid)
Still subject to damage from trauma or
disease
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Nervous System Dysfunction Nervous System Dysfunction
Trauma causes
Penetrating trauma to head
Damage to spine
Swelling tissue has no room
Medical causes
Strokes
Infection (meningitis, encephalitis)
Disease (Lou Gehrigs disease, MS)
Low blood sugar (hypoglycemia)
Endocrine System Endocrine System
Glands secrete hormones
Hormones send chemical messages to the
body to control body functions
Major organs of system:
Brain
Kidney
Pancreas
Pituitary
Thyroid, adrenal glands
Endocrine Dysfunction Endocrine Dysfunction
Organ or gland problems
Present at birth or result of illness
Too many hormones
Hyperthyroidism (too much thyroid hormone)
Problems with heart rate and temperature
regulation
Too few hormones
Diabetes
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Digestive System Dysfunction Digestive System Dysfunction
Impacts hydration levels and nutrient
transfer
Gastrointestinal (GI) bleeding
Can be slow; chronic bleeding
Can be massive, with rectal bleeding and/or
vomiting blood
continued
Digestive System Dysfunction Digestive System Dysfunction
Vomiting and diarrhea
Most common disorders
Variety of causes
May result in malnutrition and dehydration
Immune System Dysfunction Immune System Dysfunction
Hypersensitivity
Allergic reaction to certain food, drugs, other
substances
Result of exaggerated immune response
Chemicals affect more than just invader
Edema
Drop in blood pressure
Can be life-threatening
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continued
Pathophysiology allows us to understand
how negative forces impact the normal
function of the body.
Pathophysiology helps us understand how
common disorders cause changes in the
body.
Understanding how the body compensates
for insults sheds light on the signs and
symptoms we may see during
assessment.
Understanding what compensation looks
like helps us rapidly identify potentially life
threatening problems.
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Remember Remember
Cellular metabolism requires a constant
supply of oxygen and glucose. Absence of
either component disrupts normal
metabolism.
Cardiopulmonary system combines the
functions of respiratory and cardiovascular
systems to provide oxygen at the cellular
level.
continued
continued
Remember Remember
Shock occurs when the cardiopulmonary
system fails and cells become
hypoperfused.
The body is composed primarily of water,
and this fluid is distributed throughout the
body systems.
When evaluating a patient with a cardiac
problem, consider the impact on the
respiratory system. When evaluating a
patient with a respiratory problem,
consider the impact on the cardiovascular
system. What impacts do problems in
these systems have on each other?
continued
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Shock must be recognized immediately.
What is the pathophysiology of shock?
You are treating a patient who was
recently released from the intensive care
unit with a massive infection (sepsis). This
has impaired the patients ability to
regulate the size of the blood vessels.
continued
How might this affect the patients ability to
compensate for any additional illnesses?
What steps should you take to help this
patient compensate?
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11
9, 11, 14, 16, 20, 23, 27, 32, 35, 38
7.2 Describe the physical and psychological
characteristics, including normal vital signs, for
individuals in each of the following age groups:
Infant, Toddler, Preschool Age, School Age,
Adolescent, Early Adult, Middle Adult, and Late
Adult. Slides 913, 18, 22, 25, 29, 34, 37, 40
continued
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7.3 Describe the typical psychosocial characteristics
and concerns of individuals at each stage during the
life span. Slides 14, 19, 22, 25, 30, 34, 37, 40
7.4 Use knowledge of physical, physiological, and
psychosocial development to anticipate the needs
and concerns of patients of all ages. Slides 914,
1819, 22, 25, 2931, 34, 37, 40
Slide 15 Growth and Development: Major Life
TransitionInfant Video
Slide 26 School-aged Children Health Promotion Video
Slide 41 Cognitive Function of Older Adults Video
The physiological (physical) characteristics
of different age groups from infancy
through late adulthood
The psychosocial (mental and social)
characteristics of different age groups from
infancy through late adulthood
CORE CONCEPTS
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Topics Topics
Infancy (Birth to 1 Year)
Toddler Phase (1236 Months)
Preschool Age (35 Years)
School Age (612 Years)
Adolescence (1318 Years)
Early Adulthood (1940 Years)
Middle Adulthood (4160 Years)
Late Adulthood (61 Years and Older)
Infancy (Birth to 1 Year) Infancy (Birth to 1 Year)
Infancy (Birth to 1 Year) Infancy (Birth to 1 Year)
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Physiological Characteristics Physiological Characteristics
3.03.5 kg (6.67.7 lb) at birth
Weight doubles by 6 months; triples by 12
months
Head 25% of body weight
Airway narrow; easily obstructed
Nose and diaphragm used for breathing
continued
continued
Antibodies passed from mother to child in
pregnancy
Antibodies also passed through
breastfeeding
Moro reflex (startle)
Throws arms out, spreads fingers, grabs with
fingers and arms
Palmar reflex
Grasps objects placed in palm
Rooting reflex (hunger)
Turns toward side of head touched
continued
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Sucking reflex
Sucks when lips are stroked
Sleep patterns
Begin to regulate after 24 months
Then sleeps through night
Extremities grow from a combination of
growth plates and epiphyseal plates
continued
Fontanelles not fused at birthstill soft
until 918 months
Sunken fontanelles: indicate dehydration
Bulging fontanelles: indicate increased
pressure inside skull
Psychosocial Characteristics Psychosocial Characteristics
Bonding
Trust vs. mistrust
Scaffolding
Temperament
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Growth and Development: Growth and Development:
Major Life Transition Major Life TransitionInfant Video Infant Video
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development.
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Toddler Phase (12 Toddler Phase (1236 Months) 36 Months)
Toddler Phase (12 Toddler Phase (1236 Months) 36 Months)
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Pulmonary system
Nervous system
Musculoskeletal system
Immune system
Teeth
Begins to understand
cause and effect
Highly curious and
investigating
Separation anxiety
Begins to develop
magic thinking,
imagination, and
ability to role play
Preschool Age (3 Preschool Age (35 Years) 5 Years)
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Preschool Age (3 Preschool Age (35 Years) 5 Years)
Physiological and Physiological and
Physiological
Body systems continue to develop
Psychosocial
Developing interactive and social skills
School Age (6 School Age (612 Years) 12 Years)
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School Age (6 School Age (612 Years) 12 Years)
Physiological
Loss of baby teeth
Psychosocial
Less general supervision
Developing decision-making skills
More awareness of self-esteem
Values opinions of peers (positive or negative)
School School--Aged Children Aged Children
Health Promotion Video Health Promotion Video
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lifestyle in school-age children.
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6/28/2011
138
Adolescence (13 Adolescence (1318 Years) 18 Years)
Adolescence (13 Adolescence (1318 Years) 18 Years)
Growth spurt
Sexual maturity
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Strives for independence
Concern about body image and peer
pressure
May be prone to self-destructive behaviors
Developing personal code of ethics
Adolescents are often injured because of
risk taking
May be resistant to disclose what
happened
Must be encouraged to explain
circumstances surrounding an incident
Early Adulthood (19 Early Adulthood (1940 Years) 40 Years)
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Early Adulthood (19 Early Adulthood (1940 Years) 40 Years)
Physiological
Lifelong habits formed
Reaches peak physical condition
Psychosocial
Job and family stress
Marriage, childbirth, child rearing
Accidents leading cause of death
Middle Adulthood Middle Adulthood
(41 (4160 Years) 60 Years)
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Middle Adulthood Middle Adulthood
(41 (4160 Years) 60 Years)
Physiological
May need vision correction
Cancer, heart disease often develop
Weight control more difficult
Psychosocial
Empty-nest syndrome
Caring for elderly parents
Late Adulthood Late Adulthood
(61 Years and Older) (61 Years and Older)
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Late Adulthood Late Adulthood
(61 Years and Older) (61 Years and Older)
Physiological
Body systems less efficient
Psychosocial
Living environment
Self-worth
Financial burdens
Death and dying
Cognitive Function Cognitive Function
of Older Adults Video of Older Adults Video
Click here to view a video on the subject of cognitive function of
older adults.
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6/28/2011
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Understanding basic physiological and
psychosocial development for each age
group will assist you in communicating
with and assessing patients of various
ages.
continued
Physiological differences between ages
will affect your care (for example:
differences in respiratory systems; effects
of pre-existing conditions).
Infants and young children have less-
developed, smaller respiratory structures
which can worsen respiratory conditions.
continued
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Communicating with patients will depend
on their stage of development: could be
fear of strangers, separation anxiety,
embarrassment, denial, depression.
Remember Remember
Infants present massive bursts of
anatomical and psychosocial development
in the first year of life.
Although preschoolers begin to develop
independence and reason, in many ways
they still resemble the psychosocial
development of toddlers.
continued
Remember Remember
School-age children often are independent
and logical, but that may crumble with
illness or injury.
Adolescents are reaching physiological
maturity, but they often face difficult
psychosocial challenges.
continued
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Remember Remember
Early, middle, and late adults vary greatly
in terms of physiological development and
conditioning; they also face psychosocial
challenges unique to adulthood.
How do I approach a patient most
effectively based on developmental
characteristics?
Does the age of my patient pose any
assessment or care challenges based on
physiologic development?
You are called for abdominal pain in a 16-
year-old girl. She is with friends at the
park. She seems hesitant to answer any of
your questions. What characteristic of
adolescent development is most likely the
cause of this? How could you overcome
it?
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11
1215, 21, 24, 31-34, 39, 40, 54
8.2 Describe the anatomy and physiology of the upper
and lower airways. Slides 1216
8.3 Given a diagram or model, identify the structures of
the upper and lower airways. Slides 13, 15
continued
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147
8.4 Describe common pathophysiologic problems
leading to airway obstruction. Slides 1821
8.5 Demonstrate assessment of the airway in a variety
of patient scenarios. Slides 2226
8.6 Associate abnormal airway sounds with likely
pathophysiologic causes. Slide 24
continued
8.7 Identify patients who have an open airway but who
are at risk for airway compromise. Slide 23
8.8 Recognize patients who have an inadequate airway.
Slide 25
continued
continued
8.9 Demonstrate manually opening the airway in
pediatric and adult medical and trauma patients:
head-tilt, chin-lift maneuver, jaw-thrust maneuver.
Slides 3134
8.10 Describe the indications, contraindications, use, and
potential complications of airway adjuncts, including
oropharygneal airway and nasopharyngeal airway.
Slides 3952
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8.11 Recognize the indications for suctioning of the
mouth and oropharynx. Slide 54
8.12 Describe risks and limitations associated with
suctioning the mouth and oropharynx. Slides 5862,
6667
continued
8.13 Demonstrate the following airway management
skills: inserting an oropharyngeal airway; inserting a
nasopharyngeal airway; suctioning the mouth and
oropharynx. Slides 4547, 5152, 6567
8.14 Describe modifications in airway management for
pediatric patients, patients with facial trauma, and
patients with airway obstruction. Slides 7480
Slide 27 Responding to an Adult with an Obstructed
Airway Video
Slide 68 SuctioningOral Pharyngeal Video
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CORE CONCEPTS
Physiology of the airway
Pathophysiology of the airway
How to recognize an adequate or an
inadequate airway
How to open an airway
How to use airway adjuncts
Principles and techniques of suctioning
Topics Topics
Airway Physiology
Airway Pathophysiology
Opening the Airway
Airway Adjuncts
Suctioning
Keeping an Airway Open: Definitive Care
Special Considerations
Airway Physiology Airway Physiology
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Upper Airway Upper Airway
Begins at mouth and nose
Air is warmed and humidified in nasal
turbinates
Pharynx
Oropharynx, nasopharynx, and
laryngopharynx
Ends at glottic opening
continued
Upper Airway Upper Airway
Lower Airway Lower Airway
Begins at glottic opening
Trachea
Bronchial passages
Alveoli
continued
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Lower Airway Lower Airway
Alveoli Alveoli
Tiny sacs in grapelike bunches at the end
of the airway
Surrounded by pulmonary capillaries
Oxygen and carbon dioxide diffuse
through pulmonary capillary membranes
Airway Airway Pathophysiology Pathophysiology
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Airway Obstructions Airway Obstructions
Variety of obstructions interfere with air
flow
Foreign bodies: food, small toys
Liquids: blood, vomit
Obstruction may result from poor muscle
tone caused by altered mental status
continued
Obstructions can be acute or chronic
Providers must initially evaluate airway
and monitor patency over time
continued
Acute
Foreign bodies
Vomit
Blood
Occurring over time
Edema from burns, trauma, or infection
Decreasing mental status
continued
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Bronchoconstriction
Disorder of lower airway
Smooth muscle constricts internal diameter of
airway
Airway Assessment Airway Assessment
Addressed in primary assessment
Two questions must be answered
Is airway open?
Will airway stay open?
Will Airway Stay Open? Will Airway Stay Open?
Airway assessment is not just a moment in
time
Must give constant consideration
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Findings Indicating Findings Indicating
Airway Problems Airway Problems
Inability to speak
Unusual raspy quality to voice
Stridor
Snoring
Gurgling
Signs of Inadequate Airway Signs of Inadequate Airway
Foreign bodies in airway
No air felt or heard (air exchange below
normal)
Absent or minimal chest movements
Abdominal breathing
Pediatric Airway Assessment Pediatric Airway Assessment
Retractions
Nasal flaring
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Responding to an Adult Responding to an Adult
with an Obstructed Airway Video with an Obstructed Airway Video
Click here to view a video on the subject of obstructed airway
in an adult.
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Opening the Airway Opening the Airway
Patient Care: Patient Care:
Airway Management Airway Management
When primary assessment indicates
inadequate airway, a life-threatening
condition exists
Take prompt action to open and the
maintain airway
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Open Airway Open Airway
If airway is not open, use position to open
it
Head-tilt, chin-lift maneuver and jaw-thrust
maneuver move airway structures into
position allowing air movement
Head Head--Tilt Tilt
Chin Chin--Lift Maneuver Lift Maneuver
Performing Head Performing Head--Tilt Tilt
Chin Chin--Lift Maneuver Lift Maneuver
1. Place one hand on forehead and
fingertips of other hand under patients
lower jaw
2. Tilt head
3. Lift chin
4. Do not allow mouth to close
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Jaw Jaw--Thrust Maneuver Thrust Maneuver
Performing Performing
Jaw Jaw--Thrust Maneuver Thrust Maneuver
1. Place one hand on each side of patients
lower jaw at angles of jaw below ears
2. Using index fingers, push angles of
patients lower jaw forward
3. Do not tilt or rotate patients head
Airway Management Airway Management
After airway has been opened, position
must be maintained to keep airway open
Airway must be cleared of secretions and
other obstructions
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Pediatric Note: Pediatric Note:
Infants and small children often have
larger occipital regions of their heads
Lying flat may cause hyperflexion of neck
and airway occlusion
Evaluate need to pad behind patients
shoulders to achieve neutral airway
position
continued
Airway Adjuncts Airway Adjuncts
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Airway position and maneuvers are short-
term solutions
Airway adjunct provides longer term air
channel
Two most common airway adjuncts:
Oropharyngeal airway (OPA)
Nasopharyngeal airway (NPA)
Rules for Using Rules for Using
Use OPA only on patients not exhibiting
gag reflex
Open patients airway manually before
using adjunct device
When inserting airway, take care not to
push patients tongue into pharynx
continued
Have suction ready
Do not continue inserting airway if patient
gags
Maintain head position after adjunct
insertion
continued
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Patient may regain consciousness
Be prepared to remove adjunct and have
suction ready
Use infection control practices while
maintaining airway
Oropharyngeal Airway Oropharyngeal Airway
Device used to move tongue forward as it curves
back to pharynx
Sizes: infant to large adult
Sizing Oropharyngeal Airways Sizing Oropharyngeal Airways
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Inserting OPA Inserting OPA
Open mouth with crossed-finger technique
Position airway with tip pointing toward
roof of mouth
continued
1. Insert until you meet resistance
2. Gently rotate airway 180so tip is
pointing down into pharynx
3. Check that flange of airway is against lips
4. Monitor patient closely
Use tongue depressor or rigid suction tip
and insert OPA directly
Do not rotate into place
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Nasopharyngeal Airway Nasopharyngeal Airway
Soft, flexible tube inserted through nostril
and into hypopharynx
Moves tongue and soft tissue forward to
provide a channel for air
continued
Can be used in patients with intact gag
reflex or clenched jaw
Contraindicated if clear (cerebrospinal)
fluid coming from nose or ears
continued
Come in various
sizes
Must be measured
Typical adult sizes:
34, 32, 30, and 28
French
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Inserting NPA Inserting NPA
1. Lubricate outside of tube with water-
based lubricant before insertion
continued
Inserting NPA Inserting NPA
2. Push tip of nose upward; keep head in
neutral position
3. Insert into nostril;
advance until
flange rests firmly
against nostril
Suctioning Suctioning
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Patient Care: Suctioning Patient Care: Suctioning
Obvious liquids (blood, secretions, vomit)
must be removed from airway to prevent
aspiration into lungs
Use vacuum device to remove liquids from
airway
Components of Suction Unit Components of Suction Unit
Suction source
Collection container
Tubing
Suction tips or catheters
Suction Systems Suction Systems
Fixed or portable
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Suction Device Requirements
Must furnish air
intake of at least 30
Lpm at open end of
collection tube
Must generate
vacuum of no less
than 300 mmHg
when collecting tube
is clamped
Rigid Pharyngeal Suction Tip Rigid Pharyngeal Suction Tip
Also called Yankauer Tip
Larger bore than flexible catheters
continued
Rigid Pharyngeal Suction Tip Rigid Pharyngeal Suction Tip
Suction only as far as you can see
Do not lose sight of distal end
Careful insertion helps prevent gag reflex
or vagal stimulation
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Flexible Suction Catheter Flexible Suction Catheter
Designed to be used when a rigid tip
cannot be used
Can be passed through a tube such as the
nasopharyngeal or endotracheal tube
Can be used for suctioning the
nasopharynx
continued
Come in various sizes identified by a
number French
Larger the number, larger the catheter
continued
Not typically large enough to suction
vomitus or thick secretions
May kink
In event of copious, thick secretions
consider removing tip or catheter and
using large bore, rigid suction tubing
continued
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Measured in similar way as OPA
Length of catheter that should be inserted
into patients mouth equals distance
between corner of patients mouth and
earlobe
Measuring Flexible Suction Measuring Flexible Suction
Catheter Catheter
Suctioning Techniques
Use appropriate infection control
practices while suctioning
Protective eyewear, mask,
disposable gloves
continued
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Suctioning Techniques Suctioning Techniques
Suction no longer than 10 seconds at a
time
Prolonged suctioning can cause hypoxia
and bradycardia
If patient vomits for longer than 10
seconds, continue suction
continued
Suctioning Techniques Suctioning Techniques
Place tip or catheter where you want to
begin suctioning
Suction on the way out
Suctioning Suctioning
Oral Pharyngeal Video Oral Pharyngeal Video
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Keeping an Airway Open: Keeping an Airway Open:
Definitive Care Definitive Care
Keeping an Keeping an
Airway Open: Definitive Care Airway Open: Definitive Care
Keeping the airway open may exceed
capabilities of a basic EMT
Medications and/or surgical procedures
may be necessary to resolve airway
obstruction
continued
Keeping an Keeping an
Airway Open: Definitive Care Airway Open: Definitive Care
Rapidly evaluate and treat airway
problems
Quickly recognize when more definitive
care is necessary
May be advanced life support intercept
May be closest hospital
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If you were not able to manage an airway
at the basic level, what advanced
resources might be available to you?
Special Considerations Special Considerations
Facial Injuries Facial Injuries
Frequently result in severe swelling or
bleeding that may block or partially block
airway
Bleeding may require frequent suctioning
or more definitive airway
6/28/2011
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Obstructions Obstructions
Many suction units are not adequate for
removing solid objects
Objects may have to be removed with
manual techniques: abdominal thrusts,
chest thrusts, finger sweeps
Dental Appliances Dental Appliances
Leave in place during airway procedures
when possible
Partial dentures may become dislodged
during an emergency
Be prepared to remove if airway
endangered
Pediatric Patients Pediatric Patients
Present a variety of anatomical differences
to consider when managing the airway
6/28/2011
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Pediatric Pediatric
Anatomical Considerations Anatomical Considerations
Smaller mouth and nose
Larger tongue
Narrow, flexible trachea
continued
Pediatric Pediatric
Anatomical Considerations Anatomical Considerations
Pediatric Pediatric
Management Considerations Management Considerations
Open airway gently
Do not hyperextend neck
Consider adjuncts when other measures
fail
Use rigid tip with adjunct, but do not touch
back of airway
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The airway is the passageway by which air
enters the body during respiration, or
breathing.
A patient cannot survive without an open
airway.
Maintaining an open airway is the first
priority of emergency care.
continued
Airway adjuncts can help keep the airway
open.
It may be necessary to suction the airway
or to use manual techniques to remove
fluids and solids from the airway before,
during, or after artificial ventilation.
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Remember Remember
Always use proper personal protective
equipment when managing an airway.
Airway assessment must be an ongoing
process. Airway status can change over
time.
Airway management should start simply
and become more complicated only if
necessary.
Name the main structures of the airway.
Explain why care for the airway is the first
priority of emergency care.
Describe the signs of an inadequate
airway.
Explain when the head-tilt, chin-lift
maneuver should be used and when the
jaw-thrust maneuver should be used to
open the airwayand why.
Explain how airway adjuncts and
suctioning help in airway management.
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On arrival at the emergency scene, you
find an adult female patient with gurgling
sounds in the throat and inadequate
breathing slowing to almost nothing. How
do you proceed to protect the airway?
continued
When evaluating a small child you hear
stridor. What does this sound tell you?
What are your immediate concerns
regarding this sound?
continued
When assessing an unconscious patient,
you note snoring respirations. Should you
be concerned with this and if so, what
steps can you take to correct this
situation?
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11
1516, 18, 2022, 25, 29, 39, 60, 95
9.2 Explain the physiological relationship between
assessing and maintaining an open airway,
assessing and ensuring adequate ventilation, and
assessing and maintaining adequate circulation.
Slides 1422
9.3 Describe the mechanics of ventilation. Slides 1519
continued
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177
9.4 Explain mechanisms that control the depth and rate
of ventilation. Slides 1519
9.5 Explain the relationships between tidal volume,
respiratory rate, minute volume, dead air space, and
alveolar ventilation. Slides 2021
9.6 Describe the physiology of external and internal
respiration. Slides 2122
continued
9.7 Recognize patients at risk for failure of the
cardiopulmonary system. Slides 2535
9.8 Differentiate between adequate breathing,
inadequate breathing (respiratory failure), and
respiratory arrest. Slides 2533
9.9 Use information from the scene size-up and patient
assessment to anticipate hypoxia. Slides 2935
continued
9.10 Given a variety of scenarios, differentiate between
patients who require artificial ventilation and those
who do not. Slides 3036, 41
9.11 Identify patients who require administration of
supplemental oxygen. Slides 3036, 41
continued
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9.12 Discuss the potential negative effects of positive
pressure ventilation, and how to minimize
complications from positive pressure ventilation.
Slides 3940
continued
continued
9.13 Demonstrate the following techniques of artificial
respiration for pediatric (as applicable) and adult
medical and trauma patients: Mouth-to-mask, Two-
rescuer bag-valve mask (BVM), Flow-restricted,
oxygen-powered ventilation device, One-rescuer
BVM, Automatic transport ventilator (as permitted by
local protocol). Slides 4359, 6265
9.14 Assess the adequacy of artificial ventilations. Slides
56, 61
9.15 Demonstrate the application of cricoid pressure.
Slide 57
9.16 Modify artificial ventilation and oxygen techniques
for patients with stomas. Slides 6061
continued
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9.17 Discuss considerations for selecting the best device
for delivering oxygen for a variety of patient
scenarios. Slides 7685
9.18 Demonstrate administration of oxygen by:
Nonrebreather mask, nasal cannula. Slides 7680
continued
9.19 Describe the purpose and use of partial rebreather
masks, Venturi masks, and tracheostomy masks.
Slides 8185
9.20 Demonstrate safe transport, storage, and use of
oxygen. Slides 6975
9.21 Describe the purpose of each part of an oxygen
delivery system. Slides 6971, 7485
9.22 Describe the use of humidified oxygen. Slide 86
Slide 87 Oxygen DeliverySimple Mask Video
Slide 99 In-Hospital Endotracheal Intubation Video
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CORE CONCEPTS
Physiology and pathophysiology of the
respiratory system
How to recognize adequate and
inadequate breathing
Principles and techniques of positive
pressure ventilation
Principles and techniques of oxygen
administration
Topics Topics
Physiology and Pathophysiology
Respiration
Positive Pressure Ventilation
Oxygen Therapy
Special Considerations
Assisting with Advanced Airway Devices
Physiology and Physiology and
Pathophysiology Pathophysiology
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Ventilation Ventilation
Process of moving air into and out of chest
Inhalation Inhalation
Active process
Negative pressure
pulls air into lungs
continued
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Exhalation Exhalation
Passive process
Muscles relax; size
of chest decreases
Positive pressure
created; air pushed
out
continued
Respiration Terminology Respiration Terminology
Tidal volumeamount of air moved in one
breath
Dead space airair moved in ventilation
not reaching alveoli
Alveolar ventilationair actually reaching
alveoli
Ventilationboth inhaling and exhaling
continued
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Respiration Terminology Respiration Terminology
Diffusionmovement of gases from high
concentration to low concentration
External respirationdiffusion of oxygen
and carbon dioxide (exchange of gases)
between alveoli and circulating blood
Internal respirationexchange of gases
between blood and cells
In the Cells In the Cells
Oxygen from blood
diffused into cell
Carbon dioxide
diffused from cell
into blood
Categories of Categories of
Respiratory System Failure Respiratory System Failure
Mechanics of breathing disrupted
Gas exchange interrupted
Circulation problems
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Respiration Respiration
Evaluating Respiration Evaluating Respiration
Brain and body cells need a steady supply
of oxygen
Hypoxia: low oxygen level in cells
Carbon dioxide must be continuously
removed
Hypercapnea: high carbon dioxide level
continued
Evaluating Respiration Evaluating Respiration
Assesses how well cardiopulmonary
system is accomplishing oxygenation and
carbon dioxide removal
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Compensation for hypoxia or hypercapnea
is predictable
Signs
Shortness of breath (symptom)
Increased respiratory rate and depth
continued
Early on, steps of compensation can meet
the needs of the body despite respiratory
challenge
Respiratory Distress Respiratory Distress
Body compensating
for a respiratory
challenge and
meeting metabolic
needs
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Patient Assessment: Patient Assessment:
Signs of Respiratory Distress Signs of Respiratory Distress
Relatively normal mental status
Relatively normal oxygen saturation and
end tidal carbon dioxide
Relatively normal skin color
Shortness of breath
Increased respiratory rate and heart rate
Accessory muscle use and position
changes
Respiratory Failure Respiratory Failure
Occurs when challenge overcomes
compensation or compensatory steps can
no longer continue
Also known as inadequate breathing
Exceptionally important to recognize; often
a precursor to respiratory arrest
Signs of Respiratory Failure Signs of Respiratory Failure
Signs of respiratory distress
Evidence that compensation is no longer
effective
Signs of poor oxygenation and/or poor
removal of CO
2
Signs of decompensation
continued
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Signs of Respiratory Failure Signs of Respiratory Failure
Signs of failed oxygenation and/or removal
of CO
2
Altered mental status
Cyanosis
Signs of Decompensation Signs of Decompensation
No or poor air movement
Diminished or absent breath sounds
Breathing rate too rapid, too slow, or
irregular
Patient unable to speak
Unusual noises (wheezing, crowing,
stridor, snoring, gurgling, gasping)
Signs of Respiratory Signs of Respiratory
Failure: Pediatric Note Failure: Pediatric Note
In addition to other signs, look for
retractions and nasal flaring
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Critical Decisions: Critical Decisions:
When to Intervene When to Intervene
Often respiratory failure patients will be
breathing and conscious
Identify adequacy of breathing
If breathing is inadequate, immediate
intervention is necessary
What signs might identify the need to
intervene in a breathing patient?
Positive Pressure Ventilation Positive Pressure Ventilation
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Forcing air or oxygen into lungs when a
patient has stopped breathing or has
inadequate breathing
Uses force exactly opposite of how the
body normally draws air into the lungs
Negative Side Effects of Negative Side Effects of
Decreasing cardiac output/dropping blood
pressure
Gastric distention
Hyperventilation
Key Concerns with PPV Key Concerns with PPV
Do not ventilate patient who is vomiting or
has vomitus in airwayPPV will force
vomitus into patients lungs
Watch chest rise and fall with each
ventilation
Ensure rate of ventilation is sufficient
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Ventilating a Ventilating a
Breathing Patient Breathing Patient
Explain procedure to patient
After sealing mask on patients face,
squeeze bag with patients inhalation
Mouth to Mask Ventilation Mouth to Mask Ventilation
Performed using a pocket face mask
Performing Mouth Performing Mouth
to Mask Ventilation to Mask Ventilation
1. Open airway
2. Connect oxygen and run at 15 Lpm
3. Position mask on patients face
Apex over bridge of nose
Base between lower lip and prominence of
chin
continued
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Performing Mouth Performing Mouth
to Mask Ventilation to Mask Ventilation
4. Hold mask firmly in
place; maintain
head tilt
5. Exhale into mask
port
6. Allow passive
exhalation
Achieving Tight Mask Seal Achieving Tight Mask Seal
Position thumbs over top of mask, index
fingers over bottom of mask, and
remaining fingers under patients jaw
Position thumbs along side of mask and
remaining fingers under patients jaw
Bag Bag--Valve Mask (BVM) Valve Mask (BVM)
Handheld
ventilation device
Used to ventilate
nonbreathing
patient and/or
patient in
respiratory failure
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Standard Features of BVM Standard Features of BVM
Self-refilling shell that is easily cleaned
and sterilized
Non-jam valve that allows an oxygen inlet
flow of 15 Lpm
Nonrebreathing valve
continued
Standard Features of BVM Standard Features of BVM
Mechanics of BVM Mechanics of BVM
Supply of 15 Lpm O
2
attached and enters
reservoir
When squeezed, air inlet closed and
oxygen delivered to patient
When released, passive expiration by
patient occurs
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Two Two--Rescuer BVM Ventilation Rescuer BVM Ventilation
Strongly recommended by AHA
Most difficult part of BVM ventilation is
obtaining adequate mask seal
Hard to maintain seal while squeezing bag
One rescuer squeezes bag; other rescuer
maintains seal
Two Two--Rescuer BVM Rescuer BVM
Ventilation: No Trauma Suspected Ventilation: No Trauma Suspected
1. Open airway with head-tilt, chin-lift
maneuver
2. Select correct bag-valve mask size
3. Kneel at patients head; position thumbs
over top half of mask, index fingers over
bottom half
continued
4. Place apex of
triangular mask
over bridge of
nose; lower mask
over mouth and
upper chin
continued
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5. Use middle, ring, and little fingers to bring
patients jaw up to mask
Maintain head-tilt, chin-lift maneuver
continued
6. Second rescuer
connects and
squeezes bag
7. Second rescuer
releases bag;
patient exhales
passively
Ventilation: Trauma Suspected Ventilation: Trauma Suspected
1. Open airway using jaw-thrust maneuver
2. Select correct bag-valve mask size
3. Kneel at patients head; place thumb
sides of your hands along mask to hold it
firmly on patients face
continued
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Ventilation: Trauma Suspected Ventilation: Trauma Suspected
4. Use remaining
fingers to bring jaw
upward toward
mask, without tilting
head or neck
One One--Rescuer Rescuer
BVM Ventilation BVM Ventilation
1. Open airway
2. Select correct size mask
3. Position mask on patients face
4. Squeeze bag
5. Release pressure on bag and let patient
exhale passively
If Chest Does Not If Chest Does Not
Rise During BVM Ventilation Rise During BVM Ventilation
1. Reposition head
2. Check for escape of air around mask;
reposition fingers and mask
3. Check for airway obstruction or
obstruction in BVM system
4. Use alternative method
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Artificial Ventilation Artificial Ventilation
of a Stoma Breather of a Stoma Breather
1. Clear mucus plugs
or secretions from
stoma
2. Leave head and
neck in neutral
position
continued
of a Stoma Breather of a Stoma Breather
3. Use pediatric-sized mask to establish
seal around stoma
4. Ventilate at appropriate rate for patients
age
5. If unable to artificially ventilate through
stoma, seal stoma and attempt artificial
ventilation through mouth and nose
Flow Flow--Restricted Restricted,
Oxygen-Powered Ventilation Device
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Using Flow Using Flow--Restricted, Restricted,
Oxygen Oxygen--Powered Ventilation Device Powered Ventilation Device
Use on adults only
Follow same procedures for mask seal as
for BVM
Trigger device until chest rises
continued
Using Flow Using Flow--Restricted, Restricted,
Oxygen Oxygen--Powered Ventilation Device Powered Ventilation Device
Automatic Transport Automatic Transport
Ventilator (ATV) Ventilator (ATV)
Provides automated ventilations
Can adjust ventilation rate and volume
Provider must assure appropriate
respiratory rate and volume for patients
size and condition
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How would you decide which positive
pressure delivery method to use for your
patient?
Oxygen Therapy Oxygen Therapy
Conditions Requiring Conditions Requiring
Supplemental Oxygen Supplemental Oxygen
Respiratory or cardiac arrest
Heart attacks and strokes
Shock
Respiratory distress and lung diseases
Head injuries
Other serious injuries
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Oxygen Systems Oxygen Systems
Portable or installed
Oxygen System Components Oxygen System Components
Oxygen Cylinders Oxygen Cylinders
Come in various sizes
Dabout 350 L of O
2
Eabout 625 L of O
2
Mabout 3,000 L of O
2
Gabout 5,300 L of O
2
Habout 6,900 L of O
2
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Oxygen Safety Oxygen Safety
Use pressure gauges, regulators, and
tubing intended for use with oxygen
Use non-sparking wrenches
Replace disposable gaskets each time a
cylinder is changed
Properly secure oxygen cylinders in a
cool, ventilated space
Never drop cylinder or move by dragging
continued
Oxygen Safety Oxygen Safety
Never leave cylinder in upright position
without being secured
Never allow smoking around oxygen or
use oxygen equipment around open flame
Never use grease or adhesive tape on a
cylinder
Test cylinders hydrostatically every 5 years
Pressure Regulator Pressure Regulator
continued
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Pressure Regulator Pressure Regulator
Delivery Devices: Delivery Devices:
Nonrebreather Mask Nonrebreather Mask
Best way to deliver high concentrations of
oxygen to a breathing patient
continued
continued
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Provides oxygen concentrations of 80%
100%
Minimum flow rate 8 Lpm
Maximum flow rate 1215 Lpm
Nasal Cannula Nasal Cannula
Best choice for a patient who refuses to
wear an oxygen face mask
continued
Nasal Cannula Nasal Cannula
Provides oxygen concentrations of 24%
44%
Should deliver no more than 46 liters per
minute
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Partial Rebreather Mask Partial Rebreather Mask
Very similar to nonrebreather mask
No one-way valve in opening to reservoir
bag
Delivers 40%60% oxygen at 910 Lpm
Venturi Mask Venturi Mask
Delivers specific concentrations of oxygen
by mixing oxygen with inhaled air
Some have set percentage and flow rate;
others have adjustable Venturi port
continued
Venturi Mask Venturi Mask
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Tracheostomy Mask Tracheostomy Mask
Placed over stoma or tracheostomy tube
to provide supplemental oxygen
Connected to 810 Lpm
continued
Tracheostomy Mask Tracheostomy Mask
Humidifier Humidifier
Connected to
flowmeter
Provides moisture
to dry oxygen from
supply cylinder
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Oxygen Delivery Oxygen Delivery
Simple Mask Video Simple Mask Video
Click here to view a video on the subject of oxygen delivery using a
simple mask.
Back to Directory
Special Considerations Special Considerations
Facial Injuries Facial Injuries
Bleeding and swelling can disrupt
movement of air
Aggressive suction and advanced airway
maneuvers may be necessary
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Obstructions Obstructions
Foreign bodies can impede ventilation of
patients
If unable to ventilate always consider the
possibility of obstruction
Pediatric Notes Pediatric Notes
Hypoxia often occurs rapidly
Children burn oxygen at twice the rate of
adults
Account for many anatomical differences
associated with airway
Ventilating Pediatric Patients Ventilating Pediatric Patients
Avoid excessive pressure and volume
Use properly sized face masks
Flow-restricted, oxygen-powered
ventilation devices contraindicated
Gastric distention may impair adequate
ventilations
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Assisting with Advanced Assisting with Advanced
Airway Devices Airway Devices
Types of Types of
Advanced Airway Devices Advanced Airway Devices
Devices requiring direct visualization
Devices inserted blindly
Assisting with Intubation Assisting with Intubation
Maximize oxygenation prior to procedure
Position patient in sniffing position
Cricoid pressure
Confirmation
Securing tube in place
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Ventilating Ventilating
the Intubated Patient the Intubated Patient
Very little movement can displace an
endotracheal tube
Pay attention to resistance to ventilations;
report changes
If patient is defibrillated, carefully remove
bag from tube
Assisting with Assisting with
a Trauma Intubation a Trauma Intubation
Provide manual in-line stabilization
throughout procedure
Position hands to hold stabilization, but
allow for movement of jaw
Blind Insertion Devices Blind Insertion Devices
Examples
King LT-Dairway
Combitube
Laryngeal Mask Airway (LMA)

Usually do not require head to be placed
in sniffing position
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In In--Hospital Hospital
Endotracheal Intubation Video Endotracheal Intubation Video
Click here to view a video on the subject of in-hospital
endotracheal intubation.
Back to Directory
Respiratory failure (inadequate breathing):
breathing is insufficient to support life.
A patient in respiratory failure or
respiratory arrest must receive artificial
ventilations.
Oxygen can be delivered to the
nonbreathing patient as a supplement to
artificial ventilation.
continued
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Oxygen can also be administered as
therapy to the breathing patient.
Supplemental oxygen is indicated when
breathing is inadequate or in patients that
have a condition that would benefit from
additional oxygen delivery.
Remember Remember
Always use proper personal protective
equipment when managing an airway.
Assessment of breathing must be an
ongoing process. Respiratory status can
change over time.
Inadequate breathing requires immediate
action.
continued
Remember Remember
Positive pressure ventilations are very
different than normal breathing and can
have negative side effects.
Select the most appropriate method of
positive pressure ventilations based upon
the needs of the individual.
continued
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Remember Remember
Always use appropriate safety measures
when handling oxygen.
Select the appropriate delivery device to
provide supplemental oxygen.
What are the signs of respiratory distress?
What are the signs of respiratory failure?
For BVM ventilation, what are
recommended variations in technique for
one or two rescuers?
continued
How does the way positive pressure
ventilation moves air differ from how the
body normally moves air?
Describe a patient problem that would
benefit from administration of oxygen and
explain how to decide what oxygen
delivery device should be used.
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On arrival at the emergency scene, you
find an adult female patient who is
semiconscious. Her respiratory rate is 7
per minute. She appears pale and slightly
blue around her lips
continued
Is this patient in respiratory failure, and if
so what signs and symptoms indicate this?
Does this patient require artificial
ventilations?
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11
12, 19, 23, 3134
10.2 Explain the ongoing nature of scene size-up beyond
the initial moments at the scene. Slide 12
continued
continued
10.3 Given a scene-arrival scenario, list several
examples of potential hazards for which the EMT
should actively search. Slides 1520
10.4 Describe considerations in establishing a danger
zone at the scene of a vehicle collision. Slide 19
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10.5 Recognize indications of possible crime scenes and
the potential for violence. Slide 20
10.6 Use information from the scene size-up to make
decisions about the use of standard precautions to
protect against disease exposure. Slide 18
continued
10.7 Use information from the scene size-up to determine
the mechanism of injury or nature of the illness.
Slides 2335
10.8 Explain the importance of determining the number of
patients and the need for additional resources in the
scene size-up. Slides 3637
continued
10.9 Given a number of scenarios, perform a scene size-
up, including recognizing potential dangers, making
decisions about body substance isolation,
determining the nature of the illness or mechanism
of injury, determining the number of patients, and
determining the need for additional resources.
Slides 1520, 2237
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Slide 39 Physical AssessmentMechanism of Injury
Video
CORE CONCEPTS
Identifying hazards at a scene
Determining if a scene is safe to enter
Mechanisms of injury and how they relate
to patient condition
Determining what additional assistance
may be needed at a scene
Topic Topic
Scene Size-Up
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Scene Size Scene Size--Up Up
Elements of Scene Size Elements of Scene Size--Up Up
Checking scene safety
Taking standard precautions
Noting the mechanism of injury or nature
of patients illness
Determining the number of patients
Deciding what additional resources may
be necessary
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Scene Safety
The only predictable thing about
emergencies is they are often
unpredictable and can pose many dangers
Think About It
What are potential threats to emergency
providers at an EMS scene?
Scene Safety Considerations Scene Safety Considerations
Upon approaching scene
Look and listen for other emergency units
approaching
Look for signs of a collision-related power
outage
Observe traffic flow
Look for smoke in the direction of the collision
scene
continued
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When within sight of
scene
Look for clues to
escaped hazardous
materials
Look for collision victims
on or near the road
Look for smoke not seen
at a distance
Look for broken utility
poles and downed wires
continued
When within sight of scene
Be alert for persons walking along side of
road toward collision scene
Watch for signals of police officers and other
emergency service personnel
continued
As you reach scene
Follow instructions of
incident commander
Don appropriate
personal protective
equipment
continued
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Establish danger zone
Evaluate hazard and restrict area based on
threat level
Different hazards require different-sized
danger zones
continued
Evaluate for threat of violence
Fighting or loud voices
Weapons visible or in use
Signs of alcohol or other drug use
Unusual silence
Knowledge of prior violence
continued
Although any call can present a potential
safety hazard, what types of calls might
pose the highest threats of potential
violence?
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Nature of the Call Nature of the Call
Determining why EMS has been called
Mechanism of injury
Nature of illness
Forces that caused injury
Understanding forces can predict injury
patterns
continued
Mechanism of Injury
Mechanism of Injury Mechanism of Injury
Mechanism of Injury
Can be very useful in predicting injuries
associated with certain types of motor
vehicle crashes
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Mechanism of Injury: Head Mechanism of Injury: Head--on on
Collision Collision
Mechanism of Injury: Mechanism of Injury:
Head Head--on Collision on Collision
Up Up--and and--over injury pattern over injury pattern
continued
Head Head--on Collision on Collision
Down-and-under injury pattern
Rear Rear--end Collision end Collision
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Rollover Collision Rollover Collision
Mechanism of Mechanism of
Injury: Severe Fall Injury: Severe Fall
Adult: more than 20 feet
Child under 15 years: more than 10 feet
(23 times childs height)
continued
Injury: Severe Fall Injury: Severe Fall
Important factors
Height from which patient fell
Surface patient fell onto
Part of patient that hit ground
Anything that interrupted fall
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Injury: Trauma Injury: Trauma
Low-velocity (knife) injuries
Damage limited to area penetrated
May be multiple wounds
continued
Injury: Penetrating Trauma Injury: Penetrating Trauma
Medium-velocity (handgun/shotgun) and
high-velocity (rifle) injuries may be
anywhere in the body
Damage from the bullet itself
Damage from cavitation
Injury: Blunt Injury: Blunt--Force Trauma Force Trauma
Injury caused by a blow that strikes body
but does not penetrate skin or other body
tissues
Signs are often subtle and easily
overlooked
Maintain index of suspicion based on
mechanism of injury
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Nature of the Illness Nature of the Illness
Reason patient
called EMS
Nature of the Illness Nature of the Illness
Information may be obtained from many
sources
Patient
Family and bystanders
Scene
Number of Patients Number of Patients
How many patients present?
Sufficient resources on hand to care for all
patients?
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Other Additional Resources Other Additional Resources
Does the situation require specialized
resources?
Fire
Technical rescue
Hazardous materials response
What are the potential risks to me as a
responder on a poisoning or overdose
call?
What are the routes of entry into the body?
What are some things EMS can do to
prevent poisonings, especially in children?
Physical Assessment Physical Assessment
Mechanism of Injury Video Mechanism of Injury Video
Click here to view a video on the subject of mechanism of injury.
Back to Directory
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Scene size-up is the first part of the patient
assessment process.
Scene size-up first assures your safety
and the safety of fellow rescuers.
Scene size-up then assures that
appropriate resources have been
assembled to deal with the situation.
continued
Finally, you must take into account the
number of patients and other factors at the
scene to determine if you will need
additional help.
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Remember Remember
Determine what, if any, threats there may
be to your own safety and to the safety of
others at the scene.
Take appropriate Standard Precautions.
continued
Remember Remember
Determine the nature of the call by
identifying the mechanism of injury or
nature of a patients illness.
Determine the number of patients and any
additional resources necessary.
For each of these dangers, what actions
must be taken to remain safe at a collision
scene?
Leaking gasoline
Toxic or hazardous material spill
Vehicle on fire
Downed power lines
continued
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What are common mechanism-of-injury
patterns for the following situations?
Head-on collision
Rear-end collision
Fall from a height
You are called to the scene of a shooting
at a fast food restaurant. En route, you
plan your scene size-up strategy. What
actions do you anticipate taking on arrival?
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11
1112, 14, 1921, 28
11.2 Explain the purpose of the primary assessment.
Slides 1113
continued
continued
11.3 Discuss the difference in first steps to assessment if
the patient is apparently lifeless (C-A-B approach) or
if the patient has signs of life, including a pulse
(A-B-C approach). Slides 1113
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11.4 Given several scenarios, do the following: form a
general impression, determine the chief complaint,
determine the patients mental status, assess the
airway, assess breathing, assess circulation,
determine the patients priority for transport.
Slides 1829
continued
11.5 Recognize findings in the primary assessment that
require immediate intervention. Slides 22, 27
continued
11.6 Differentiate the approach to the primary
assessment based on the following: mechanism of
injury/nature of the illness and level of
responsiveness, patients age (adult, child, or
infant). Slides 3435
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Slide 31 Prehospital Patient Video
Slide 32 Initial Assessment Procedures Video
CORE CONCEPTS
Deciding on the approach to the primary
assessment
Manual stabilization of the head and neck
The general impression
Assessment of mental status using the
AVPU scale
The ABCs as part of the assessment
process
How to make a priority decision
Topics Topics
Primary Assessment
Patient Characteristics and Primary
Assessment
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Primary Assessment Primary Assessment
Approach to the Approach to the
Focus on life threats
Airway (A), breathing (B), circulation (C)
May vary depending on
Patients condition
On the scene resources
Other
continued
Approach to the Approach to the
Order of A-B-C depends on initial
impression of patient
Sequence will vary
A-B-C if patient has signs of life
C-A-B if patient appears lifeless, no pulse
Immediate interventions may be needed
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Primary Assessment Steps Primary Assessment Steps
Forming a general impression
Assessing mental status
Assessing airway
Assessing breathing
Assessing circulation
Determining patient priority
General Impression General Impression
Assesses environment, patients chief
complaint, and appearance
Helps determine patient severity
Helps set priorities for care and transport
continued
Look Test: feeling
from environmental
observations as
well as first look at
patient
continued
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Findings that indicate critical patient
Anxiety
Pale, sweaty skin
Obvious trauma to head, chest, abdomen,
pelvis
Specific positions indicating distress
continued
Patients appearing lifeless
Resuscitate by beginning CPR compressions
Prepare AED as soon as possible
Forming a General Impression Forming a General Impression
Look
Patients age, sex, and position
Listen
Moaning, snoring, or gurgling respirations
Smell
Fumes, urine, feces, vomitus, or decay
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Chief Complaint Chief Complaint
Patients description of why EMS was
called
May be specificabdominal pain
May be vaguenot feeling good
Assess Mental Status: AVPU Assess Mental Status: AVPU
Alert
Document orientation to person, place, and
time
Verbal response
Painful response
Unresponsive
Assess ABCs Assess ABCs
Order of primary
assessment will
vary depending on
patients condition
Airway
Breathing
Circulation
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Airway Airway
If airway is not
open or is
endangered, take
measures to open
Breathing Breathing
Situations calling for breathing assistance
Respiratory arrest
Not alert, inadequate breathing
Some alertness, inadequate breathing
Adequate breathing, but signs suggesting
respiratory distress or hypoxia
Circulation Circulation
Assess pulse
Assess skin
Assess bleeding
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Three results of assessing pulse
Within normal limits
Unusually slow
Unusually fast
continued
Assessing skin
Good circulation: warm, pink, dry skin
Shock: pale, clammy (cool and moist) skin
Immediate Intervention Immediate Intervention
Treat any life-
threatening ABC
problem as soon
as discovered!
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Determining Patient Priority Determining Patient Priority
Stable
Vital signs in normal range
Potentially unstable
Potential for deterioration can indicate
potentially unstable category
Unstable
Threat to ABCs rules out stability
Need for Priority Transport Need for Priority Transport
Initiate priority transport if a life-threatening
problem cannot be controlled or threatens
to recur
Continue assessment and care en route
Why must you continue to re-evaluate the
primary assessment?
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Prehospital Patient Video Prehospital Patient Video
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prehospital patient.
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Initial Assessment Initial Assessment
Procedures Video Procedures Video
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procedures.
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Patient Characteristics and Patient Characteristics and
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Patient Characteristics Patient Characteristics
Patient characteristics determine the form
of assessment
Medical or traumatic problem?
Altered mental status?
Child or adult?
Pediatric Note Pediatric Note
Adjust assessment to social and
physiological norms of children
How might normal findings in a primary
assessment differ for a child compared
with an adult?
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Steps of Primary Assessment Steps of Primary Assessment
Despite patient characteristics, follow
primary assessment steps systematically
General impression
Mental status
ABCs
Priority for transport
Primary assessment is a systematic
approach to quickly find and treat
immediate threats to life.
General impression, although subjective,
can provide extremely useful information
regarding urgency of a patients condition.
Determination of mental status follows the
AVPU approach.
continued
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Evaluating airway, breathing, and
circulation quickly but thoroughly will
reveal immediate threats to life that must
be treated before further assessment.
Patients priority describes how urgent
patients need to be transported is and
how to conduct the rest of the
assessment.
Remember Remember
Determine if a problem is medical or
traumatic in nature.
Determine if a patient is responsive or
unresponsive; an adult, child, or infant.
Rapidly identify the need for immediate
airway intervention.
continued
Remember Remember
Determine if the patients condition is
stable enough to allow further assessment
and treatment at the scene.
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What factors will you take into account in
forming a general impression of a patient?
How should you assess a patients mental
status with regard to the AVPU levels of
responsiveness?
continued
How should you assess airway, breathing,
and circulation during the primary
assessment?
What is meant by the term priority
decision?
A middle-aged male is lying on the street
after being hit by a car. He appears
unresponsive as you approach. You notice
that he is bleeding from a laceration on his
forearm and making gurgling sounds from
his airway.
continued
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If you are alone, what factors do you
consider in deciding what to do first?
Why?
11
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1315, 17, 2122, 26, 28, 30, 3233, 35, 44, 4748,
50, 55, 60
12.2 Identify the vital signs used in prehospital patient
assessment. Slide 13
12.3 Explain the use of vital signs in patient care decision
making. Slide 11
continued
12.4 Integrate assessment of vital signs into the patient
assessment process, according to the patients
condition and the situation. Slides 1314
12.5 Discuss the importance of documenting vital signs
and the times they were obtained in the patient care
record. Slides 31, 36, 59
continued
12.6 Demonstrate assessment of pulse, respirations,
skin, pupils, blood pressure, oxygen saturation, and
blood glucose. Slides 16, 2530, 36, 38, 4042, 44
46, 4856, 5965
12.7 Integrate assessment of mental status and ongoing
attention to the primary assessment while obtaining
vital signs. Slides 11, 14
continued
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12.8 Differentiate between vital signs that are within
expected ranges for a given patient, and those that
are not. Slides 1820, 34, 3940, 4243, 46, 59,
61, 67
12.9 Discuss situations in which assessing body
temperature may be appropriate and acceptable
methods of measuring body temperature.
Slides 5859
continued
12.10 Compare and contrast the techniques of
assessment and expected vital sign values for
pediatric and adult patients. Slides 29, 41
Slide 69 Health and Physical Assessment: Vital Signs
Video
Slide 70 Blood Pressure Assessment Video
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CORE CONCEPTS
How to obtain vital signs, including pulse,
respirations, blood pressure, skin,
temperature, and pupils
How to document vital signs on a
prehospital care report
How to use various monitoring devices
Topics Topics
Gathering the Vital Signs
Vital Signs
Gathering the Vital Signs Gathering the Vital Signs
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Importance of Vital Signs Importance of Vital Signs
Outward signs of what is going on inside
the body
Identify important conditions or trends in
patient conditions
Gathered on virtually every EMS patient
Patient severity and treatment priorities
may prevent acquisition
Vital Signs Vital Signs
What Are Vital Signs? What Are Vital Signs?
Pulse
Respiration
Skin color, temperature, and condition
(plus capillary refill in infants and children)
Pupils
Blood pressure
continued
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What Are Vital Signs? What Are Vital Signs?
Baseline vital signs: first vital signs
obtained
Repeat vital signs: gain further information
by establishing trends
Pulse Pulse
Palpable pressure of heart beating,
causing blood to move through arteries in
waves
continued
Pulse Pulse
Can be felt by
placing fingertip
over artery where it
lies close to bodys
surface and
crosses over bone
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Pulse Rate Pulse Rate
Number of beats of heart per minute
Varies among individuals
continued
Normal rate for adult at rest is between 60
and 100 beats per minute
Rate above 100 beats per minute is rapid
Tachycardiarapid pulse
continued
Rate below 60 beats per minute is
considered slow
Bradycardiaslow pulse
continued
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Above 120 beats or below 50 beats per
minute is considered a serious finding
What normal situations might account for a
heart rate outside the normal range?
Pulse Quality Pulse Quality
Two factors determine pulse quality
Rhythm
Force
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Pulse Rhythm Pulse Rhythm
Reflects regularity
Regular when intervals between beats are
constant
Irregular when intervals are not constant
Pulse Force Pulse Force
Pressure of pulse wave as it expands
artery
Pulse should feel strong
Threadywhen pulse feels weak and thin
Common Pulse Locations Common Pulse Locations
Radial
Brachial
Carotid
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Used in patients older than 1 year
Wrist pulse
continued
Found by placing
first three fingers
on thumb side of
patients wrist just
above the crease
Brachial Pulse Brachial Pulse
Used in patients younger than 1 year
Upper arm pulse
continued
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Brachial Pulse
Found by placing three fingers on patients
anterior upper arm (between bicep and triceps
muscle) just distal to armpit
Carotid Pulse Carotid Pulse
Felt along large carotid artery on either
side of the neck
Assessing Pulse Assessing Pulse
Count pulsations for 30 seconds and
multiply by 2
If rate, rhythm, or force is not normal,
continue with count for full 60 seconds
Judge rhythm and force
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Respirations Respirations
With regard to vital signs, respiration
means the act of breathing in and out
Measurement includes both rate and
quality
Respiratory Rate Respiratory Rate
Respiratory ratenumber of breaths the
patient takes in 1 minute
Rate of respiration is classified as normal,
rapid, or slow
continued
Respiratory Rate Respiratory Rate
Normal rate for adult at rest: 1220
breaths per minute
Age, sex, size, physical conditioning, and
emotional state influence breathing rates
Rates above 24 breaths per minute (rapid)
or below 8 breaths per minute (slow) are
potentially serious findings
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Respiratory Quality Respiratory Quality
Four categories
Normal
Shallow
Labored
Noisy
Assessing Respirations Assessing Respirations
Count respirations after assessing pulse
rate
Count number of breaths taken over 30
seconds and multiply by 2
Note rate, quality, and rhythm of
respiration
Skin Skin
Color, temperature, and condition of skin
can provide valuable information regarding
circulation
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Skin Color Skin Color
Best places to assess skin color
Nail beds
Inside of cheek
Inside of lower eyelids
continued
Skin Color Skin Color
Abnormal skin colors
Pale
Cyanotic (blue-gray)
Flushed (red)
Jaundiced (yellow)
Skin Temperature Skin Temperature
Feel patients skin with back of hand
Note if skin feels normal (warm), hot,
cool, or cold
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Skin: Pediatric Note
For children under 6
years, also evaluate
capillary refill
Evaluating Capillary Refill Evaluating Capillary Refill
Press on nail bed or top of hand or foot
and release
Observe how long it takes normal pink
color to return
Normalless than 2 seconds
Pupils Pupils
Black center of eye
Dim environmentpupil will dilate
Bright environmentpupil will constrict
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Note baseline size
Cover one eye and shine a light
into other eye
Repeat with other eye
continued
Assessing Pupils Assessing Pupils
Look for
Size
Equality
Reactivity
continued
Constricted pupils Dilated pupils
Unequal pupils
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Change is more significant than one
measurement
Normal pressure
Systolic no greater than 120 mmHg
Diastolic no greater than 80 mmHg
Measuring Blood Pressure Measuring Blood Pressure
Measured with a sphygmomanometer and
stethoscope
Cuff should cover two thirds of upper arm
continued
Measuring Blood Pressure Measuring Blood Pressure
Wrap cuff around patients upper arm
Lower edge of cuff placed about 1 inch
above crease of elbow
Center of bladder placed over brachial
artery
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Assessing Blood Assessing Blood
Pressure by Auscultation Pressure by Auscultation
Position cuff and stethoscope
Palpate brachial artery at crease of elbow
Position stethoscope
continued
continued
Assessing Blood
Pressure by Auscultation
Place diaphragm of
stethoscope
directly over
brachial pulse or
medial anterior
elbow
Inflate cuff
Listen and inflate until gauge reads 30 mm
higher than the point the pulse sound
disappeared
continued
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Obtain systolic pressure
Slowly release air from cuff
When you hear the first of these sounds, note
the reading on gauge
continued
Obtain diastolic pressure
Continue to deflate cuff
When sounds turn to dull, muffled thuds, the
reading on the gauge is diastolic pressure
Assessing Blood Pressure Assessing Blood Pressure
by Palpation by Palpation
Position cuff and
find radial pulse
Inflate cuff
continued
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Obtain and record
systolic pressure
Slowly deflate cuff
Note reading when
radial pulse returns
(systolic pressure)
Assessing Blood Pressure Assessing Blood Pressure
by Palpation by Palpation
Difficult to obtain on infants and children
younger than 3 years
Use age/size-appropriate cuff
Temperature Temperature
Narrow range of temperature allows
chemical reactions and other activities to
take place inside the body
Core temperature reflects level of heat
inside trunk
continued
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Temperature Temperature
Normal
temperature
depends on
Time of day
Activity level
Age
Where measured
Oxygen Saturation
Measurement of proportion of
oxygen attached to hemoglobin
Measured with pulse oximeter
continued
Oxygen Saturation Oxygen Saturation
Normal: 96%100%
Mild hypoxia: 91% 95%
Significant or moderate hypoxia: 86%
90%
Severe hypoxia: 85% or less
continued
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Oxygen Saturation Oxygen Saturation
Accuracy of reading can be affected by
Shock, hypothermia
Carbon monoxide, certain other uncommon
types of poisoning
Excessive movement, nail polish, anemia
Blood Glucose Blood Glucose
Measures quantity of glucose in the
bloodstream
Can help identify some diabetic
emergencies
Blood Glucose Monitor
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Blood Glucose Measurement Blood Glucose Measurement
Permission from medical direction or by
local protocol is required to perform blood
glucose monitoring using a blood glucose
meter
Monitors must be calibrated and stored
according to manufacturers
recommendations
Acquiring Blood Acquiring Blood
Glucose Measurement Glucose Measurement
1. Prepare device, test strip, and lancet
2. Cleanse patients finger with alcohol
3. Perform finger stick with lancet
4. Wipe away first drop of blood
5. Apply blood to test strip
6. Use glucose meter to analyze sample
and provide reading
Blood Glucose Levels Blood Glucose Levels
Normal level
Usually at least 6080 mg/dL
No more than 120 or 140 mg/dL
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Vital Signs: Pediatric Note Vital Signs: Pediatric Note
Age is one of the most important factors
determining normal range
Infants and children: faster pulse and
respiratory rates, and lower blood
pressures than adults
Health and Physical Health and Physical
Assessment: Vital Signs Video Assessment: Vital Signs Video
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Assessment Video Assessment Video
Click here to view a video on the subject of assessing blood pressure.
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Can gain a great deal of information about
patients condition by taking complete set
of baseline vital signs, including pulse,
respirations, skin, pupils, and blood
pressure.
EMT must become familiar with normal
ranges for pulse, respirations, and blood
pressure in adults and children.
continued
Trends in patients condition will become
apparent only when vital signs are
repeated, an important step in continuing
assessment.
How often you repeat vital signs will
depend on patients condition: at least
every 15 minutes for stable patients and at
least every 5 minutes for unstable
patients.
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Remember Remember
Consider if there is time to obtain vital
signs or if you must wait to obtain them
en route to the hospital.
Consider when to apply a pulse oximeter.
Should you apply it to a patient with
difficulty breathing? Without difficulty
breathing?
continued
Remember Remember
Consider whether abnormal vital signs are
a result of an illness or injury or the result
of some other factor.
Name the vital signs.
Explain why vital signs should be taken
more than once.
How much time should the EMT spend
looking for a pulse when the radial pulse is
absent or extremely weak?
continued
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How should you react when the blood
pressure monitor gives a reading that is
extremely different from previous
readings?
How can you get an accurate pulse
oximeter reading on a patient with thick
artificial nails?
Sometimes a patients heart will have an
electrical problem and beat more than 200
times a minute. Why is the pulse so weak
in such a patient?
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11
15, 26, 32, 3536, 39, 46
13.2 Differentiate between trauma patients with
significant mechanism of injury and those without a
significant mechanism of injury. Slides 14, 24, 3134
continued
continued
13.3 Conduct a systematic secondary assessment of the
trauma patient with no significant mechanism of
injury. Slides 1423
13.4 Select the appropriate physical examination for a
patient with no significant mechanism of injury.
Slides 1620
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13.5 Recognize patients for whom manual stabilization of
the cervical spine and application of a cervical collar
are indicated. Slides 2730
13.6 Conduct a systematic secondary assessment of an
unstable or potentially unstable trauma patient, or
patient with a significant mechanism of injury. Slides
3141
continued
13.7 Explain the purpose of the rapid trauma
assessment. Slide 32
13.8 Recognize significant findings in the rapid trauma
assessment. Slides 3441
13.9 Recognize situations in which you should consider
requesting advanced life support personnel to assist
with the management of a trauma patient. Slide 41
continued
13.10 Incorporate a detailed physical examination of the
unstable or potentially unstable trauma patient at the
appropriate time for a given scenario. Slides 4647,
5051
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Slide 44 Multiple System/Trauma: Paramedic Video
CORE CONCEPTS
The difference between assessment
procedures for a trauma patient with no
significant mechanism or injury and for a
patient with a significant mechanism or
injury
continued
CORE CONCEPTS
How to conduct a history of the present
illness for a trauma patient
How to perform a physical exam for a
trauma patient
continued
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CORE CONCEPTS
How to obtain a past medical history for a
trauma patient
How to perform a rapid trauma
assessment
When and how to perform a detailed
physical examination for a trauma patient
Topics Topics
Secondary Assessment of the Trauma
Patient
Detailed Physical Exam
Comparing Assessments
Secondary Assessment of the Secondary Assessment of the
Trauma Patient Trauma Patient
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Components of Components of
Secondary Assessment Secondary Assessment
Focused history gathering
Physical examination
Patient with Patient with
No Significant MOI No Significant MOI
Assessment focused on areas patient
notes are painful or that MOI indicates
Chief complaint (why patient called EMS)
History of present illnessinformation on
how injury occurred
Elements of Elements of
History of Present Illness History of Present Illness
Nature of force involved
Direction and strength of force
Protective equipment used by patient
Actions taken to prevent or minimize injury
Areas of pain and injuries resulting from
incident
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Physical Examination
Areas assessed depend on
injuries and chief complaint
Mechanism of injury may point
to potential injuries
Three techniques: inspection,
palpation, auscultation
Physical Physical
Examination: Inspection Examination: Inspection
Look for
Abnormalities in symmetry
Color
Shape
Movement
Physical Physical
Examination: Palpation Examination: Palpation
Feel for
Abnormalities in shape
Temperature
Texture
Sensation
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Physical Physical
Examination: Auscultation Examination: Auscultation
Listen for
Decreased or absent breath sounds
Physical Physical
Examination: DCAP Examination: DCAP--BTLS BTLS
Deformities
Contusions
Abrasions
Punctures and penetrations
Burns
Tenderness
Lacerations
Swelling
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Punctures/Penetrations
Swelling Swelling
Obtain baseline vital signs
Obtain past medical history
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Baseline Vital Signs Baseline Vital Signs
Signsobjective
Things you see, hear, feel, smell during exam
Vital signs
Sweaty skin, staggering, vomiting
Symptomssubjective
Patient feels and tells you about
Chest pain, dizziness, nausea
Past Medical History Past Medical History
SAMPLE
Signs and symptoms
Allergies
Medications
Pertinent past history
Last oral intake
Events leading to injury or illness
Apply Cervical Collar Apply Cervical Collar
Apply if MOI, history, or signs and
symptoms indicate use
Make sure collar is correct size
continued
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Assess patients neck prior to placing
collar
Reassure patient
Size collar
Remove jewelry and move hair
continued
Apply Cervical Collar
Slide collar into
place from front continued
Collar alone does not provide adequate in-
line immobilization
Must be paired with manual stabilization or
fixation to long board
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Secondary Assessment:
Significant MOI
Continue manual stabilization
Request ALS
Complete head-to-toe rapid trauma
assessment instead of focused exam
Rapid Trauma Assessment Rapid Trauma Assessment
Requires only a few moments
Should be performed at scene
Care provided en route will be based on
this assessment
Rapid Trauma Assessment Rapid Trauma Assessment
Head
Neck
Chest
Abdomen
Pelvis
Back
Extremities
Baseline vital signs
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General Principles General Principles
In all areas look for DCAP-BTLS or other
abnormal findings
Communicate with patient
Expose injured area before examining it
Assume spinal injury
Stop or alter assessment process to
provide care
Head and Neck Head and Neck
In addition to DCAP-BTLS, look for
Cerebrospinal fluid in ears and nose
Unequal pupils
Jugular venous distention
Consider applying cervical collar
Chest and Abdomen
In addition to DCAP-BTLS,
look for
Paradoxical motion
Crepitation
Equal breath sounds
Distention
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Assessing the Chest
Assessing the Abdomen
Palpate all four quadrants
Pelvis and Extremities Pelvis and Extremities
In addition to DCAP-BTLS, look for
Priapism
Distal circulation, sensation, and motor
function
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Assess Distal Circulation, Assess Distal Circulation,
Sensation, Motor Function Sensation, Motor Function
Posterior/Back
Roll patient to assess back
What criteria would you use to decide
whether to perform a focused exam or a
rapid trauma exam?
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Trauma Assessment: Trauma Assessment:
Lesser mechanisms can cause significant
damage
Need to explain assessments more
thoroughly in this population
Multiple System/ Multiple System/
Trauma: Paramedic Video Trauma: Paramedic Video
Click here to view a video on the subject of managing treatment of a
trauma patient.
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Detailed Physical Exam Detailed Physical Exam
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Typically completed en route to hospital
Gathers additional information
Complements primary and secondary
assessments
Performed after all critical interventions
completed
Primary assessment re-evaluated again
before initiating
Performing Performing
Expose patient
Work around immobilization equipment
Components similar to rapid trauma exam
More detail and focus
Is it necessary to always complete a
detailed assessment on a trauma patient
with no significant mechanism or injury?
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Comparing Assessments Comparing Assessments
Responsive Child: Responsive Child:
Chief complaint
Physical exam
History
Detailed physical exam and further care
Unresponsive Adult: Unresponsive Adult:
Significant MOI Significant MOI
History of present illness
Manual stabilization of head and neck
ALS request
Rapid trauma assessment
Past medical history
Detailed physical exam
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The patient without significant MOI
receives history of present illness and
physical exam focused on areas patient
complains about and areas you think may
be injured based on MOI.
Gather a set of baseline vital signs and a
past medical history.
continued
For patient with significant injury or MOI,
ensure continued manual stabilization of
the head and neck, consider whether to
call ALS (if available), get a brief history of
the present illness, and then perform a
rapid trauma assessment.
continued
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Look for wounds, tenderness, deformities,
plus additional signs appropriate to part
being assessed.
Systematically examine head, neck, chest,
abdomen, pelvis, extremities, posterior
body.
After assessing neck, apply cervical collar.
continued
After completing physical assessment,
immobilize patient to spine board and get
baseline set of vital signs and past medical
history.
After performing appropriate critical
interventions and transport has begun,
patient may receive detailed physical
exam en route to hospital.
continued
Detailed physical exam is very similar to
the rapid trauma assessment, but there is
time to be more thorough.
Detailed physical exam does not take
place before transport unless transport is
delayed.
continued
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Detailed physical exam is most
appropriate for trauma patient who is
unresponsive or has significant injury or
unknown MOI.
Responsive trauma patient with no
significant injury or MOI will seldom
require detailed physical exam.
Remember Remember
Use MOI to determine the need for a rapid
trauma assessment.
Assume spinal injury.
Work as a team to complete the
assessment.
How do the focused history and physical
exam of a trauma patient with a significant
MOI differ from those for a trauma patient
with no significant MOI?
continued
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List the steps and areas covered in the
rapid trauma assessment. How are these
steps different in the detailed assessment?
You are assessing a patient who fell three
stories. He is unresponsive and bleeding
into his airway. The driver of the
ambulance is positioning the vehicle and
bringing equipment to you.
continued
How do you balance the patients need for
airway control (he requires frequent
suctioning) with the need to assess his
injuries?
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11
1112, 15
14.2 Adapt the secondary assessment process to both
responsive and unresponsive medical patients.
Slides 1120, 2226, 3031
14.3 Collect a systematic history of the present illness.
Slides 1315
14.4 Collect a relevant past medical history. Slides 1617
continued
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14.5 Adapt the secondary assessment process to
specific patient complaints. Slides 1317
14.6 Adapt your approach to secondary assessment of
the medical patient to overcome challenges,
according to the circumstances. Slides 1317
14.7 Conduct a rapid physical examination for the
unresponsive medical patient. Slides 2324
continued
14.8 Explain the importance of checking baseline vital
signs in the unresponsive medical patient.
Slides 24, 31
14.9 Recognize situations in which you should consider
requesting the assistance of advance life support
personnel for a medical patient. Slide 25
continued
14.10 Identify other sources of patient information for the
unresponsive or uncooperative medical patient.
Slides 22, 2627
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Slide 28 Physical Examination Techniques; Inspection,
Palpation, Auscultation, and Percussion Video
Slide 32 EMS Initial Patient Assessment: Paramedic
Video
CORE CONCEPTS
The difference between assessment
procedures for a responsive medical
patient and for an unresponsive medical
patient
How to perform a secondary assessment
for a responsive medical patient
continued continued
CORE CONCEPTS
How to tailor the physical exam for a
responsive medical patient using a body
systems approach
How to perform a secondary assessment
for an unresponsive medical patient
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Topics Topics
Secondary Assessment of the Medical
Patient
Secondary Assessment of the Secondary Assessment of the
Medical Patient Medical Patient
Responsive vs. Responsive vs.
Unresponsive Patient Unresponsive Patient
Assessment varies depending on patients
ability to communicate
Responsive medical patient: focus on chief
complaint
Unresponsive medical patient: focus on
physical findings
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of Responsive Medical Patient of Responsive Medical Patient
Focused physical exam
History of Present Illness
Obtain from patient
Obtain from family or bystanders
Ask open-ended questions
continued
History of Present Illness History of Present Illness
Chief complaint
Why patient activated EMS
What is bothering patient most
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History of History of
Present Illness Present IllnessOPQRST OPQRST
Onset: What were you doing when it
started?
Provokes: What makes pain worse?
Quality: Describe pain.
Radiation: Where is pain? Does it seem to
spread?
Severity: How bad is pain? (110 scale)
Time: When did pain start?
Past Medical History
Symptoms
Allergies
Medications
Pertinent past history
Last oral intake
Events leading to illness
Tailoring Past History Tailoring Past History
Important information can be gained by
tailoring history to patients chief complaint
Ask questions pertinent to complaint
Body systems approach: focus
questioning and examination on particular
body system most likely involved
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Gathering History Gathering History
Get on same level with child
Put questions in simple language
Gather information from caregivers
Perform Focused
Physical Exam
Usually brief
Examine areas of concern
based on chief complaint
Obtain Baseline Vital
Signs
Essential to assessment of
medical patient
Later assessments of vital signs
will be compared to baseline
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Where would you focus your physical
examination on a patient complaining of
shortness of breath?
Secondary Assessment of Secondary Assessment of
Unresponsive Medical Patient Unresponsive Medical Patient
Inability to communicate shifts initial focus
from chief complaint and history taking
Begin with physical exam and baseline vital
signs
Gather history from bystanders or family
members
Do rapid assessment of entire body
Rapid Physical Exam Rapid Physical Exam
Similar to physical exam for trauma patient
Assess head, neck, chest, abdomen,
pelvis, extremities, and posterior
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Important Physical Findings Important Physical Findings
Neck: JVD, medical identification devices
Chest: breath sounds
Abdomen: distention, firmness or rigidity
Pelvis: incontinence of urine or feces
Extremities: pulse, motor function,
sensation, oxygen saturation, medical
identification devices
Determine if ALS Required Determine if ALS Required
Consider a request for ALS personnel
History of Present History of Present
Illness and Past Medical History Illness and Past Medical History
Question bystanders
What is patients name?
What happened?
Did you see anything else?
Did patient complain before this happened?
Does patient have any illnesses or problems?
Is patient taking medications?
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What other
mechanisms might
you have to obtain
patient history
other than
speaking to
bystanders?
Physical Examination Physical Examination
Techniques Video Techniques Video
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examination techniques.
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Responsive Adult Responsive Adult
Medical Patient Medical Patient
Primary assessment
Patient alert; no life-threatening problems
Secondary assessment
Past medical history and physical exam
Vital signs
Transport
Unresponsive Unresponsive
Adult Medical Patient Adult Medical Patient
Primary assessment
Patient not alert; ABCs compromised
Rapid physical exam
Vital signs
Past medical history from family
Transport
Prepared for more detailed exam en route
EMS Initial Patient EMS Initial Patient
Assessment: Paramedic Video Assessment: Paramedic Video
Click here to view a video on the subject of information gathered from
patient assessment.
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The history and physical exam of the
medical patient takes two forms,
depending on whether the patient is
responsive.
continued
continued
You assess the responsive patient by
getting a history of the present illness and
a past medical history, then performing a
physical exam of affected parts of the
body before getting baseline vital signs.
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Since unresponsive medical patients
cannot communicate, it is appropriate to
start the assessment with a rapid physical
exam. Baseline vital signs come next, and
then you interview bystanders, family, and
friends to get any history that can be
obtained.
continued
You may not change any field treatment as
a result of the information gathered here,
but the results of the assessment may be
very important to the emergency
department staff.
Remember Remember
Determine if the patient is responsive
enough to provide a history.
If a patient cannot provide a history, can
someone present at the scene do so?
continued
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Remember Remember
Consider what kind of history and physical
exam the patients chief complaint
suggests.
Explain how and why the history and
physical exam for a medical patient differs
from the history and physical exam for a
trauma patient.
continued
Explain how and why the history and
physical exam for a responsive medical
patient differs from the history and
physical exam for an unresponsive
medical patient.
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You are trying to get information from the
very upset son of an unresponsive man.
He is the only available family member. He
is so upset that he is having difficulty
talking to you.
continued
How can you quickly get him to calm down
and give you his fathers medical history?
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11
15.1 Define key terms introduced in this chapter.
Slides 9, 20
15.2 Explain the importance of reassessment.
Slides 910
15.3 Identify the proper points in the patient care process
at which reassessment should be performed. Slides
2122
continued
15.4 Discuss the purpose of each of the components of
reassessment. Slides 1213, 15, 17, 19
15.5 Adapt the reassessment process and frequency of
reassessment based on patients conditions. Slides
1922
continued
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15.6 Recognize both obvious and subtle changes in
patient condition. Slides 1922
15.7 Assign meaning to trends in patient condition over
time. Slides 1920
Slide 23 Ongoing Assessment Video
Slide 27 Detailed Assessment Video
CORE CONCEPTS
How to perform reassessment
The significance of changes in vital signs
over time
The difference in reassessments for stable
versus unstable patients
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Topics Topics
Reassessment
Reassessment Reassessment
Continues on initial steps of assessment
Identifies changes and trends
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What Reassessment What Reassessment
Identifies Identifies
Changes (subtle and profound)
Trends
Deterioration
Improvement
Communicate with Patient Communicate with Patient
Explain process
Consider patients feelings, such as
anxiety or embarrassment
Repeat Primary Assessment Repeat Primary Assessment
Recheck for life-threatening problems
Reassess mental status
Maintain open airway
Monitor breathing (rate and quality)
Reassess pulse (rate and quality)
Monitor skin color and temperature
Re-establish patient priorities
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Reassess Vital Signs Reassess Vital Signs
Compare results with baseline
measurements
Re-evaluate oxygen
Document findings to record and identify
trends
Think of an example of a problem that
might develop into a life threat to the
patient on the way to the hospital.
Repeat Focused Assessment Repeat Focused Assessment
Chief complaint may change, especially
with regard to severity
Ask about changes in symptoms,
especially ones anticipated because of
treatments administered
Repeat physical exam to identify changes
from baseline
Check any interventions
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Repeat Focused Assessment Repeat Physical Exam
Check Interventions Check Interventions
Ensure adequacy of
oxygen delivery and
artificial ventilation
Ensure management
of bleeding
Ensure adequacy of
other interventions
Describe an example of an intervention
that might need to be reevaluated and
discuss your process for examining it.
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Observing Trends
Repeat reassessment steps frequently
Establish and document trends
continued
Observing Trends
Trending: observing patterns that have
emerged among vital signs
Trends may indicate new treatments or
adjustments to ongoing treatments.
Reassessment for Reassessment for
Stable and Unstable Patients Stable and Unstable Patients
Patient condition, as well as length of time
with patient, will determine how often you
reassess
The more serious patients condition, the
more often you reassess
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When to Reassess When to Reassess
Every 15 minutes for stable patient
Every 5 minutes for unstable or potentially
unstable patient
If you believe there may have been a
change in patients condition, repeat at
least primary assessment
Ongoing Assessment Video Ongoing Assessment Video
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ongoing assessment.
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Reassessment: Reassessment:
Stable Medical Patient Stable Medical Patient
Repeat primary assessment
Repeat and record vital signs
Repeat pertinent parts of history and
physical exam
Check interventions you performed
Repeat all steps every 15 minutes
Reassessment: Reassessment:
Unstable Trauma Patient Unstable Trauma Patient
Repeat primary assessment to check for
life-threatening problems
Repeat and record vital signs
Repeat trauma assessment
Check interventions you performed
Repeat all steps every 5 minutes
Detailed Assessment Video Detailed Assessment Video
Click here to view a video on the subject of a detailed exam
of a patient.
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Reassessment is the last step in your
assessment of a patient.
You should reassess a stable patient at
least every 15 minutes and an unstable
patient at least every 5 minutes.
continued
Elements of reassessment include the
primary assessment, vital signs, pertinent
parts of the history and physical exam,
and checking the interventions you
performed for the patient.
Interventions you need to check include
oxygen, bleeding, spine immobilization,
and splints.
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Remember Remember
Assess if the patients condition changed
in any way, indicating the need for new
interventions. Is the airway clear? Is
breathing adequate? Is circulation intact?
Check the interventions you performed.
Are they functioning as they should?
Adjust interventions if necessary.
Name the four steps of reassessment and
list what assessments you will make
during each step.
Explain the value of recording, or
documenting, your assessment findings,
and explain the meaning of the term
trending.
What must you do if your reassessment
turns up one of these findings?
Gurgling respirations
Bag on nonrebreather mask collapses
completely when patient inhales
Snoring respirations
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11
1416
16.2 Compare and contrast EMTs and physicians
diagnoses. Slides 1216
16.3 Explain the relationship between critical thinking and
diagnosis. Slide 9
16.4 Explain typical steps used in the basic approach to
reaching diagnoses. Slide 13
continued
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16.5 Explain how diagnosis in emergency situations may
differ from traditional approaches to diagnosis.
Slides 1416
16.6 Identify some of the special challenges to EMS
providers in the diagnostic process. Slides 1415
16.7 Discuss the relationship between diagnosis and
treatment in emergency situations. Slide 18
continued
16.8 Discuss the benefits and pitfalls of diagnostic
shortcuts (heuristics). Slide 18
16.9 Identify heuristics commonly used by highly
experienced physicians. Slide 18
16.10 Describe ways in which EMTs can improve their
critical thinking processes. Slides 2123
Slide 10 Obstacles to Problem Solving Video
Slide 19 Decision-Making Information Video
Slide 25 Leadership Video
Slide 26 Delegating Authority Video
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CORE CONCEPTS
What an EMT diagnosis is
The role of critical thinking in EMS
How you as an EMT can improve your
critical thinking skills
Topics Topics
EMT Diagnosis and Critical Thinking
How a Clinician Reaches a Diagnosis
How an EMT Can Learn to Think Like an
Experienced Physician
EMT Diagnosis and Critical EMT Diagnosis and Critical
Thinking Thinking
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EMT Diagnosis EMT Diagnosis
and Critical Thinking and Critical Thinking
Diagnosis is label for
condition
Based on history,
physical examination,
vital signs
Involves both physical
and intellectual
activity
Obstacles to Obstacles to
Problem Solving Video Problem Solving Video
Click here to view a video on the subject of solving problems.
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How a Clinician Reaches a How a Clinician Reaches a
Diagnosis Diagnosis
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How a Clinician How a Clinician
Reaches a Diagnosis Reaches a Diagnosis
Clinicians have different levels of training,
experience, time, resources
Techniques vary among types of clinicians
Traditional Traditional
Approach to Diagnosis Approach to Diagnosis
Assess patient
List of conditions or
diagnoses
Differential diagnosis
Further evaluation
Reevaluate the
differential
Final diagnosis
Emergency Medicine Emergency Medicine
Approach to Diagnosis Approach to Diagnosis
Quickly rule out and treat immediate life
threats
Stabilize patient
Return to gather additional information
Focus on ruling out worst-case scenario
Red flags suggest problem serious
May be responsible for multiple patients
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EMS Approach to Diagnosis EMS Approach to Diagnosis
Must be very efficient
Be available for another call as soon as
possible
Work in uncontrolled environment
Limited tools and skill set
Narrow educational focus
continued
EMS Approach to Diagnosis EMS Approach to Diagnosis
Follows same steps as emergency
physician
Most are abbreviated or limited
Considers most serious conditions
associated with patient
Rules them in or out
Creates a differential
You can reach a diagnosis, but your work
is not done. Why?
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The Experienced Clinician The Experienced Clinician
Experienced clinicians learn heuristics
(shortcuts)
Pattern recognition
Features narrowing possibilities
Allows efficient diagnosis and prompt
treatment
Realizes limitations of shortcuts
Understands common biases of heuristics
Decision Decision--Making Making
Information Video Information Video
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How an EMT Can Learn to How an EMT Can Learn to
Think Like an Experienced Think Like an Experienced
Physician Physician
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Thinking Like an Thinking Like an
Experienced Physician Experienced Physician
Love ambiguity
Uncertainty natural part of EMS
Understand limitations
Peoples limitations
Technologys limitations
continued
continued
Thinking Like an Thinking Like an
Experienced Physician Experienced Physician
Utilize different methods
No one single way always right
Remain open-minded and flexible
Learn from others
Form strong foundation of knowledge
Be familiar with conditions
Remain up-to-date
Continue learning
Thinking Like Thinking Like
an Experienced Physician an Experienced Physician
Be organized
Be a lifelong
student
Reflect on what
you have learned
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What are some of the important things to
remember as you learn how to make a
diagnosis and improve your critical
thinking skills in EMS?
Leadership Video Leadership Video
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Delegating Authority Video Delegating Authority Video
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EMTs make some diagnoses in the field,
although they are not as extensive or
detailed as physicians diagnoses.
continued
The traditional approach to reaching a
diagnosis is to assess the patient, draw up
a list of differential diagnoses, assess
further to rule in or rule out different
conditions, and narrow the list until you
reach a conclusion.
continued
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Highly experienced physicians dont
always use the traditional approach. They
use heuristics and their experience and
training to speed up the process of
reaching a diagnosis.
Heuristics has limitations.
continued
Learn to think more critically by accepting
ambiguity, understanding limitations of
people and technology, forming a strong
foundation of knowledge, and organizing
data in your mind.
When considering the cause of a patients
condition, dont let your search for a cause
delay your treatment of the patient.
Remember Remember
Critical thinking an analytical process.
Organized and efficient way to solve problem.
Reflective, reasonable, focused thinking.
EMT must be efficient, yet accurate.
Patients often have more than one thing
wrong.
Do not stop looking.
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What is a differential diagnosis based on?
What is an emergency physicians first
priority when formulating a differential?
How are heuristics helpful in critical
thinking?
How can we as providers enhance our
critical thinking and diagnostic skills?
A 52-year-old man complains of chest pain
while sitting at his desk at work. He
appears alert and oriented. He tells you he
thinks it may just be stress. How would
you arrive at a diagnosis?
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11
1315, 3031
17.2 Describe the role of communication technology in
EMS systems. Slide 13
17.3 Describe various types of communication devices
and equipment used in EMS system
communication. Slides 1415
continued
17.4 Explain the role of the Federal Communications
Commission as it relates to EMS system
communication. Slide 16
17.5 Discuss how to communicate effectively by radio
with dispatch and hospital personnel. Slides 1722
continued
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17.6 Provide a thorough, organized, concise report of
pertinent patient information when giving a radio
report or requesting orders. Slides 2527
17.7 Explain the importance of asking for information to
be repeated for confirmation and clarification.
Slide 28
continued
17.8 Deliver an organized, complete, and concise report
of pertinent patient information when giving a verbal
report to receiving hospital personnel. Slides 3031
17.9 Demonstrate principles and techniques of effective
verbal and nonverbal interpersonal communication.
Slides 3638
continued
17.10 Adapt communication principles for effective
interaction with patients of various ages and
cultures. Slide 39
17.11 Complete a prehospital care report in the format or
formats required by your service. Slides 4253
17.12 Understand legal issues and special situations
associated with documentation. Slides 5657,
6061
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Slide 32 Effective Communication Video
Slide 40 Alternate Methods of Communication With
Children Video
Slide 54 Understanding Cultural Perspectives Video
CORE CONCEPTS
Radio procedures used at various stages
of the EMS call
Delivery and format of a radio report to the
hospital
Delivery and format of a verbal hand-off
report to the hospital
continued
CORE CONCEPTS
Communication skills used when
interacting with other members of the
health care team
Communication skills used when
interacting with the patient
Components and procedures for the
written prehospital care report
continued
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CORE CONCEPTS
Legal aspects and benefits of
documentation
Documentation concerns in patient refusal
Topics Topics
Communication Systems and Radio
Communication
The Verbal Report
Interpersonal Communication
Prehospital Care Report
Special Documentation Issues
Communication Systems and Communication Systems and
Radio Communication Radio Communication
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Communication Systems Communication Systems
EMS uses various communication
systems:
Radios
One-way pagers
Cell phones
Traditional telephones (landlines)
Radio Systems Radio Systems
EMS radio systems consist of:
Base station
Mobile radios
Portable radios
Repeaters
Microwave transmissions
Digital radio signals
Repeaters Repeaters
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Radio Radio
Communication Regulation Communication Regulation
Regulated by the Federal Communications
Commission (FCC)
Assign and license designated radio
frequencies
Establish rules regarding appropriate
language
Monitor radio traffic
Principles of Principles of
Radio on and volume adjusted properly
Reduce background noise
Ensure frequency is clear before starting
Press PTT (press to talk) button on radio;
wait 1 second before speaking
continued
Lips about 23 inches from microphone
Use unit names or numbers
Call units attention first; wait for go
ahead
Unit may say stand by until ready
continued
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Speak slowly and clearly
Keep it brief
Use plain English, avoid codes
Avoid unnecessary words (be advised or
please)
continued
If number might be unclear, say number
and repeat individual digits
Never use patients name over radio
Never use profanities or slander
Use objective, impartial statements
continued
Use we instead of I
Affirmative and negative preferred over
yes and no
Give assessment information about
patient; avoid offering diagnosis
continued
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After transmitting, say Over
Avoid slang or unauthorized abbreviations
Use EMS frequencies for authorized EMS
communication only
Other Radio Procedures Other Radio Procedures
If two units transmit simultaneously, only
one will be heard by listeners
Dispatch often confirms receipt of
transmission by repeating part of it back
Dispatch may end transmission with time
for documentation
continued
Other Radio Procedures Other Radio Procedures
Carry portable radio whenever you leave
unit
Radios need proper care and maintenance
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Medical Radio Reports Medical Radio Reports
Report must be given to destination
hospital so it can prepare for arrival
Usually done by radio
Structured to present
only most important
information
Speak clearly and slowly
Parts of Medical Report Parts of Medical Report
1. Unit identification and level of provider
2. Estimated time of arrival (ETA)
3. Patients age and sex
4. Chief complaint
5. Brief, pertinent history of present
illness/injury
6. Major past illnesses
continued
Parts of Medical Report Parts of Medical Report
6. Mental status
7. Baseline vital signs
8. Pertinent findings of physical exam
9. Emergency care given
10.Response to medical care
11.Medical direction if required, or if
questions
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Communicating Communicating
With Medical Control With Medical Control
Give information clearly and accurately
After receiving order or denial for
medication or procedure, repeat back
word for word
If order unclear, ask physician to repeat
If order seems inappropriate, question
physician
The Verbal Report The Verbal Report
Detailed Verbal Report Detailed Verbal Report
Given upon arrival at destination
Introduce patient by name
Give complete and detailed report
continued
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Detailed Verbal Report Detailed Verbal Report
Elements of report
Chief complaint
History of present illness/injury
Assessment findings, including pertinent
negatives
Treatment given and response
Complete vital signs
Effective Communication Video Effective Communication Video
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Interpersonal Communication Interpersonal Communication
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Team Communication Team Communication
EMT must communicate with others
involved in patients care
First responders
Advanced EMTs, paramedics
Home healthcare aides, family
Speak candidly and respectfully
Collect information about patient
Therapeutic Communication Therapeutic Communication
Communication techniques learned by
experience
May be more difficult with those in crisis
Everyone can improve communication skills
Communication Techniques Communication Techniques
Use eye contact
Shows interest, comfort, and respect
Be aware of position and body language
Face patient at eye level, arms down
continued
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Use appropriate language
Ensure patient understands
Be honest
Dishonesty ruins confidence and rapport
continued
Use patients proper name
Sign of respect, especially with older patients
Listen
Important to establish trust
continued
Special considerations
Always be compassionate and respectful
Mentally disabled
Visual or hearing impaired
Language barriers
Pediatric patients
Come down to their level
Be truthful
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Alternate Methods of Alternate Methods of
Communication With Children Video Communication With Children Video
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with children.
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Prehospital Care Report Prehospital Care Report
Prehospital Prehospital
Care Report (PCR) Care Report (PCR)
Written documentation of everything that
happened during call
Several forms
Handwritten
Laptop
Electronic tablet
Web based
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Functions of PCR Functions of PCR
Patient care record
Documents findings and treatment
Conveys picture of scene
Entered into patients permanent medical
record
continued
Legal document
Can be subpoenaed and used as evidence
May help patient win a case
May be used against you in case of
negligence
continued
Administrative
Demographic information
Insurance information
Billing address
continued
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Education and research
Clinical research
Statistics
Continuing education
Tracking EMTs personal experience
continued
Quality improvement
Routine call review
Ensures compliance to standards
Can reveal providers deserving special
recognition
Can reveal opportunities for improvement
continued
Elements of PCR Elements of PCR
Run data
Agency name, date, times, call number,
unit personnel, certification levels, other
information mandated by service
Use official time given by dispatch so all
times in report match
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continued
Patient information
Name, address, phone number
Gender, age, date of birth
Weight
Race and/or ethnicity
Billing and insurance information
Information gathered during call
General impression of patient
Narrative summary of call
Patient history and treatment as required
by service
Transport information
Narrative Summary Narrative Summary
Objective information
Observable, measurable, verifiable
Subjective information
Subject to interpretation or opinion (often
reported by patient)
continued
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Chief complaint
Primary complaint, as stated by patient
Best recorded as a direct quote
Pertinent negatives
Important negative findings
continued
Plain English and approved abbreviations
Avoid codes and unofficial abbreviations
Legible; correct spelling and grammar
Information must be read easily and
accurately
PCR is a reflection of your care
Appropriate medical terminology
If it happened, record it
Understanding Understanding
Cultural Perspectives Video Cultural Perspectives Video
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cultural diversity.
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Special Documentation Issues Special Documentation Issues
Documentation Issues Documentation Issues
Confidentiality
Covered by HIPAA
Accountability and security
Refusals
High liability
Document all details in a refusal of care form
continued
Documentation Issues Documentation Issues
Falsification
Covering up errors
Recording something you forgot to do
Correction of errors
Mistakes in documentation
Additions
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You respond to a call for an unconscious
male. Upon arrival the patient is awake,
alert, and walking away. He states he was
just sleeping, and does not need or want
treatment or transport.
continued
Is this a patient?
Is a complete assessment and physical
exam needed?
How will you document this call?
Should you obtain a formal patient
refusal?
Special Situation Reports Special Situation Reports
Multiple casualty incidents
Logistical problem for EMS
Many patients
Care and evaluation by several providers at
different times and locations
continued
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Special Situation Reports Special Situation Reports
Provider exposures
Provider injuries
Hazardous or unsafe scenes
Referrals to social service agencies
Reports of abuse
Radio report should include unit ID and
provider level; ETA; patients age and sex;
chief complaint; pertinent HPI; major past
illnesses; mental status; baseline vital
signs; physical exam findings; emergency
care given and response; request to
contact medical direction.
continued
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continued
PCR should include patients name,
address, date of birth, age, and sex; billing
and insurance information; nature of call;
MOI; location patient was found; treatment
given before EMT arrival.
PCR may be a legal document in a court
proceeding.
Data from PCRs may help determine
future treatments, trends, research, and
quality improvement.
continued
Your report should paint a picture of your
patient and their condition, accurately
describing your contact with the patient
throughout the call.
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continued
Remember Remember
Emergency medical communication
comes in many forms and is essential to
team-based patient care.
The medical radio report is structured to
present pertinent facts about the patient
without providing more detail than
necessary.
Remember Remember
A proper verbal report will include the chief
complaint, any history that was not given
previously, additional treatment given, and
additional vital signs taken en route.
continued
Remember Remember
Interpersonal communication is often
challenging in EMS. Adopting best
practices can improve communication
capabilities significantly.
Confidentiality, patient refusals, and
falsification of records are all-important
legal concepts that an EMT must consider
when documenting a call.
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How can you improve your interpersonal
communication with patients and team
members?
What is objective and subjective
information in the narrative portion of the
PCR?
Organize this random information, and
present a radio report to the hospital.
Chest pain radiating to shoulder
56 years old
Oxygen applied at 15 L/minute via
nonrebreather
Alert and oriented
Female
continued
Came on 20 minutes ago while mowing lawn
History of high blood pressure and diabetes
Pulse 86, respirations 22, skin cool and moist,
blood pressure 110/66, SpO
2
96%
Oxygen relieved pain slightly
Denies difficulty breathing
Requesting orders from medical direction
You are on Community BLS Ambulance 4
continued
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Lung sounds equal on both sides
Placed in a position of comfort
ETA20 minutes
continued
Write a narrative report for the same call.
Will you use different information?
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11
1320, 26, 34
18.2 List the drugs in your scope of practice. Slides
1322
continued
continued
18.3 For each medication you may administer or assist a
patient in self-administering, describe the following:
generic and common trade names; indication(s);
contraindications; side effects and untoward effects;
form(s); route(s) of administration. Slides 2526,
3233
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18.4 Follow principles of medication administration
safety, including the five rights of medication
administration. Slides 2730
18.5 Discuss the importance of looking up medications
and requesting information from medical direction
when needed. Slides 2628, 37
continued
18.6 Identify the type of medical direction (on-line or off-
line) required to administer each medication in the
scope of practice. Slide 28
18.7 Describe the characteristics of the oral, sublingual,
inhaled, intravenous, intramuscular, subcutaneous,
and endotracheal routes of administration. Slides
3233
continued
18.8 Identify special considerations in medication
administration related to patients ages and weights.
Slide 34
18.9 Explain the importance of accurate documentation
of drug administration and patient reassessment
following drug administration. Slide 35
continued
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18.10 Discuss the importance of having readily available
references to identify drugs commonly taken by
patients. Slide 37
18.11 Discuss the steps an EMT may take in assisting with
IV therapy. Slides 4149
Slide 23 Oral Glucose Administration Video
CORE CONCEPTS
Which medications may be carried by the
EMT
Which medications the EMT may help
administer to patients
What to consider when administering any
medication
continued
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CORE CONCEPTS
The role of medical direction in medication
administration
How the EMT may assist in IV therapy
Topics Topics
Medications EMTs Can Administer
General Information About Medications
Medications Patients Often Take
Assisting in IV Therapy
Medications EMTs Can Medications EMTs Can
Administer Administer
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Aspirin
Oral Glucose
Oxygen
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Activated Charcoal
Bronchodilator
Inhaler
Prescribed Prescribed
Bronchodilator Inhalers Bronchodilator Inhalers
Used in patients with asthma,
emphysema, and chronic bronchitis
Enlarges constricted breathing tubes
Side effects: increased heart rate, patient
jitteriness
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Nitroglycerin
Prescribed Nitroglycerin Prescribed Nitroglycerin
Taken by patients with history of chest
pain of cardiac origin
Helps dilate coronary vessels
Contraindications: low blood pressure or
taking medications for erectile dysfunction
(Viagra, Levitra, Cialis, or similar)
Vasodilator
Side effect: dropping blood pressure
Epinephrine
Auto-Injector
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Prescribed Prescribed
Epinephrine Auto Epinephrine Auto--Injectors Injectors
Prescribed and used for patients with
severe allergic reactions classified as
anaphylaxis
Vasoconstrictor; relaxes smooth muscles
and airway passages
Side effects: increased heart rate and
blood pressure
Oral Glucose Oral Glucose
Administration Video Administration Video
Click here to view a video on the subject of oral glucose
administration.
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General Information About General Information About
Medications Medications
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Drug Names Drug Names
Each drug is listed by a generic name
Each drug has at least three names
Chemical name
Generic name
Brand name (one or more trade names given
to the drug by manufacturers)
What You Need to What You Need to
Know When Giving a Medication Know When Giving a Medication
Indications
Contraindications
Side effects
Untoward effects
Medication Safety Medication Safety
and Clinical Judgment and Clinical Judgment
Administering or assisting with
medications is a serious responsibility
Know the medication
Use good judgment
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Medication Authorization Medication Authorization
Off-line medical direction
Do not speak to physician
Use standing orders
On-line medical direction
Speak directly to physician
Listen to order; then repeat order back
Ask for clarification if necessary
The Five Rights The Five Rights
of Medications of Medications
The Five Rights The Five Rights
1. Do I have the right patient?
2. Is it the right time to administer this
medication?
3. Is this the right medication?
4. Is this the right dose?
5. Am I giving this medication by the right
route of administration?
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What would be the potential risk to the
patient if each of the five rights were not
checked prior to administration?
Routes of Administration Routes of Administration
Oral (swallowed)
Sublingual (dissolved under tongue)
Inhaled (breathed into lungs), usually as
tiny aerosol particles such as from an
inhaler or as a gas such as oxygen
Intravenous (injected into vein)
continued
Routes of Administration Routes of Administration
Intramuscular (injected into muscle)
Subcutaneous (injected under skin)
Intraosseous (injected into bone marrow
cavity)
Endotracheal (sprayed directly into tube
inserted into trachea)
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Age Age-- and and
Weight Weight--Related Considerations Related Considerations
Pharmacodynamics
Study of effects of medications on body
What effect will medication have on this
patient?
Patient-specific factors change how
medication works
and Documentation and Documentation
After administering medication, reassess
patient
Clearly document medications
administered
Medications Patients Medications Patients
Often Take Often Take
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Medications Medications
Patients Often Take Patients Often Take
Herbal Agents and Basic Uses Herbal Agents and Basic Uses
6/28/2011
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Assisting in IV Therapy Assisting in IV Therapy
Ways of Ways of
Administering IV Fluids Administering IV Fluids
Heparin (saline) lock
Catheter placed into vein
Cap (lock) placed over end of catheter
Lock has port for administering medications
Traditional IV bag
Hangs above patient
Constantly flows fluids and medications into
patient
IV Fluid Administration Set IV Fluid Administration Set
Clear plastic tubing connecting fluid bag to
needle or catheter
Three important parts
Drip chamber
Flow regulator
Drug or needle port
Extension set (extra tubing)
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Setting Up an IV Fluid
Administration Set
continued
Administration Set
continued
Administration Set
continued
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Setting Up an Setting Up an
continued
continued
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371
Maintaining an IV Maintaining an IV
Troubleshoot flow problems
Constricting bands left in place by mistake
Flow regulator left closed
Clamp closed on tubing
Tubing kinked
Line pinched under backboard (trauma)
Adjust flow rate properly
Monitor IV sites for infiltration
Aspirin, oral glucose, charcoal, and
oxygen are medications carried on the
ambulance that the EMT may administer
to a patient under specific conditions.
Inhalers, nitroglycerin, and epinephrine in
auto-injectors are medications that, if
prescribed, the EMT may assist the patient
in taking
continued
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You may need to have permission from
medical direction to administer or assist
the patient with a medication. Follow local
protocols.
continued
Find out what medications a patient is
taking when you take the SAMPLE. Your
main purpose in finding this out is to report
this information to your Medical Director or
hospital personnel.
Remember Remember
EMTs administer aspirin, oral glucose,
activated charcoal, and oxygen as part of
patient care.
EMTs may assist with inhaled respiratory
medications, nitroglycerine, and
epinephrine auto-injectors.
continued
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Remember Remember
EMTs should understand the names,
indications, contraindications, and side
effects of medications that they intend to
administer.
EMTs must have appropriate authorization
to give a drug and always must follow the
five rights of medication administration.
continued
Remember Remember
Reassessment and documentation are
important elements of medication
administration.
Should I administer a medication?
How can I get more information about a
drug?
What are the necessary steps that must
occur after medication administration?
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A patient is complaining of chest pain.
Heres some nitroglycerin, says a family
member. Give him that. What do you do?
11
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1415, 41, 54
19.2 Describe the anatomy and physiology of respiration.
Slides 1315
19.3 Differentiate between adequate and inadequate
breathing based on the rate, rhythm, and quality of
breathing. Slides 1618
continued
19.4 Discuss differences between the adult and pediatric
airways and respiratory systems. Slide 20
19.5 Recognize signs of inadequate breathing in pediatric
patients. Slide 19
19.6 Provide supplemental oxygen and assisted
ventilation as needed for patients with inadequate
breathing. Slides 2223
continued
19.7 Assess the effectiveness of artificial ventilation.
Slides 2223
19.8 Discuss how to recognize and assess the patient
with difficulty breathing. Slides 2738
19.9 Discuss the care to provide for the patient with
difficulty breathing. Slides 3940
continued
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19.10 Recognize the indications, contraindications, risks,
and side effects of CPAP. Slides 4143
19.11 Use CPAP to assist the patient with difficulty
breathing, as permitted by medical direction. Slides
4447
continued
19.12 Assist a patient with administration of a prescribed
bronchodilator by inhaler or small volume nebulizer,
as permitted by medical direction. Slides 8387,
9091
continued
19.13 Describe the pathophysiology, signs, and symptoms
of COPD, asthma, pulmonary edema, pneumonia,
spontaneous pneumothorax, pulmonary embolism,
epiglottitis, cystic fibrosis, and viral respiratory
infections. Slides 4979
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377
Slide 80 Chronic Obstructive Pulmonary Diseases
Video
Slide 81 Spontaneous Pneumothorax Video
Slide 88 Using a Metered Dose Asthma Inhaler and
Spacer Video
CORE CONCEPTS
How to identify adequate breathing
How to identify inadequate breathing
How to identify and treat a patient with
breathing difficulty
Use of continuous positive airway
pressure (CPAP) to relieve difficulty
continued
CORE CONCEPTS
Use of a prescribed inhaler and how to
assist a patient with one
Use of a prescribed small-volume
nebulizer and how to assist a patient with
one
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Topics Topics
Respiration
Breathing Difficulty
Respiratory Conditions
The Prescribed Inhaler
The Small-Volume Nebulizer
Respiration Respiration
Respiratory A&P Respiratory A&P
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Inspiration Inspiration
Active process: uses muscle contraction to
increase size of chest cavity
Intercostal muscles and diaphragm
contract
Diaphragm moves down; ribs move
upward and outward
Air is pulled into lungs
Expiration Expiration
Passive process
Muscles and diaphragm relax
Size of chest cavity decreases
Air flows out of lungs
Adequate Breathing Adequate Breathing
Breathing sufficient to support life
Signs
No obvious distress
Ability to speak in full sentences
Normal color, mental status, and orientation
continued
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Adequate Breathing Adequate Breathing
May be determined by observing rate,
rhythm, quality
1220 breaths/minute for adult
1530 breaths/minute for child
2550 breaths/minute for infant
Rhythm usually regular
Breath sounds normally present and equal
Inadequate Breathing Inadequate Breathing
Breathing not sufficient to support life
Signs
Rate out of normal range
Irregular rhythm
Diminished or absent lung sounds
Poor tidal volume
continued
Signs of inadequate breathing in infants
and children
Nasal flaring
Grunting
Seesaw breathing
Retractions
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Structure of an infants and childs airway
differs from that of an adult
Smaller airway easily obstructed
Proportionately larger tongues
Smaller, softer, more flexible trachea
Less developed, less rigid cricoid cartilage
Heavy dependence on diaphragm for
respiration
Assisted ventilation with supplemental
oxygen
Pocket face mask with supplemental oxygen
Two-rescuer/one rescuer BVM with
supplemental oxygen
Flow-restricted, oxygen-powered ventilation
device
Can be adequate or inadequate
Chest rise and fall should be visible with
each breath
Adequate artificial ventilation rates
12 breaths per minute for adults
20 breaths per minute for infants and children
continued
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Increasing pulse rates can indicate
inadequate artificial ventilation in adults
Decreasing pulse rates can indicate
inadequate artificial ventilation in pediatric
patients
How might you recognize the progression
from adequate breathing to inadequate
breathing in the assessment of your
patient?
How might your patient change during this
transition?
Breathing Difficulty Breathing Difficulty
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Breathing Difficulty Breathing Difficulty
Patients subjective perception
Feeling of labored, or difficult, breathing
Amount of distress felt may or may not
reflect actual severity of condition
OPQRST OPQRST
OnsetWhen did it begin?
ProvocationWhat were you doing when
this came on?
QualityDo you have a cough? Are you
bringing anything up with it?
continued
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OPQRST OPQRST
RadiationDo you have pain or
discomfort anywhere else in your body?
SeverityOn a scale of 1 to 10, how bad
is your breathing trouble?
TimeHow long have you had this
feeling?
Assessment: Observation Assessment: Observation
Unusual anatomy
Barrel chest
Patients position
Tripod position
Sitting with feet dangling, leaning forward
continued
Work of breathing
Retractions
Use of accessory muscles
Flared nostrils
Pursed lips
Number of words patient can say without
stopping
continued
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Pale, cyanotic, or flushed skin
Pedal edema
Sacral edema
Coughing
continued
continued
Noisy breathing
Audible wheezing (heard without stethoscope)
Gurgling
Snoring
Crowing
Stridor
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Assessment: Auscultation Assessment: Auscultation
Lung sounds on
both sides during
inspiration and
expiration
continued
Wheezeshigh-pitched sounds created
by air moving through narrowed air
passages
Cracklesfine crackling caused by fluid in
alveoli or by opening of closed alveoli
continued
Rhonchilow sounds resembling snoring
or rattling, caused by secretions in larger
airways
Stridorhigh-pitched, upper-airway
sounds indicating partial obstruction of
trachea or larynx
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Assessment: Assessment:
Vital Sign Changes Vital Sign Changes
Increased or
decreased pulse rate
Changes in breathing
rate
Changes in breathing
rhythm
Hypertension or
hypotension
Oxygen saturation
Patient Care Patient Care
Assure adequate
ventilations
If breathing is
inadequate, begin
artificial ventilation
If breathing is
adequate, non-
rebreather mask at
15 Lpm
continued
Place patient in position of comfort
Administer prescribed inhaler
Administer continuous positive airway
pressure (CPAP)
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Patient Care: CPAP Patient Care: CPAP
Simple principles
Blowing oxygen or air continuously at low
pressure into airway
Prevents alveoli from collapsing at end of
exhalation
Can prevent fluid shifting into alveoli from
surrounding capillaries
continued
Common uses
Pulmonary edema
Drowning
Asthma and COPD
Respiratory failure in general
continued
Contraindications
Severely altered mental status
Lack of normal, spontaneous respiratory rate
Hypotension/shock
Nausea and vomiting
Penetrating chest trauma
Upper GI bleeding
Conditions preventing good mask seal
continued
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389
Side effects
Hypotension
Pneumothorax
Increased risk of aspiration
Drying of corneas
Using CPAP Using CPAP
Explain procedure to patient
Start with low level CPAP
continued
Reassess mental
status, vital signs,
and dyspnea level
frequently
Raise CPAP level if
no relief within a
few minutes
continued
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390
If patient
deteriorates,
remove CPAP and
ventilate with bag-
mask
Respiratory Conditions Respiratory Conditions
Chronic Obstructive Chronic Obstructive
Pulmonary Disease Pulmonary Disease
Broad classification of chronic lung
diseases
Includes emphysema, chronic bronchitis,
and black lung
Overwhelming majority of cases are
caused by cigarette smoking
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391
COPD: Chronic Bronchitis COPD: Chronic Bronchitis
Bronchiole lining inflamed
Excess mucus produced
Cells in bronchioles that normally clear
away mucus accumulations are unable to
do so
continued
COPD: Chronic Bronchitis COPD: Chronic Bronchitis
COPD: Emphysema COPD: Emphysema
Alveoli walls break downsurface area for
respiratory exchange is greatly reduced
Lungs lose elasticity
Results in air being trapped in lungs,
reducing effectiveness of normal breathing
continued
6/28/2011
392
COPD: Emphysema COPD: Emphysema
Asthma Asthma
Chronic disease with episodic
exacerbations
During attack, small bronchioles narrow
(bronchoconstriction); mucus is
overproduced
Results in small airway passages
practically closing down, severely
restricting air flow
continued
Asthma Asthma
Air flow mainly restricted in one direction
Inhalationexpanding lungs exert outward
pull, increasing diameter of airway and
allowing air flow into lungs
Exhalationopposite occurs and air
becomes trapped in lungs
continued
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393
Asthma Asthma
Pulmonary Edema Pulmonary Edema
Abnormal accumulation of fluid in alveoli
Congestive heart failure (CHF) patients
may experience difficulty breathing
because of this
continued
Pressure builds up in pulmonary
capillaries
Fluid crosses the thin barrier and
accumulates in and around alveoli
Fluid occupying lower airways makes it
difficult for oxygen to reach blood
Patient experiences dyspnea
continued
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394
Common signs and symptoms
Dyspnea
Anxiety
Pale and sweaty skin
Tachycardia
Hypertension
Low oxygen saturation
continued
Common signs and symptoms
In severe cases, crackles or sometimes
wheezes may be audible
Patients may cough up frothy sputum, usually
white, but sometimes pink-tinged
continued
Treatment
Assess for and treat inadequate breathing
High-concentration oxygen
If possible, keep patients legs in dependent
position
CPAP
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Might it be possible for a patient to have
multiple respiratory disorders?
Could a person with an underlying
diagnosis of COPD also have pulmonary
edema?
Pneumonia Pneumonia
Infection of one or both lungs caused by
bacteria, viruses, or fungi
Results from inhalation of certain microbes
Microbes grow in lungs and cause
inflammation
continued
Pneumonia Pneumonia
Signs and symptoms
Shortness of breath with or without exertion
Coughing
Fever and severe chills
Chest pain (often sharp and pleuritic)
Headache
Pale, sweaty skin
Fatigue
Confusion
continued
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Pneumonia Pneumonia
Treatment
Care mostly supportive
Assess for and treat inadequate breathing
Oxygenate
Transport
Spontaneous Pneumothorax Spontaneous Pneumothorax
Lung collapses without injury or other
obvious cause
Tall, thin people, and smokers are at
higher risk for this condition
continued
Signs and symptoms
Sharp, pleuritic chest pain
Decreased or absent lung sounds on side
with injured lung
Shortness of breath/dyspnea on exertion
Low oxygen saturation, cyanosis
Tachycardia
continued
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397
Treatment
Transport for definitive care, as patients
frequently require chest tube
Administer oxygen
CPAP contraindicated
Pulmonary Embolism Pulmonary Embolism
Blockage in blood supply to lungs
Commonly caused by deep vein
thrombosis (DVT)
Increased risk from limb immobility, local
trauma, abnormally fast blood clotting
continued
Signs and symptoms
Chest pain
Shortness of breath
Low oxygen saturation/cyanosis
Tachycardia
Wheezing
continued
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Treatment
Difficult to differentiate in field
Transport to definitive care
Oxygenate
Epiglottitis Epiglottitis
Infection causing swelling around glottic
opening
In severe cases, swelling can cause
airway obstruction
continued
Signs and symptoms
Sore throat, drooling, difficult swallowing
Preferred upright or tripod position
Sick appearance
Muffled voice
Fever
Stridor
continued
6/28/2011
399
Treatment
Keep patient calm and comfortable
Do not inspect throat
Administer high-concentration oxygen if
possible without alarming patient
Transport
Cystic Fibrosis Cystic Fibrosis
Genetic disease typically appearing in
childhood
Causes thick, sticky mucus accumulating
in the lungs and digestive system
Mucus can cause life-threatening lung
infections and serious digestion problems
continued
Signs and symptoms
Coughing with large amounts of mucus
Fatigue
Frequent occurrences of pneumonia
Abdominal pain and distention
Coughing up blood
Nausea
Weight loss
continued
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400
Treatment
Caregiver often best resource for baseline
assessment of patient
Caregivers can often guide treatment
Assess for, and treat, inadequate breathing
Transport
Viral Respiratory Infections Viral Respiratory Infections
Infection of respiratory tract
Usually minor but can be serious,
especially in patients with underlying
respiratory diseases like COPD
continued
Viral Respiratory Infections Viral Respiratory Infections
Often starts with sore or scratchy throat
with sneezing, runny nose, and fatigue
Fever and chills
Infection can spread into lungs, causing
shortness of breath
Cough can be persistent; may produce
yellow or greenish sputum
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Chronic Obstructive Chronic Obstructive
Pulmonary Diseases Video Pulmonary Diseases Video
Click here to view a video on the subject of chronic obstructive
pulmonary diseases.
Back to Directory
Spontaneous Spontaneous
Pneumothorax Animation Pneumothorax Animation
Click here to view an animation on the subject of
spontaneous pneumothorax.
Back to Directory
The Prescribed Inhaler The Prescribed Inhaler
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Metered-dose inhaler
Provides a metered (exactly measured)
inhaled dose of medication
Most commonly prescribed for conditions
causing bronchoconstriction
continued
Before administering
inhaler
Right patient, right
medication, right dose,
right route
Check expiration date
Shake inhaler vigorously
Patient alert enough to
use inhaler
Use spacer device if
patient has one
Art: Emergency Care 11 Ch. 16 PPT Slide 83
6/28/2011
403
Spacer Device
To administer inhaler
Have patient exhale
deeply
Have patient put lips
around opening
Press inhaler to activate
spray as patient inhales
deeply
Make sure patient holds
breath as long as
possible so medication
can be absorbed
Using a Metered Dose Asthma Using a Metered Dose Asthma
Inhaler and Spacer Video Inhaler and Spacer Video
Click here to view a video on the subject of using a
metered dose inhaler.
Back to Directory
6/28/2011
404
The Small The Small--Volume Nebulizer Volume Nebulizer
Medications in metered-dose inhalers can
also be administered by a small-volume
nebulizer (SVN)
Nebulizingrunning oxygen or air through
liquid medication
Patient breathes vapors created
continued
Produces continuous flow of aerosolized
medication that can be taken in during
multiple breaths over several minutes
Gives patient greater exposure to
medication
6/28/2011
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It is important to understand the anatomy,
physiology, pathophysiology, assessment
and care for patients experiencing
respiratory emergencies.
Patients with respiratory complaints may
exhibit inadequate breathing.
continued
Very slow and shallow respirations are
often the end-point of a serious condition
and are a precursor to death.
continued
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continued
The history usually provides significant
information about the patients condition.
In addition to determining a pertinent past
history and medications, determine the
patients signs and symptoms with a
detailed description including OPQRST
and events leading up to the episode.
Important physical examination points
include the patients work of breathing,
accessory muscle use, pulse oximetry
readings, assuring adequate and equal
lung sounds bilaterally, and examining for
excess fluid and vital signs.
There are several medications which may
help a patients difficulty breathing.
Remember Remember
Determine if the patients breathing is
adequate, inadequate, or absent.
Choose the appropriate oxygenation or
ventilation therapy.
continued
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407
Remember Remember
Consider whether to assist a patient with
or administer respiratory medications.
Do I have protocols and medications that may
help this patient?
Does the patient have a presentation and
condition that may fit these protocols?
Are there any contraindications or risks to
using medications in my protocols?
What would you expect a patients
respiratory rate to do when the patient
gets hypoxic? Why?
What would you expect a patients pulse
rate to do when the patient gets hypoxic?
Why?
List the signs of inadequate breathing.
continued
Would you expect to assist a patient with
their prescribed inhaler when they are
experiencing congestive heart failure?
Why or why not?
List some differences between adult and
infant/child respiratory systems.
6/28/2011
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A 72-year-old female complains of severe
shortness of breath. Her husband notes
she is confused. You note respiratory rate
of 8 breaths/minute and cyanosis. Patient
has a history of COPD and CHF. Discuss
the treatment steps to assist this patient.
11
6/28/2011
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14, 20, 23, 3435, 3738, 4042, 5051
20.2 Describe the anatomy and physiology of the
cardiovascular system. Slides 1417
20.3 Define acute coronary syndrome and discuss its
most common signs and symptoms. Slides 2024
continued
20.4 Discuss the management of a patient with acute
coronary syndrome. Slides 2527
20.5 Discuss the indications, contraindications, dosage,
and administration of nitroglycerin to a patient with
chest pain. Slides 2526
continued
continued
20.6 Discuss the indications (including conditions that
must be met), contraindications, and administration
of aspirin to a patient with chest pain. Slides 2728
6/28/2011
410
continued
20.7 Discuss the following conditions and how each may
lead to a cardiac emergency: coronary artery
disease (CAD), aneurysm, electrical malfunctions of
the heart, mechanical malfunctions of the heart,
angina pectoris, acute myocardial infarction (AMI),
and congestive heart failure (CHF). Slides 3346
20.8 Discuss the following factors in the chain of survival
and how each may contribute to patient survival of
cardiac arrest: immediate recognition and activation,
early cardiopulmonary resuscitation (CPR), rapid
defibrillation, effective advanced life support, and
integrated post-cardiac arrest care. Slides 4854
continued
20.9 List the skills necessary for the EMT to manage a
patient in cardiac arrest. Slides 5557
20.10 Discuss types of automated external defibrillators
(AEDs) and how AEDs work. Slides 5866
20.11 Discuss the effective coordination of CPR and AED
for a patient in cardiac arrest. Slides 6774
continued
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411
20.12 Discuss special considerations for AED use,
including general principles, coordination with
others, and post-resuscitation care. Slides 7576
20.13 Discuss the purpose and use of mechanical CPR
devices. Slide 77
Slide 78 Using an AED Video
Slide 79 Cardiac Arrest Video
Slide 80 AEDs Video
Slide 81 Understanding Myocardial Infarctions Video
CORE CONCEPTS
Aspects of acute coronary syndrome
(ACS)
Conditions that may lead to a cardiac
emergency
Cardiac arrest and the chain of survival
Management of a cardiac arrest patient
Use of an automated external defibrillator
(AED)
continued
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412
CORE CONCEPTS
Special considerations in AED use
Use of mechanical cardiopulmonary
resuscitation (CPR) devices
Topics Topics
Cardiac Anatomy and Physiology
Acute Coronary Syndrome
Causes of Cardiac Conditions
Cardiac Arrest
Cardiac Anatomy and Cardiac Anatomy and
Physiology Physiology
6/28/2011
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Cardiac A&P Cardiac A&P
Four Chambers of the Heart Four Chambers of the Heart
Right Atrium
Right Ventricle
Left Atrium
Left Ventricle
Receives blood from
veins; pumps to right
ventricle.
Receives blood
from lungs; pumps
to left ventricle.
Pumps blood to
the lungs.
Pumps blood through
the aorta to the body.
Cardiac Conduction System Cardiac Conduction System
6/28/2011
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How does the normal function of the heart
and blood vessels relate to blood pressure
and distal pulses?
How is shock related to the function of the
heart and blood vessels?
Acute Coronary Syndrome Acute Coronary Syndrome
6/28/2011
415
Acute Coronary Acute Coronary
Syndrome (ACS) Syndrome (ACS)
Sometimes called cardiac compromise
Refers to any time the heart may not be
getting enough oxygen
Many different kinds of problems under the
ACS heading
continued
Acute Coronary Acute Coronary
Syndrome (ACS) Syndrome (ACS)
Symptoms often mimic non-cardiac
conditions
Treat all patients with ACS-like signs and
symptoms as though they are having a
heart problem
Symptoms Symptoms
Chest pain is best-known symptom
Can be described as crushing, dull,
heavy, or squeezing
Sometimes described only as pressure or
discomfort
Radiates to arms, upper abdomen, jaw
continued
6/28/2011
416
Symptoms Symptoms
Dyspnea also
found in ACS
May be the only
finding in some
patients
Other Signs and Symptoms Other Signs and Symptoms
Anxiety, feeling of impending doom
Nausea and pain or discomfort in upper
abdomen (epigastric pain)
Sweating
Abnormal pulse (tachycardia/bradycardia)
Abnormal blood pressure
Assessment Assessment
Perform primary assessment
Obtain history and physical exam
Use OPQRST to get history of present
illness
Obtain SAMPLE history
Take baseline vital signs
6/28/2011
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Treatment Treatment
Place patient in position of
comfort (typically sitting up)
Apply high-concentration oxygen
Transport
Treatment Treatment
If trained, equipped, and authorized to do
so, obtain a 12-lead electrocardiogram
(ECG)
Follow local protocol as to whether to
transmit it to hospital for interpretation
continued
Treatment Treatment
Indications for administering nitroglycerin
Chest pain
History of cardiac problems and prescribed
nitroglycerin
Patient has nitroglycerin
Medical direction
authorizes administration
continued
6/28/2011
418
Treatment Treatment
Contraindications for administering
nitroglycerin
Systolic blood pressure less than 90100
(consult local protocol)
Patient has taken Viagra or similar drug for
erectile dysfunction within 4872 hours
continued
Treatment Treatment
Indications for administering aspirin
Chest pain
Ability to safely swallow
Medical control authorization
continued
Treatment Treatment
Contraindications for administering aspirin
Inability to swallow
Allergy to aspirin
History of asthma
Patient already taking other anti-clotting
medications
6/28/2011
419
Causes of Cardiac Conditions Causes of Cardiac Conditions
Causes of Cardiac Conditions Causes of Cardiac Conditions
Heart problems caused by a number of
disorders affecting condition and function
of blood vessels and heart
Coronary Artery Disease Coronary Artery Disease
Conditions that narrow or block arteries of heart
Often result from fatty deposit build-up on inner
walls of arteries
Build-up narrows inner vessel diameter, restricts
flow of blood
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420
Thrombusocclusion of blood flow
caused by formation of a clot on rough
inner surface of diseased artery
Thrombus can break loose and form an
embolism
Emboli can move to occlude flow of blood
downstream in a smaller artery
continued
Reduced blood supply to myocardium
causes emergency in majority of cardiac-
related medical emergencies
Chest pain is most common symptom of
reduced blood supply
Aneurysm Aneurysm
Weakened
sections of blood
vessels begin to
dilate (balloon)
Bursting can cause
rapid, life-
threatening internal
bleeding
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Electrical Electrical
Malfunction of the Heart Malfunction of the Heart
Malfunction of hearts electrical system
generally results in dysrhythmia
Dysrhythmias include bradycardia,
tachycardia, and rhythms that may be
present when there is no pulse
Mechanical Mechanical
Malfunctions of the Heart Malfunctions of the Heart
Angina pectoris
Acute myocardial infarction (AMI)
Congestive Heart Failure (CHF)
Angina Pectoris Angina Pectoris
Chest pain caused by insufficient blood
flow to the myocardium
Typically due to narrowed arteries
secondary to coronary artery disease
Pain usually during times of increased
myocardial oxygen demand, such as
exertion or stress
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Acute Myocardial Acute Myocardial
Infarction (AMI) Infarction (AMI)
Death of a portion of the myocardium due
to lack of oxygen
Coronary artery disease is usually the
underlying reason
Congestive Congestive
Heart Failure (CHF) Heart Failure (CHF)
Inadequate pumping of the heart
Often leads to excessive fluid build-up in
lungs and/or body
May be brought on by diseased heart
valves, hypertension, obstructive
pulmonary disease
Often a complication of AMI
Progression of CHF Progression of CHF
Patient sustains AMI
Myocardium of left ventricle dies
Because of damage to left ventricle, blood
backs up into pulmonary circulation and
lungs
If untreated, left heart failure commonly
causes right heart failure
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Signs and Signs and
Symptoms of CHF Symptoms of CHF
Tachycardia
Dyspnea and cyanosis
Normal or elevated blood pressure
Diaphoresis
Pulmonary edema
continued
continued
Signs and Signs and
Anxiety or confusion due to hypoxia
Pedal edema
Engorged, pulsating neck veins (late sign)
Enlarged liver and spleen
Signs and Signs and
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Cardiac Arrest Cardiac Arrest
The Chain of Survival The Chain of Survival
Five elements
1. Immediate recognition and activation
2. Early CPR
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care
Teamwork
Coordination
Immediate Immediate
Recognition and Activation Recognition and Activation
Requires prompt notification of EMS
system
Most likely a bystander responsibility
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Early CPR Early CPR
Increases survival chances significantly
Three ways CPR can be delivered earlier
Get CPR-trained professionals to patient
faster
Train laypeople in CPR
Train dispatchers to instruct callers how to
perform CPR
Rapid Defibrillation
Sooner defibrillator arrives, more likely
patient will survive cardiac arrest
Effective Effective
Advanced Life Support Advanced Life Support
Generally EMT-paramedics who respond
to scene or rendezvous with BLS unit en
route to hospital
Rapid transport to hospital may be the
most time-efficient means of obtaining ALS
6/28/2011
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Integrated Integrated
Post Post--Cardiac Arrest Care Cardiac Arrest Care
Coordinating numerous means of
assessment and interventions that
together maximize the chance of
neurologically intact survival
continued
Integrated Integrated
Post Post--Cardiac Arrest Care Cardiac Arrest Care
Maintaining adequate oxygenation
Avoiding hyperventilation
Performing 12-lead ECG
Managing treatable causes of arrest
Appropriate destination for patient
Possibly inducing hypothermia
Management of Cardiac Arrest Management of Cardiac Arrest
EMT provides two links in chain of survival
Early CPR
Rapid defibrillation
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Treatment of Cardiac Arrest Treatment of Cardiac Arrest
Standard Precautions
ALS (when available)
One- and two-rescuer CPR
Using an automated external defibrillator
continued
Treatment of Cardiac Arrest Treatment of Cardiac Arrest
Artificial ventilations and airway
management
Interviewing bystanders and family
members
Lifting and moving patients
Automated Automated
External Defibrillator (AED) External Defibrillator (AED)
Semiautomatic
Advises EMT to press button that causes
machine to deliver shock through pads
Fully automatic
Does not advise EMT to take any action;
delivers shock automatically
continued
6/28/2011
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Automated Automated
Classified by type of shock delivered
Monophasic: sends single shock from
negative pad to positive pad
Biphasic: sends shock in one direction and
then the other
continued
Automated External
Defibrillator (AED)
Analyzes cardiac rhythm to determine
whether shock is indicated
continued
Automated Automated
Most common conditions resulting in
cardiac arrest are shockable rhythms
Ventricular fibrillation
Ventricular tachycardia
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AED Safety AED Safety
Do not defibrillate soaking-wet patient
Do not defibrillate if patient is touching
anything metallic that other people are
touching
Remove nitroglycerin patches before
defibrillating
continued
Verbally and visually CLEAR patient
before defibrillating
Defibrillation can be performed on patient
with an implanted device
Position defibrillation pads on patients
chest to avoid contact with the device
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AED Maintenance AED Maintenance
Use checklist at beginning of every shift to
ensure you have all supplies and AED is
functioning properly
Make sure battery is charged and you
have a spare with defibrillator
AED Quality Improvement AED Quality Improvement
Involves multiple functions
Medical direction
Initial training
Maintenance of skills
Case review
Trend analysis
Strengthening links in chain of survival
Coordinating CPR and AED Coordinating CPR and AED
Interrupt CPR only when absolutely
necessary and for as short a period as
possible
CPR must be paused for rhythm analysis
and defibrillation
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Patient Assessment
If bystanders are doing CPR when
you arrive, have them stop
Verify pulselessness, apnea, absence
of other signs of life no longer than 10
seconds
Patient Care
Apply AED
Bare patients chest; quickly shave
area where pads will be placed if
necessary
If available, use pediatric AED pads
If using adult pads, do not overlap
continued
Patient Care
Use AED
Turn on AED
Attach pads to cables and
then to patient
Stop CPR and analyze
Clear patient and shock if
indicated
continued
6/28/2011
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Patient Care
Immediately begin CPR after delivering a shock
Reassess patient after providing 2 minutes or 5
cycles of CPR
continued
If AED finds no shockable ECG rhythm,
will advise that no shock is indicated
Pulseless electrical activity
Asystole
Resume CPR immediately
continued
When providing CPR
Compressions must not be interrupted for any
longer than 10 seconds
Compressions at least 2 inches deep for adult
and at least one-third depth of chest for
infants and children with full chest recoil
Rate should be at least 100 per minute
Rotate personnel through compressor
position to prevent fatigue
continued
6/28/2011
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If patient wakes or begins to
move
Administer high-concentration
oxygen
Transport
continued
Post Post--Resuscitation Care Resuscitation Care
Patient has a pulse
Manage airway; avoid hyperventilation
Keep defibrillator on patient during transport
in case patient goes back into arrest
Reassess frequently (every 5 minutes)
Consider hypothermia protocols
continued
Post Post--Resuscitation Care Resuscitation Care
Patient goes back into cardiac arrest
Stop vehicle, resume CPR
Analyze rhythm as soon as possible
Deliver shock if indicated
Continue with 2 shocks separated by 2
minutes (5 cycles)
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Mechanical CPR Devices Mechanical CPR Devices
Mechanical devices assist EMTs to
provide high-quality compressions
Thumper
Auto-Pulse
Using an AED Video Using an AED Video
Click here to view a video on the subject of how to use an AED.
Back to Directory
Cardiac Arrest Video Cardiac Arrest Video
Click here to view a video on the subject of cardiac arrest.
Back to Directory
6/28/2011
435
Click here to view a video on the subject of AEDs.
Back to Directory
AEDs Video AEDs Video
Click here to view a video on the subject of myocardial infarctions.
Back to Directory
Understanding Understanding
Myocardial Infarctions Video Myocardial Infarctions Video
6/28/2011
436
Patients with cardiac compromise or ACS
can have many different presentations.
Some complain of pressure or pain in the
chest with difficulty breathing. Others may
have just mild discomfort that they ignore
or that goes away and returns.
continued
Between 10%20% of heart attack
patients have no chest discomfort.
Because of these possibilities and the
severe complications of heart problems,
have a high suspicion and treat patients
with these symptoms for cardiac
compromise.
continued
ACS patients need high-concentration
oxygen and prompt, safe transportation to
definitive care.
You may be able to assist patients who
have their own nitroglycerin.
continued
6/28/2011
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To provide maximum chance of survival for
patients in cardiac arrest, EMS agencies
must strengthen their performance of the
chain of survival: immediate recognition
and activation, early CPR, rapid
defibrillation, effective ALS, and integrated
post-cardiac arrest care.
continued
Remember Remember
The heart is a simple pump that moves
deoxygenated blood to the lungs and
oxygenated blood to the body. Pressure
within the cardiovascular system is critical
to the moving of blood.
continued
Remember Remember
Acute coronary syndrome (ACS) is a
blanket term that refers to a number of
situations in which perfusion of the heart is
inadequate.
Although there are common symptoms of
ACS, EMTs must recognize atypical
findings and err on the side of caution.
6/28/2011
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continued
Remember Remember
Oxygen, nitroglycerine, and aspirin are key
medications indicated to treat ACS.
However, the definitive treatment is
transportation of the patient to a facility
that can open the blocked artery.
continued
Remember Remember
Most cardiac conditions are caused by
arterial problems. Angina pectoris and
acute myocardial infarction are caused by
inadequate perfusion of the heart.
Heart failure can be caused by either
electrical or mechanical problems.
continued
Remember Remember
The most important element of cardiac
arrest care is the administration of high-
quality chest compressions.
The American Heart Associations chain of
survival describes the key elements
necessary to maximize the cardiac arrest
patients chance of survival.
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Remember Remember
AED provides early defibrillation in cardiac
arrest patients with ventricular tachycardia
and ventricular fibrillation.
Post-cardiac arrest care is an essential
element of cardiac arrest care.
Mechanical CPR devices provide
automated chest compressions in cardiac
arrest settings.
What position is best for a patient with:
Difficulty breathing and a blood pressure of
100/70?
Chest pain and a blood pressure of 180/90?
Describe how to clear a patient before
administering a shock.
continued
List three safety measures to keep in mind
when using an AED.
List the steps in the application of an AED.
6/28/2011
440
A 78-year-old male has been complaining
of severe shortness of breath for 20
minutes prior to your arrival. When you
arrive, you find the patient unconscious
and not moving. What are your immediate
priorities?
11
6/28/2011
441
13, 26, 2829, 32, 39, 5255, 6364, 79
21.2 Consider several possible causes of altered mental
status when given scenarios involving patients with
alterations in mental status. Slide 15
21.3 Describe the basic physiological requirements for
maintaining consciousness. Slides 1314
continued
21.4 Perform primary and secondary assessments on
patients with altered mental status. Slides 1923
21.5 Describe the pathophysiology of diabetes and
diabetic emergencies. Slides 2939
21.6 Determine a patients blood glucose level using a
blood glucose meter, as allowed by local protocol.
Slides 4345
continued
21.7 Develop a plan to manage patients with diabetic
emergencies involving hyperglycemia and
hypoglycemia. Slides 4649
21.8 Recognize the signs, symptoms, and history
consistent with other causes of altered mental
status, including seizures, stroke, dizziness, and
syncope. Slides 5288
continued
6/28/2011
442
21.9 Given a variety of scenarios involving patients with
seizures, search for potential underlying causes.
Slides 52, 56
21.10 Develop a plan to assess and manage patients who
are having or who have just had a seizure. Slides
5863
21.11 Explain the causes of strokes. Slide 64
continued
continued
21.12 Develop a plan to assess and manage patients who
are exhibiting signs and symptoms of a stroke.
Slides 6576
21.13 Given a scenario of a patient complaining of
dizziness or syncope, search for potential underlying
causes. Slides 7784
21.14 Develop a plan to assess and manage patients with
complaints of dizziness and syncope. Slides 8588
6/28/2011
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Slide 50 DiabetesEtiology and Pathophysiology
Video
Slide 90 Transient Ischemic Attacks Video
CORE CONCEPTS
General approaches to assessing the
patient with an altered mental status
Understanding the causes, assessment,
and care of diabetes and various diabetic
emergencies
and care of seizure disorders
continued
CORE CONCEPTS
and care of stroke
and care of dizziness and syncope
6/28/2011
444
Topics Topics
Pathophysiology
Assessing the Patient with Altered Mental
Status
Diabetes
Other Causes of Altered Mental Status
Pathophysiology Pathophysiology
Mental Status Regulation Mental Status Regulation
Regulated by neurologic circuits in brain
that comprise reticular activating system
(RAS)
RAS responsible for functions of staying
awake, paying attention, and sleeping
RAS keeps person alert and oriented
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Requirements Requirements
to Maintain Mental Status to Maintain Mental Status
Oxygen to perfuse brain tissue
Glucose to nourish brain tissue
Water to keep brain tissue hydrated
Causes of Causes of
Altered Mental Status Altered Mental Status
Deficiences in oxygen, glucose, water to
brain tissue
Trauma, infection, chemical toxins harming
brain tissue
Primary brain problem (stroke)
Problem within another system (hypoxia
due to asthma)
Assessing the Patient with Assessing the Patient with
6/28/2011
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Safety Safety
Patient with altered mental status can be
dangerous to responders
Always consider safety of yourself and
your team before approaching a patient
Use law enforcement when necessary
Hypoxia is one of the most common
causes of altered mental status
Always consider the possibility of an
airway and/or breathing problem
continued
6/28/2011
447
Identify and treat life-threatening problems
Consider oxygen administration
Be alert to the need for positioning and
suctioning if patient requires it or if mental
status worsens
Secondary Assessment
Thoroughly examine patient exhibiting new,
unusual behavior
Even slightly altered mental status indicates
serious underlying issues
continued
Body systems exam and complete history
may reveal information about the
suspected cause of altered mental status
Interview family members and bystanders
to obtain patients baseline mental status
Family may provide information patient is
unable to give
continued
6/28/2011
448
Patients medicines may point to relevant
medical history
Look for medic alert bracelets or other
health-related items at scene
What kind of information about a patients
altered mental status might you obtain
from the scene?
How might bystanders help you identify
the cause of altered mental status?
Diabetes Diabetes
6/28/2011
449
Glucose Glucose
Form of sugar
Bodys basic source of energy
Body cells require glucose to remain alive
and create energy
Glucose and the Glucose and the
Digestive System Digestive System
Glucose molecule is large
Will not pass into cell without insulin
Insulin Insulin
Produced by pancreas
Binds to receptor sites on cells
Allows large glucose molecule to pass into
cells
Sugar intakeinsulin production balance
allows body to use glucose effectively as
energy source
6/28/2011
450
Diabetes Mellitus Diabetes Mellitus
Two types
Type 1
Underproduction of insulin by pancreas
Type 2
Inability of bodys cells to use insulin properly
Type 1 Diabetes Type 1 Diabetes
Pancreatic cells do not function properly
Insulin not secreted normally
Not enough insulin to transfer circulating
glucose into cells
Synthetic insulin typically prescribed to
supplement inadequate natural insulin
Type 2 Diabetes Type 2 Diabetes
Bodys cells fail to utilize insulin properly
Pancreas is secreting enough insulin, but
body is unable to use it to move glucose
into cells
Condition often controlled through diet
and/or oral antidiabetic medications
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Diabetic Emergencies Diabetic Emergencies
Hypoglycemia (low blood sugar)
Hyperglycemia (high blood sugar)
Hypoglycemia: Causes Hypoglycemia: Causes
Diabetic takes too much insulin
Diabetic does not eat
Diabetic overexercises or overexerts
Diabetic vomits
Hypoglycemia: Signs Hypoglycemia: Signs
Very rapid onset
May present with abnormal behavior
mimicking drunken stupor
Pale, sweaty skin
Tachycardia
Seizures
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452
Hypoglycemia: Results Hypoglycemia: Results
Starvation of brain cells
Unconsciousness
Permanent brain damage
Hyperglycemia: Causes Hyperglycemia: Causes
Decrease in insulin
May be due to bodys inability to produce
insulin
May exist because insulin injections not given
in sufficient quantity
Infection
Stress
Increasing dietary intake
Hyperglycemia: Signs Hyperglycemia: Signs
Develops over days or weeks
Chronic thirst and hunger
Increased urination
Nausea
6/28/2011
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Hyperglycemia: Results Hyperglycemia: Results
Profound dehydration
Excessive waste products released into
system
Diabetic ketoacidosis (DKA)
Diabetic Ketoacidosis: Diabetic Ketoacidosis:
Signs and Symptoms Signs and Symptoms
Profoundly altered mental status
Shock (caused by dehydration)
Rapid breathing
Acetone odor on breath
Scene safety
Primary assessment
Identify altered mental status
continued
6/28/2011
454
History of present episode
How episode occurred, time of onset,
duration, associated symptoms, any MOI or
other evidence of trauma, any interruptions to
episode, seizures, or fever
continued
SAMPLE
Determine if history of diabetes
Question patient or bystanders
Look for medical identification bracelet
Look in refrigerator or elsewhere at scene for
medications such as insulin
continued
Assessment
Blood glucose meter
Measures amount of glucose in bloodstream
Often used by patients at home
Sometimes used by EMTs (follow local protocol)
continued
6/28/2011
455
Blood glucose measurement
Less than 6080 mg/dL in symptomatic
diabetic: hypoglycemia
Less than 50 mg/dL: significant alterations in
mental status
Over 140 mg/dL: hyperglycemia
Over 200300 mg/dL for prolonged time:
dehydration, other more serious symptoms
continued
Special glucometer readings
May display word instead of number
High or HI: indicates extremely high level,
usually greater than 500 mg/dL
LOW: indicates
extremely low level,
often less than
15 mg/dl
Occasionallycan treat person with mild
hypoglycemia and minor altered mental
status by simply giving something to eat
Never administer food or liquids to patient
at risk for aspiration
continued
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456
Oral glucosecriteria for administration
History of diabetes
Awake enough to swallow
continued
Patient Care
Oral glucose
Patient squeezes glucose from tube directly
into mouth
EMT can administer glucose using tongue
depressor
continued
Oral glucose
Reassess after administration
If condition does not improve, consult medical
direction about whether to administer more
6/28/2011
457
Diabetes DiabetesEtiology Etiology
and Pathophysiology Video and Pathophysiology Video
Click here to view a video on the subject of the etiology and
pathophysiology of diabetes.
Back to Directory
Other Causes of Altered Mental Other Causes of Altered Mental
Status Status
Seizure Disorder Seizure Disorder
If normal brain function is upset by injury,
infection, or disease, the brains electrical
activity can become irregular
Irregularity can bring about seizure:
sudden change in sensation, behavior, or
movement
Seizure is a sign of underlying defect,
injury, or disease
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Tonic Tonic--Clonic Seizure Clonic Seizure
Unconsciousness and major motor activity
Tonic phasebody rigid up to 30 seconds
Clonic phasebody jerks violently for 12
minutes
Postictal phaseafter convulsions stop;
often slow period of regaining
consciousness
Aura Aura
Some seizures preceded by aura
(sensation patient has just before it is
about to happen)
Patient may note smell, sound, or just a
general feeling right before seizure
Partial Seizure Partial Seizure
Not all seizures present as generalized
tonic-clonic
Partial seizure: uncontrolled muscle
spasm or convulsion while patient is fully
alert
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Causes of Seizure Causes of Seizure
Hypoxia
Stroke
Traumatic brain injury
Toxins
Hypoglycemia
continued
Causes of Seizure Causes of Seizure
Brain tumor
Congenital brain defects
Infection
Idiopathic
Epilepsy
Scene Safety: Scene Safety:
Multiple patients seizing at the same
timemajor red flag
Possibility of chemical weapon or similar
weapon of mass destruction
Take appropriate precautions
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What was person doing before seizure
started?
Exactly what did person do during
seizure?
How long did seizure last?
What did person do after seizure?
When Seizure Occurs When Seizure Occurs
Place patient on floor or ground
Loosen restrictive clothing
Remove objects that may harm patient
Protect patient from injury, but do not try to
hold patient still during convulsions
After Convulsions End After Convulsions End
Protect airway
If no possibility of spine injury, position
patient on side
If patient is cyanotic, ensure open airway
and provide artificial ventilations with
supplemental oxygen
continued
6/28/2011
461
After Convulsions End After Convulsions End
Seizure usually only 13 minutes long
Patient breathing adequately may be given
oxygen by mask or nasal cannula
Treat injuries patient may have sustained
during convulsions
Transport
Status Epilepticus Status Epilepticus
Two or more convulsive seizures lasting
510 minutes or more without regaining
full consciousness
High-priority emergency requiring
immediate transport to hospital and
possible ALS intercept
Stroke Stroke
Death or injury of brain tissue from oxygen
deprivation
Causes
Blockage of artery supplying blood to part of
the brain
Bleeding from a ruptured blood vessel in the
brain
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Signs of Stroke Signs of Stroke
One-sided weakness (hemiparesis): very
common
Headache caused by bleeding from
ruptured vessel: less common, but very
important
Other Signs and Other Signs and
Symptoms of Stroke Symptoms of Stroke
Confusion
Dizziness
Numbness, weakness, or paralysis
(usually on one side of body)
Loss of bowel or bladder control
Impaired vision
High blood pressure
continued
Other Signs and Other Signs and
Symptoms of Stroke Symptoms of Stroke
Difficult respiration or snoring
Nausea or vomiting
Seizures
Unequal pupils
Headache
Loss of vision in one eye
Unconsciousness (uncommon)
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with a Stroke Patient with a Stroke Patient
Often difficult to communicate with a
stroke patient
Damage to brain can cause partial or
complete loss of the ability to use words
Aphasia: general term meaning difficulty in
communication
Transient Transient
Ischemic Attack (TIA) Ischemic Attack (TIA)
Small clots temporarily block circulation to
part of brain
Causes stroke-like symptoms
Symptoms resolve when clots break up
Complete resolution of symptoms without
treatment within 24 hours (usually much
sooner)
Assessment: Stroke Assessment: Stroke
Cincinnati
Prehospital Stroke
Scale
Ask patient to
grimace or smile
Stroke patient more
likely to show
abnormal response
continued
6/28/2011
464
Cincinnati Prehospital
Stroke Scale
Ask patient to close
eyes and extend arms
straight out in front for
10 seconds
Stroke patient is more
likely to show an
abnormal response
continued
Cincinnati Prehospital Stroke Scale
Ask patient to say something: The sky is blue
in Cincinnati.
Stroke patient is more likely to give abnormal
or no response
Patient Care: Stroke Patient Care: Stroke
For conscious patient who can maintain
airway
Calm and reassure patient
Monitor airway
Administer high-concentration oxygen
Transport patient in semi-sitting position
continued
6/28/2011
465
For unconscious patient or patient who
cannot maintain airway
Provide high-concentration oxygen
Transport with patient lying on affected side
continued
Transport suspected stroke patient to
hospital with capabilities for managing
stroke patient
Capabilities must include CT scan at
minimum
continued
Determine and document exact time of
onset of symptoms
Document contact information if person
other than patient provides time of onset
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Dizziness and Syncope Dizziness and Syncope
Can indicate serious or life-threatening
problems
May be impossible to diagnose true cause
of syncope
Dizziness Dizziness
Common term meaning different things to
different people
Vertigo: sensation of surroundings
spinning around you
Lightheadedness: sensation you are about
to pass out (pre-syncope)
Syncope Syncope
Brief loss of consciousness with
spontaneous recovery
Typically very shorta few seconds to a
few minutes
Patients often have some warning that
syncopal episode (fainting spell) is about
to occur
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Causes of Causes of
Hypovolemic
Metabolic
Environmental/ toxicological
Cardiovascular
Hypovolemic Causes Hypovolemic Causes
Low fluid/blood volume causes dizziness
or syncope, especially when patient
attempts to sit up or stand
Source of bleeding may not be obvious
Metabolic and Metabolic and
Structural Causes Structural Causes
Alterations in brain chemistry or structure
can lead to diminished level of
consciousness
Inner and middle ear problems also cause
dizziness or syncope
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Environmental/ Environmental/
Toxicological Causes Toxicological Causes
Alcohol and drugs can cause fluctuations
in consciousness
Cardiovascular Causes Cardiovascular Causes
Bradycardia and tachycardia can cause
decreased cardiac output and syncope
Vasovagal syncope is thought to be the
result of stimulation of the vagus nerve,
which signals the heart to slow down;
decreased cardiac output causes syncope
Rapidly identify and treat life threats
Gather important information that will
assist in overall treatment
Ask:
Have you had any similar episodes in the
past?
What do you mean by dizziness?
continued
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469
Ask:
Did you have any warning?
When did it start?
How long did it last?
What position were you in when the episode
occurred?
continued
Ask:
Are you on medication for this kind of
problem?
Did you have any other signs or symptoms;
nausea?
Did you witness any unpleasant sight or
experience a strong emotion?
Did anyone witness involuntary movements of
the extremities (like seizures)?
Call for ALS
Loosen tight clothing around neck
Lay patient flat
Treat associated injuries patient may have
incurred from fall
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Is the seizure or syncope a symptom of a
larger problem?
Transient Transient
Ischemic Attacks Video Ischemic Attacks Video
Click here to view a video on the subject of transient ischemic attacks.
Back to Directory
6/28/2011
471
Diabetic emergencies are usually caused
by poor management of the patients
diabetes.
Diabetic emergencies are often brought
about by hypoglycemia, or low blood
sugar.
The chief sign of this hypoglycemia is
altered mental status.
continued
Whenever a patient has an altered mental
status and a history of diabetes, and can
swallow, administer oral glucose.
Seizures may have a number of causes.
Assess and treat for possible spinal injury,
protect the patients airway, and provide
oxygen as needed.
continued
Gather information about the seizure to
give to hospital personnel.
A stroke is caused when an artery in the
brain is blocked or ruptures.
continued
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472
continued
Signs and symptoms of stroke include
altered mental status, numbness or
paralysis on one side, speech difficulty.
For stroke patients, ensure open airway
and provide supplemental oxygen.
Determine exact time of onset of
symptoms and transport promptly.
Dizziness and syncope (fainting) may
have a variety of causes.
For syncope, administer oxygen, loosen
clothing around neck, and place patient
flat with raised legs if there is no reason
not to. Treat injuries and transport.
Remember Remember
Determine if the patients altered mental
status is being caused by hypoxia.
In a patient with a hypoglycemic
emergency, determine whether the mental
status will allow the administration of oral
glucose.
continued
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Remember Remember
Assess the seizure patient to determine
the need for artificial ventilation.
Determine when the symptoms of the
stroke began.
List the chief signs and symptoms of a
diabetic emergency.
Explain how you can determine a medical
history of diabetes.
Explain what treatment may be given by
an EMT for a diabetic emergency and the
criteria for giving it.
continued
Explain the care that should be given to a
conscious and to an unconscious patient
with suspected stroke.
Explain the care that should be given to a
patient who has experienced dizziness or
syncope.
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A 62-year-old male is witnessed to have a
tonic-clonic seizure. You find him actively
seizing. His skin is pale and moist and
slightly cyanotic. Discuss the immediate
treatment necessary.
11
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10, 14, 19, 37, 39
22.2 Differentiate between the signs and symptoms of an
allergic reaction and an anaphylactic reaction.
Slides 1824
22.3 Describe the relationship between allergens and
antibodies necessary for an allergic reaction to
occur. Slides 1113
continued
22.4 Describe the effects of histamine and other
chemicals in producing the signs and symptoms of
anaphylaxis. Slides 1314
22.5 List common allergens. Slides 1516
22.6 Prioritize the steps in assessment and management
of patients with allergic and anaphylactic reactions.
Slides 2528
continued
22.7 Recognize the indications for administering and
assisting a patient in the use of an epinephrine auto-
injector. Slides 29, 31
22.8 Describe the desired effects and side effects
associated with the administration of epinephrine.
Slides 3738
continued
6/28/2011
476
22.9 Demonstrate administration of epinephrine by auto-
injector. Slides 3941
22.10 Describe the considerations in reassessment of
patients with allergic and anaphylactic reactions.
Slides 3031
Slide 34 Allergic ReactionAnaphylaxis Video
Slide 35 Information About Allergic Rhinitis Video
CORE CONCEPTS
How to identify a patient experiencing an
allergic reaction
Differences between a mild allergic
reaction and anaphylaxis
How to treat a patient experiencing an
allergic reaction
Who should be assisted with an
epinephrine auto-injector
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Topics Topics
Allergic Reactions
Self-Administered Epinephrine
Allergic Reactions Allergic Reactions
Allergic Reactions Allergic Reactions
Immune system naturally responds to
foreign substances in body
Allergic reaction: exaggerated response to
foreign substance
Allergen: substance causing exaggerated
effect
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Bodys Reaction to Allergen Bodys Reaction to Allergen
First exposure
Immune system forms antibodies
Antibodies identify and attack particular
foreign substance
Antibodies combine only with allergen they
were formed in response to
continued
Second (and subsequent) exposures
Antibodies exist
Antibody combines with allergen, leading to
release of histamine and other chemicals into
bloodstream
Chemicals cause harmful effects
continued
Effects of histamine and other chemicals
Inflammation (swelling)
Bronchoconstriction
Vasodilation
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Anaphylaxis Anaphylaxis
Severe, life-threatening allergic reaction
Can cause:
Dilation of blood vessels (hypotension)
Airway swelling (airway obstruction)
Bronchoconstriction (respiratory failure)
Common Allergens Common Allergens
Insects
Foods
Plants
Medications
Others
Dust, makeup,
soap, etc.
Latex Allergy Latex Allergy
Common concern in EMS
Many patients have latex sensitivity
Providers can develop latex allergy from
prolonged exposure
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Course of Reaction Course of Reaction
No way to predict exact course of an
allergic reaction
Severe reaction often takes place
immediately, but can be delayed 30
minutes or more
Mild allergic reaction can rapidly progress
to anaphylaxis
Signs and Signs and
Symptoms: Skin Symptoms: Skin
Swelling
Flushing (red skin)
Warm, tingling feeling
in face, mouth, chest,
feet, or hands
Signs and Symptoms: Hives
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Signs and Signs and
Symptoms: Respiratory Symptoms: Respiratory
Tightness in throat or chest
Cough
Rapid, labored, and/or noisy breathing
Hoarseness, muffled voice, loss of voice
Stridor
Wheezing
Signs and Signs and
Symptoms: Cardiac Symptoms: Cardiac
Decreased blood pressure
Signs and Signs and
Symptoms: Generalized Symptoms: Generalized
Itchy, watery eyes and/or runny nose
Headache
Feeling of impending doom
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Signs and Symptoms: Signs and Symptoms:
Anaphylactic Shock Anaphylactic Shock
Flushed, dry skin or pale, cool, clammy
skin
Nausea or vomiting
Changes in vital signs
Increased pulse, respirations
Decreased blood pressure
Distinguishing Anaphylaxis Distinguishing Anaphylaxis
from Mild Allergic Reaction from Mild Allergic Reaction
Any of previous signs and symptoms can
be associated with an allergic reaction
Anaphylaxis: patient has either respiratory
distress or signs and symptoms of shock
Primary assessment
Identify and treat life-threatening problems
Airway
Breathing
Circulation
continued
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History and physical exam
History of allergies
Exposure
What was the patient exposed to?
How (what method/route) was the patient
exposed?
Signs and symptoms
Progression
Interventions
Treatment Treatment
Manage patients airway and breathing
Apply high-concentration oxygen
Provide artificial ventilations if patient is
not breathing adequately
Consider assisting patient with
continued
Treatment Treatment
If patient is not wheezing or showing signs
of respiratory distress or shock
Continue with assessment
Consult medical direction regarding use of
auto-injector
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Use of Auto Use of Auto--Injector Injector
When use of auto-injector may be
appropriate
If patient has come in contact with substance
that caused allergic reaction in the past
If patient also has respiratory distress or
exhibits signs and symptoms of shock
After Administering
Auto-Injector
Record administration
of auto-injector
Transport patient
Reassess
Additional Doses Additional Doses
of Epinephrine of Epinephrine
Reassessment may show patient condition
deteriorating
Additional doses of epinephrine may be
necessary
Requires on-line medical control
Requires bringing patients additional auto-
injectors in ambulance
continued
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Additional Doses of Additional Doses of
Epinephrine Epinephrine
If no auto-injector available
Request ALS intercept
Treat for shock
Should you administer an auto-injector for
a simple allergic reaction?
What assessment findings would indicate
the need for epinephrine?
Allergic Reaction Allergic Reaction
Anaphylaxis Video Anaphylaxis Video
Click here to view a video on the subject of anaphylactic shock.
Back to Directory
6/28/2011
486
Information About Information About
Allergic Rhinitis Video Allergic Rhinitis Video
Click here to view a video on the subject of allergic rhinitis.
Back to Directory
Self Self--Administered Epinephrine Administered Epinephrine
Epinephrine Epinephrine
Commonly prescribed to patients with a
history of allergy
Auto-injectors are common for people to
carry or have at home
Hormone produced by body
Constricts blood vessels
Dilates bronchioles
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Side Effects of Epinephrine Side Effects of Epinephrine
Increased cardiac workload
Auto Auto--Injector Injector
Spring-loaded needle and syringe with a single
dose of epinephrine
Upon administration, medication automatically
releases and injects
Administering Auto Administering Auto--Injector Injector
Injection site typically anterior-medial thigh
(midway between waist and knee)
Remove clothing from site if possible
Use standard precautions
Remove cap
continued
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Administering Auto Administering Auto--Injector Injector
Press tip of auto-injector firmly against
patients thigh
Once needle is deployed, allow full
injection of medication before removing
from injection site
Carefully discard
auto-injector into
sharps container
Two sizes of auto-injectors
Adult dose: 0.3 mg
Childrens dose (for child less than 66
pounds): 0.15 mg
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Allergic reactions are common.
Anaphylaxis, a true life-threatening allergic
reaction, is rare.
The most common symptom in these
cases is itching. Patients with anaphylaxis
will also display life-threatening difficulty
breathing and/or signs and symptoms of
shock.
continued
Patients with anaphylaxis will be extremely
anxious. Their bodies are in trouble and
are letting them know it.
The signs and symptoms of anaphylaxis
result from physiological changes:
vasodilation, bronchoconstriction, leaky
capillaries, and thick mucus.
continued
By quickly recognizing the condition,
consulting medical direction, and
administering the appropriate treatment,
you can literally make the difference
between life and death for these patients.
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Remember Remember
In an allergic reaction, the bodys immune
system overreacts to an allergen and
causes potentially harmful side effects.
Anaphylaxis is a severe, systemic form of
allergic reaction; it is a life-threatening
emergency.
continued
continued
Remember Remember
EMTs must use assessment to
differentiate a localized allergic reaction
from a systemic anaphylactic reaction.
Epinephrine is useful in anaphylaxis
because it constricts dilated blood vessels
and opens bronchial passages.
Remember Remember
Epinephrine has potentially dangerous
side effects and should be used only in the
event of anaphylaxis.
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What are the indications for administration
of an epinephrine auto-injector?
List some of the more common causes of
allergic reactions.
continued
List signs or symptoms of an anaphylactic
reaction associated with each of the
following:
Skin
Respiratory system
Cardiovascular system
A 24-year-old male ate a meal that he
believes contained shellfish. He is allergic
to shrimp. He is sweating and nervous. He
appears to be breathing adequately. You
do not note any wheezing or stridor.
continued
6/28/2011
492
His face is slightly red. His pulse is 88
strong and regular, respirations 24, blood
pressure 108/74, and skin warm and
moist. Should you administer epinephrine?
11
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12, 16, 23, 31, 46, 55, 5963
23.2 Describe ways in which poisons can enter the body.
Slide 15
23.3 Identify potential dangers to EMS providers and
others at scenes where poisoning, alcohol abuse, or
substance abuse is involved. Slides 32, 35, 52, 72
continued
23.4 Collect key elements in the history of a patient who
has been poisoned. Slides 1720, 34
23.5 Describe the use of activated charcoal in the
management of ingested poisons. Slides 2327
23.6 Explain the management of patients who have
ingested a poison. Slides 2223
continued
23.7 Develop a plan for managing patients who have
inhaled poisons. Slides 35, 40, 43
23.8 Develop a plan for managing patients who have
absorbed poisons through the skin. Slide 47
23.9 Describe the health risks associated with alcohol
abuse. Slides 5052
continued
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23.10 Recognize the signs and symptoms of alcohol
abuse and withdrawal. Slides 5456
23.11 Recognize signs, symptoms, and health risks
associated with abuse of substances, including
stimulants, depressants, narcotics, volatile
chemicals, and hallucinogens. Slides 5969
continued
23.12 Given a variety of scenarios, develop a treatment
plan for patients with emergencies related to alcohol
and substance abuse. 57, 7072
Slide 73 Cocaine Video
6/28/2011
495
CORE CONCEPTS
How to know if a patient has been
poisoned
Assessment and care for ingested poisons
Assessment and care for inhaled poisons
Assessment and care for absorbed
poisons
continued
CORE CONCEPTS
Assessment of injected poisons
Assessment and care for alcohol abuse
Assessment and care for substance abuse
Topics Topics
Poisoning
Alcohol and Substance Abuse
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Poisoning Poisoning
Poison Poison
A poison is any substance that can harm
the body
The harm it can cause can result in a
medical emergency
All things are poison and nothing is
without poison, only the dose permits
something not to be poisonous.
Paracelsus
Common Poisons Common Poisons
Medications
Petroleum products
Cosmetics
Pesticides
Plants
Food
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Effects of a Poison Effects of a Poison
Harm to body based on nature of poison,
concentration, route of entry, patients age
and health
Damage to skin and tissues from contact
Suffocation
Localized or systemic damage to body
systems
Classification of Classification of
Poisons (By Routes of Entry) Poisons (By Routes of Entry)
Ingested
Inhaled
Absorbed
Injected
Ingested Poison Ingested Poison
Child: may accidentally eat or drink a toxic
substance
Adult: often an accidental or deliberate
medication overdose
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Ingested Poisons Ingested Poisons
What substance was involved?
Look for container; check labels
Transport with patient to hospital
When did exposure occur?
Quick-acting poison requires faster treatment
ER personnel need to know for appropriate
testing and treatment
continued
How much was ingested?
Estimate missing pills by looking at
prescription label
Over how long a time?
Treatments may vary
Was medication taken for very first time?
Was medication being taken chronically?
continued
What interventions have been taken?
Treatments indicated on label,
Other home remedies (syrup of ipecac)
What is patients weight?
Rate of onset of toxic effects is related to
weight
continued
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499
What effects has patient experienced?
Nausea, vomiting, altered mental status,
abdominal pain, diarrhea, chemical burns
around mouth, unusual breath odors
Food Poisoning Food Poisoning
Can be caused by improperly handled or
prepared food
Symptoms: nausea, vomiting, abdominal
cramps, diarrhea, fever
May occur within hours of ingestion, or a
day or two later
Treatment Treatment:: Food Poisoning Food Poisoning
Activated Charcoal
Antidotes
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Activated Charcoal Activated Charcoal
Works through adsorption, allowing
substances to attach to its surface
Not an antidote: prevents or reduces
amount of poison absorbed by body
Treatment: Activated Charcoal Treatment: Activated Charcoal
continued
continued
6/28/2011
501
continued
Think about your own home. Is it safe for a
small child?
Are there potential poisons within three
feet of the floor, or behind unlocked doors?
Are there household cleaners that look like
juices and drinks familiar to children?
continued
6/28/2011
502
Can flavored childrens medications be
mistaken for candy?
What sense does a small child typically
use to identify things?
Public Education Public Education
Many EMS agencies are involved in
educating the public to the dangers of
child poisoning
Child-proofing homes
Mr. Yuk
Inhaled Poisons Inhaled Poisons
Common types
Carbon monoxide
Ammonia
Chlorine
Agricultural chemicals and pesticides
Carbon dioxide
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503
Approach scene with
caution
Protective clothing
and self-contained
breathing apparatus
may be required
If not trained or
equipped, call for
additional resources
Signs and Signs and
Symptoms: Inhaled Poisons Symptoms: Inhaled Poisons
Difficulty breathing
Chest pain
Coughing
Hoarseness
Headache, confusion, altered mental
status
Seizures
Assessment: Inhaled Poisons Assessment: Inhaled Poisons
What substance is involved (exact name)?
When did exposure occur?
Over how long did exposure occur?
What interventions has anyone taken?
Remove patient?
Ventilate area?
What effects is patient experiencing?
6/28/2011
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Treatment: Inhaled Poisons Treatment: Inhaled Poisons
Move patient from unsafe environment
using trained and equipped personnel
Open airway; provide high flow oxygen
History, physical exam, vital signs
Transport with all containers, bottles, and
labels
Ongoing assessment en route
Carbon Monoxide Carbon Monoxide
(CO) Poisoning (CO) Poisoning
Colorless, odorless, tasteless gas created
by combustion
Can be caused by improper venting of
fireplaces, portable heaters, generators
Common cause of death during winter and
power outages
Signs and Signs and
Symptoms: CO Poisoning Symptoms: CO Poisoning
Headache (band around head)
Dizziness/nausea
Breathing difficulty
Cyanosis
May be multiple patients with similar
symptoms in confined area together
6/28/2011
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CO Monitor CO Monitor
Some fire/EMS
systems have
monitoring devices
that allow crews to
determine CO
exposure levels in
the field
CO Detectors CO Detectors
Public education programs should
encourage people to have both smoke and
CO detectors in their homes to reduce the
risk of injury and death
Treatment: CO Poisoning Treatment: CO Poisoning
High flow oxygen is appropriate treatment,
but CO bonds to red blood cells much
more strongly than oxygen does
Can take several hours or days to wash
CO from bloodstream
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Smoke Inhalation Smoke Inhalation
Smoke from burning materials can contain
poisonous and toxic substances, including
CO, ammonia, chlorine, cyanide
Substances can irritate skin and eyes,
damage lungs, and progress to respiratory
or cardiac arrest
Signs and Signs and
Symptoms: Smoke Inhalation Symptoms: Smoke Inhalation
Coughing
Smoky or chemical smell on breath
Black (carbon) residue in mouth, nose or
sputum
Singed nasal or facial hair
Treatment: Smoke Inhalation Treatment: Smoke Inhalation
Move patient to safe area
Maintain airway; provide high flow oxygen
Monitor patient closelyairway burns may
lead to swelling of airway
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Detergent Suicides Detergent Suicides
Method of suicide started in Japan and
becoming more common in the U.S.
Mix two easily-obtained chemicals to
release hydrogen sulfide gas
Commonly released inside enclosed
space such as a car
Detergent Suicides: Detergent Suicides:
Exposure to fumes may injure EMS
personnel
Warning note may be left on vehicle, but
this is not assured
May need to treat first as a hazmat scene
Absorbed Poisons Absorbed Poisons
Can be absorbed through skin
May or may not cause damage to skin
Patient may require decontamination prior
to treatment
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Treatment: Absorbed Poisons Treatment: Absorbed Poisons
Assess for immediate life threats
History, physical exam, vital signs
Brush off powder, then irrigate
Irrigate skin and eyes for at least 20
minutes and during transport
Transport with all containers
Ongoing assessment en route
Poison Control Centers Poison Control Centers
Excellent resource
Information on poisons, signs and
symptoms, and treatments
Follow local protocol for contact
procedures
Alcohol and Substance Abuse Alcohol and Substance Abuse
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509
Alcohol and Substance Abuse Alcohol and Substance Abuse
See many patients whose conditions are
caused either directly or indirectly by
alcohol or substance abuse
Abuse of alcohol and other drugs crosses
all geographic and economic boundaries
Alcohol Abuse Alcohol Abuse
Potent drug affects central nervous system
Can be addictive
Emergencies may result from recent
consumption or years of abuse
Treat patients as any others
Abuse can lead to or worsen other medical
conditions
continued
Alcohol Abuse Alcohol Abuse
Alcohol often consumed with other drugs,
which can result in a serious medical
emergency
Impaired patients can be uncooperative or
combative
Contact law enforcement if safety concern
6/28/2011
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Assessment: Alcohol Abuse Assessment: Alcohol Abuse
Many medical conditions mimic alcohol
intoxication
Intoxicated patients may also have
medical problems
All patients receive full assessment
regardless of suspicion of intoxication
Signs and Signs and
Symptoms: Alcohol Abuse Symptoms: Alcohol Abuse
Alcohol odor on breath
Unsteady on feet
Slurred, rambling speech
Flushed, complaining of being warm
Nausea/vomiting
Poor coordination
Blurred vision
Confusion/altered mental status
Alcohol Withdrawal Alcohol Withdrawal
Abrupt cessation of drinking may cause
some alcoholics to suffer from delirium
tremens (DTs)
Can be serious, resulting in tremors,
hallucinations, and seizures
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Signs and Signs and
Symptoms: Alcohol Withdrawal Symptoms: Alcohol Withdrawal
Confusion and restlessness
Unusual behavior, demonstrating insane
behavior
Hallucinations, gross tremor of hands,
profuse sweating
Seizures
Patient Care: Alcohol Abuse Patient Care: Alcohol Abuse
Vomiting common; standard precautions
are essential
Keep suction ready
Stay alert for airway and respiratory
problems
Monitor vital signs
Gather history from patient, bystanders
Stay alert for seizures
Substance Abuse Substance Abuse
Any chemical substance taken for other
than therapeutic (medical) reasons
Includes illicit
drugs, prescription
medications,
industrial
chemicals
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Uppers Uppers
Stimulants that affect the nervous system
Cocaine
Amphetamines
May be snorted, smoked, or injected
Downers Downers
Central nervous system depressants
Barbiturates
Rohypnol (Roofies)
GHB
Narcotics Narcotics
Used to relieve pain or help with sleep
Opiates
Heroin, codeine, morphine
Oxycodone
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Hallucinogens Hallucinogens
Create intense state of excitement and
distorted perception
LSD, PCP, XTC
Volatile Chemicals Volatile Chemicals
Produce vapors
that are inhaled
Initial rush, then
can act as central
nervous system
depressant
Substance Abuse Substance Abuse
May be difficult
Patients level of consciousness
Patient may have taken more than one type of
drug
Patient may be uncooperative or
combative
Be aware of a possibility of contaminated
needles and the presence of chemicals
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Signs and Symptoms: Downers Signs and Symptoms: Downers
Sluggishness, poor coordination
Decreased pulse and respirations
Signs and Signs and
Symptoms: Uppers Symptoms: Uppers
Excitement, restlessness
Increased pulse and respirations
Sweating
Hyperthermia
No sleep for a long time, possibly days
Signs and Signs and
Symptoms: Narcotics Symptoms: Narcotics
Lethargy (patient very sleepy)
Pinpoint pupils
Cool skin
Respiratory depression
Coma
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Signs and Signs and
Symptoms: Hallucinogens Symptoms: Hallucinogens
Rapid pulse
Dilated pupils
Flushed face
Seeing or hearing things
Signs and Signs and
Symptoms: Volatile Chemicals Symptoms: Volatile Chemicals
Dazed/disoriented
Swollen membranes in nose or mouth
Numbness or tingling sensation inside
head
Changes in heart rhythm
May be residue of chemical on face or in
bag
Treatment: Substance Abuse Treatment: Substance Abuse
Be aware of possible airway problems and
respiratory distress
Provide oxygen and assist respirations as
needed
Treat for shock
Talk to patient to keep them calm and
cooperative
continued
6/28/2011
516
Perform physical
exam
Look for evidence
of injection sites
(track marks)
continued
Transport as soon as possible
Consult with medical control on further
treatment
Follow local protocol concerning
consideration for restraint
Cocaine Video Cocaine Video
Click here to view a video on the subject of cocaine dependency.
Back to Directory
6/28/2011
517
Perform primary assessment and
immediately treat life-threatening
problems. Ensure an open airway.
Administer high-concentration oxygen if
the poison was inhaled or injected.
continued
continued
Perform a history and physical exam,
including baseline vital signs. Find out if
the poison was ingested, inhaled,
absorbed, or injected; what substance was
involved; how much poison was taken in,
when, and over how long a period; what
interventions others have already done;
and what effects the patient experienced.
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Consult medical direction. As directed,
administer activated charcoal, water, or
milk for ingested poisons.
Remove patient who has inhaled poison
from the environment and administer high-
concentration oxygen; remove poisons
from skin by brushing off or diluting.
continued
Transport patient with all containers,
bottles, and labels from substance.
Reassess patient en route.
Carefully document all information about
poisoning, interventions, and patients
responses.
Remember Remember
Safety is always the first concern when
dealing with a poisoning or substance-
abuse patient.
Poisonings are generally classified by
route of exposure. Effects vary greatly,
depending upon type of poison and
method of entrance into body.
continued
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Remember Remember
EMTs must use thorough assessment,
including scene clues, to help identify the
nature and severity of poisoning.
Poison control centers offer a wealth of
resources to assist in assessment and
treatment of poisoning patient.
continued
Remember Remember
Alcohol is a common underlying issue with
patients. In some patients it may be the
most significant problem.
The effects of substance abuse can vary
greatly, based on the type of substance.
Determining the type of drug ingested can
shed light on effects to come.
What are potential risks to the responder
on a poisoning or overdose call?
What are the routes of entry into the body?
What are some things EMS can do to
prevent poisonings, especially in children?
6/28/2011
520
A farmer calls 911 because one of his farm
hands has tried to clean up spilled
pesticide powder with his hands. On
arrival, you find that the patient insists he
has brushed all the powder off, feels fine,
and doesnt need to go to the hospital.
continued
As he talks, he continues to make
brushing motions at his jeans on which
you can see the marks of a powdery
residue. How do you manage the
situation?
6/28/2011
521
11
24.1 Define key terms introduced in this chapter. 13, 15,
18, 2022
24.2 Describe the location, structure, and function of the
organs in the abdominal cavity. Slides 1116
24.3 Explain the origins and characteristics of visceral,
parietal, and tearing pain. Slides 18, 2122
continued
24.4 Associate areas of referred pain with the likely
origins of the pain. Slide 21
24.5 Recognize the common signs and symptoms of
abdominal conditions, including appendicitis,
peritonitis, cholecystitis, pancreatitis, ulcers,
abdominal aortic aneurysm, hernia, and renal colic.
Slides 2435
continued
6/28/2011
522
24.6 Discuss the type of abdominal pain that may
indicate cardiac involvement. Slide 36
24.7 Discuss appropriate assessment and management
of patients complaining of abdominal pain. Slides
3847
continued
24.8 Elicit key information in the history of patients
complaining of abdominal pain, including history
specific to female patients. Slides 4143
Slide 50 Abdominal Aortic Aneurysm Video
6/28/2011
523
CORE CONCEPTS
Understanding the nature of abdominal
pain
Becoming familiar with abdominal
conditions that may cause pain or
discomfort
How to assess and care for patients with
abdominal pain
Topics Topics
Abdominal Anatomy and Physiology
Abdominal Pain or Discomfort
Abdominal Conditions
Assessment and Care of Abdominal Pain
or Discomfort
Introduction Introduction
Abdomen contains many organs, from
several different body systems
Can cause confusion when determining
the cause of abdominal emergencies
Thorough patient assessment key
Specific diagnosis may not be necessary;
treatment is the same for most conditions
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Abdominal Anatomy and Abdominal Anatomy and
Physiology Physiology
Abdomen Abdomen
Region between diaphragm and pelvis
Contains many organs and organ systems
Digestive
Reproductive
Endocrine
Regulatory
Organs of the Abdomen Organs of the Abdomen
continued
6/28/2011
525
Peritoneum: thin membrane lining the
abdominal cavity and covering each organ
Parietal peritoneum lines abdominal cavity
Visceral peritoneum covers each organ
continued
Most enclosed within parietal peritoneum
A few lie in extra-peritoneal space (outside
the peritoneum)
Kidneys, pancreas, part of aorta lie in
retroperitoneal space, behind peritoneum
Bladder and part of rectum lie inferior to
peritoneum
Peritoneal and Peritoneal and
Extraperitoneal Space Extraperitoneal Space
6/28/2011
526
Abdomen divided
into quadrants
RUQ, LUQ, RLQ,
LLQ
Epigastric region
Abdominal Pain or Discomfort Abdominal Pain or Discomfort
Visceral Pain Visceral Pain
Originates from the visceral peritoneum
Fewer nerve endings allow for only diffuse
sensations of pain
Frequently described as dull or achy
continued
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527
Visceral Pain Visceral Pain
Colic (intermittent pain) may result from
distention and/or contraction of hollow
organs
Persistent or constant pain often originates
from solid organs
Parietal Pain Parietal Pain
Originates from the parietal peritoneum
Many nerve endings allow for specific,
efficient sensations of pain
Frequently described as sharp
Pain is often severe, constant, and
localized to a specific area
Referred Pain Referred Pain
Perception of pain in skin or muscles at
distant locations
Abdomen has many nerves from different
parts of the nervous system
Nerve pathways overlap as they return to the
spinal cord
Pain sensation is transmitted from one system
to another
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Tearing Pain Tearing Pain
Originates in the aorta
Separation of layers of this large blood
vessel caused by aneurysm
Retroperitoneal location of aorta causes
pain to be referred to back
Abdominal Conditions Abdominal Conditions
Appendicitis Appendicitis
Infection of appendix
Appendectomy is usually indicated
Signs and symptoms
Persistent RLQ pain
Pain often initially referred to umbilical region
Rupture of appendix
Sudden, severe increase in pain
Contents released into abdomen causes severe
peritonitis
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Peritonitis Peritonitis
Irritation of peritoneum, usually caused by
foreign material in peritoneal space
Parietal peritoneum is sensitive, especially
to acidic substances
Irritation causes involuntary contraction of
abdominal muscles
Signs and symptoms
Abdominal pain and rigidity
Cholecystitis Cholecystitis
Inflammation of the gallbladder
Often caused by blockage of its outlet by
gall stones (cholecystolithiasis)
Symptoms often worsened by ingestion of
fatty foods
Signs and symptoms
Sharp RUQ or epigastric pain
Pain often referred to shoulder
Pancreatitis Pancreatitis
Inflammation of the pancreas
Common with chronic alcohol abuse
Signs and symptoms
Epigastric pain
Often referred to back or shoulder
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Gastrointestinal (GI) Bleeding Gastrointestinal (GI) Bleeding
Hemorrhage within the lumen of the GI
tract
May be minor to severe
Blood eventually exits (mouth or rectum)
Often painless
Gastric ulcers (holes in GI system from
highly acidic gastric juices) can cause
severe pain and peritonitis
continued
Gastrointestinal (GI) Bleeding Gastrointestinal (GI) Bleeding
Signs and symptoms
Dark-colored stool (maroon to black), often
tarry (Melena)
Frank blood from rectum (hemorrhoid)
Vomiting coffee ground appearing blood
Vomiting frank blood
Pain: absent to severe
Abdominal Aortic Abdominal Aortic
Aneurysm (AAA) Aneurysm (AAA)
Weakening of inner wall of the aorta
Tears and separates from outer layers
(dissection)
Weakened vessel bulges, may continue to
grow
May eventually rupture
continued
6/28/2011
531
Signs and symptoms
Progressive (often tearing) abdominal pain
Frequently radiates to back (lumbar)
Palpable abdominal mass, possibly pulsating
Possible inequality in pedal pulses
continued
Signs and symptoms
Sudden, severe increase in pain may indicate
rupture
High aortic pressure causes rapid internal bleeding
Sudden progression of shock
Likely exsanguination (fatal hemorrhage)
Hernia Hernia
Hole in the abdominal wall, allowing tissue
or parts of organs (commonly intestines) to
protrude under skin
May be precipitated by heavy lifting
May cause strangulation of tissue or bowel
obstruction
May require surgical repair
continued
6/28/2011
532
Hernia Hernia
Signs and symptoms
Sudden onset of abdominal pain, often
following exertion
Palpable mass or lump on abdominal wall or
crease of groin (inguinal hernia)
Renal Colic Renal Colic
Severe pain caused by kidney stones
traveling down the ureter
Signs and symptoms
Severe, cramping, intermittent pain in flank or
back
Frequently referred to groin
Nausea, vomiting
Cardiac Involvement Cardiac Involvement
Pain of myocardial infarction can produce
Nausea or vomiting
Epigastric pain
Indigestion
Always consider the possibility of a cardiac
emergency as a cause of abdominal
symptoms
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Assessment and Care of Assessment and Care of
Assessment and Care of Assessment and Care of
Many potential causes of abdominal pain
Role of EMT is not to diagnose
Focus efforts
Perform thorough history and physical exam
Identify serious or life-threatening conditions
Protect self from blood-borne pathogens
Be aware of odors
Determine if patients condition is medical,
trauma, or both
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General impression
ABCs
Level of consciousness
History of the Present Illness History of the Present Illness
O: When did it begin? What were you doing?
P: What makes it better or worse? Movement?
Position?
Q: Describe your discomfort.
R: Point to its location. Does it radiate or
move?
S: How bad is the pain on a scale of 110?
T: Do you have pain all the time? Is it
intermittent? Has it changed?
continued
History of the Present Illness History of the Present Illness
Female patients
Where in your cycle are you?
Is your period late?
Are you experiencing vaginal bleeding?
Is your flow normal?
Have you experienced this pain before?
Is it possible you are pregnant?
Are you using birth control?
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Past Medical History Past Medical History
S: Symptoms
A: Allergies
M: Medications
P: Pertinent past history
L: Last oral intake
E: Events leading to emergency
Geriatric Note: Assessment Geriatric Note: Assessment
Decreased ability to perceive pain
More serious causes of abdominal pain
More likely to be life-threatening
May be complicated by medications
Physical Exam Physical Exam
Inspection
Distention
Discoloration
Protrusions
Palpation (use fingertips; painful area last)
Rigidity
Pain
Guarding
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Vital Signs Vital Signs
Baseline, then every 5 minutes
Pulse
Blood pressure
Respirations
Skin condition, color, temperature
Mental status
Maintain airway
Be prepared to suction
Administer oxygen
15 LPM via NRB
Position of comfort
LLR for airway protection
Transport to appropriate facility
An 89-year-old female with a history of
diabetes, hypertension, and gallstones is
complaining of nausea and dizziness
about 20 minutes after eating.
continued
6/28/2011
537
What are the concerns with this patient?
Is this an abdominal emergency, a diabetic
emergency, or a cardiac emergency?
How will you know?
What will your treatment be?
Aneurysm Video Aneurysm Video
Click here to view a video on the subject of abdominal
aortic aneurysm.
Back to Directory
6/28/2011
538
Abdominal complaints must be treated as
serious emergencies requiring transport.
Diagnosis is difficult; your responsibility is
to assess the patient and report findings.
Assessment should include thorough
history, physical exam, and vital signs.
continued
Quickly identify life-threatening
emergencies: aneurysms, internal
bleeding, shock.
Care consists of airway management,
oxygen, positioning, transport.
Use standard precautions, including
disinfecting equipment.
Remember Remember
Abdominal organs provide a variety of
important functions to the body.
The abdomen can be divided into four
quadrants, with reference to the midline
and umbilicus.
Classifications of pain can help identify
specific abdominal dysfunctions.
continued
6/28/2011
539
Remember Remember
Assessment and management always
take a higher priority than determining the
exact cause of abdominal pain.
Knowledge of the characteristics of
specific abdominal disorders can aid
differential diagnosis when assessing a
patient with abdominal pain.
continued
Remember Remember
Care for a patient with abdominal pain
should include treatment of immediate life
threats, administration of oxygen, placing
patient in a position of comfort, and
appropriate transport.
What are five signs and symptoms of
abdominal distress?
Describe the difference between visceral
and parietal pain. Describe a condition that
may be responsible for each.
continued
6/28/2011
540
What is the emergency care for a patient
experiencing abdominal pain or distress?
Name the four abdominal quadrants. How
are the quadrants determined?
You are called to a patient with abdominal
pain. He describes the pain as severe and
says it has been on and off over the past
several days, becoming severe within the
last hour.
continued
What additional questions would you ask
the patient?
In what position would he likely be most
comfortable?
6/28/2011
541
11
13, 3637
25.2 Recognize behaviors that are abnormal in a given
context. Slide 13
25.3 Discuss medical and traumatic conditions that can
cause unusual behavior. Slides 1415
continued
6/28/2011
542
25.4 For a patient whose abnormal behavior appears to
be caused by stress, discuss techniques to calm the
patient and gain his cooperation. Slides 1617
continued
25.5 Discuss the assessment of a patient who appears to
be suffering from a behavioral or psychiatric
emergency. Slide 21
25.6 Discuss the steps in managing a patient presenting
with a behavioral or psychiatric emergency. Slides
2223
25.7 Describe factors often associated with a risk of
suicide. Slide 24
25.8 Discuss care for a patient who is a potential or
attempted suicide. Slides 2526
25.9 Recognize indications that a patient may become
violent. Slide 29
continued
6/28/2011
543
25.10 Explain considerations in using force and restraint
when managing behavioral emergency calls. Slides
3235
25.11 Explain considerations when faced with a behavioral
emergency patient who refuses treatment and
transport. Slide 39
Slide 41 SafetyRestraints Video
CORE CONCEPTS
The nature and causes of behavioral and
psychiatric emergencies
Emergency care for behavioral and
psychiatric emergencies
Emergency care for potential or attempted
suicide
continued
6/28/2011
544
CORE CONCEPTS
Emergency care for aggressive or hostile
patients
How to restrain a patient safely and
effectively
Medical/legal considerations in behavioral
and psychiatric emergencies
Topics Topics
Behavioral and Psychiatric Emergencies
Emergency Care for Behavioral or
Psychiatric Emergencies
Introduction Introduction
Patients may present
with unexpected or
dangerous behavior
May result from
Stress
Physical trauma or
illness
Drug or alcohol abuse
Psychiatric condition
6/28/2011
545
Behavioral and Psychiatric Behavioral and Psychiatric
Emergencies Emergencies
What Is a What Is a
Behavioral Emergency? Behavioral Emergency?
Behavior
Manner in which a person acts or performs
Behavioral emergency
Abnormal behavior (in a given situation)
unacceptable or intolerable to patient, family,
or community
Behavioral patients may appear confused
and have altered mental status
Psychiatric Causes of Psychiatric Causes of
Behavioral Emergencies Behavioral Emergencies
Psychiatric condition (mental disorder)
Anxiety or panic disorder
Depression
Bipolar disorder
Schizophrenia
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Physical Causes of Physical Causes of
Behavioral Emergencies Behavioral Emergencies
Non-psychiatric
causes of altered
mental status can
be life-threatening
and must be
considered first
Altered
Mental
Status
Hypoglycemia
Hypoxia
Stroke
Headtrauma
Substance
abuse
Hypothermia
Hyperthermia
Situational Stress Reactions Situational Stress Reactions
Normal reactions to stressful situations
produce emotions
Fear
Grief
Anger
Caring for Patients Caring for Patients
with Situational Stress Reactions with Situational Stress Reactions
Do not rush
Tell patient you are there to help
Remain calm
Keep emotions under control
Listen to patient
Be honest
Stay alert for changes in behavior
6/28/2011
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Emergency Care for Behavioral Emergency Care for Behavioral
or Psychiatric Emergencies or Psychiatric Emergencies
Behavioral and Behavioral and
Psychiatric Patient Presentations Psychiatric Patient Presentations
Range of presentations
Withdrawn, not communicating
Talkative, agitated
Bizarre or threatening behavior
Wish to harm selves or others
General Rules for Interactions General Rules for Interactions
Identify yourself and role
Speak slowly and clearly
Eye contact
Listen
Dont judge
Open, positive body language
Dont enter patients space (3 ft)
Alert for behavior changes
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548
Perform careful scene size-up
Identify yourself and your role
Perform focused physical exam
Gather thorough history
Common Patient Presentations Common Patient Presentations
Panic or anxiety
Unusual appearance (disordered clothing,
poor hygiene)
Agitated or unusual activity
Unusual speech patterns
Bizarre behavior or thought patterns
Self-destructive behavior
Violence or aggressive behavior
Treat life-threatening problems
Consider medical or traumatic causes
Follow general rules for positive
interactions
Encourage patient to discuss feelings
Never play along with hallucinations
Consider involving family or friends
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Suicide Suicide
Eighth leading
cause of death
Third leading
cause in 1524-
year-olds
Rising numbers in
geriatric population
Suicide
Factors
Depression
Age
Suicide Plan
Stress levels
Sudden
Improve-
ment
Recent
emotional
trauma
Substance
Abuse
Suicide Patient Assessment Suicide Patient Assessment
Explore the following possibilities
Depression
High stress levels (current or recent)
Recent emotional trauma
Age (1525 and 40+ highest risk)
Drug or alcohol abuse
Threats of suicide
Suicide plan
Previous attempts or threats
Sudden improvement from depression
Suicide Patient Care Suicide Patient Care
Personal interaction is important
Do not argue, threaten, or indicate using
force
1. Scene safety
2. Identify, treat life-threatening problems
3. Perform history, physical exam
Detailed exam only if safe
4. Reassess frequently
5. Notify receiving facility
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550
Patient is 23-year-old male. His girlfriend
called 911 after a domestic dispute. He is
uncooperative and refusing treatment. The
girlfriend reports patient is depressed and
suicidal. He owns a gun and has
threatened to shoot himself.
continued
Can you treat the patient if he did not call?
Should you believe the girlfriend?
Does the patient need treatment or
transport?
Can you treat and transport the patient
against his will?
What should you do?
Aggressive or Aggressive or
Hostile Patients Hostile Patients
Consider clues
Dispatch information
Information from family or bystanders
Patients stance or position in room
Ensure escape route
Do not threaten patient
Stay alert for weapons of any type
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551
Hostile Patient Assessment Hostile Patient Assessment
Ensure safety
Calm patient
Perform a thorough assessment
Restrain patient if necessary
Hostile Patient Care Hostile Patient Care
Scene size-up
Request additional help if necessary
Seek advice from medical control if
necessary
Watch for sudden changes in behavior
Reassess frequently
Consider restraint
Reasonable Reasonable
Force and Restraint Force and Restraint
Reasonable force: force necessary to
keep patient from injuring self or others
Reasonable determined by
Patients size and strength
Type of behavior
Mental status
Available methods of restraint
continued
6/28/2011
552
Reasonable Reasonable
Force and Restraint Force and Restraint
Some systems do not
allow restraint without
police or medical
control orders
Never attempt
restraint without
proper legal authority
and sufficient
assistance
Restraining a Patient Restraining a Patient
Have adequate help
Plan actions
Stay beyond patients reach until prepared
Act quickly
One EMT talks to and calms patient
Requires four persons, one at each limb
Restrain all limbs with approved leather
restraints in supine position ALWAYS
continued
Restraining a Patient Restraining a Patient
EMT is responsible for restrained patients
airway
Ensure patient is adequately secured
throughout transport
Apply a surgical mask to spitting patients
Reassess frequently
Document thoroughly
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553
Excited Delirium Excited Delirium
Extremely agitated or psychotic behavior
during struggle, followed by cessation of
struggling, respiratory arrest, then death
Patient is often hyperthermic and shouting
incoherently
Usually preceded by cocaine use
continued
Excited Delirium Excited Delirium
Often linked to improper restraint in a
position where patient cannot expand
chest to breathe adequately (positional
asphyxia)
Be alert for this sequence of events
Transport to Transport to
Appropriate Facility Appropriate Facility
Not all hospitals are prepared to treat
behavioral emergencies
Choose correct facility based on
capabilities and local protocol
6/28/2011
554
Medical/Legal Considerations Medical/Legal Considerations
Consent
Refusals and restraints cause significant
medical/legal risk
Laws typically allow providers to treat and
transport patients against their will if a danger
to selves or others
Local protocol may require medical control
contact and/or police presence
continued
Medical/Legal Considerations Medical/Legal Considerations
Sexual misconduct
Behavioral patients, especially those requiring
physical contact such as restraint, sometimes
accuse EMS providers
Have same-sex provider attend to patient
Have third-party witness present at all times,
on scene and during transport
Safety SafetyRestraints Video Restraints Video
Click here to view a video on the subject of proper use of
soft restraints.
Back to Directory
6/28/2011
555
Ensure your own safety when caring for
violent or potentially violent patients.
Patients with behavioral problems are in
crisis and need compassionate care.
Always consider abnormal behavior to be
altered mental status, with a medical or
traumatic cause.
continued
Because treatment of these patients
usually requires long-term management,
little medical intervention can be done in
the acute situation, but how you interact
with them is crucial for their continued
well-being.
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Remember Remember
Safety is the first priority when
approaching a patient with altered mental
status.
Psychiatric and behavioral emergencies
are prevalent in our society. EMTs should
treat them as they would any other
potentially life-threatening disorder.
continued
Remember Remember
Assessment of altered mental status
should rule out physical causes first.
Psychiatric and behavioral emergencies
can present differently, depending upon
the disorder. There are best practices
EMTs employ in approaching, assessing,
and treating such patients.
continued
Remember Remember
Follow local protocols and use appropriate
procedures to restrain patients when
necessary.
6/28/2011
557
What methods help calm the patient
suffering a behavioral or psychiatric
emergency?
What can you do when scene size-up
reveals it is too dangerous to approach the
patient?
What factors help assess the patients risk
for suicide?
You respond to an intoxicated minor who
is physically aggressive, threatens suicide,
and whose parents permit you to treat, but
not transport the patient. How would you
manage this patient?
6/28/2011
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11
1314, 2122, 2426, 31
26.2 Describe the structure and function of the
hematologic system. Slides 1112
26.3 Identify medications that can interfere with blood
clotting. Slide 12
continued
26.4 Explain the pathophysiology and complications of
sickle cell anemia. Slides 1415
26.5 Discuss assessment and management for patients
with emergencies related to sickle cell anemia.
Slide 16
26.6 Describe the structure and function of the renal
system. Slide 20
continued
6/28/2011
559
26.7 Describe the causes and consequences of acute
and chronic renal failure. Slides 2122
26.8 Explain the purpose of hemodialysis and peritoneal
dialysis. Slides 2426
continued
continued
26.9 Recognize patients with complications of end-stage
renal disease, dialysis, and missed dialysis. Slides
2730
26.10 Provide treatment for patients with complications of
end-stage renal disease, dialysis, and missed
dialysis. Slide 31
26.11 Describe special considerations for patients who
have received a kidney transplant. Slide 32
6/28/2011
560
Slide 18 Sickle Cell Anemia Video
Slide 33 Information About Renal Failure Video
CORE CONCEPTS
Disorders of the hematologic system
Disorders of the renal system
Topics Topics
The Hematologic System
The Renal System
6/28/2011
561
The Hematologic System The Hematologic System
Blood Blood
Represents its own organ system
Has specific functions
Clotting
Delivery of oxygen and removal of CO
2
Removal and delivery of waste products to
organs that remove them
continued
Blood Blood
Made up of solid components
Red blood cells
White blood cells
Platelets
Plasma
Medications can affect some components
of blood
6/28/2011
562
Anemia Anemia
Lower-than-normal amount of red blood
cells
Acute anemia
Sudden blood loss
Chronic
Excessive menstrual periods
Slow gastrointestinal bleeding
Diseases affecting bone marrow
Sickle Cell Anemia Sickle Cell Anemia
Genetic disease affecting RBCs
More prevalent in certain ethnicities
African Americans
Indian or Middle Eastern descent
Defective shape resembles a sickle
Cells have a short life span leading to
anemia
Complications of Complications of
Destruction of spleen
Sickle pain crisis
Acute chest syndrome
Priapism
Stroke
6/28/2011
563
Treatment of Treatment of
High flow
supplemental oxygen
Monitor for respiratory
distress
Monitor for signs of
hypoperfusion
Transport to stroke
center if stroke is
suspected
One in twelve African Americans have the
sickle cell trait.
Sickle cell trait doesnt always lead to
complications.
Possible to lead a normal life with sickle
cell trait.
Sickle Cell Anemia Video Sickle Cell Anemia Video
Click here to view a video on the subject of sickle cell anemia.
Back to Directory
6/28/2011
564
The Renal System The Renal System
Components and Functions Components and Functions
Components
Two kidneys
Two ureters
One urethra
Responsible for filtering blood and
removing waste
Maintains fluid balance
Maintains acid/base balance
Renal Failure Renal Failure
Occurs when kidneys lose ability to
adequately filter and remove toxins
Acute failure typically results from shock or
toxic ingestion
Chronic failure may be inherited or
secondary to damage from uncontrolled
diabetes or hypertension
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End End--Stage Stage
Renal Disease (ESRD) Renal Disease (ESRD)
Irreversible renal failure
Requires dialysis
Hemodialysis
Peritoneal dialysis
90% receive hemodialysis in specialized
centers
More than 350,000 people in America
receive some type of treatment for ESRD.
Only 8% treat themselves at home.
ESRD patients often rely on EMS for
transport to and from dialysis.
Hemodialysis Hemodialysis
Patient connected to a machine that
pumps blood through specialized
membranes
Treatments last several hours, multiple
times a week
continued
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566
Two types of access to blood circulation
Two-port catheter
A-V fistula
Two-port catheter A-V fistula
Peritoneal Dialysis Peritoneal Dialysis
Uses peritoneal cavitys large surface area
Special fluid infused into abdominal cavity
and left for several hours to absorb waste
and excess fluid
Fluid is removed and
discarded
Medical Medical
Emergencies in ESRD Emergencies in ESRD
Two broad groups
Loss of kidney function
Complication of dialysis
Most dialysis patients have underlying
medical factors
Diabetes
Hypertension
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567
Complications of ESRD Complications of ESRD
Usually relate to patient missing dialysis
Present with signs and symptoms similar
to congestive heart failure
Shortness of breath
Edema
Electrolyte disturbances
Missed Dialysis Missed Dialysis
Assess ABCs
Be aware of fistulas
Administer oxygen
Monitor vital signs closely and have AED
ready
Transport to facility capable of dialysis
Complications of Dialysis Complications of Dialysis
Bleeding fromA-V fistula
Clotting and loss of A-V fistula function
Infection
Peritonitis
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Treatment of Treatment of
Dialysis Complications Dialysis Complications
Assess ABCs
Control bleeding
Contact medical control if necessary
Administer oxygen
Treat for shock
Keep patient supine and warm
If peritonitis is suspected, transport
dialysis fluid for confirmation
Kidney Transplant Patients Kidney Transplant Patients
Kidneys are the most-transplanted organs
Approximately 16,000 transplants per year
Patients spend their lives on specialized
medications
Help prevent organ rejection
Increased susceptibility to infections
Information Information
About Renal Failure Video About Renal Failure Video
Click here to view a video on the subject of renal failure.
Back to Directory
6/28/2011
569
Blood consists of red cells, white cells, and
plasma.
Anemia is lack of red blood cells in
circulation.
continued
Sickle cell anemia is an inherited disease
in which a defect in the hemoglobin results
in sickle shape to red blood cells. This
misshaping inhibits movement of red blood
cells through capillaries, causing
sludging and blockages in smaller blood
vessels.
continued
6/28/2011
570
The renal system is comprised of the
kidneys, ureters, and urethra.
The kidneys perform vital filtering of the
blood to remove waste products. They
also help maintain water balance within
the body.
continued
Problems with the renal system include
infection, kidney stones, and renal failure.
Renal failure is a condition in which the
kidneys are unable to filter waste and
provide a balance of fluids in the body.
continued
In dialysis, an external system filters the
blood and removes excess fluid from the
body. Dialysis may be performed in either
of two ways: hemodialysis or peritoneal
dialysis.
continued
6/28/2011
571
Dialysis at dialysis centers is generally
performed three times per week.
The main complications with patients in
end stage renal disease generally occur
after the patient has missed a dialysis
appointment.
Remember Remember
Blood has specific cellular components.
Abnormal blood cells can significantly
affect patients.
The renal system is critical to maintaining
homeostasis.
Renal failure can be chronic or acute.
End stage renal disease is managed
through dialysis.
Does my patient have a history of sickle
cell disease or ESRD?
Does my patient have an A-V fistula?
Will I need to make an early request for
ALS because of complications from a
missed dialysis appointment?
6/28/2011
572
You have a patient who is transported
routinely for dialysis three times per week.
She was sick and canceled the trip
yesterday. Now she calls saying she cant
breathe and feels like she is going to die.
Is it possible that she has a legitimate
complaint after missing dialysis by only
one day?
11
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17, 21, 2830, 47, 49, 5254
27.2 Describe the structure and function of the circulatory
system, including the functions of the blood. Slides
1216
27.3 Explain the concept of perfusion. Slide 17
continued
27.4 Compare and contrast arterial, venous, and capillary
bleeding. Slide 21
27.5 Discuss causes and effects of severe external
bleeding. Slides 2021, 3436
27.6 Discuss assessment and management of external
bleeding, including methods of controlling external
bleeding. Slides 2331, 3335
continued
continued
27.7 Identify patients at risk for internal bleeding. Slides
3839
27.8 Recognize signs of internal bleeding and discuss
patient care for internal bleeding. Slides 4044
27.9 Discuss the causes of shock and its effects on the
body. Slides 4750
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574
27.10 Explain the concepts of compensated,
decompensated, and irreversible shock. Slide 49
27.11 Discuss the types of shock. Slides 5154
27.12 Relate the signs and symptoms of shock to the
bodys attempts to compensate for blood loss.
Slide 55
continued
27.13 Discuss the management of patients in shock.
Slides 5659
Slide 45 Bleeding Control/Shock Management Video
Slide 60 Shock Video
6/28/2011
575
CORE CONCEPTS
How to recognize arterial, venous, and
capillary bleeding
How to evaluate the severity of external
bleeding
How to control external bleeding
continued
CORE CONCEPTS
Signs, symptoms, and care of a patient
with internal bleeding
Signs, symptoms, and care of a patient
with shock
Topics Topics
The Circulatory System
Bleeding
Shock
6/28/2011
576
The Circulatory System The Circulatory System
Circulatory System Circulatory System
Arteries Arteries
Carry oxygen-rich blood away from the
heart
Comprised of thick, muscular walls that
enable dilation and constriction
6/28/2011
577
Veins Veins
Carry oxygen-depleted blood rich in
carbon dioxide back to the heart
Contain one-way valves to prevent back
flow of blood
Capillaries Capillaries
Microscopic blood vessels
Vital exchange site: oxygen, nutrients
passed through
capillary walls in
exchange for
carbon dioxide
from cells
Functions of Blood Functions of Blood
Transportation of gases
Nutrition
Excretion
Protection
Regulation
6/28/2011
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Perfusion
Hypoperfusion
(Shock)
Adequate
circulation of
blood
throughout
body
Inadequate
circulation of
blood to
tissues and
organs
Bleeding Bleeding
Types of Bleeding Types of Bleeding
External
Internal
6/28/2011
579
External Bleeding External Bleeding
Spurting Steady
External Bleeding External Bleeding
How severe is the bleeding? Is it
exsanguinating hemorrhage? If so, how
does that affect the priorities of treatment?
6/28/2011
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Patient Assessment Patient Assessment
Open
Airway
Standard
Precautions
Monitor
Respirations
Ventilate
if Necessary
Control Bleeding
Skin: Color, Temp,
Condition,
Check Pulses
Methods to Methods to
Control External Bleeding Control External Bleeding
Direct Pressure Direct Pressure
Apply firm pressure to wound with gloved
hand and gauze bandage
Hold pressure until bleeding is controlled
If necessary, add dressings when lower
ones are saturated
continued
6/28/2011
581
Direct Pressure Direct Pressure
Never remove bandageseven when
bleeding is controlled
When controlled, check for pulse distal to
wound
Elevate Elevate
Elevate injured extremity above level of
the heart while applying direct pressure
Do not elevate if musculoskeletal injury is
suspected
Pressure Dressing Pressure Dressing
Place several gauze pads on wound
Hold dressings in place with self-adhering
roller bandage wrapped tightly over
dressings and above and below wound
site
Create enough pressure to control
bleeding
6/28/2011
582
Hemostatic Agents Hemostatic Agents
Commonly, dressing containing substance
that absorbs and traps red blood cells
Can be wadded up and inserted into
wound
May be a powder poured directly into the
wound
Manual pressure is always necessary
Tourniquet Tourniquet
Use if bleeding is uncontrollable via direct
pressure
Use only on
extremity
injuries
continued
Tourniquet Tourniquet
Once applied, do not remove or loosen
Attach notation to patient alerting other
providers tourniquet has been applied
6/28/2011
583
Is the current method of bleeding control
working? Do you need to move on to a
more aggressive step? How would you
evaluate this?
Other Ways to Stop Bleeding Other Ways to Stop Bleeding
Splinting
Cold application
Pneumatic anti-shock
garment (PASG)
Special Bleeding Situations Special Bleeding Situations
Head injury
From increased intracranial pressure, not
direct trauma
Stopping bleeding only increases intracranial
pressure
6/28/2011
584
Nosebleed
(Epistaxis)
Have patient sit
and lean forward
Apply direct
pressure to fleshy
portion of nostrils
Keep patient calm
and quiet
continued
Nosebleed (Epistaxis)
Do not let patient lean back
If patient becomes unconscious, place patient
in recovery position and be prepared to
suction
Internal Bleeding Internal Bleeding
Damage to internal organs and large blood
vessels can result in loss of a large
quantity of blood in short time
Blood loss commonly cannot be seen
Severe blood loss can even result from
injuries to extremities
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Blunt Trauma Blunt Trauma
Leading cause of internal bleeding
Falls
Motor vehicle crashes
Automobilepedestrian collisions
Blast injuries
Penetrating Trauma Penetrating Trauma
Common penetrating injuries
Gunshot wounds
Stab wounds
Impaled objects
Signs of Internal Bleeding Signs of Internal Bleeding
Injuries to surface of body
Bruising, swelling, or pain over vital organs
Painful, swollen, or deformed extremities
Bleeding from mouth, rectum, or vagina
continued
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Signs of Internal Bleeding Signs of Internal Bleeding
Tender, rigid, or distended abdomen
Vomiting coffee-ground or bright-red
material
Pediatric Considerations Pediatric Considerations
Infants and childrenefficient
compensating mechanisms maintain blood
pressure until half of volume is depleted
Potential for shock must be recognized
and treated before tell-tale signs appear
Cultural Considerations Cultural Considerations
Places on body to look to assess
circulation via skin color
Fingernails and lips
Conjunctiva in eyes
Palms of hands; soles of feet
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Treatment of Internal Bleeding Treatment of Internal Bleeding
Maintain
ABCs Administer
Oxygen
Control
External
Bleeding
Rapid Transport to
Appropriate Medical
Facility
Bleeding Control/ Bleeding Control/
Shock Management Video Shock Management Video
Click here to view a video on the subject of controlling bleeding and
shock management.
Back to Directory
Shock Shock
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Shock Shock
Inability to supply
cells with oxygen
and
nutrients
Inadequate
removal
of waste
products from
cells
Causes of Shock Causes of Shock
Failure of any component of circulatory
system
Heart: loses ability to pump
Blood vessels: dilate, making too large a
container to fill
Blood: loses volume from bleeding
Severity of Shock Severity of Shock
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Types of Shock Types of Shock
Hypovolemic
Cardiogenic
Neurogenic
Hypovolemic Shock Hypovolemic Shock
Results from a decreased volume of
circulating blood and plasma
Called hemorrhagic shock if caused by
uncontrolled bleeding (internal or external)
Can be caused by burns or crush injuries
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Cardiogenic Shock Cardiogenic Shock
Seen in patients suffering myocardial
infarction
Results from inadequate perfusion to
heart, decreasing strength of contractions
Hearts electrical system may malfunction,
causing heartbeat that is too slow, too fast,
or irregular
Neurogenic Shock Neurogenic Shock
Results from inability to control dilation of
blood vessels because of nerve paralysis
No blood loss, but vessels dilated so much
that blood volume cant fill them
Rarely seen in the field
Signs and Symptoms of Shock Signs and Symptoms of Shock
Pale, cool, clammy skin
Nausea and vomiting
Vital sign changes
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Care for Shock Care for Shock
Aggressive airway maintenance
Attempt to stop cause of shock
Apply and inflate PASG if approved
continued
Care for Shock Care for Shock
Splint any suspected bone or joint injuries
Prevent loss of body heat
Deliver patient to appropriate medical
facility within golden hour
Speak calmly and reassure throughout
assessment and care
PASGApplication PASGApplication
Step 1 Step 2
Step 3
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PASGApplication PASGApplication
Step 4
Step 5
Step 6
Shock Video Shock Video
Click here to view a video on the subject of shock.
Back to Directory
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593
Almost all external bleeding can be
controlled by direct pressure and
elevation. If these dont work, apply
tourniquet if bleeding is on an extremity.
Emergency care for internal bleeding is
based on prevention and treatment of
shock.
continued
Early signs of shock: restlessness, anxiety,
pale skin, rapid pulse and respirations.
If shock is uncontrolled, patients blood
pressure falls (late sign of shock).
Signs and symptoms may not be evident
early; treatment based on MOI may be life-
saving.
continued
Treat shock by airway maintenance;
administration of high-concentration
oxygen; controlling bleeding; and keeping
the patient warm. One of most important
treatments is early recognition of shock
and immediate transport.
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Remember Remember
The circulatory system is designed to
ensure adequate perfusion of body
tissues.
The classification of hemorrhage is directly
related to the type of vessel ruptured and
the pressure within that vessel.
continued
continued
Remember Remember
Treatment of external hemorrhage
includes progression through the following
steps: direct pressure, elevation,
tourniquet application, use of hemostatic
agents.
Internal bleeding is impossible to evaluate.
The most appropriate treatment must be
rapid transport to an appropriate facility.
Remember Remember
Shock develops if the heart fails, blood
volume is lost, or blood vessels dilate,
resulting in inadequate perfusion.
Signs of shock reflect the bodys attempts
at compensating for inadequate perfusion.
continued
6/28/2011
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continued
Remember Remember
The most significant treatment for the
shock patient is early recognition and
prompt transport to a hospital where the
patient will receive definitive care.
What can I use for a tourniquet that will
control bleeding but not damage tissue?
When treating a patient with shock, what
should I do at the scene and what should I
do en route to the hospital?
continued
Is a patient with pale, cool skin,
tachycardia, and rapid, shallow
respirations in shock or just under stress?
How will continuing assessment help in
making that decision?
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A patient has been involved in a motor-
vehicle collision. There is considerable
damage to the vehicle. The steering
column and wheel are badly deformed.
The patient complains of a sore chest.
You note no external bleeding.
continued
The patients vital signs are pulse 116,
respirations 20, blood pressure 106/70.
How would you proceed to assess and
care for this patient?
6/28/2011
597
11
13, 1617, 22, 4345
28.2 Describe the structure and function of the skin.
Slide 13
28.3 Describe types of closed soft tissue wounds and the
assessment and management of closed soft tissue
wounds. Slides 1620
continued
continued
28.4 Predict internal injuries that may be indicated by
various contusion (bruise) types and locations.
Slide 18
28.5 Describe types of open soft tissue wounds and
general assessment and care for open soft tissue
wounds. Slides 22, 2425
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28.6 Describe specific treatment for abrasions and
lacerations, puncture wounds, impaled objects,
avulsions, amputations, and genital injuries.
Slides 2739
28.7 Discuss complications associated with burns.
Slide 41
continued
28.8 Classify burns by agent, source, depth, and severity.
Slides 4245
28.9 Describe specific treatment for thermal burns and
chemical burns. Slides 4749
continued
28.10 Describe assessment and management for
electrical burns. Slides 5153
28.11 Describe considerations in the dressing and
bandaging of open wound. Slides 5659
6/28/2011
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Slide 14 Integumentary Anatomy Video
Slide 54 Electrical Injuries Video
CORE CONCEPTS
Understanding closed wounds and
emergency care for closed wounds
Understanding open wounds and
emergency care for open wounds
Understanding burns and emergency care
for burns
continued
CORE CONCEPTS
Understanding electrical injuries and
emergency care for electrical injuries
How to dress and bandage wounds
6/28/2011
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Topics Topics
Soft Tissues
Closed Wounds
Open Wounds
Treating Specific Types of Open Wounds
Burns
Electrical Injuries
Dressing and Bandaging
Soft Tissues Soft Tissues
Soft Tissues Soft Tissues
Skin
Fatty tissues
Muscles
Blood vessels
Fibrous tissues
Membranes
Glands
Nerves
6/28/2011
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Skin Skin
Protection
Water balance
Temperature
regulation
Excretion
Shock absorption
Integumentary Anatomy Video Integumentary Anatomy Video
Click here to view a video on the subject of skin layers and wounds.
Back to Directory
Closed Wounds Closed Wounds
6/28/2011
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Contusion
Bruise
Hematoma
Similar to contusion
More tissue
damage
Involves larger
blood vessels
continued
Closed crush injury
Excessive force
crushing or rupturing
internal (generally
solid) organs
Bruising may be
internal injury or
bleeding
Consider
mechanism of
injury
Crush injuries are
difficult to identify
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Treatment: Treatment:
Take appropriate Standard Precautions
Manage airway, breathing, and circulation
Always manage for internal bleeding and
shock if there is a possibility of internal
injuries
continued
Splint extremities that are painful, swollen,
or deformed
Stay alert for vomiting
Continuously monitor for changes and
transport
Open Wounds Open Wounds
6/28/2011
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Abrasion
Laceration
Puncture
Avulsion
Amputation
Crush injury
Blast injury
Does an open wound necessitate using
more than just gloves as standard
precautions?
Can an open injury affect the patients
airway or breathing?
Treatment: Open Injuries Treatment: Open Injuries
Expose wound
Clean surface of wound
Control bleeding
Provide care for shock
Prevent further contamination
continued
6/28/2011
605
Treatment: Open Injuries Treatment: Open Injuries
Bandage dressings in place after bleeding
is controlled
Keep patient still
Reassure patient
Treating Specific Types of Treating Specific Types of
Abrasions and Lacerations Abrasions and Lacerations
Reduce wound contamination
Hold direct pressure to control bleeding
Always check pulse, motor, and sensory
function distal to injury to assure function
Never open edges of laceration to see
inside or further clean wound
6/28/2011
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Puncture Wounds Puncture Wounds
Use cautionobjects may be embedded
deeper than they appear
Check for exit wounds
May require immediate care
Bullets can fracture bones as they enter
Stab wounds are considered serious if in a
vital area of body
continued
Puncture Wounds Puncture Wounds
Reassure patient
Search for exit
wound
Assess need for
shock care
Follow local
protocols regarding
spinal immobilization
Transport patient
Impaled Objects Impaled Objects
Do not remove object; may cause severe
bleeding
Expose wound area
Control profuse bleeding by direct
pressure
Apply several layers of bulky dressing to
splint object in place
continued
6/28/2011
607
continued
Secure dressings
Treat for shock
Provide rapid transport
Splint object Secure dressings
Impaled Object in Cheek Impaled Object in Cheek
Take care that object does not enter oral
cavity, causing airway obstruction
If cheek wall is perforated, profuse
bleeding into mouth and throat can cause
nausea and vomiting
External wound care will not stop the flow
of blood into the mouth
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Examine wound site, both inside and
outside mouth
If you find the perforation and can see
both ends, remove
object
If object is impaled
into another structure,
stabilize in place
continued
Position patient to allow for drainage
Monitor patients airway
Dress outside of wound
Provide oxygen
Provide care for shock
Treatment: Avulsions Treatment: Avulsions
Clean wound surface
Fold skin back into normal position
Control bleeding and dress with bulky
dressings
If avulsed parts are completely torn away,
save in sterile dressing and keep moist
with sterile saline
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Treatment: Amputations Treatment: Amputations
Apply pressure dressing over stump
Use pressure points to control bleeding;
use tourniquet only if all other methods fail
continued
Treatment: Amputations Treatment: Amputations
Wrap amputated part in sterile dressing
and place in plastic bag; put bag in pan
with water and cold packs
Do not immerse amputated part directly in
icy cold water
Treatment: Genital Injuries Treatment: Genital Injuries
Control bleeding
Preserve avulsed parts
Consider if injury suggests another,
possibly more serious, injury
Calm, professional manner
Maintain patients dignity
Dress and bandage wound
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Burns Burns
Burns Burns
May involve more than just skin-level
structures
If respiratory structures are affected,
swelling may occur, causing life-
threatening obstruction
Dont let burn distract from spinal damage
or fractures
Assessment: Burns Assessment: Burns
Classifying burns
Agent and source
Depth
Severity
6/28/2011
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Burns: Depth Burns: Depth
Superficial (1st Degree)
Involves only epidermis
Reddening with minor swelling
Partial Thickness (2nd Degree)
Epidermis burned through, dermis damaged
Deep, intense pain
Blisters and mottling
continued
Burns: Depth Burns: Depth
Full Thickness (3rd Degree)
All layers of skin burned
Blackened areas surrounded by dry and white
patches
Burns: Severity Burns: Severity
Rule of Nines
Helps estimate extent of burn area
Adult body is divided into 11 main areas
Each represents 9 percent of body surface
6/28/2011
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Burns: Burns:
Geriatrics and Pediatrics Geriatrics and Pediatrics
Minor burn area in a young adult can be
fatal to a geriatric adult
Infants and children have a much greater
relationship of body surface area to total
body size, resulting in greater fluid and
heat loss from burned skin
Treatment: Thermal Burns Treatment: Thermal Burns
Use sterile dressings
Never apply ointments, sprays, or butters
Do not break blisters
Treatment: Chemical Burns Treatment: Chemical Burns
Wash away
chemical with
copious amounts
of flowing water
If dry chemical,
brush away, then
flush with water
continued
6/28/2011
613
Treatment: Chemical Burns Treatment: Chemical Burns
Remove contaminated clothing
Apply sterile dressings
Treat for shock
Electrical Injuries Electrical Injuries
Electrical Injuries Electrical Injuries
Severe damage through body by
disrupting nerve pathways
Entry and exit burns are possible
Respiratory/cardiac arrest are possible
Bones may fracture from violent muscle
contractions
6/28/2011
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Treatment: Electrical Injuries Treatment: Electrical Injuries
Provide airway care
Be alert and prepared for cardiac rhythm
changes; be ready to defibrillate
Treat for shock and provide oxygen
continued
Treatment: Electrical Injuries Treatment: Electrical Injuries
Care for spinal and head injuries as well
as extremity fractures
Evaluate burn sites
Cool burning areas and apply sterile
dressings
Electrical Injuries Video Electrical Injuries Video
Click here to view a video on the subject of injuries
caused by electricity.
Back to Directory
6/28/2011
615
Dressing and Bandaging Dressing and Bandaging
Dressing: any
material applied to
wound to control
bleeding and
prevent
contamination
Pressure Dressing
Occlusive Dressing
Bandage: any
material used to
hold dressing in
place
6/28/2011
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Dressing Open Wounds Dressing Open Wounds
Expose wound
Completely cover wound area
Dressings should not be removed unless
bulky dressing is blood soaked and new
one must be applied to maintain direct
pressure
Control bleeding by direct pressure or
pressure dressings
Bandaging Open Wounds Bandaging Open Wounds
Do not bandage too
tightly or too loosely
Do not leave loose
ends
Do not cover tips of
fingers or toesmust
observe distal skin
color changes
Cover all edges of
dressings
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Soft-tissue injuries may be closed or open.
Closed injuries include contusions,
hematomas, and crush injuries. Open
wounds include abrasions, lacerations,
avulsions, amputations, and crush injuries.
continued
For open wounds, expose the wound,
control bleeding, and prevent further
contamination.
For both open and closed injuries, take
appropriate Standard Precautions.
continued
Burn severity is determined by considering
the source, the region affected, depth of
burn, extent of burn, age of the patient,
and other patient illnesses or injuries.
continued
6/28/2011
618
continued
Care for burns includes stopping the
burning, covering a thermal burn with a dry
sterile dressing, flushing a chemical burn
with sterile water, protection of the airway,
administration of oxygen, treatment for
shock, and transport.
For treatment of electrical injuries, be sure
that you and the patient are in a safe zone
away from possible contact with electrical
sources. Protect airway, breathing, and
circulation. Be prepared to care for
respiratory or cardiac arrest. Treat for
shock, care for burns, and transport.
Remember Remember
The soft tissue of the body is made up of
skin, fatty tissues, muscles, blood vessels,
fibrous tissues, membranes, glands, and
nerves.
The skin provides protection, water
balance, temperature regulation,
excretion, and shock absorption.
continued
6/28/2011
619
continued
Remember Remember
Open or closed in reference to a soft-
tissue injury is dictated by whether or not
the skin is still intact.
Closed injuries must be evaluated with
consideration to underlying anatomy and
mechanism of injury.
Remember Remember
Open injuries typically are easier to
visualize, but they often can mask
underlying injuries.
Burns involve immediate destruction of
tissue but also can have a long-term
effect, both physically and emotionally.
continued
Remember Remember
Safety must be a key concern when
treating a patient with a burn or an
electrical injury.
The goal of dressing and bandaging
wounds is to control bleeding and to
prevent infection.
6/28/2011
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Does the patient have a patent airway and
is breathing adequate?
If the wound is penetrating, is there an exit
wound?
What is the best way to immobilize an
impaled object?
continued
Is there respiratory involvement with the
burn?
Have we irrigated the chemical burn
sufficiently?
Does the electrical burn have an exit
wound?
Is the bandage securely fastened to hold
the dressing?
A 21-year-old male lacerated his anterior
elbow when he fell through a window.
There is a lot of blood around the patient.
Bystanders have applied numerous towels
and washcloths over the wound (at least 3
inches thick).
continued
6/28/2011
621
There are so many dressings on the
wound that you cant tell if it is still
bleeding. The patient is alert, but pale and
anxious. The radial pulse on his uninjured
arm is weak and rapid. How much
assessment of the wound should you do
and how do you do it without making
things worse?
11
6/28/2011
622
11, 15, 18, 27
29.2 Describe mechanisms of injury commonly
associated with chest injuries. Slides 910
continued
continued
29.3 Describe specific chest injuries, including flail chest,
open chest wounds, pneumothorax, tension
pneumothorax, hemothorax, hemopneumothorax,
traumatic asphyxia, cardiac tamponade, aortic
injury, commotio cordis, and the assessment and
management for each of these specific injuries.
Slides 1116, 1824
29.4 Discuss mechanisms and types of abdominal injury.
Slide 27
29.5 Demonstrate the assessment and management of
patients with blunt and penetrating abdominal
injuries, including management of evisceration.
Slides 2833
6/28/2011
623
Slide 25 Open Pneumothorax and Hemothorax Video
Slide 34 Liver Injuries Video
CORE CONCEPTS
Understanding chest injuries and
emergency care for chest injuries
Understanding abdominal injuries and
emergency care for abdominal injuries
Topics Topics
Chest Injuries
Abdominal Injuries
6/28/2011
624
Chest Injuries Chest Injuries
Blunt trauma
Can fracture ribs, sternum, and costal (rib)
cartilages
Compression
Occurs when severe blunt trauma causes the
chest to rapidly compress
continued
Penetrating objects
Bullets, knives,
pieces of metal or
glass, steel rods,
pipes, other objects
Can damage
internal organs and
impair respiration
6/28/2011
625
Closed Chest Injuries Closed Chest Injuries
Flail Chest
Paradoxical Motion
Assessment: Flail Chest Assessment: Flail Chest
Mechanism of injury
Difficulty breathing/hypoxia
Chest wall muscle contraction
Treatment: Flail Chest Treatment: Flail Chest
Primary assessment for life threats
Administer oxygen
Use bulky dressing to stabilize flail
segment
Monitor patient for respiratory rate and
depth
Assist ventilations if too shallow
6/28/2011
626
Open Chest Injuries Open Chest Injuries
Difficult to tell what is injured from
entrance wound
Assume all wounds are life-threatening
Open wounds allow air into chest
Sets imbalance in pressure
Causes lung to collapse
Open Chest Wound Open Chest Wound
Sucking chest
wound
Direct entrance
wound to chest
May or may not be
a sucking sound
May be gasping for
air
Open Chest Wounds Open Chest Wounds
Maintain open
airway
Seal wound
Occlusive dressing
Administer oxygen
Treat for shock
Immediate transport
Consider ALS
6/28/2011
627
Does the patients chest injury need to be
treated during the primary assessment?
Does the open chest injury require an
occlusive dressing?
Does the patients injury necessitate
immediate transport to a trauma center?
Flutter Valve
Injuries Within the Chest Cavity Injuries Within the Chest Cavity
Traumatic Asphyxia Traumatic Asphyxia
Sudden compression of chest forcing
blood out of organs and rupturing blood
vessels
Neck and face are a darker color than rest
of the body
May cause bulging eyes, distended neck
veins, broken blood vessels in face
6/28/2011
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Cardiac Tamponade Cardiac Tamponade
Direct injury to heart causing blood to flow
into the pericardial sac around the heart
Pericardium is a tough sac that rarely
leaks
Increased pressure on heart so chambers
cannot fill
continued
Cardiac Tamponade Cardiac Tamponade
Blood backs up into veins
Usually a result of penetrating trauma
Distended neck veins
Shock and narrowed pulse pressure
Aortic Injury Aortic Injury
Aorta is the largest blood vessel in the
body
Penetrating trauma can cause direct
damage
Blunt trauma can sever or tear the aorta
Damage can cause high-pressure
bleeding; often fatal
continued
6/28/2011
629
Aortic Injury Aortic Injury
Patient complains of pain in chest,
abdomen, or back
Signs of shock
Differences in blood pressure between
right and left arms
Commotio Cordis Commotio Cordis
Uncommon condition
Trauma to chest when heart is vulnerable
Ventricular fibrillation (VF)
Treat like VF patient: CPR, defibrillation
Open Pneumothorax and Open Pneumothorax and
Hemothorax Video Hemothorax Video
Click here to view a video on the subject of open pneumothorax
and hemothorax.
Back to Directory
6/28/2011
630
Abdominal Injuries Abdominal Injuries
Can be open or closed
Internal bleeding can be severe if organs
or blood vessels are lacerated or ruptured
Serious, painful
reactions if hollow
organs rupture
Evisceration may
occur
Pain, initially mild but rapidly becoming
intolerable as bleeding worsens
Nausea
Weakness
Thirst
continued
6/28/2011
631
Indications of blunt trauma to chest,
abdomen, or pelvis
Coughing up or vomiting blood
Rigid and/or distended abdomen
Carefully monitor airway in presence of
vomiting
Place patient on back with knees flexed to
reduce tension on abdominal muscles
Administer oxygen
Treat for shock
continued
If allowed, utilize pneumatic anti-shock
garments (PASG)
Nothing to patient by mouth
Continuously monitor vital signs
6/28/2011
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Treatment: Evisceration Treatment: Evisceration
Do not touch or replace eviscerated
organs
Apply sterile dressing moistened with
sterile saline over wound site
For large evisceration, maintain warmth by
placing layers of bulky dressing over
occlusive dressing
Impaled Object Impaled Object
Do not remove
Stabilize with bulky dressings bandaged in
place
Leave patients legs in position found to
avoid muscular movement that may move
impaled object
Liver Injuries Video Liver Injuries Video
Click here to view a video on the subject of liver injuries.
Back to Directory
6/28/2011
633
An open chest or abdominal wound is
considered to be one that penetrates not
only the skin but the chest and abdominal
wall to expose internal organs.
Open chest and abdominal wounds are life
threatening.
continued
A flail chest is characterized by
paradoxical motion.
Seal an open chest wound with an
occlusive dressing taped on three sides to
make a one-way valve.
Closed chest wounds are difficult to
distinguish.
continued
6/28/2011
634
A patient who collapses in cardiac arrest
after a force to the center of the chest
should receive CPR.
If a patient develops signs of tension
pneumothorax, arrange immediately for
ALS intercept.
continued
When solid abdominal organs are injured,
life threatening amounts of blood loss can
occur.
When hollow abdominal organs are
injured, their contents spill into the
abdominal cavity causing irritation.
Remember Remember
Blunt trauma, penetrating trauma, and
compression are mechanisms that can
injure the chest and abdomen.
Open or closed pertains to the integrity of
the chest or abdominal wall after injury.
Seal open chest wounds to prevent air
from entering the chest cavity.
continued
6/28/2011
635
continued
Remember Remember
Closed chest and abdominal wounds bear
a high risk for underlying organ system
damage and internal bleeding. Use
mechanism of injury and patient
assessment to recognize the signs and
symptoms of shock.
Remember Remember
EMTs should learn signs and symptoms,
and treatment procedures for specific
chest and abdominal injuries.
Is the patients breathing adequate,
inadequate, or absent?
Is the patient displaying signs of shock?
Is there an open wound in the chest that
needs to be sealed?
continued
6/28/2011
636
Is the patient displaying signs of a tension
pneumothorax?
Is there an open wound in the abdomen
that needs to be dressed and covered?
You are caring for a patient who was shot
in the chest with a nail gun. You applied an
occlusive dressing around the wound. The
patient is suddenly deteriorating. He is
having extreme difficulty breathing and his
color has worsened.
continued
Breath sounds have become almost totally
absent on the side with the impaled nail.
What complication might you suspect is
causing his worsening condition? How
could this be corrected?
6/28/2011
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11
1112, 1920, 2223, 37
30.2 Describe the anatomy of elements of the
musculoskeletal system. Slides 1116
30.3 Associate mechanisms of injury with the potential for
musculoskeletal injuries. Slide 18
continued
6/28/2011
638
30.4 Describe the four types of musculoskeletal injury
(fracture, dislocation, sprain, and strain) and define
open and closed extremity injuries. Slides 1921
30.5 Discuss the assessment of musculoskeletal injuries,
including compartment syndrome. Slides 2224
continued
30.6 Discuss the general care of musculoskeletal injuries.
Slides 2627
30.7 Discuss specific considerations for splinting. Slides
2837
continued
30.8 Discuss considerations in the assessment and
management of specific types of injuries, including
shoulder girdle injuries, pelvic injuries, hip
dislocation, hip fracture, femoral shaft fracture, knee
injury, tibia or fibula injury, ankle or foot injury.
Slides 3952
6/28/2011
639
Slide 53 Hip Fractures Video
Slide 54 Immobilizing a Long Bone Video
CORE CONCEPTS
Understanding bones, muscles, and other
elements of the musculoskeletal system
Understanding general guidelines for
emergency care of musculoskeletal
injuries
continued
CORE CONCEPTS
Purposes and general procedures for
splinting
Assessment and care of specific injuries to
the upper and lower extremities
6/28/2011
640
Topics Topics
Musculoskeletal System
General Guidelines for Emergency Care
Emergency Care of Specific Injuries
Bones
Joints
Muscles
Cartilage
Ligaments
Tendons
6/28/2011
641
Physiology of Physiology of
Bones: framework
Joints: bending
Muscles: movement
Cartilage: flexibility
Ligaments: connect bone to bone
Tendons: connect muscle to bone
Bones Bones
Formed of dense
connective tissues
Vascular and
susceptible to
bleeding on injury
Shapes of Bones Shapes of Bones
Irregular
Long
Short
Flat
6/28/2011
642
Self Self--Healing Nature of Bone Healing Nature of Bone
Break causes soft tissue swelling and a
blood clot in the fracture area
Interruption of blood supply causes the
bone section to die
Cells further from fracture divide rapidly
forming tissue that heals the fracture and
develops into new bone
Muscles, Cartilage, Muscles, Cartilage,
Ligaments, and Tendons Ligaments, and Tendons
General Guidelines for General Guidelines for
Emergency Care Emergency Care
6/28/2011
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Mechanisms of Mechanisms of
Musculoskeletal Injury Musculoskeletal Injury
Direct force
Indirect force
Twisting
(rotational) force
Injury to Injury to
Bones and Connective Tissue Bones and Connective Tissue
Fracture: any break in a bone (open or
closed)
Comminutedbroken in several places
Greenstickincomplete break
Angulatedbent at angle
Dislocation: coming apart of a joint
continued
continued
Injury to Injury to
Sprain: stretching and tearing of ligaments
Strain: overstretching of muscle
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Injury to Injury to
Not all injuries can
be confirmed as a
fracture in the field
Splinting an
extremity with a
suspected fracture
helps prevent
blood loss from
bone tissues
Musculoskeletal Injuries Musculoskeletal Injuries
Rapidly identify and treat life-threatening
conditions
Be alert for injuries besides grotesque
wound
Pain and tenderness
Deformity and angulation
continued
Grating (crepitus)
Swelling
Bruising
Exposed bone ends
Nerve/blood vessel compromise
(decreased CMS)
Compartment syndrome
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Six Ps of Assessment Six Ps of Assessment
Pain or tenderness
Pallor (pale skin)
Parasthesia (pins and needles)
Pulses diminished or absent
Paralysis
Pressure
Do my patients musculoskeletal injuries
add up to serious multiple trauma?
Does my patient have circulation,
sensation, and motor function distal to the
suspected fracture or dislocation?
Take standard
precautions
Perform primary
assessment
Take spinal
precautions, if
necessary
continued
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Splint any
suspected
extremity fractures
after treating life-
threatening
conditions
Cover open
wounds with sterile
dressings
Advantages of Splinting Advantages of Splinting
Minimizes movement of disrupted joints
and broken bone ends
Prevents additional injury to soft tissues
(nerves, arteries, veins, muscles)
Decreases pain
Minimizes blood loss
Can prevent a closed fracture from
becoming an open fracture
Principles of Splinting Principles of Splinting
Care for life-threatening problems first
Expose injury site
Assess distal CSM
Align long-bone injuries to anatomical
position
Do not push protruding bones back into
place
continued
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Principles of Splinting Principles of Splinting
Immobilize both injury site and adjacent
joints
Choose splinting method based on
severity of condition and priority decision
Apply splint before moving patient to
stretcher
Pad voids
Realigning Realigning
Deformed Extremity Deformed Extremity
Assists in restoring
effective circulation to
extremity and to fit it
to splint
If not realigned, splint
may be ineffective,
causing increased
pain and possible
further injury
continued
Realigning Realigning
Deformed Extremity Deformed Extremity
If not realigned, increased chance of
nerves, arteries, and veins being
compromised
Increased pain is only momentary
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Hazards of Splinting Hazards of Splinting
Splinting patient to deathsplinting
before life-threatening conditions
addressed
Not ensuring ABCs
Too tightcompresses soft tissues
Too looseallows too much movement
Splinting in deformed position
Splinting Long Bone and Joints Splinting Long Bone and Joints
Select splint
appropriate to
injury
Standard
precautions
Manually stabilize
injury site
continued
continued
Assess circulation,
sensation, and
motor function
Realign injury if
deformed or if
distal extremity is
cyanotic or
pulseless
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Measure or adjust
splint; move it into
position
Apply and secure
splint to immobilize
injury site, adjacent
joints
Reassess CSM
distal to injury
Treatment: Traction Splint Treatment: Traction Splint
Emergency Care of Emergency Care of
Specific Injuries Specific Injuries
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Shoulder Girdle Injuries Shoulder Girdle Injuries
Assessment
Pain in shoulder
Dropped shoulder
Severe blow to
back over scapula
continued
Shoulder Girdle Injuries Shoulder Girdle Injuries
Treatment
Assess distal CSM
Use sling and
swathe
Do not attempt to
straighten or
reduce
Reassess distal
CSM
Forearm, Forearm,
Wrist, and Hand Injuries Wrist, and Hand Injuries
Signs
Forearm: deformity and tenderness
Wrist: deformity and tenderness
Hand: deformity and pain; dislocated fingers
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continued
Splinting Forearm, Splinting Forearm,
Padded rigid splint
From elbow past fingertips
Roll of bandage placed in hand
Sling and swathe
Splinting Forearm, Splinting Forearm,
Soft splint
Roll of bandage
placed in hand
Tie forearm, wrist, and
hand into fold of one
pillow or between two
pillows
Tape finger to adjacent
uninjured finger
Pelvic Injuries Pelvic Injuries
Assessment
Pain in pelvis, hips, or groin
Pain when pressure applied
Cannot lift legs
Lateral rotation of foot
Unexplained pressure in bladder
continued
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Pelvic Injuries Pelvic Injuries
Treatment
Move patient as little as possible
Determine CSM distal to injury
Straighten lower limbs to anatomical position
Stabilize lower limbs
Assume spinal injuries
Treat for shock
Hip Dislocation/Fracture Hip Dislocation/Fracture
Assessment
Anterior hip dislocation
Posterior hip dislocation
Rotation of leg and foot
Pain and unable to stand
continued
Hip Dislocation/Fracture Hip Dislocation/Fracture
Treatment
Assess distal CSM
Move patient onto spine board
Immobilize limb with
pillows and blankets
Secure patient to
spine board
Reassess distal CSM
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Femoral Shaft Fracture Femoral Shaft Fracture
Assessment
Intense pain
Possibly open
fracture
Injured limb may be
shortened
Treatment
Control bleeding
Assess distal CSM
Apply traction splint
Reassess distal
CSM
Treat for shock
Knee Injury Knee Injury
Assessment
Pain and tenderness
Swelling
Deformity with swelling
Treatment
Assess distal CSM
Immobilize in current position
Reassess distal CSM
Tibia/Fibula Injury Tibia/Fibula Injury
Assessment
Pain and tenderness
Swelling
Possible deformity
Treatment
Air inflated splint
Two-splint method
Single splint with ankle hitch
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Ankle/Foot Injury Ankle/Foot Injury
Assessment
Pain
Swelling
Possible deformity
continued
Ankle/Foot Injury Ankle/Foot Injury
Treatment
Assess distal CSM
Stabilize limb
Lift limb
Place cravats under ankle
Lower limb into pillow
Tie pillow around ankle
Apply ice pack as needed
Hip Fractures Video Hip Fractures Video
Click here to view a video on the subject of hip fractures.
Back to Directory
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Immobilizing Immobilizing
a Long Bone Video a Long Bone Video
Click here to view a view a video on the subject of splinting a
long bone injury.
Back to Directory
Bones bleed. Fractures cause blood loss
within the bone.
Splinting of long bone fractures involves
immobilizing adjacent joints.
Splinting protects the patient from further
injury.
continued
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You may need to be creative while
splinting. There are many correct ways to
splint the same extremity.
Injuries to bones and joints should be
splinted prior to moving the patient.
continued
If patient has multiple trauma or appears
to have shock do not waste time splinting
individual fractures. Place patient on long
spine board and secure limbs to board.
Splint individual fractures en route if time
and priorities allow.
Remember Remember
Bones, joints, muscles, cartilage, tendons,
and ligaments make up the
musculoskeletal system.
Bones provide the body with structure,
store metabolic materials, and produce red
blood. Joints are the places where bones
articulate to create movement.
continued
6/28/2011
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continued
Remember Remember
Fractures, dislocations, sprains, and
strains are musculoskeletal injuries that
are caused by direct force, indirect force,
and twisting force. Injuries should be
splinted prior to moving the patient.
Remember Remember
A closed extremity injury is one in which
the skin has not been broken. An open
extremity injury is one in which the skin
has been broken.
Pelvic fractures and femoral shaft
fractures often indicate more severe
internal injuries.
continued
Remember Remember
EMTs must learn specific techniques for
immobilizing particular injuries but at the
same time must foster creativity while
applying the general rules of splinting.
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Have I fully addressed life threats and
maintained my priorities even in the
presence of a grossly deformed extremity?
Does the patient have an injury that
requires splinting?
continued
Does the patient have multiple fractures,
multiple trauma, or shock?
Does the patient have adequate CSM
distal to the musculoskeletal injury?
Should I align the angulated extremity
fracture?
Patients who suffer fractures can be in
extreme pain. Pain can cause anxiety and
elevated pulse rates. How could you
differentiate between a patient with a rapid
pulse and anxiety from pain versus a
patient with rapid pulse and anxiety from
shock?
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11
1315, 17, 19, 28
31.2 Describe the components and function of the
nervous system and the anatomy of the head and
spine. Slides 1315
31.3 Describe types of injuries to the skull and brain.
Slides 1719, 22
continued
6/28/2011
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continued
31.4 Describe the general assessment and management
of skull fractures and brain injuries. Slides 2223
31.5 Describe specific concerns in the management of
cranial injuries with impaled objects. Slide 21
31.6 Describe specific concerns in the management of
injuries to the face and jaw. Slide 21
31.7 Define nontraumatic brain injuries. Slide 22
31.8 Explain the purpose and elements of the Glasgow
Coma Scale. Slide 23
continued
continued
31.9 Discuss the assessment and management of open
wounds to the neck. Slides 2526
31.10 List types and mechanisms of spine injury. Slide 28
31.11 Discuss the assessment and management of spine
and spinal cord injury. Slides 2931
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31.12 Discuss issues in the immobilization of the head,
neck, and spine, specifically for the following:
applying a cervical collar; immobilizing a seated
patient, including rapid extrication for high priority
patients; applying a long backboard; rapid
extrication from a child safety seat; immobilizing a
standing patient; and immobilizing a patient wearing
a helmet. Slides 3439
continued
31.13 Discuss issues in selective spine immobilization.
Slides 28, 3031
Slide 32 Spinal Injuries Video
Slide 40 KED Overview Video
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662
CORE CONCEPTS
Understanding the anatomy of the nervous
system, head, and spine
Understanding skull and brain injuries and
emergency care for skull and brain injuries
Understanding wounds to the neck and
emergency care for neck wounds
continued
CORE CONCEPTS
Understanding spine injuries and
emergency care for spine injuries
Understanding immobilization issues and
how to immobilize various types of
patients with a potential spine injury
Topics Topics
Nervous and Skeletal Systems
Injuries to the Skull and Brain
Wounds to the Neck
Injuries to the Spine
Immobilization Issues
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663
Nervous and Skeletal Systems Nervous and Skeletal Systems
Nervous System Nervous System
Controls thought, sensations, and motor
functions
Central nervous system
Brain, spinal cord
Peripheral nervous system
Vertebral nerves
Cranial nerves
Bodys motor and sensory nerves
Anatomy of the Head Anatomy of the Head
Cranium
Facial Bones (14)
Mandible
Maxillae
Nasal bones
Malar (zygomatic)
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Anatomy of the Spine Anatomy of the Spine
Vertebrae
Cervical (7)
Thoracic (12)
Lumbar (5)
Sacral (5)
Coccyx (4)
Injuries to the Skull and Brain Injuries to the Skull and Brain
Injuries to the Skull and Brain Injuries to the Skull and Brain
Scalp injuries
Lots of blood
vessels
Profuse bleeding
Skull injuries
Open head injury
Closed head injury
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Brain Injuries Brain Injuries
Traumatic Brain Injuries (TBI)
Concussion
Contusion
Coup
Contrecoup
Laceration
Hematoma
Subdural Hematoma
Epidural Hematoma
Intracerebral Hematoma
Intracranial Pressure Intracranial Pressure
Does my patient have a serious or
potentially serious head injury? Should the
patient be transported to a trauma center?
Do my patients complaint and MOI
indicate spinal stabilization? Is
immobilization warranted?
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Injuries to the Head and Face Injuries to the Head and Face
Cranial injuries with impaled objects
Stabilize object in place
Injuries to the face and jaw
Primary concern: Airway
When possible, position to allow for drainage
from mouth
Nontraumatic Brain Injuries Nontraumatic Brain Injuries
Many signs of brain injury may be caused
by an internal brain event (hemorrhage,
blood clot)
Signs are the same as for traumatic injury,
except no evidence of trauma and no MOI.
Glasgow Coma Scale (GCS) Glasgow Coma Scale (GCS)
May use GCS in addition to AVPU for
ongoing neurological assessment
Considerations for use of GCS
Eye opening
Verbal response
Motor response
Do not spend extra time at the scene
calculating GCS
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Wounds to the Neck Wounds to the Neck
Wounds to the Neck Wounds to the Neck
Large, major vessels close to surface
create the potential for serious bleeding
Pressure in large vein is lower than
atmospheric pressure
Great possibility of air embolus being
sucked through
Treatment: stop bleeding, prevent air
embolism
Treatment: Open Neck Wound Treatment: Open Neck Wound
Ensure open airway
Place gloved hand over wound
Apply occlusive dressing
Apply pressure to stop bleeding
Bandage dressing in place
Immobilize spine if MOI suggests cervical
injury
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Injuries to the Spine Injuries to the Spine
Injuries to the Spine Injuries to the Spine
Assume possible cervical-spine injury if
MOI exerts great force on upper body or if
soft-tissue damage to head, face, or neck
Spinal cord is a relay between most of
body and brain for sending messages
Neurogenic shock: form of shock resulting
from nerve paralysis; causes uncontrolled
dilation of blood vessels
Assessment: Spinal Injury Assessment: Spinal Injury
Paralysis of extremities
Pain without movement
Pain with movement
Tenderness anywhere along spine
Impaired breathing
Deformity
Priapism
Loss of bowel or bladder control
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Treatment: Spinal Injury Treatment: Spinal Injury
Provide manual in-line stabilization
Assess ABCs
Rapidly assess head and neck; apply
rigid cervical collar
Rapidly assess for sensory and motor
function
continued
Treatment: Spinal Injury Treatment: Spinal Injury
Apply appropriate spinal immobilization
device
Reassess sensory and motor function
Spinal Injuries Video Spinal Injuries Video
Click here to view a video on the subject of treating cervical injuries.
Back to Directory
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670
Immobilization Issues Immobilization Issues
Applying a Cervical Collar Applying a Cervical Collar
Always maintain
manual
stabilization
Use in conjunction
with a long
backboard
Immobilizing a Seated Patient Immobilizing a Seated Patient
Low priority: Use a
short board or
vest-immobilization
device
High priority:
Maintain manual
stabilization while
moving patient
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Applying a Long Backboard Applying a Long Backboard
Log roll patient
Pad voids between board and head/torso
Secure head last
If pregnant, tilt board to left after
immobilizing
Standing Patient Standing Patient
Rapid takedown
Requires three providers, cervical collar, and
long backboard
Patient Found Patient Found
Wearing a Helmet Wearing a Helmet
When to leave helmet in place
Fits snugly, allowing no movement
Absolutely no impending airway or breathing
issues
Removal would cause further injury
Proper spinal immobilization can be done with
helmet in place
continued
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672
Patient Found Patient Found
Wearing a Helmet Wearing a Helmet
When to remove helmet
Interferes with ability to assess and manage
airway
Improperly fitted
Interferes with immobilization
Cardiac arrest
KED Overview Video KED Overview Video
Click here to view a video on the use of a vest-style extrication device.
Back to Directory
6/28/2011
673
The two main divisions of the nervous
system are the central nervous system
and the peripheral nervous system.
Maintain a high index of suspicion for head
or spine injury whenever there is a
relevant mechanism of injury.
continued
continued
Provide cervical spine stabilization before
beginning any other patient care when
head or spine injury is suspected.
Altered mental status is an early and
important indicator of head injury. Monitor
and document your patients mental status
throughout the call.
A traumatic brain injury is any injury that
disrupts function of the brain and may
include anything from a slight concussion
to a severe hematoma.
Always secure the torso to the backboard
before the head.
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Remember Remember
The key components of the nervous
system are the brain and the spinal cord.
These organs regulate thought,
sensations, and motor functions.
The skull, vertebrae, and cerebrospinal
fluid efficiently protect the brain and spinal
cord.
continued
continued
Remember Remember
In a closed head injury, the skull remains
intact. This is dangerous, for the skull is a
closed container with little room for
bleeding or swelling.
Neck wounds are at risk for massive
bleeding and air entry, causing emboli.
Remember Remember
The spine is injured most often by
compression or excessive flexion, by
extension, or rotation from falls, by diving
injuries, and by motor-vehicle collisions.
These injuries can interrupt nervous
system control of body functions.
continued
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Remember Remember
In-line immobilization of 33 spinal bones is
the essential component of spinal injury
immobilization.
Specific procedures apply to different
immobilization and extrication situations.
EMTs should be proficient in handling the
basics of these procedures.
Does my patient have a mechanism of
injury that would indicate the need for
spinal immobilization?
Do my patients potential head or spine
injuries require prompt transport to a
trauma center?
You are treating a patient with a head
injury. He has an altered mental status and
a significant MOI to the head. Your partner
thinks you should hyperventilate. When
should you hyperventilate? What are the
signs and symptoms that would indicate
this is necessary?
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11
32.1 Define key terms introduced in this chapter.
Slides 12, 24
32.2 Describe the considerations for teamwork, timing,
and transport decisions in assessing and managing
patients with multisystem trauma or multiple trauma.
Slides 1819
continued
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32.3 Discuss the physiologic, anatomic, and mechanism
of injury criteria for determining patient severity with
regard to trauma triage and transport decisions.
Slides 1316
continued
32.4 Recognize special patient considerations that
increase the patients priority for transport, such as
age, anti-coagulation bleeding disorders, burns,
time-sensitive extremity injuries, end-stage renal
disorders requiring dialysis, and pregnancy.
Slides 1316
continued
32.5 Discuss general principles of multisystem trauma
management. Slides 2023
32.6 Describe the purposes of trauma scoring systems.
Slides 2426
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Slide 27 Emergency: Gunshot Wound Video
Slide 28 Multiple System Injuries in Front-end Collisions
Video
Slide 29 Mechanism of Injuries in Vehicle Collisions
Video
CORE CONCEPTS
How to balance the critical trauma
patients need for prompt transport against
the time needed to treat all the patients
injuries at the scene
How to determine the severity of the
trauma patients condition, priority for
transport, and appropriate transport
destination
continued
CORE CONCEPTS
How to select the critical interventions to
implement at the scene for a multiple-
trauma patient
How to calculate a trauma score
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Topics Topics
Multisystem Trauma
Managing the Multisystem Trauma Patient
Multisystem Trauma Multisystem Trauma
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Patient with one or more injuries serious
enough to affect more than one body
system
Determining Patient Severity Determining Patient Severity
Physiologic criteria
Anatomic criteria
Mechanism of injury
continued
Determining Patient Severity Determining Patient Severity
Physiologic criteria
Altered mental status (GCS <14): head injury
Hypotension (systolic <90mmHg): shock,
internal bleeding
Abnormally slow respiratory rate: head injury,
later stages of shock
Abnormally high respiratory rate: shock
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Anatomic Criteria Anatomic Criteria
Injury to specific a body part/area requiring
immediate surgical intervention
Injuries to the head and chest
Multiple musculoskeletal injuries
Amputations
Severely mangled extremities
Pelvic injuries
Mechanism of Injury Mechanism of Injury
In absence of anatomic or physiologic
signs, MOI is considered if severe
Fall
High-risk auto crash
Automobile-pedestrian crash
Motorcycle crash
Managing the Multisystem Managing the Multisystem
Trauma Patient Trauma Patient
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Preparing for Preparing for
Multisystem Trauma Patients Multisystem Trauma Patients
Practice with crew: determine roles
En route to call, review roles each member
of the crew will have
Scene safety is paramount
Different trauma is associated with
different dangers
Auto crash will have passing traffic
Penetrating traumaassailant may still be
on the scene
Treating Treating
Follow priorities determined by primary
assessment
Attend to threats to life
Reassess what to treat on scene and what
needs definitive care
Call hospital so they can prepare
continued
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683
Postpone
vitals
Alert hospital
Treating Treating
continued
Treating Treating
Limit scene treatment
Suction airway
Insert oral or nasal airway
Restore patent airway
Ventilate with bag-valve mask
Administer oxygen
Control bleeding
Immobilize patient
Expect the Unexpected Expect the Unexpected
Adapt to situation
Do what is necessary to ensure an open
airway
Perform urgent or emergency moves as
necessary
If part of patients body is not accessible,
assess part of the body you can reach
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Trauma Scoring Trauma Scoring
Numerical rating system for trauma
Assigns number to certain patient
characteristics to create a score
Objectively describes severity
Helps determine transport to a trauma
center or local hospital
Helps trauma centers evaluate the care of
similar patients
Revised Trauma Score (RTS) Revised Trauma Score (RTS)
Components
Glasgow Coma Scale (GCS)
Systolic blood pressure
Respiratory rate
Follow local protocol for use of the trauma
scoring system
Do not let it interfere with patient care
Sample RTS Form Sample RTS Form
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Emergency: Emergency:
Gunshot Wound Video Gunshot Wound Video
Click here to view a video on the subject of treating gunshot wounds.
Back to Directory
Multiple System Injuries Multiple System Injuries
in Front in Front--end Collisions Video end Collisions Video
Click here to view a video on the subject of trauma due to
front-end collisions.
Back to Directory
Injuries in Vehicle Collisions Video Injuries in Vehicle Collisions Video
Click here to view a view a video on the types of injuries in
motor vehicle collisions.
Back to Directory
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Multisystem trauma is a serious condition
in which two or more major body systems
are injured or affected.
Recognizing multisystem trauma, triaging
properly, transporting promptly, and
choosing the correct destination are vital
for the survival of your patient.
continued
continued
The CDC has issued guidelines for trauma
triage and transport. These are a guide
and should be used in conjunction with
your protocols.
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The revised trauma score (RTS) is one
method of classifying trauma patients by
severity and includes the Glasgow Coma
Score (GCS), systolic blood pressure, and
respiratory rate.
Remember Remember
Your primary assessment should
determine whether your patient is
seriously injured or potentially seriously
injured.
Limit scene treatment to life-threatening
conditions.
The golden hour begins from the time of
trauma.
continued
Remember Remember
Use patient severity (physiologic criteria,
anatomic criteria, MOI) to decide whether
to transport to a trauma center or local
hospital.
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Is my patient seriously injured or
potentially seriously injured?
Should I expedite my scene time?
What is the most appropriate transport
destination for my patient?
A patient was involved in a car crash with
significant intrusion into the area where
the patient was sitting. The patient is alert
and complains of pain in the ribs. Pulse:
96 and regular; respirations: 30 and
adequate; blood pressure: 100/62; pupils:
equal and reactive; skin: cool and dry.
continued
Your partner says the patient is stable and
could be easily transported to the
community hospital nearby. You think the
patient should be transported to the
trauma center. How would you justify your
decision to your partner?
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11
1314, 17, 29, 32, 38
33.2 Describe the process of heat loss and heat
production by the body. Slides 13, 21
33.3 Recognize predisposing factors and exposure
factors in relation to hypothermia. Slides 1415
continued
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33.4 Recognize signs and symptoms of hypothermia.
Slide 16
33.5 Describe the indications, contraindications, benefits,
and risks of passive and active rewarming
techniques. Slide 17
continued
continued
33.6 Prioritize steps in assessment and management of
patients with varying degrees of hypothermia.
Slides 16, 18
33.7 Discuss assessment and management for early or
superficial local cold injury and for late or deep local
cold injury. Slide 19
33.8 Discuss the effects of heat on the human body.
Slide 21
33.9 Differentiate between assessment and management
priorities for heat emergency patients with moist,
pale, normal-to-cool skin, and those with hot skin
that is either dry or moist. Slides 2225
continued
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continued
33.10 Anticipate the types of injuries and medical
conditions that may be associated with water-related
accidents. Slide 27
33.11 Discuss the assessment and management of the
following water-related emergencies: drowning
(including rescue breathing and care for possible
spinal injuries), diving accidents, and scuba diving
accidents. Slides 2832
33.12 Discuss the assessment and management of the
following types of bites and stings: insect bites and
stings, snakebites, and poisoning from marine life.
Slides 3840
Slide 36 Emergency: Near Drowning Video
Slide 41 Effects of Venomous Snake Bites Video
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CORE CONCEPTS
Effects on the body of generalized
hypothermia; assessment and care for
hypothermia
Effects on the body of local cold injuries;
assessment and care for local cold injuries
continued
CORE CONCEPTS
Personal effects on the body of exposure
to heat; assessment and care for patients
suffering from heat exposure
Signs, symptoms, and treatment for
drowning and other water-related injuries
Signs, symptoms, and treatment for bites
and stings
Topics Topics
Exposure to Cold
Exposure to Heat
Water-Related Emergencies
Bites and Stings
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Exposure to Cold Exposure to Cold
How the Body Loses Heat How the Body Loses Heat
Conduction
Convection
Radiation
Evaporation
Respiration
Generalized Hypothermia Generalized Hypothermia
Exposure to cold reduces body heat
Body is unable to maintain proper core
temperature
May lead to death
Predisposing factors of hypothermia
Injury
Chronic illness
Geriatric/pediatric
continued
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Generalized Hypothermia Generalized Hypothermia
Obvious and subtle
exposure
Alcohol ingestion
Underlying illness
Overdose or
poisoning
Major trauma
Assessment: Hypothermia Assessment: Hypothermia
Shivering, in early stages
Numbness
Stiff or rigid posture
Drowsiness
Rapid breathing or pulse
Loss of motor coordination
Joint/muscle stiffness
Unconsciousness
Cool abdominal skin temperature
Rewarming Rewarming
Passive
Cover patient
Remove wet clothing
Active
Apply external heat
source
Central
Apply heat to lateral
chest, neck, armpits,
and groin
6/28/2011
695
Extreme Hypothermia Extreme Hypothermia
Patient unconscious, no discernible vital
signs
Heart rate can slow to 10 beats/minute
Very cold to touch
If no pulse, start CPR with AED
If pulse present, care as for any
unresponsive patient
Youre not dead until youre warm and
dead
Localized Cold Injuries Localized Cold Injuries
Most commonly affects ears, nose, face,
hands, and feet
Blood flow limited by constriction of blood vessels
Tissues freeze, may form ice crystals
Early/superficial (frostnip)
Remove from cold and cover
Late/deep (frostbite)
Cover and immobilize gently
Exposure to Heat Exposure to Heat
6/28/2011
696
Effects of Heat on Body Effects of Heat on Body
Heat not needed for temperature
maintenance, and not lost, creates
hyperthermia
Left unchecked, leads to death
Heat cramps and heat exhaustion
Moist, pale, normal-to-cool skin
Heat stroke
Hot, dry, or possibly moist skin
Heat Exhaustion: Heat Exhaustion:
Muscular cramps
Weakness or exhaustion
Rapid, shallow breathing
Weak pulse
Heavy perspiration
Loss of consciousness
Heat Exhaustion: Treatment Heat Exhaustion: Treatment
Remove from hot environment
Administer oxygen
Loosen or remove clothing
Position supine
Small sips of water
Transport
6/28/2011
697
Heat Stroke: Heat Stroke:
Rapid, shallow breathing
Full, rapid pulse
Generalized weakness
Little or no perspiration
Dilated pupils
Seizures
Heat Stroke: Treatment Heat Stroke: Treatment
Remove from hot environment
Remove clothing
Apply cool packs to neck, groin, and
armpits
Administer oxygen
Transport immediately
Water Water--Related Emergencies Related Emergencies
6/28/2011
698
Types of Accidents Types of Accidents
Occurring on or Near Water Occurring on or Near Water
Boating
Water-skiing
Wind surfing
Jet-skiing
Diving
Scuba-diving
Drowning Drowning
Often begins as person struggles to keep
afloat
When they start to submerge, they try to
take one more deep breath
Water may enter airway, followed by
coughing and swallowing, and involuntary
swallowing of more water
continued
Drowning Drowning
Reflex spasm of larynx is triggered,
sealing airway; unconsciousness results
from hypoxia
Some who die from drowning die just from
lack of air
Most attempt a final breath (or are
unconscious) and water enters lungs
6/28/2011
699
Drowning Drowning: Treatment : Treatment
Begin rescue breathing without delay
If you reach a non-breathing patient in
water, support patient in semi-supine
position and provide ventilations
May encounter airway resistance; will
probably have to ventilate more forcefully
than other patients
Do not delay transport
Diving Accidents Diving Accidents
Most involve head and neck, but many
also involve spine, hands, feet, and ribs
Emergency care is the same as for any
accident patient out of water
Scuba Scuba--Diving Accidents Diving Accidents
Arterial gas embolism (gas bubbles in
bloodstream): diver holding breath
May be due to inadequate training, equipment
failure, underwater emergency, or trying to
conserve air
Decompression sickness: diver surfacing
too quickly from deep, prolonged dive
Takes 148 hours to appear
6/28/2011
700
Diver Alert Network (DAN) Diver Alert Network (DAN)
Formed to assist rescuers with care of
underwater diving accident patients
Gives EMT or dispatcher information on
assessment, care, and how to transfer
patient to hyperbaric trauma care center
Emergency: 919-684-8111
Non-Emergency: 919-684-2948
Water Rescue Water Rescue
Reach
Hold object for patient
to grab
Throw
Throw object that will
float
Row
Row boat to patient
Go
Swim to patient (last
resort)
Ice Rescue Ice Rescue
Throw flotation device to patient
Toss rope with loop
Push out flat bottomed aluminum boat
Lay ladder flat on ice to distribute weight of
rescuer
Treat patient for hypothermia
Always transport
6/28/2011
701
Emergency: Emergency:
Near Drowning Video Near Drowning Video
Click here to view a video on the subject of a near drowning.
Back to Directory
Bites and Stings Bites and Stings
Spider and Spider and
Insect Bites and Stings Insect Bites and Stings
All spiders are poisonous
Insect stings and bites are rarely
dangerous
Anaphylactic shock
is a major concern
Remove stinger
quickly
6/28/2011
702
Snakebites Snakebites
Require special care but are not usually
life-threatening
Death is not sudden unless anaphylactic
shock develops
Stay calm
Keep patient calm
and at rest
Marine Life Poisoning Marine Life Poisoning
Can occur in variety of ways
Eating improperly prepared seafood or
poisonous organisms
Stings and punctures
Fresh water activates toxins on skin,
increasing pain
Use salt water to rinse affected area
Effects of Effects of
Venomous Snake Bites Video Venomous Snake Bites Video
Click here to view a video on the subject of venomous snake bites.
Back to Directory
6/28/2011
703
Patients suffering from exposure to heat or
cold must be removed from the harmful
environment as quickly and as safely as
possible.
Generalized cold injuries involve cooling
the entire body (hypothermia). Treatment
is based on whether the patient has
normal or altered mental status.
continued
continued
Patients who have hypothermia with
altered mental status are considered to
have severe hypothermia.
Local cold injury involves an isolated part
or parts of the body (frostbite). Early injury
may be rewarmed gently.
6/28/2011
704
continued
Late local cold injury involves freezing of
tissue. Transport rather than rewarming
unless transport is significantly delayed or
if advised by medical direction.
continued
Hyperthermia is a heat emergency.
Severity is determined by skin
temperature. Skin which is normal to cool
is considered less severe than skin which
is hot to the touch. All heat emergency
patients should be removed from the heat
and cooled.
continued
Altered mental status in the setting of
hyperthermia indicates a life-threatening
emergency.
Follow local protocols in reference to
rewarming or cooling procedures.
6/28/2011
705
Immediate resuscitation of a water-related
emergency patient may require quick,
persistent intervention. Always assure your
own safety before attempting any rescue.
For injection or ingestion of poisons of
insects, spiders, snakes, and marine life,
call medical direction and follow local
protocol.
Remember Remember
Heat is lost and gained through
convection, conduction, evaporation,
respiration, and radiation. Certain
illnesses, medications, and underlying
conditions make patients more susceptible
to heat and cold injuries.
continued
continued
Remember Remember
Actively rewarm alert and responsive
hypothermia patients. Passively rewarm
hypothermic patients with an altered level
of consciousness.
In a patient with signs of heat exhaustion
and altered mental status, the EMT must
assume heat stroke is present. Active
cooling is essential.
6/28/2011
706
continued
Remember Remember
Providers never should attempt a water
rescue unless they have been properly
trained to do so.
The two special problems seen in scuba-
diving accidents are arterial gas emboli
and decompression sickness.
Remember Remember
When treating a scuba-related injury,
EMTs should contact medical control to
determine the most appropriate
destination.
Certain species of spiders, scorpions, and
snakes can be poisonous to humans.
Is the scene safe from heat, cold, or
venomous creatures?
How can I get the patient from the water
safely?
Hypothermia: Does the patient have an
altered mental status?
Hyperthermia: Is the patients skin
temperature cool to normal, or hot?
6/28/2011
707
You are with your family at a local lake.
You observe a boat capsize near the
middle of the lake. Screams can be heard
from the scene. You are a marginal
swimmer. Several civilians begin
swimming out to the site. Apply the
concepts learned in scene size-up to this
scene.
11
6/28/2011
708
17, 22, 25, 34, 36, 39, 51, 60, 6569, 7475
34.2 Identify the anatomy of the female reproductive
system and fetal development. Slides 1619
34.3 Explain the physiology of pregnancy. Slide 21
continued
34.4 Explain and describe measures to prevent or correct
supine hypotensive syndrome. Slide 22
34.5 Describe the three stages of labor. Slides 2527
34.6 Discuss the assessment of a patient in labor,
including history and physical examination.
Slides 3133
continued
34.7 Discuss how to decide if delivery is imminent or if
the patient in labor should be transported to a
medical facility for delivery. Slides 3334
34.8 State findings that may indicate the need for
neonatal resuscitation. Slides 3536
continued
6/28/2011
709
34.9 Discuss the role of the EMT in normal childbirth,
including preparation and delivery. Slides 3943,
4549
34.10 Describe the normal steps in care of the neonate.
Slides 5153
continued
34.11 Explain the indications and procedures for neonatal
resuscitation, following the inverted pyramid order of
priorities. Slides 5556
34.12 Discuss after-delivery care of the mother, including
delivery of the placenta, controlling vaginal bleeding,
and providing comfort to the mother. Slides 5962
continued
continued
34.13 Describe and discuss the special care required for
complications of delivery, including: breech
presentation, limb presentation, prolapsed umbilical
cord, multiple birth, premature birth, and meconium.
Slides 6570
6/28/2011
710
continued
emergencies in pregnancy, including: excessive
prebirth bleeding, ectopic pregnancy, seizures in
pregnancy, miscarriage and abortion, trauma in
pregnancy, stillbirths, and accidental death of a
pregnant woman. Slides 7281
gynecological emergencies, including: vaginal
bleeding, trauma to the external genitalia, and
sexual assault. Slides 8587
Slide 29 Information About Childbirth Video
Slide 82 Information About Preeclampsia Video
Slide 83 Ectopic Pregnancy Video
6/28/2011
711
CORE CONCEPTS
Anatomy and physiology of the female
reproductive system
Physiologic changes in pregnancy
Care of the mother and baby during labor
and childbirth
Care of the neonate
Post-delivery care of the mother
continued
CORE CONCEPTS
Complications of delivery
Emergencies in pregnancy
Gynecological emergencies
Topics Topics
Anatomy and Physiology
Physiologic Changes in Pregnancy
Labor and Delivery
Patient Assessment
Normal Childbirth
The Neonate
Care After Delivery
continued
6/28/2011
712
Topics Topics
Childbirth
Complications
Gynecological
Emergencies
6/28/2011
713
Female Genitalia Female Genitalia
External
Labia
Perineum
Mons pubis
Internal
Vagina
Ovaries
Fallopian tubes
Female Reproductive Cycle Female Reproductive Cycle
Menstruation
Stimulated by estrogen and progesterone
Ovaries release ovum
Uterus walls thicken
Fallopian tubes move egg (peristalsis)
Uterine walls expelled (bleeding 35 days)
continued
Female Reproductive Cycle Female Reproductive Cycle
Fertilization
Sperm reaches ovum
Ovum becomes embryo
Embryo implants in uterus
Fetal stage begins
6/28/2011
714
Physiologic Changes in Physiologic Changes in
Pregnancy Pregnancy
Changes in the Changes in the
Reproductive System Reproductive System
Supine Hypotensive Syndrome Supine Hypotensive Syndrome
Placenta, infant, and amniotic fluid total
2024 lbs.
When supine, mass compresses inferior
vena cava
Cardiac output decreases
Dizziness and drop in blood pressure
6/28/2011
715
How does the development of the fetus
affect other body systems?
Labor and Delivery Labor and Delivery
First Stage
6/28/2011
716
Second Stage Second Stage
Third Stage
Why is childbirth such an exhausting
ordeal for the mother?
6/28/2011
717
Information Information
About Childbirth Video About Childbirth Video
Click here to view a video on the subject of childbirth.
Back to Directory
Patient Assessment Patient Assessment
6/28/2011
718
Assessing the Assessing the
Woman in Labor Woman in Labor
Assessment focused on imminent delivery
Name, age, expected due date
First pregnancy?
Seen doctor about pregnancy?
When did labor pains start?
continued
Assessing the Assessing the
Woman in Labor Woman in Labor
Feel the urge to push?
Examine for crowning
Feel for uterine contractions
Take vital signs
Crowning Crowning
6/28/2011
719
Possible Need for Resuscitation Possible Need for Resuscitation
No prior prenatal care
Premature delivery
Labor induced by trauma
Multiple births
continued
Possible Need for Resuscitation Possible Need for Resuscitation
History of pregnancy problems (especially
placenta previa and breech presentation)
Labor induced by drug use (especially
narcotics) and alcohol
Meconium staining when water breaks
How can you get necessary information
from a patient who may be having
uncontrolled pain from contractions?
6/28/2011
720
Normal Childbirth Normal Childbirth
Cephalic Delivery Cephalic Delivery
Imminent Delivery Imminent Delivery
Control scene
Proper PPE
Place mother on bed, floor, or ambulance
stretcher
Remove clothing obstructing vagina
Position assistant and OB kit
6/28/2011
721
Preparing Mother for Delivery Preparing Mother for Delivery
Preparing the OB Kit
Off Off--Duty Delivery Supplies Duty Delivery Supplies
Clean sheets and towels
Heavy, flat twine or new shoelaces
Towel or plastic bag (for placenta)
Clean, unused rubber gloves and eye
protection
6/28/2011
722
Are there legal/moral/ethical concerns for
an off-duty delivery?
Delivering the Baby
continued
Delivering the Baby Delivering the Baby
continued
6/28/2011
723
continued
continued
6/28/2011
724
The Neonate The Neonate
Assessing the Neonate Assessing the Neonate
Keeping the Baby Warm Keeping the Baby Warm
Heat retention is high priority
Dry baby
Discard wet blankets
Wrap baby in a dry blanket (infant
swaddler or space blanket)
Cover head
6/28/2011
725
Cutting the Umbilical Cord Cutting the Umbilical Cord
Why is it so important to stimulate the
baby?
Neonatal Resucitation Neonatal Resucitation
continued
6/28/2011
726
Neonatal Resucitation Neonatal Resucitation
What are the first steps in neonatal
resuscitation?
What is central cyanosis?
When is artificial ventilation required, and
what is the rate of artificial ventilations?
Care After Delivery Care After Delivery
6/28/2011
727
Caring for the Mother Caring for the Mother
Mother at risk for serious bleeding,
infection, emboli
Deliver placenta
Control vaginal bleeding
Comfort
Delivering the Placenta Delivering the Placenta
Afterbirth: placenta with umbilical cord,
amniotic sac membranes, and tissues
lining uterus
Placental delivery starts with labor pains
May take 30 minutes or longer
Begin transport in 10 minutes (do not wait
to deliver placenta)
Controlling Vaginal Bleeding Controlling Vaginal Bleeding
6/28/2011
728
Providing Providing
Comfort to the Mother Comfort to the Mother
Take vital signs frequently
Acts of kindness will be appreciated and
remembered
Wipe face and hands with damp washcloth
Replace blood-soaked sheets and
blankets
What are your responsibilities in caring for
the mother?
What is considered to be the usual blood
loss?
Give examples of acts of kindness toward
the mother.
Childbirth Complications Childbirth Complications
6/28/2011
729
Breech Presentation Breech Presentation
Limb Presentation Limb Presentation
Prolapsed Umbilical Cord Prolapsed Umbilical Cord
6/28/2011
730
Multiple Birth Multiple Birth
Have appropriate resources
Clamp or tie cord of first baby
Assist with delivery of second baby
Placenta and cord care are same as single
delivery
Keep babies and mother warm
Premature Birth Premature Birth
Keep baby warm
Keep airway clear
Provide ventilations and chest
compressions
Watch umbilical cord for bleeding
Oxygen (blow by)
Call ahead to emergency department
Meconium Meconium
Dont stimulate infant before suctioning
Suction mouth, then nose
Provide ventilations and/or chest
compressions
6/28/2011
731
Why is it important to have your partner or
another person (birthing coach or other
adult acceptable to the mother) observing
as you help the mother through childbirth?
Emergencies in Pregnancy Emergencies in Pregnancy
Excessive prebirth bleeding
Ectopic pregnancy
Seizures in pregnancy
Miscarriage and abortion
Trauma in pregnancy
Stillbirths
Accidental death of pregnant woman
Excessive Prebirth Bleeding Excessive Prebirth Bleeding
Main sign is unusually profuse bleeding
Abdominal pain may or may not be felt
Assess for signs of shock
High-concentration oxygen and transport
Place sanitary napkin over vagina
continued
6/28/2011
732
Excessive Prebirth Bleeding Excessive Prebirth Bleeding
Ectopic Pregnancy Ectopic Pregnancy
Seizures in Pregnancy Seizures in Pregnancy
Existing preeclampsia
Elevated blood pressure
Excessive weight gain
Excessive swelling to face, ankles hands,
and feet
Altered mental status or headache
6/28/2011
733
Miscarriage and Abortion Miscarriage and Abortion
Cramping, abdominal pains
Bleeding: moderate to severe
Discharge of tissue and blood from vagina
Trauma in Pregnancy Trauma in Pregnancy
Pulse 1015 beats faster than non-
pregnant women
Blood loss may be 30%35% before
signs/symptoms appear
Ask patient if she received blows to
abdomen
continued
Trauma in Pregnancy Trauma in Pregnancy
6/28/2011
734
Stillbirths Stillbirths
Do not resuscitate if it is obvious the baby
died some time before birth
Resuscitate if baby is born in cardiac or
respiratory arrest
Prepare to provide life support
Emotional support for family
Accidental Accidental
Death of Pregnant Woman Death of Pregnant Woman
Chance to save unborn child
Begin CPR on mother immediately
Continue CPR until emergency cesarean
section can be performed or you are
relieved in emergency department
Preeclampsia Video Preeclampsia Video
Click here to view a video on the subject of preeclampsia.
Back to Directory
6/28/2011
735
Ectopic Pregnancy Video Ectopic Pregnancy Video
Click here to view a video on the subject of ectopic pregnancy.
Back to Directory
Gynecological Emergencies Gynecological Emergencies
Vaginal Bleeding Vaginal Bleeding
Treat as potential life threat
Check for associated abdominal pain
Monitor for hypovolemic shock
6/28/2011
736
Trauma to External Genitalia Trauma to External Genitalia
Observe MOI
Look for signs of severe blood loss and
shock
Consider additional internal injuries
Sexual Assault Sexual Assault
Treat immediate life threats
Do not disturb potential evidence
Examine genitals only if severe bleeding is
present
Discourage bathing, voiding, or cleansing
wounds
Fulfill mandated reporting requirements
When arriving at a crime scene, what are
the key things to keep in mind as you
respond?
6/28/2011
737
Although birth is a natural process that
usually takes place without complications,
involvement of EMS usually indicates
something unusual has happened.
The EMTs role at a birth is generally to
provide reassurance and to assist the
mother in the delivery of her baby.
continued
During normal delivery, determine if there
should be immediate transport or if birth is
imminent and will take place at the scene.
If birth is to take place at the scene, have
equipment ready and appropriate
resources on hand. Always be prepared
for resuscitation.
continued
6/28/2011
738
Complications of delivery are a true
emergency. Be prepared to initiate rapid
transport.
There may also be pre-delivery
emergencies or emergencies associated
with pregnancy that you must be prepared
to treat.
continued
Stillbirth and death of the mother and
sexual assault are difficult emergencies
the EMT is occasionally called upon to
manage. Emotional care for these issues
may be as important as medical care.
Remember Remember
Female reproductive organs present new
anatomy and specific potential
emergencies. EMTs should recognize the
different anatomy and be prepared to
address reproductive emergencies.
A growing fetus creates massive change
to the mothers body. All systems undergo
major alterations.
continued
6/28/2011
739
continued
Remember Remember
Assessment of the woman in labor is
designed to predict imminent delivery and
to recognize likely resuscitation.
The urge to push and crowning indicate
imminent delivery. Transport typically
should be deferred for a home delivery.
continued
Remember Remember
Lack of prenatal care, premature labor,
multiple gestation, and underlying
conditions indicate a likelihood of neonatal
resuscitation.
Childbirth requires a high level of personal
protective equipment.
continued
Remember Remember
The most important aspect of care for a
neonate is keeping the baby warm.
Resuscitation may be indicated by
assessing breathing and heart rate.
After delivery there are two patients to
care for: the infant and the mother.
6/28/2011
740
Remember Remember
EMTs should be familiar with the
pathophysiology and emergency treatment
of the various complications of childbirth.
Care of the sexual assault patient must
include medical, legal, and psychological
considerations.
What is the difference between abruptio
placenta and placentae previa?
How do you care for a prolapsed cord?
What do you do if the bag of water is still
intact during delivery?
You are called to a pregnant woman in
labor. During your evaluation you find that
it is the womans first pregnancy, the
babys head is not crowning, and
contractions are 10 minutes apart.
continued
6/28/2011
741
You ask the mother if she feels the need to
move her bowels, and she says no. Do
you prepare for delivery at the scene? Or
do you transport the mother to the
hospital?
11
6/28/2011
742
19, 21, 54
35.2 Describe the anatomic and physiologic
characteristics of infants and children compared to
adults and the implications of each for assessment
and care of the pediatric patient. Slides 1926
continued
35.3 Discuss the normal vital signs ranges for infants and
children. Slide 19
35.4 Adapt history-taking and assessment techniques to
patients in each pediatric age group. Slides 2830
continued
35.5 Discuss special considerations in dealing with
adolescent patients. Slide 31
35.6 Discuss the importance of involving caretakers in
the assessment and emergency care of pediatric
patients and anticipate reactions of parents and
caregivers in response to an ill or injured child.
Slides 3435
continued
6/28/2011
743
continued
35.7 Discuss the use of the pediatric assessment triangle
in assessing pediatric patients. Slides 3840
35.8 Explain special aspects of the steps of assessment
for pediatric patients, including the scene size-up,
primary assessment, secondary assessment with
physical exam, and reassessment. Slides 4258
continued
35.9 Demonstrate adaptations to techniques and
equipment to properly manage the airway,
ventilation, and oxygenation of pediatric patients.
Slides 6069
continued
35.10 Compare and contrast the causes, presentation,
and management of shock in pediatric and adult
patients. Slides 7072
35.11 Recognize the particular concern for preventing heat
loss in pediatric patients. Slide 73
6/28/2011
744
continued
35.12 Recognize the signs, symptoms, and history
associated with common pediatric medical
emergencies including: difficulty breathing, croup,
epiglottitis, fever, meningitis, diarrhea and vomiting,
seizures, altered mental status, poisoning,
drowning, and sudden infant death syndrome
(SIDS). Slides 7691
35.13 Discuss injury patterns common in pediatric trauma
patients. Slides 94107
35.14 Discuss care for burns in pediatric patients.
Slides 109110
continued
continued
35.15 Recognize indications of child abuse and neglect,
and explain your ethical and legal responsibilities
when you suspect child abuse or neglect.
Slides 112117
6/28/2011
745
35.16 Manage pediatric patients with special challenges,
including those dependent on tracheostomy tubes,
home artificial ventilators, central intravenous lines,
gastrostomy tubes, and shunts. Slides 120126
Slide 32 Communicating With Toddlers Video
Slide 36 Caring and Empathy Video
Slide 92 Information About SIDS Video
CORE CONCEPTS
Anatomic and physiologic characteristics
of children
Psychological and personality
characteristics of children of different ages
How to interact with pediatric patients and
their supporters and caregivers
continued
6/28/2011
746
CORE CONCEPTS
continued
How to assess the pediatric patient
How to identify and treat special concerns
with the ABCs, shock, and potential
hypothermia
How to assess and care for various
pediatric medical emergencies, especially
respiratory disorders
CORE CONCEPTS
How to assess and care for various
pediatric trauma emergencies
How to deal with issues of child abuse and
neglect and children with special needs
Topics Topics
Developmental Characteristics of Infants
and Children
Supporting the Parents or Other Care
Providers
Assessing the Pediatric Patient
Special Concerns in Pediatric Care
Pediatric Medical Emergencies
continued
6/28/2011
747
Topics Topics
Pediatric Trauma Emergencies
Child Abuse and Neglect
Infants and Children With Special
Challenges
The EMT and Pediatric Emergencies
Developmental Characteristics Developmental Characteristics
of Infants and Children of Infants and Children
Pediatric Age Categories Pediatric Age Categories
Newborns and infants: birth to 1 year
Toddlers: 13 years
Preschool: 36 years
School age: 612 years
Adolescent: 1218 years
6/28/2011
748
Anatomic and Anatomic and
Physiologic Differences Physiologic Differences
Infants and children differ from adults in
psychology, anatomy, and physiology
Understanding differences will help you
assess and care for young patients
The Head The Head
Airway and Airway and
6/28/2011
749
Chest and Abdomen Chest and Abdomen
Less developed, more elastic in young
patients
Infants and children: abdominal breathers
Abdominal organs less protected than in
adults
Body Surface Body Surface
Larger than adults in proportion to body
mass
More prone to heat loss through skin
More vulnerable to hypothermia
Blood Volume Blood Volume
6/28/2011
750
Psychological Psychological
and Personality Characteristics and Personality Characteristics
What techniques would you utilize when
attempting to assess a crying infant?
Interacting with the
Pediatric Patient
continued
6/28/2011
751
Interacting Interacting
with the Pediatric Patient with the Pediatric Patient
Identify yourself
Let child know that someone has called or
will call parents
If no life threats, continue at a calm pace
during the evaluation process
Let child have a nearby toy
Kneel at childs eye level
continued
Interacting Interacting
with the Pediatric Patient with the Pediatric Patient
Smile
Touch or hold childs hand or foot
Do not use equipment without first
explaining what you will do with it
Let child see your face
Stop occasionally to find out if child
understands
Never lie to child
The Adolescent Patient The Adolescent Patient
6/28/2011
752
With Toddlers Video With Toddlers Video
Click here to view a video on the subject of communicating with
toddlers.
Back to Directory
Supporting the Parents or Supporting the Parents or
Other Care Providers Other Care Providers
6/28/2011
753
Supporting the Supporting the
Parents or Other Care Providers Parents or Other Care Providers
Possible reactions to childs illness/injury:
denial, shock, crying, screaming, anger,
self-blame, guilt
May interfere with care of child
Ask to help by holding/comforting child
and giving medical history
Caring and Empathy Video Caring and Empathy Video
Click here to view a video on the subject of caring and empathy for
patient and family.
Back to Directory
Assessing the Pediatric Patient Assessing the Pediatric Patient
6/28/2011
754
Pediatric Assessment Triangle Pediatric Assessment Triangle
and Safety and SafetyPediatric Pediatric
6/28/2011
755
Primary Assessment: Primary Assessment:
Pediatric Care Pediatric Care
Rapidly identifies critical patient
Essential component of pediatric
assessment
Forming a General Impression Forming a General Impression
Assessing Mental Status Assessing Mental Status
Alert
Verbal
Painful
Gently tap unresponsive infant or child
6/28/2011
756
Assessing Airway Assessing Airway
Assessing Breathing Assessing Breathing
Assessing
Circulation
6/28/2011
757
Identifying Priority Patients Identifying Priority Patients
Secondary Secondary
Assessment: Pediatric Assessment: Pediatric
Physical Exam: Pediatric Physical Exam: Pediatric
Start with toes/trunk and work way toward
head.
If no injuries, patient should be held in
parents lap
Protect childs modesty
Explain why each piece of clothing must
be removed
6/28/2011
758
Physical Exam: Head Physical Exam: Head
Do not apply pressure to soft spots
Meningitis and head trauma can cause
bulging of fontanelle
Sunken fontanelle may be due to
dehydration
Physical Exam::
Nose and Ears
Physical Exam: Neck Physical Exam: Neck
Vulnerable to spinal cord injuries
Children have proportionately larger and
heavier heads
Muscles and bone structures are less
developed
May be sore, stiff, or swollen
6/28/2011
759
Physical Exam:: Airway
Physical Exam: Chest Physical Exam: Chest
Be alert for wheezes and other noises
Check for symmetry
Check for bruising
Check for paradoxical motion and
retraction
Physical Exam: Physical Exam:
Abdomen and Pelvis Abdomen and Pelvis
Abdomen
Note if rigid
Check for distension or discoloration
Abdominal injury may impede movement of
the diaphragm
Pelvis
Check for stability of pelvic girdle
6/28/2011
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Physical Exam: Extremities Physical Exam: Extremities
Capillary refill
Distal pulse
Pulses
Motor
Sensory
Reassessment: Pediatric Reassessment: Pediatric
Mental status
Monitor breathing
Reassess pulse
continued
Reassessment: Pediatric Reassessment: Pediatric
Monitor skin color, temperature, and
moisture
Reassess vital signs
Ensure all appropriate care and treatment
are being given
6/28/2011
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Special Concerns in Pediatric Special Concerns in Pediatric
Care Care
Maintaining an Open Airway Maintaining an Open Airway
Align and open airway
Use head-tilt, chin-lift if no trauma; jaw-
thrust with spinal immobilization if trauma
is suspected
Suction
Check blockage of airway by tongue
Oropharyngeal Airway
6/28/2011
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Nasopharyngeal Airway
Clearing an Airway Obstruction Clearing an Airway Obstruction
Identify type: partial or complete
Partial obstruction
Place patient in position of comfort
Offer high-flow oxygen
Transport
Complete obstruction
Perform airway clearance techniques
continued
Clearing an Airway Obstruction
continued
6/28/2011
763
Clearing an
Airway
Obstruction
Providing Supplemental Providing Supplemental
Oxygen and Ventilations Oxygen and Ventilations
continued
continued
6/28/2011
764
continued
Providing Supplemental
Oxygen and Ventilations
Common Causes Common Causes
of Shock in Pediatric Patients of Shock in Pediatric Patients
Diarrhea and/or vomiting
Infection
Trauma (especially abdominal injuries)
Blood loss
Allergic reactions
Poisoning
Cardiac events (rare)
6/28/2011
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of Shock in Pediatric Patients of Shock in Pediatric Patients
Caring for Caring for
Shock in Pediatric Patients Shock in Pediatric Patients
Protecting Protecting
Against Hypothermia Against Hypothermia
Cover patients head and body
Keep patient compartment warm
Avoid rough handling
Consult medical control about active
rewarming of patient
6/28/2011
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How do you balance the need to examine
a hypothermic patient with the need to
keep the patient covered to maintain
warmth?
Pediatric Medical Emergencies Pediatric Medical Emergencies
Respiratory Disorders Respiratory Disorders
Likeliest cause of cardiac arrest in a child,
other than trauma
Distinguish whether probable cause is
upper or lower airway problem
Care for upper airway obstruction not
indicated for lower airway disorder
Critical to be alert for early signs of
respiratory failure
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Signs of Breathing Difficulty Signs of Breathing Difficulty
Nasal flaring
Retractions
Use of abdominal muscles
Stridor (high-pitched, harsh sound)
Audible wheeze
Grunting
More than 60 breaths/min
continued
Signs of Breathing Difficulty Signs of Breathing Difficulty
Slowing or irregular respiratory rate
Cyanosis
Decreased muscle tone
Poor peripheral perfusion
Decreased heart rate
continued
Differentiating Upper and Differentiating Upper and
Lower Airway Disorders Lower Airway Disorders
Upper airway disorder
Affects mouth, throat, larynx
Foreign body obstructions, trauma, swelling
from burns and infections
Commonly identified by difficulty breathing,
stridor, or difficulty speaking
6/28/2011
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Differentiating Upper and Differentiating Upper and
Lower Airway Disorders Lower Airway Disorders
Lower airway disorder
Affects large and small bronchiole tubes,
alveoli
Asthma, pneumonia, other respiratory
infections
Commonly identified by difficulty breathing,
wheezing lung sounds
Croup Croup
Mild fever and some soreness (daytime)
Loud seal-bark cough
Restlessness
Paleness with cyanosis
Sudden onset of high fever
Painful swallowing (child often drools)
Tripod position
Patient sits very still
Appears more ill than with croup
6/28/2011
769
Fever Fever
Remove childs clothing
Cover in towel soaked in tepid water
Monitor for shivering
Follow protocols for water or ice chips
Dont submerge in cold water
Meningitis Meningitis
Monitor ABCs, vital signs
Provide high-concentration oxygen by
nonrebreather mask
Ventilate with BVM or pocket mask if
necessary
Provide CPR
Be alert for seizures
Diarrhea and Vomiting Diarrhea and Vomiting
Provide oxygen
Contact medical control if signs of shock
are present
Immediate transport
6/28/2011
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Seizures Seizures
Maintain open airway (not oral airway)
Position on side if no spinal injury
Be alert for vomiting
Provide oxygen
Transport
Be alert for MOI
Be alert for signs of shock
Look for evidence of poisoning
Attempt to get history of diabetes and
seizure disorder
Poisoning Poisoning
Contact poison control center
Consider activated charcoal
Provide oxygen
Transport
Continue to monitor responsiveness
6/28/2011
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Care for Unresponsive Care for Unresponsive
Poisoning Patient Poisoning Patient
Ensure open airway
Provide oxygen
Be prepared to provide artificial ventilation
Transport
Rule out trauma
Drowning Drowning
Provide artificial ventilation or CPR
Protect airway
Consider spinal immobilization
Protect against hypothermia
Treat any trauma
Transport
Sudden Infant Death Syndrome Sudden Infant Death Syndrome
No accepted reason why these babies die
Treat as any patient in cardiac or
respiratory arrest
Resuscitate unless there is rigor mortis
Give emotional support for parents
6/28/2011
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Information About SIDS Video Information About SIDS Video
Click here to view a video on the subject of Sudden Infant Death
Syndrome (SIDS).
Back to Directory
Pediatric Trauma Emergencies Pediatric Trauma Emergencies
Pediatric Injury Patterns Pediatric Injury Patterns
During motor vehicle collisions
Unrestrained: head and neck
Restrained: abdominal, lower spinal
When struck by vehicle
Head
Abdominal, possible internal bleeding
Lower extremity, possible fractured femur
continued
6/28/2011
773
Pediatric Injury Patterns
Examine Head
Examine Eyes
6/28/2011
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Examine Neck
Examine
Chest
Contents of Thorax Contents of Thorax
6/28/2011
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Auscultate for Breath Sounds
Examine
Abdomen
6/28/2011
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Examine
Pelvis
Examine Arms
Examine Legs
6/28/2011
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Examine Back and Spine
Immobilizing Child With KED Immobilizing Child With KED
Burns Burns
Identify candidates for burn centers
Cover burn with nonadherent sterile
dressing
Ensure open airway
Suction as needed
Immobilize spine
continued
6/28/2011
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Burns Burns
Child Abuse and Neglect Child Abuse and Neglect
6/28/2011
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Signs of Possible Signs of Possible
Physical and Sexual Abuse Physical and Sexual Abuse
Slap marks, bruises, abrasions,
lacerations, incisions
Broken bones
Head injuries
Abdominal injuries
Bite marks
Burn marks
Possible Indicators Possible Indicators
That Adult Is Abuser That Adult Is Abuser
Inappropriate concern about child
Trouble controlling anger
Appears to be in deep depression
Indications of alcohol or drug abuse
Suicidal thoughts
Care for Abuse Patients Care for Abuse Patients
Dress and provide other appropriate care
Preserve evidence
Transport
6/28/2011
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Role of EMT in Cases of Role of EMT in Cases of
Suspected Abuse or Neglect Suspected Abuse or Neglect
Gather information from adults without
judgment
Talk with child separately
Plainly and clearly report to medical staff
any finding or suspicion regarding physical
or sexual abuse
continued
Role of EMT in Cases of Role of EMT in Cases of
Suspected Abuse or Neglect Suspected Abuse or Neglect
Use terms suspected and possible even
when talking to partner, hospital staff,
police, and superiors
Contact state child abuse reporting hotline
What should be your concern if a parent in
a possible child abuse case reveals
suicidal ideas?
6/28/2011
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Infants and Children With Infants and Children With
Special Challenges Special Challenges
Common Special Challenges Common Special Challenges
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
Tracheostomy Tubes Tracheostomy Tubes
Potential complications
Obstruction
Bleeding from or around tube
Air leaking around tube
Infection
Dislodged tube
continued
6/28/2011
782
Tracheostomy Tubes
Home Artificial Ventilators Home Artificial Ventilators
Central Intravenous Lines
6/28/2011
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Care for Patients With Care for Patients With
Gastrostomy Tubes Gastrostomy Tubes
Be alert for altered mental status
Ensure open airway
Suction airway as needed
Provide oxygen if needed
Transport sitting or on right side
Care for Patients With Shunts Care for Patients With Shunts
Ventilate with pocket mask or BVM and
high-concentration oxygen
Transport patient
The EMT and Pediatric The EMT and Pediatric
Emergencies Emergencies
6/28/2011
784
Psychiatric Effects on EMT Psychiatric Effects on EMT
Pediatric calls are among the most
stressful
May identify patient with own children
May be anxious about dealing with
children
Most serious stresses over very sick,
injured, or abused child, or child who dies
during or after emergency care
Dealing With Stress Dealing With Stress
Communicating with and treating children
can be learned
Care mostly consists of applying
knowledge of adult patients and adjusting
for children
Talk with other EMTs
Talk with your services counselor
6/28/2011
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Assessment and treatment of children is
often different than for adults.
Children often differ from adults both
anatomically and psychosocially.
continued
Assessment and treatment procedures
must take into account these specific
differences.
As an EMT, you must learn these
differences to enable you to better serve
this special population.
Remember Remember
Pediatric patients present unique anatomy
and psychosocial development. EMTs
must develop an understanding of core
differences to best establish assessment
baselines and expectations.
continued
6/28/2011
786
continued
Remember Remember
Caregiver interaction sets the tone for
scene management. Be professional with
a calm demeanor.
Pediatric assessment triangle allows rapid
assessment of severity of injury or illness
by reviewing appearance, work of
breathing, and skin.
Remember Remember
Proper pediatric assessment takes into
account differences in anatomy and
psychosocial development.
Airway and breathing maintenance, shock
care, and prevention of hypothermia are
universal points of importance in pediatric
care.
continued
continued
Remember Remember
Shock is subtle in children. Learn to
recognize the signs of compensation.
Recognize respiratory failure in children,
and differentiate upper and lower airway
disorders.
6/28/2011
787
continued
Remember Remember
Different anatomy leads to slightly different
patterns of traumatic injury in pediatric
patients. Use your knowledge of pediatric
A&P to enhance assessment and
treatment.
Be alert for findings of potential abuse.
Treat medical issues first, then document
and report.
Remember Remember
Many children have special health care
needs. Most caregivers are trained to
handle emergencies and can be important
resources for assessment. Be prepared for
unusual circumstances.
Critical incident stress management is
essential to an EMTs well-being plan.
How do you plan to approach your first
pediatric call?
How do you determine appropriate mental
status for a child?
Given certain situations, how would you
involve the parent or caregiver in
treatment?
6/28/2011
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You are called to a home for a 3-year-old
child who has been running a low-grade
fever all day and now is drooling. As you
enter the childs bedroom, you hear what
you think is a seal-like bark.
continued
What do you suspect is wrong with this
patient? How will you and your partner
treat this patient and handle the situation?
6/28/2011
789
11
36.1 Describe common changes in body systems that
occur in older age. Slide 9
36.2 Discuss adaptations that may be required in
communicating with and assessing older patients.
Slides 1012, 1422
continued
continued
36.3 Discuss the need for awareness of and the special
considerations regarding medical conditions and
injuries to which older patients are prone, including
effects of medications, shortness of breath, chest
pain, altered mental status, gastrointestinal
complaints, dizziness/weakness/malaise,
depression/suicide, rash, pain, flulike symptoms,
and falls and the possible significance of general or
nonspecific complaints in older adults. Slides 2433
6/28/2011
790
36.4 Recommend changes to improve safety in the home
of an elderly person. Slide 13
36.5 Discuss possible indications of elder abuse. Slide 34
36.6 Discuss psychosocial concerns of older patients,
including the fear of loss of independence. Slide 35
Slide 37 Information About Alzheimers Disease Video
Slide 38 Elder Mistreatment and Abuse Video
CORE CONCEPTS
Age-related changes in the elderly
Communicating with older patients
Assessing and caring for older patients
Illness and injury in older patients
6/28/2011
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Topics Topics
The Geriatric Patient
The Geriatric Patient The Geriatric Patient
Age Age--Related Changes Related Changes
After age 30, organ systems lose 1
percent of function each year
Maximum heart rate declines
Older patient with internal bleeding wont
exhibit heart rate as rapid as expected
If unaware, EMT may miss that older
patient is in shock
6/28/2011
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with Older Patients with Older Patients
Causes of patients communication
difficulties
Changes in hearing, vision, memory
Loss of teeth
Loss of brain function (Alzheimers most
common)
First assume altered mental status result
of present injury/illness
History and History and
Assessment of Older Adult Patient Assessment of Older Adult Patient
Scene size-up and safety
Primary assessment
6/28/2011
793
Scene Size Scene Size--up and Safety up and Safety
Look inside and outside residence for
clues to physical and mental abilities
Condition of residence
Half-eaten food
House dirty or clean
Items left out that patient can trip on
General
impression
Mental status
Airway
Breathing
Circulation
Identifying
Priority Patients
6/28/2011
794
History
Take time needed to get full information
Find out whether patient is compliant with
medical advice
Ask family members, others familiar with
patients condition
Physical exam
Components of Physical Exam Components of Physical Exam
Head and neck
Chest and abdomen
Pelvis and extremities
Spine
Head and Neck Head and Neck
6/28/2011
795
Chest and Abdomen
Pelvis and Extremities Pelvis and Extremities
Hip and proximal femur commonly
fractured in fall
Weakening of bone results in injuries to
wrists and proximal humerus, also
Check extremities for edema and swelling
When significant, these can be signs of
underlying heart, vascular, or liver disease
Spine Spine
Very commonly injured in motor-vehicle
collisions
Abnormal curvature may make
immobilization challenging
Do best to keep vertebrae in alignment
and reduce patients discomfort
6/28/2011
796
Reassessment
What is commonly seen when assessing
an elderly patients blood pressure?
What is most commonly fractured in
female elderly patients?
What are some challenges you might face
in immobilizing elderly patients?
Illness and Illness and
Injury in Older Patients Injury in Older Patients
Elderly patients prone to some problems
because of age-related changes
Problems present differently than in
younger patients
May present with vague signs or
symptoms
6/28/2011
797
Medication Side Medication Side
Effects and Interactions Effects and Interactions
Drug-patient
interactions
Drug-drug
interactions
Shortness of Breath Shortness of Breath
Chest Pain Chest Pain
6/28/2011
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Altered Mental Status
Abdominal Pain and
Gastrointestinal Bleeding
Dizziness, Dizziness,
Weakness, and Malaise Weakness, and Malaise
Dont take complaints lightly
Can be associated with a number of
serious conditions
Can be life threatening
Be diligent in assessment, even for vague
symptoms
6/28/2011
799
Depression and Suicide Depression and Suicide
Causes in elderly patients
Conditions that limit activity
Medications that sap energy
Loss of friends and spouse
Biochemical imbalance
Rash, Pain, Flulike Symptoms Rash, Pain, Flulike Symptoms
Shingles
Virus reawakens after years
Appears as belt-like band around torso
Scabs over after a few days
Pain on side of torso
EMT can contract it from fluid
Falls Falls
Death may result from complications of fall
Bruised ribs, cant cough because of pain,
develops pneumonia
May indicate more serious problem
Abnormal heart rhythm, stroke, internal
bleeding
Assess for cause of fall as well as injuries
from fall
6/28/2011
800
Elder Abuse
and Neglect
Loss of Independence Loss of Independence
Help patient who is losing independence
due to illness/injury
Treat patient with dignity
Dont minimize fears and concerns
Lock up house
Arrange for care for pets
Be reassuring
Empathize
What are some important facts to
remember when treating elderly patients?
What are the best preventative measures
for an EMT who comes in contact with
shingles?
What is a side effect of NSAID use?
6/28/2011
801
Alzheimers Disease Video Alzheimers Disease Video
Click here to view a video on the subject of Alzheimers disease.
Back to Directory
Elder Elder
Mistreatment and Abuse Video Mistreatment and Abuse Video
Click here to view a video on the subject of elder
mistreatment and abuse.
Back to Directory
6/28/2011
802
Despite generalizations, older people are
individuals who can differ significantly in
their health needs.
The prevalence of many diseases
increases with age, increasing the portion
of the older population that requires health
care.
continued
Age-related decline in system function
alters the bodys response to illness and
injury, requiring modified interpretation of
assessment findings and complaints.
Multiple medical problems and
medications can lead to unpredictable
problems and drug interactions.
continued
Nervous system changes, along with
isolation, financial problems, loss of loved
ones, and chronic health problems
increase the risk for depression in the
elderly. This can interfere with a persons
self-care and ability to communicate.
6/28/2011
803
Remember Remember
Aging produces common body changes,
with different impacts on different patients.
Evaluate older patients individually.
In some cases, EMT must adapt
assessment and treatment procedures to
account for age-related anatomic and
psychosocial changes.
continued
Remember Remember
Medication difficulties are common in older
patients. EMTs must keep this in mind
when assessing and treating this age
group.
Elder abuse is a far too common problem.
EMTs must learn to recognize the signs of
abuse and neglect.
What size blood pressure cuff might be
better suited to an elderly patient?
What challenges might you encounter
when assessing the mental status of an
elderly patient?
6/28/2011
804
You are called to the nursing facility for an
85-year-old female who is having trouble
breathing and is very confused. What do
you suspect may be wrong with this
patient? What actions would you take in
treating this patient?
11
6/28/2011
805
10, 12, 14, 33, 35, 37, 40, 42, 44, 47, 50, 53, 55, 59
37.2 Describe special challenges patients may have,
including various disabilities, terminal illness,
obesity, homelessness/poverty, and autism.
Slides 1019
37.3 Describe general considerations in responding to
patients with special challenges. Slides 2226
continued
continued
37.4 Recognize physical impairments and common
medical devices used in the home care of patients
with special challenges, including respiratory
devices, cardiac devices, gastrourinary devices,
central IV catheters and discuss EMT assessment
and transport considerations for each. Slides 2930,
3262
continued
37.5 Explain why patients with special challenges are
often especially vulnerable to abuse and neglect
and what the EMTs obligations are in such
situations. Slides 6466
6/28/2011
806
Slide 20 Autism Video
CORE CONCEPTS
The variety of challenges that may be
faced by patients with special needs
Types of disabilities and challenges
patients may have
Special aspects of prehospital care for a
patient with special needs
continued
CORE CONCEPTS
Congenital and acquired diseases and
conditions
Types of advanced medical devices
patients may rely on
How to recognize and deal with cases of
abuse and neglect
6/28/2011
807
Topics Topics
Patients with Special Challenges
General Considerations in Responding to
Patients with Special Challenges
Diseases and Conditions
Advanced Medical Devices
Abuse and Neglect
Patients with Special Patients with Special
Challenges Challenges
Disability Disability
Condition interfering with the ability to
engage in activities of daily living
Developmental disability
Cerebral palsy, Down syndrome
Result of traumatic injury or medical
condition
Multiple sclerosis, Parkinsons, stroke,
traumatic brain injury, spinal cord injury
6/28/2011
808
Terminal Illness Terminal Illness
End stage cancer, heart failure, kidney
failure, progressive fatal diseases
(Huntingtons, Lou Gehrigs)
May depend on technology to sustain life
or relieve pain
Advance directives
Special emotional needs
Obesity Obesity
Increases risk of multiple diseases
Special measures to care for obese
patient
Allow patient to assume comfortable
position for breathing
Have enough assistance when lifting or
moving patient
Homelessness and Poverty Homelessness and Poverty
Serious health problems related to
homelessness and poverty
Mental health problems
Malnutrition
Substance abuse problems
HIV/AIDS
Tuberculosis
Pneumonia
6/28/2011
809
Autism Autism
Affects 1 in 91 children
Affects ability to communicate
May need to modify assessment
techniques and treatment protocols
ABCS of ABCS of
Dealing with Autistic Patients Dealing with Autistic Patients
Awareness
Basic
Calm
Safe
Awareness Awareness
EMT must adapt approach and strategies
to patient
Disruption of routine not well tolerated by
patient
Communication can be challenging
May have escalation or meltdown
involuntary tantrum-like behavior
6/28/2011
810
Basic Basic
Instructionssimple, clear precise
Questionsshort, closed-ended
Equipmentkeep to minimum; do not
overstimulate
Treatmentdefer interventions that are
precautions rather than necessary
Calm Calm
Calm creates calm
Start with one-to-one contact
Clear, controlled voice
Empathy, compassion
Take extra timeunless life-threatening
emergency, follow patients timeline
Safe Safe
Begin treatment where patient is found
Remove things that may aggravate child
Do toe-to-head survey, one step at a time
Consider taking breaks during exam
Let patient tell you when ready for next
step
6/28/2011
811
Autism Video Autism Video
Click here to view a video on the subject of autism.
Back to Directory
General Considerations in General Considerations in
Responding to Patients with Responding to Patients with
Special Challenges Special Challenges
Advanced Medical Advanced Medical
Devices in the Home Devices in the Home
6/28/2011
812
Knowledgeable Caregivers Knowledgeable Caregivers
Caregivers likely trained on device
Ask: Has problem occurred before? What
fixed it?
Have you been taught how to fix this
problem?
Have you tried to fix this problem? What
happened?
How do you normally move patient?
Knowledgeable
Patients
EMT
Assessment and Transport
6/28/2011
813
Following Protocols Following Protocols
Is the problem with the device life
threatening?
Do I have the knowledge to fix this
problem?
Do I have supplies needed to fix this
problem?
Is it within my protocols or within medical
control authorization?
What is important to do with an autistic
child who is escalating?
What would be the most important
question to ask yourself when a medical
device fails?
Diseases and Conditions Diseases and Conditions
6/28/2011
814
Types of Diseases Types of Diseases
Congenital
Congenital heart disease, cleft palate,
congenital deafness
Acquired
COPD, AIDS, traumatic spinal cord injury,
deafness
Special Concerns Special Concerns
Patient with a chronic disease may
experience sudden worsening of disease
Patient may also develop acute illness
Acute illness may be more devastating
because of coexisting chronic disease
Advanced Medical Devices Advanced Medical Devices
6/28/2011
815
Respiratory Devices Respiratory Devices
Continuous positive airway pressure
devices
Tracheostomy tubes
Home ventilators
Continuous Positive Airway
Pressure Devices (CPAP)
EMT EMT
Assessment and Transport Assessment and Transport
Problems not usually related to machine
Patient may wish to bring machine to
hospital
Alert ER staff of use in radio report
6/28/2011
816
Tracheostomy Tubes Tracheostomy Tubes
Surgical opening through neck into
trachea in which breathing tube is placed
BVM fits on end of tube
Mucus build-up in tube
Patient may or may not be able to speak
EMT EMT
Check tube
If clogged, clear using whistle tip catheter
Patient may buck during suction
May need to ventilate with BVM
During transport, elevate patients head to
allow drainage
Home Ventilators Home Ventilators
6/28/2011
817
EMT EMT
Make sure vent tube has no mucus
build-up
Assure that BVM is connected to oxygen
If transporting ventilator, secure device
Cardiac Devices Cardiac Devices
Implanted pacemaker
Automatic implanted cardiac defibrillator
(AICD)
Left ventricular assist device (LVAD)
Implanted Pacemaker Implanted Pacemaker
6/28/2011
818
Implanted
Pacemaker
AICD AICD
Implanted in upper left chest or upper left
abdominal quadrant
Detects life-threatening cardiac rhythms
Delivers shock to correct dysrhythmia
Shock very painful to patient
Cannot be felt by caregivers
EMT EMT
May want to request ALS
Treat as high-risk cardiac patient
High-concentration oxygen
Frequent reassessment
If cardiac arrest, use CPR and AED as
indicated
6/28/2011
819
Left Ventricular Assist Device Left Ventricular Assist Device
EMT EMT
Battery failure: plug into AC source
Pump failure: use hand or foot pump
Battery should be secured so as not to pull
tubing
Gastrourinary Devices Gastrourinary Devices
Feeding tubes
Urinary catheters
Ostomy bags
6/28/2011
820
Feeding Tubes
Feeding Tubes
EMT EMT
Secure tube to patients body with tape
prior to transport
Keep nutrients higher than tube
Put protective cap in place to prevent
leakage
6/28/2011
821
Urinary Catheters
Urinary Catheters Urinary Catheters
EMT EMT
During transport, keep catheter bag lower
than patient (not on floor)
Document any urine discoloration or odor
Empty bag if one-third to one-half full
Document amount emptied
6/28/2011
822
Ostomy Bags Ostomy Bags
Connected to site of colostomy or
ileostomy
Not visible through clothing
Common problems: infection at stoma site,
blockage, dislodgement
EMT EMT
Use care when transporting patient
Object is to prevent breakage or
dislodgement of bag
Dialysis Dialysis
Patient has renal failure
Dialysis replaces functions of kidney:
waste removal and fluid removal
Two forms of dialysis
Hemodialysis
Peritoneal dialysis
6/28/2011
823
Performed by attaching patient to external
machine (dialyzer)
Usually at dialysis center
Large needles and tubing remove and
return blood
Complications: bleeding fromA-V fistula,
infection
Peritoneal Dialysis Peritoneal Dialysis
Permanent catheter implanted through
abdominal wall into peritoneal cavity
Dialysis solution runs into abdominal
cavity and is absorbed by intestines
Complications: dislodging of catheter,
infection (peritonitis)
EMT EMT
Dont take blood pressure on any arm with
shunt, fistula, or graft
Rupture of shunt, fistula, or graft causes
fast, significant blood loss
Direct pressure to control bleeding
Treat for shock
Transport
6/28/2011
824
Central IV Catheters Central IV Catheters
Surgically inserted for long-term delivery of
medications or fluids
IV chemotherapy, parenteral nutrition
Peripherally inserted central catheter
(PICC)
Central venous line
Implanted port
Complication: infection at site
EMT EMT
Use of central IV usually restricted to
hospital personnel
Be aware of type of catheter
Avoid tugging
Avoid contamination
Physical Impairments Physical Impairments
Hearing, sight, speech, walking, standing
Each limitation requires different
assessment/treatment approaches
Physical impairment does not mean
mental impairment
Impairment may be partial or complete
6/28/2011
825
EMT EMT
Provide necessary assistance
Assess impairmentbaseline or new
Determine comfort level
Explain actions and treatments
When transporting, bring all aids required
by patient
Abuse and Neglect Abuse and Neglect
Vulnerable Population Vulnerable Population
Patients dependent on others
More vulnerable to physical and sexual
abuse, exploitation, neglect
May be children or adults
Elderly especially vulnerable
6/28/2011
826
What to Look For What to Look For
Stories that are inconsistent with injuries
Multiple injuries in various stages of
healing
Repeated injuries
Caregivers indifference to patient
What to Do What to Do
Do not make accusations
Do best to get patient out of environment
Report suspicions according to
requirements of jurisdiction
How does your approach in cases of
possible abuse or neglect differ from your
approach in other cases?
6/28/2011
827
Patients with special challenges include
those who are homeless or living in
poverty, are very obese, have sensory
impairments, are terminally ill, have
developmental disorders, and who are
technology-dependent.
continued
continued
A disability is a condition that interferes
with a persons ability to engage in
everyday activities, such as working or
caring for oneself.
The homeless, poor, and obese are at
increased risk for health problems.
6/28/2011
828
Do not assume that a particular patient
with special challenges requires EMS for
problems related to the disability or
chronic condition.
Treat patients with special challenges with
empathy and respect.
continued
When dealing with patients who have
autism, use ABCS: Awareness, Basic,
Calm, and Safety.
Patients, their families, and their
caregivers are often very knowledgeable
about patient needs and special
equipment. Rely on their expertise and
involve them in care.
Remember Remember
Assistive equipment and special
accommodations allow many with special
challenges to live normal lives.
Beware of overstimulating a patient with
an autism spectrum disorder.
continued
6/28/2011
829
continued
Remember Remember
To ensure proper care, you must
recognize, understand, and evaluate the
patients special health care challenges in
addition to the presenting problem or chief
complaint that led to the call to EMS.
continued
Remember Remember
Caregivers and patients can provide
valuable information on special health
challenges and advanced medical
devices.
A chronic disease or medical condition
may present as a primary problem or may
complicate another illness or injury.
Remember Remember
When encountering an advanced medical
device, consider what the device is doing
for the patient and how important the
device is to the patients survival.
Special health challenges often make
patients more vulnerable to abuse and
neglect.
6/28/2011
830
What does ABCS stand for when treating
an autistic child?
What does a CPAP machine do ?
Can a responder be injured by an AICD
that discharges?
You are called to transport a ventilator
patient. As you begin your survey, the
ventilator stops functioning. What steps
should you take to care for this patient?
What transport considerations do you
have?
6/28/2011
831
11
38.1 Recognize the four types of ambulances currently
specified by the US Department of Transportation.
Slide 15
38.2 Describe the types of equipment required to be
carried by EMS response units. Slide 16
continued
continued
38.3 Describe the components of the vehicle and
equipment checks done at the start of every shift.
Slides 1718
38.4 Describe the roles and responsibilities of the
Emergency Medical Dispatcher. Slide 21
6/28/2011
832
38.5 Discuss the principles of safe ambulance operation
while responding to the scene. Slide 22
38.6 Explain laws that typically apply to ambulance
operations. Slide 22
38.7 Discuss how to maintain safety at highway
incidents. Slides 2324
continued
continued
38.8 Describe the steps necessary for transferring the
patient to the ambulance. Slides 2629
38.9 Describe the EMTs responsibilities while
transporting a patient to the hospital. Slides 30,
3234
continued
38.10 Describe the EMTs responsibilities when
transferring care of patients to the emergency
department staff. Slides 3637
6/28/2011
833
continued
38.11 Describe the EMTs responsibilities in terminating
the call and readying the vehicle for the next
response after a call and returning to quarters.
Slides 3941
38.12 Identify when and how to call for air rescue, how to
set up a landing zone, and how to approach a
helicopter when assisting with an air rescue.
Slides 4547
Slide 42 SanitationMedical Assistant Video
Slide 43 Information About Body Substance Isolation
and Equipment Video
6/28/2011
834
CORE CONCEPTS
Phases of an ambulance call
Preparation for a call
Operating an ambulance
Transferring and transporting the patient
Transferring the patient to the emergency
department staff
continued
CORE CONCEPTS
Terminating the call, replacing and
exchanging equipment, cleaning and
disinfecting the unit and equipment
When and how to use air rescue
Topics Topics
Preparing for the Ambulance Call
Receiving and Responding to a Call
Transferring the Patient to the Ambulance
Transporting the Patient to the Hospital
continued
6/28/2011
835
Topics Topics
Transferring the Patient to the Emergency
Department Staff
Terminating the Call
Air Rescue
Preparing for the Preparing for the
Ambulance Call Ambulance Call
Preparing for the Call Preparing for the Call
Type 1 Ambulance Type 2 Ambulance
Type 3 Ambulance Type 4 Ambulance
6/28/2011
836
Ambulance Ambulance
Supplies and Equipment Supplies and Equipment
Learn where each item is, what it is for,
and when it should be used
Daren C Potter
Ensuring Ensuring
Readiness for Service Readiness for Service
Make sure vehicle
and equipment are
ready for use at
beginning of every
shift
Daren C Potter
Ensuring Ensuring
Ambulance Readiness for Service Ambulance Readiness for Service
Ambulance
inspection, engine off
Ambulance
inspection, engine on
Inspection of patient
compartment supplies
and equipment
Daren C Potter
6/28/2011
837
As I walk around the vehicle (engine-on
and engine-off check), what information do
I get from what I hear, see, and smell?
Receiving and Responding to a Receiving and Responding to a
Call Call
Receiving and Receiving and
Responding to a Call Responding to a Call
Emergency Medical Dispatcher
Interrogate caller and assign priority to call
Provide pre-arrival medical instructions to
callers and information to crews
Dispatch and coordinate EMS resources
Coordinate with other public safety agencies
6/28/2011
838
Operating the Ambulance Operating the Ambulance
Safe operation
Understand the law
Use warning devices
Speed and safety
Escorted or multiple-
vehicle responses
Respond safely
Highway Safety Highway Safety
Keep unnecessary
units and people
off highway
Avoid crossovers
unless turn can be
completed without
obstructing traffic
continued
Highway Safety Highway Safety
Wear all PPE
Place cones/flares
and reduce
emergency lighting
Unit placement is
important
6/28/2011
839
Transferring the Patient to the Transferring the Patient to the
Ambulance Ambulance
Four Steps of Transferring Four Steps of Transferring
Select proper
patient-carrying
device
Package patient for
transfer
Move patient to
ambulance
Load patient into
ambulance
Packaging the Patient Packaging the Patient
Readying patient to be moved and
combining patient and patient-carrying
device as unit ready for transfer
Sick or injured patient must be packaged
so that condition is not aggravated
continued
6/28/2011
840
Packaging the Patient Packaging the Patient
Before placing patient on carrying device
Complete necessary care for wounds, other
injuries
Stabilize impaled objects
Check dressings and splints
Cover patient and secure to patient-
carrying device
Protecting the Patient Protecting the Patient
Must be secured to patient-carrying device
Minimum of three straps to secure
Chest level, waist level, lower extremities
Use shoulder harness if available
Protecting the EMT Protecting the EMT
EMT at greater risk in patient compartment
Make sure all equipment is secured
Remain seated
Wear seat belt and harness if possible
Avoid unnecessary movement during
response and transport
6/28/2011
841
Transporting the Patient to the Transporting the Patient to the
Hospital Hospital
Preparing Patient Preparing Patient
for Transport to Hospital for Transport to Hospital
Continue assessment
Secure stretcher in place in ambulance
Position and secure patient
Adjust security straps
continued
Preparing Patient Preparing Patient
for Transport to Hospital for Transport to Hospital
Prepare for respiratory and cardiac
complications
Loosen constricting clothing
Load personal effects
Talk to the patient
6/28/2011
842
Caring for Caring for
Patient En Route to Hospital Patient En Route to Hospital
Notify hospital
Continue to provide emergency care as
required
Use safe practices during transport
Compile additional patient information
Transferring the Patient to the Transferring the Patient to the
Emergency Department Staff Emergency Department Staff
Transferring Patient to Transferring Patient to
Emergency Department Emergency Department
If routine admission or non-life-threatening
injury, check what is to be done with
patient
Assist emergency department staff,
provide verbal report
continued
6/28/2011
843
Transferring Patient to Transferring Patient to
Emergency Department Emergency Department
As soon as free from patient care, prepare
prehospital care report
Transfer patients personal effects
Obtain your release from hospital
Terminating the Call Terminating the Call
Terminating the Terminating the
Call: At the Hospital Call: At the Hospital
Clean patient
compartment
Prepare equipment for
service
Replace expendable
items
Exchange equipment
according to local policy
Make up ambulance cot
6/28/2011
844
Call: En Route to Quarters Call: En Route to Quarters
Radio dispatch with
your status
Air out ambulance if
necessary for odor
control
Refuel ambulance
Call: In Quarters Call: In Quarters
Place badly contaminated linens in
biohazard containers
Clean equipment
Disinfect non-disposable equipment
Sanitation Sanitation
Medical Assistant Video Medical Assistant Video
Click here to view a video on the subject of sanitization and
equipment disinfection.
Back to Directory
6/28/2011
845
Information About Body Substance Information About Body Substance
Isolation and Equipment Video Isolation and Equipment Video
Click here to view a video on the subject of body substance isolation.
Back to Directory
Air Rescue Air Rescue
When to Call for Air Rescue When to Call for Air Rescue
Operational reasons
Speeding transport to
distant trauma center
Medical reasons
High priority patients
requiring advanced
care or procedures not
available at local
hospital
6/28/2011
846
Information to Give Information to Give
When Calling for Air Rescue When Calling for Air Rescue
Name and call-back number
Agency name
Nature of situation
Exact location (crossroads, major
landmarks)
Exact location and description of landing
zone
Landing Zone Landing Zone
Setting up landing
zone
Approaching
helicopter
6/28/2011
847
Inspect the vehicle to assure that it is
complete and that critical items can be
easily located.
The laws in most states allow the driver of
an emergency vehicle running hot to
break some of the vehicle and traffic laws;
however it must be done with due regard.
continued
Pay attention to driving.
Secure all gear.
Always wear your seat belt.
Know the medical and operational reasons
for helicopter transport and know how to
set up a safe landing zone.
continued
Remember Remember
Ambulances must be properly stocked and
prepared. Pre-call inspections assure
readiness and appropriate equipment.
Emergency Medical Dispatchers enhance
patient care by providing pre-arrival
instructions and by obtaining information
for responders.
6/28/2011
848
continued
Remember Remember
Each state has statutes regulating
operation of emergency vehicles. EMTs
must be familiar with local rules and
regulations.
EMTs should use good judgment and due
regard for safety of others when operating
an ambulance.
continued
Remember Remember
The four steps involved in transferring the
patient to the ambulance are selecting
proper patient-carrying device, packaging
patient for transfer, moving patient to
ambulance, and loading patient into
ambulance.
continued
Remember Remember
Patients should be safely secured prior to
the ambulances moving. Assessment and
care must continue during transport.
The primary concern of transfer of care is
continuation of patient care. Failure to do
so properly can be considered
abandonment.
6/28/2011
849
continued
Remember Remember
Cleaning the ambulance, replacing used
supplies and equipment, and readying the
ambulance stretcher are important
elements the EMT must complete while
terminating a call. However, EMTs should
be prepared for unusual circumstances.
Remember Remember
Indications for utilizing air rescue may
include both operational and medical
reasons. EMTs should be familiar with
local protocols for accessing and utilizing
air rescue transport.
Does the patient have a true emergency
adversely affected by time?
How can I park to best protect the scene
and personnel?
Does my personal protective equipment
match what is being worn by others?
6/28/2011
850
What equipment should you include in a
kit that you carry to the scene?
How should the equipment be positioned
so that you can reach urgently needed
items quickly?
What special items, if any, should be in the
kit to meet local needs?
11
6/28/2011
851
14, 20, 22, 2729, 31
39.2 Anticipate situations in which hazardous materials
may be involved. Slide 16
continued
39.3 Describe the roles in hazardous materials response
of providers trained at each of the four levels of
hazardous materials training specified by OSHA.
Slide 15
39.4 Describe the responsibilities of the EMT at a
hazardous materials incident. Slides 1624
continued
continued
39.5 Given a description of a hazardous materials
incident, identify the safe and danger zones; and
then the hot, warm, and cold zones. Slides 16, 20
6/28/2011
852
39.6 Explain how to identify specific hazardous materials
using the NFPA 704 and Department of
Transportation placard systems, packaging labels,
invoices, bills of lading, shipping manifests, and
Material Safety Data Sheets. Slide 17
continued
continued
39.7 Identify sources of information on initial actions to
take once the hazardous material has been
identified, including the Emergency Response
Guidebook, hotlines, and poison control centers.
Slides 1819
continued
39.8 Discuss how to establish a treatment area and
decontamination and care for patients at a
hazardous materials incident. Slides 2124
39.9 Describe multiple casualty incident operations.
Slide 27
6/28/2011
853
39.10 Describe the principles and features of the Incident
Command System. Slides 2830
39.11 Describe the principles of primary triage, secondary
triage, and the START triage system. Slides 3135
continued
39.12 Discuss transportation and staging logistics at a
multiple-casualty incident. Slide 36
39.13 Recognize the psychological aspects of multiple-
casualty incidents for patients and responders.
Slide 37
CORE CONCEPTS
How to identify and take appropriate action
in a hazardous materials incident
How to identify a multiple-casualty incident
The role of an EMT at a multiple-casualty
incident
continued
6/28/2011
854
CORE CONCEPTS
The incident command system
Triage
Transportation and staging logistics
Psychological aspects of multiple-casualty
incidents
Topics Topics
Hazardous Materials
Multiple-Casualty Incidents
Hazardous Materials Hazardous Materials
6/28/2011
855
What Are What Are
Hazardous Materials? Hazardous Materials?
Any substance or material in a form which
poses an unreasonable risk to health,
safety, and property when transported in
commerce.U.S. Department of
Transportation (DOT)
Levels of Training Levels of Training
First Responder Awareness (no minimum)
First Responder Operations (8 hours)
Hazardous Materials Technician (24
hours)
Hazardous Materials Specialist (24
additional hours)
Responsibilities Responsibilities
of the EMT of the EMT
Recognize hazmat incident
Control scene
Establish danger zone and safe zone
Attempt to identify substance
6/28/2011
856
continued
Identify Hazardous Material Identify Hazardous Material
Signs, labels, placards
Binoculars from safe distance
NFPA704 system placards
Diamond-shaped DOT labels
Other sources
MSDS, bill of lading, invoice, manifest
Interview workers
continued
Get expert advice
about next actions
Dispatcher
Hazardous materials
expert
Emergency Response
Guidebook
Get expert advice about next actions
CHEMTREC (800-424-9300)
CHEM-TEL (800-255-3924)
State/federal radiation control authorities
Regional poison control center
6/28/2011
857
Control Zones Control Zones
Hot zone
Area of contamination or danger
Warm zone
Area immediately adjacent to hot zone
Cold zone
Area immediately adjacent to warm zone
Where equipment and emergency rescuers
are staged
Treatment Area Treatment Area
Rehabilitation operations
Located in cold zone
Protected from weather
Large enough to accommodate multiple
rescue crews
Easily accessible to EMS units
continued
Care of injured and contaminated patients
Decontaminate in warm zone
Treat in cold zone
Phases of decontamination
Gross decontamination
Secondary decontamination
continued
6/28/2011
858
Mechanisms for decontamination
Emulsification
Chemical reaction
Disinfection
Dilution
Absorption or adsorption
Removal
Disposal
continued
Decontamination procedures
Victims wearing PPE
Victims not wearing PPE
Multiple Multiple--Casualty Incidents Casualty Incidents
6/28/2011
859
Multiple Multiple--Casualty Casualty
Incident Operations Incident Operations
Know local disaster plan
Written to address events conceivable for
particular location
Well publicized
Realistic
Rehearsed
Command
Operations Planning Logistics Finance
Incident Command System Incident Command System
National Incident Management System
(NIMS)
6/28/2011
860
Communications Communications
On arrival, give brief report and request
necessary resources
Incident commander only person to
converse with communications center,
disseminates information to others
Have face-to-face conversations among
command staff whenever possible
EMS Branch Functions EMS Branch Functions
Under Command Structure Under Command Structure
Mobile command center
Extrication
Staging area
Triage area
Treatment area
Transportation area
Rehabilitation area
Triage Triage
Goal: afford greatest number of people
greatest chance of survival
Prioritizing patients
Priority 1: Treatable life-threatening illness or
injury
Priority 2: Serious but not life-threatening illness
or injury
Priority 3: Walking wounded
Priority 4 (sometimes called Priority 0): Dead or
fatally injured
6/28/2011
861
continued
START Triage START Triage
Simple Triage and Rapid Treatment
Foundation of system is speed, simplicity,
consistency of application
Simple commands to patients
Patient evaluation based on RPM
Respiration
Pulse
Mental status
Able to walk?
Yes: Priority 3
No: Check respirations
Respirations present?
Yes and >30/minute: Priority 1
Yes and <30/minute: Check pulse
No: Position airway; recheck respirations
Still no respirations: Priority 4 (or 0)
continued
Good pulse?
Unresponsive, not breathing, no pulse:
Priority 4 (or 0)
Breathing, no apparent pulse: Priority 1
Breathing, pulse, good skin signs, capillary
refill: Check mental status
Good mental status?
Alert: Priority 2
Altered mental status: Priority 1
6/28/2011
862
Patient Identification Patient Identification
Color code patients by priority
Priority 1: Red
Priority 2: Yellow
Priority 3: Green
Priority 4: Black
Transportation Transportation
and Staging Logistics and Staging Logistics
Triaged and treated patients next
transported using priority system
Ambulances stage in designated area to
await direction and patients
Receiving facilities contacted early to
determine capabilities and update on
expected patient counts
Psychological Psychological
Aspects of MCIs Aspects of MCIs
Caring, honest demeanor can reassure
patient
Do not attempt to psychoanalyze persons
distress
Psychological first aid may be necessary
on the scene of MCI
6/28/2011
863
If you are the first rescue vehicle to reach
the scene of an MCI, what should you do?
Be suspicious. Many hazmat incidents
start out as routine EMS calls.
Remember the Hot Zone-Warm Zone-Cold
Zone.
Patients who have been decontaminated
still have some contamination.
continued
6/28/2011
864
Use your MCI plan and procedure at small
incidents and larger ones will be easier
when they occur.
Learn and practice START triage
essentials.
Be alert for signs of stress and seek help
as necessary.
Remember Remember
A hazardous materials response requires
specialized training and resources.
Common responsibilities of initial
responders must be identification of the
incident, scene control, and activation of
appropriate resources.
continued
continued
Remember Remember
Scene safety is highest priority; when
possible, use scene clues, product
information, and specific resources to
identify hazardous materials.
Decontamination prevents the spread of a
hazardous material. EMTs are commonly
involved in various levels of this process.
6/28/2011
865
continued
Remember Remember
Multiple-casualty incident overwhelms
resources of responding units. When this
occurs, organization is the most important
priority.
NIMS and its incident command system
provide organization resources and
structure to improve management of large-
scale incidents.
Remember Remember
Triage allows EMTs to prioritize care and
transport of patients when resources are
limited.
What is the hazardous substance? What
risk does it pose?
If a patient has some contamination, can
we safely start decontamination?
Should I start using triage tags?
6/28/2011
866
Your call is to a motor-vehicle collision with
an unknown number of injuries. As your
unit approaches the scene, you see that
three cars and downed wires are involved.
You get a whiff of gasoline as you pass by.
continued
The drivers are visible in each vehicle
one appears to be conscious and the other
two are bent forward or slumped back.
There are passengers visible in two
vehicles, one or more of whom may need
extrication. How should you proceed?
6/28/2011
867
11
40.1 Describe the risks to EMS providers during highway
emergency operations. Slides 12, 15
40.2 Given a variety of highway response scenarios,
describe how to create as safe a work area as
possible. Slides 1214
continued
continued
40.3 Discuss particular considerations in ensuring safety
during night operations. Slide 15
40.4 List the ten phases of vehicle extrication and rescue
operations. Slides 1920
6/28/2011
868
40.5 In a rescue situation, recognize and manage
hazards by wearing appropriate protective gear,
safeguarding your patient, managing traffic, safely
dealing with deployed air bags and energy-
absorbing bumpers, and managing spectators, and
exercising safe practices around electrical hazards.
Slides 21, 2326
continued
40.6 Describe actions taken at a rescue scene by those
trained to do so regarding control of vehicle fires,
stabilizing a vehicle, and gaining access to patients.
Slides 2733
Slide 34 Information About Rapidly Extricating Patients
Video
6/28/2011
869
CORE CONCEPTS
How to position emergency apparatus to
create a safe work zone at a highway
incident
How to recognize and manage hazards at
the highway rescue scene
How to stabilize a vehicle
continued
CORE CONCEPTS
How to gain access to the patient in a
crashed vehicle
How to disentangle a patient from a
crashed vehicle
Topics Topics
Highway Emergency Operations
Vehicle Extrication
6/28/2011
870
Highway Emergency Highway Emergency
Operations Operations
Initial Response Initial Response
Limited access highways: only primary or
first-due units should proceed directly to
scene
On-scene units: park single file in same
direction to minimize on-scene congestion
6/28/2011
871
Position Blocking Apparatus Position Blocking Apparatus
Create one-and-a-
half to two lanes of
blockage
Position apparatus
at angle; front
wheels rotated
away from incident
Position Other Apparatus Position Other Apparatus
Leave space immediately next to crash for
vehicle extrication units
Position ambulances, command vehicles,
and other units downstream from crash
Allows safer patient loading and rapid
departure from scene
Emergency Highway Safety Emergency Highway Safety
Exit vehicle into safe
zone
Be alert for oncoming
traffic
Place flares or cones to
slow traffic and channel
away from incident lane
Night operation: shut off
vehicles white
response lights and
headlights
6/28/2011
872
Is it safe to enter the highway scene?
Which units are necessary?
Vehicle Extrication Vehicle Extrication
6/28/2011
873
Phases of Extrication Phases of Extrication
1. Preparing for rescue
2. Sizing up situation
3. Recognizing and managing hazards
4. Stabilizing vehicle prior to entering
5. Gaining access to patient
continued
Phases of Extrication Phases of Extrication
6. Providing primary patient assessment
and rapid trauma exam
7. Disentangling patient
8. Immobilizing and extricating patient
from vehicle
9. Providing assessment, care, and
transport
10. Terminating rescue
Protective Gear Protective Gear
for EMS Responders for EMS Responders
ANSI reflective safety vest
6/28/2011
874
What does scene size-up tell me about the
need for extrication?
Protective Gear Protective Gear
for EMS Responders for EMS Responders
Helmets
Eye protection
Hand protection
Body protection
Managing Traffic Managing Traffic
Use flares for traffic control
6/28/2011
875
Supplemental Supplemental
Restraint System: Air Bags Restraint System: Air Bags
Air bags designed to inflate on impact,
dissipate kinetic energy, minimize trauma
to body
Creates smoke in vehiclecornstarch
and talcum powder (and sometimes
sodium hydroxide)
Electrical Hazards Electrical Hazards
High voltage lines common
Assume entire area around exposed wire
dangerousconductors may have
touched and energized
Ordinary protective clothing gives no
protection against electrocution
Vehicle Fires Vehicle Fires
Small fires: 15- or
20-pound class
A:B:C dry chemical
fire extinguisher
extinguishes almost
anything burning
Fire under hood: do not attempt
extinguishment unless hood fully open
continued
6/28/2011
876
Vehicle Fires Vehicle Fires
Fire in passenger compartment: apply
extinguisher sparingly until occupants can
be freed
Fire in trunk: apply same principles as
engine compartment fire
Stabilizing a Vehicle Stabilizing a Vehicle
Vehicle on wheels
Turn off engine; step-chock three sides
Stabilizing a Vehicle Stabilizing a Vehicle
Vehicle on side
Stabilize with ropes,
cribbing, or stabilizer
bars
Vehicle on roof
Utilize 4x4 wood
blocks to build crib box
6/28/2011
877
Gaining Access Gaining Access
Simple access
Check if door or window can be opened
Try before you pry
Complex access
Utilize tools and equipment
Break glass in side or rear window as far from
passengers as possible
Disentanglement Disentanglement
Gain access by disposing of doors and
roof
Makes vehicle interior accessible
Creates large exit-way
Provides fresh air and helps cool heated
patient
continued
Disentanglement Disentanglement
Disentangle occupants by displacing front
end
Easily accomplished with heavy duty jacks
and hacksaws
Do not cut steering column or airbag
wiring; may cause unexpected firing
6/28/2011
878
Rapidly Extricating Patients Video Rapidly Extricating Patients Video
Click here to view a video on the subject of rapidly extricating patients
from a vehicle.
Back to Directory
Highway operations are a high-risk scene.
Scene size-up is key to determine how
many patients.
Protect yourself from traffic, un-deployed
airbags, loaded bumpers and sharp metal.
continued
6/28/2011
879
Ensure scene safety.
Try simple means to gain access first.
Protect your patient during the extrication
process.
continued
Remember Remember
Highway response is a significant safety
hazard for EMTs. Specific safety planning
and procedures must be utilized to keep
responders safe.
Responding units should evaluate need for
further units, institute blocking to protect
work area, and always exit apparatus into
safe zone.
continued
Remember Remember
Use protective equipment and warning
devices.
Vehicle extrication often requires
specialized training and resources. Know
local resources and procedure for
activating those resources.
6/28/2011
880
continued
Remember Remember
Determine extrication resources needed
and patient extrication priority through
thorough scene size-up.
Extrication can pose a variety of threats.
Evaluate the scene carefully and employ
safety procedures.
Remember Remember
Gaining access to patients frequently
requires mechanical and technological
assistance. Always start simply and
escalate only when simple measures fail.
What is the best access for my unit?
Where should I park the apparatus?
Does the vehicle need to be stabilized?
6/28/2011
881
The highway crash you are dispatched to
is a seven-car pile-up. Your unit is first on
the scene. What steps are required that
are different from those for a crash
involving one car striking a tree?
11
6/28/2011
882
1316, 19, 3839, 4950, 6164
41.2 List the CBRNE agents, also called weapons of
mass destruction, that are often involved in terrorist
incidents. Slide 16
41.3 Describe the risks to first responders in terrorism
incidents. Slide 19
continued
continued
41.4 Discuss clues, such as occupancy or location, type
of event, timing of events, and on scene warning
signs that help with identification of suspicious
events. Slides 2024
41.5 Given a scenario involving a terrorism incident,
predict the types of harm that may occur.
Slides 2526
41.6 Discuss the principles of time, distance, and
shielding that may minimize exposure to harm from
terrorism incidents. Slides 2931
continued
6/28/2011
883
continued
41.7 Discuss types of harm and self protection measures
for each of the following: chemical incident,
biological incident, radiological/nuclear incident, and
explosive incident. Slides 3347
41.8 Discuss how chemical and biological agents can be
disseminated and weaponized. Slides 4950
41.9 Describe the characteristics associated with the
following: chemical agents, biological agents,
radiological/nuclear devices, and incendiary
devices. Slides 5259
continued
41.10 Describe blast injury patterns and treatment for blast
injuries. Slide 59
41.11 Discuss strategy, tactics, and self-protection with
regard to a terrorist incident. Slides 6164, 6670
6/28/2011
884
CORE CONCEPTS
Types of terrorism and terrorist events
How to identify the type of threat posed by
a terrorist event
Use of time/distance/shielding for
protection at a terrorist event
continued
CORE CONCEPTS
How to respond to and deal with harms
from a terrorist event
Applying strategy and tactics at a terrorist
event
Self-protection at a terrorist event
Topics Topics
Defining Terrorism
Terrorism and EMS
Time/Distance/Shielding
Responses to Terrorism
Dissemination and Weaponization
Characteristics of CBRNE Agents
Strategy and Tactics
Self-Protection at a Terrorist Incident
6/28/2011
885
Defining Terrorism Defining Terrorism
Terrorism Terrorism
The unlawful use of force or violence
against persons or property to intimidate
or coerce a government, the civilian
population or any segments thereof, in
furtherance of political or social objectives
6/28/2011
886
Domestic Terrorism Domestic Terrorism
Groups or individuals whose terrorist
activities are directed at a government or
population, without foreign direction
Environmental terrorists
Survivalists
Militias
Racial-hate groups
Extreme political or religious groups
International Terrorism International Terrorism
Groups or individuals whose terrorist
activities are foreign-based and/or directed
by countries or groups outside the
targeted country or whose activities cross
national borders.
Growing trend toward loosely organized,
international networks of terrorists (for
example, Al Qaeda)
Types of Terrorism Incidents Types of Terrorism Incidents
Weapons of mass destruction (CBRNE)
Chemical
Biological
Radiological
Nuclear
Explosive
Criminal activities
6/28/2011
887
Terrorism and EMS Terrorism and EMS
First Responders as Targets First Responders as Targets
First responders often principle targets of
terrorist attacks
Safety of EMS provider is most important
consideration when responding to
potential terrorist incident
6/28/2011
888
Identify Threat Posed by Event Identify Threat Posed by Event
Incident that is a potential act of terrorism
is also a crime scene
Recognizing OTTO signs may help protect
against secondary attack
Occupancy (or location)
Type of event
Timing of event
On-scene warning signs
Occupancy or Location Occupancy or Location
Symbolic or historic targets
Public buildings or assembly areas
Controversial businesses
Infrastructure systems
Type of Event Type of Event
Types of events with high suspicion of
terrorist involvement
Explosions and/or use of incendiaries
Incidents involving firearms
Nontrauma mass casualty incidents
6/28/2011
889
Timing of Event Timing of Event
National holidays
Anniversary dates of previous attacks
Incidents occurring in major public areas
at busy points of business day
On On--Scene Warning Signs Scene Warning Signs
Unexplained patterns of illness or death
Unexplained signs and symptoms or skin,
eye, or airway irritation
Containers that appear out of place
Recognize Harms Recognize Harms
Posed by Threat Posed by ThreatTRACEM TRACEM--PP
Thermal: caused by either extreme heat or
extreme cold
Radiological: from alpha particles, beta
particles, or gamma rays, generally
produced by nuclear events
Asphyxiation: caused by lack of oxygen in
atmosphere
continued
6/28/2011
890
Recognize Harms Recognize Harms
Posed by Threat Posed by ThreatTRACEM TRACEM--PP
Chemical: caused by toxic or corrosive
materials
Etiological: caused by disease
Mechanical: caused by physical trauma
(gunshot, bomb fragments)
Psychological: results from any violent
event
How can I tell if I am responding to a
terrorist incident?
Time/Distance/Shielding Time/Distance/Shielding
6/28/2011
891
Time Time
Minimize time in dangerous area or
exposed to hazardous material, biological
agent, or radiation
Execute rapid entries to perform
reconnaissance or rescue
Distance Distance
Maximize distance from hazard area or
projected hazard area
Follow recommended guidelines regarding
hazardous materials in Emergency
Response Guidebook
Shielding Shielding
Use appropriate shielding for specific
hazards
Can be vehicles, buildings, fire-protection
clothing, hazmat suits, positive-pressure
self-contained breathing apparatus, PPE
Vaccinations against specific diseases
6/28/2011
892
Responses to Terrorism Responses to Terrorism
Chemical Incident Chemical Incident
Includes many classes of hazardous
materials
Can be inhaled, ingested, absorbed, injected
Can include industrial chemical or warfare-
type agents
Harms of Chemical Incident Harms of Chemical Incident
Thermal (secondary): reactions create
heat
Asphyxiation (secondary): reactions
deplete oxygen
Chemical (primary): systemic effects
Mechanical (secondary): corrosive
chemicals weaken structures
Psychological (secondary)
6/28/2011
893
Self Self--Protection Measures Protection Measures
Respiratory protection
Protective clothing
Be aware of possible contamination from
patients
Biological Incident Biological Incident
Presents as focused emergency or public
health emergency
Focused emergency: potential or actual point
of origin located; attempts made to prevent or
minimize damage and spread
Public health emergency: sudden demand
upon public health infrastructure with no
apparent explanation
continued
continued
Causative agents
Bacteria
Viruses
Toxins
6/28/2011
894
Four major routes of entry to body
Absorption: skin contact
Ingestion: by mouth
Injection: from needles or projectiles
Inhalation: by breathing
Exposure/Contamination Exposure/Contamination
Exposure: substance taken into body
through route of exposure
Contamination: substance clings to
surface areas of body or clothing
Harms of Biological Incident Harms of Biological Incident
Chemical (secondary): scene of
clandestine laboratory
Etiological (primary): agents classified as
poisons
Mechanical (secondary): explosives used
to disperse agents
6/28/2011
895
PPE and respiratory protection
Get as much information as possible
Prioritize protective measures
Self-protection
Buddy system
Availability of rapid intervention teams
Civilian protection
Radiological/Nuclear Incident Radiological/Nuclear Incident
Small nuclear devices (suitcase bombs)
stockpiled in foreign nations
Radiologic dispersion more practical and
difficult to detect as radiation symptoms
are delayed for hours or days
Sickness treatable if detected early
Harms of Harms of
Radiological/Nuclear Incident Radiological/Nuclear Incident
Thermal (primary): nuclear explosion
Radiological (primary): radiological
materials (ongoing hazard)
Chemical (secondary): radiological
substances also chemical hazards
Mechanical (primary): explosion
6/28/2011
896
Time, distance, shielding
Radiologic detecting equipment helps
determine effectiveness of measures
Assume dissemination of radiological,
biological, or chemical materials
Follow decontamination procedures
Explosive Incident Explosive Incident
Wide variety of devices from small pipe
bombs to large vehicle bombs
May involve attacks on a fixed target or
group of people
May be designed to disperse biological,
chemical, or radiological materials
Harms of Explosive Incident Harms of Explosive Incident
Thermal (primary): heat of detonation
Asphyxiation (secondary): possibility of
extremely dusty conditions
Chemical (secondary): result of explosive
reaction from chemicals present at detonation
site
Mechanical (primary): typically seen at
bombing incidents
6/28/2011
897
Responder needs both preblast and
postblast protection
Preblast: operations occurring after written or
verbal warning received but before explosion
takes place
Postblast: operations occurring after at least
one detonation
Dissemination and Dissemination and
Weaponization Weaponization
Dissemination Dissemination
of CBRNE Materials of CBRNE Materials
Respiratory route
Most effective, most common means
Ingestion route
Dermal route
Human-to-human contact
6/28/2011
898
Weaponization Weaponization
of CBRNE Materials of CBRNE Materials
Most effective when targeted through
inhalation route
Particles in 35 micron size
Such airborne dissemination can be
created by applying energy to material
Heat, explosives, sprayers can aerosolize
materials
Characteristics of Characteristics of
CBRNE Agents CBRNE Agents
Chemical Agents Chemical Agents
Can be gaseous, liquid, or solid
Vapor pressures and densities can vary
across the spectrum
Volatility
Low boiling point and
high vapor pressure will
evaporate more readily
Allows agent to have
greater airborne
release potential
6/28/2011
899
Classes of Chemical Agents Classes of Chemical Agents
Choking agents
Predominately respiratory
Vesicating (blister) agents
Cause chemical changes in cells of exposed
tissue
Cyanides
Prevent use of oxygen within cells
continued
Classes of Chemical Agents Classes of Chemical Agents
Nerve agents
Inhibit enzyme critical to proper nerve
transmission, causing out-of-control
parasympathetic nervous system
Riot control agents
Irritating materials and lacrimators (tear-flow
increasers)
Nerve Agents Nerve AgentsSLUDGEM SLUDGEM
Signs and symptoms of exposure
Salivation
Lacrimation
Urination
Defecation
GI Upset
Emesis
Miosis
6/28/2011
900
Biological Agents Biological Agents
Role of EMS
primarily
supportive
Some material can
replicate itself
creating greater
potential for
transmission from
person to person
Radioactive/Nuclear Devices Radioactive/Nuclear Devices
Military nuclear device
Improvised nuclear device
Radiological dispersal device (dirty bomb)
Sabotage
Effects of Radiation Effects of Radiation
Radiologic
exposure affects
bone marrow,
gastrointestinal
system, central
nervous system
6/28/2011
901
Incendiary Devices Incendiary Devices
Blast injury patterns
Lung injury: bradycardia, apnea, and
hypotension from blast wave
Ear injury: rupture of tympanic membrane
Abdominal injury: rupture of gas-containing
section of intestine
Brain injury: concussion or mild traumatic
brain injury (MTBI) from blast wave
Strategy and Tactics Strategy and Tactics
Isolation Isolation
Controlling scene, isolating hazards, and
attempting to conduct controlled
evacuation is resource-intensive and
requires law enforcement personnel
Law enforcement must establish and
control perimeter throughout incident
6/28/2011
902
Notification Notification
Generally required by established
directives, procedures, and statutes
Request for additional specialized
agencies carried out by communications
center based upon early reports of EMTs
on scene
Identification and Protection Identification and Protection
Identification of agent
Observe indicators of particular agent or
presence of chemical containers or lab
materials
Protection of critical assets
People, vehicles, equipment/supplies
Requires close partnership between EMS and
security agencies
Decontamination Decontamination
Gross decontamination by EMS personnel
Removing surface contamination via
mechanical means and initial rinsing
Amount of surface contamination significantly
reduced
6/28/2011
903
Self Self--Protection at a Terrorist Protection at a Terrorist
Incident Incident
Recognition: Scene Size Recognition: Scene Size--up up
Victims displaying signs of hazardous
substance exposure?
Unconscious victims?
Victims exhibiting SLUDGEM signs?
Blistering, reddening of skin, discoloration
or skin irritation?
Victims having difficulty breathing?
Recognition: Recognition:
Situational Awareness Situational Awareness
Medical mass casualties or fatalities with
minimal or no trauma
Responder casualties
Dead animals and vegetation
Unusual odors, color of smoke, vapor
clouds
6/28/2011
904
Remember OTTO Clues
Occupancy (location)
Type of event
Timing
On-scene clues
Dont Rush In Dont Rush In
Wait until appropriate authority says scene
is safe
Follow incident command protocols
Wear appropriate PPE
Beware possible secondary explosive
devices
Search all patients for explosives or
weapons
Protect Yourself Protect Yourself
Understand
TRACEM-P harms
Time, distance,
shielding
Use specific tactics
for each CBRNE
threat
6/28/2011
905
There have been terrorist attacks
throughout history. After 9/11 the world has
been a different place because of the
threat of terrorism.
CBRNE helps recall the types of agents
and weapons that can be used by
terrorists. TRACEM-P helps recall the
types of hazards of these agents.
continued
You must be sure to protect yourself from
terrorist attacks as well as secondary
attacks which are designed to injure or kill
rescuers and further the physical and
psychological impact of the attack.
6/28/2011
906
Remember Remember
Responders often are targets of terrorists.
Safety must be the highest priority. Use
scene clues to identify potential terrorist
incidents.
Adapt protective measures to the specific
threat. Know the protective principles of
CBRNE events.
continued
continued
Remember Remember
Important priorities for responders at a
terrorist incident are life safety, incident
stabilization, and protection of property.
Isolation, perimeter control, and
appropriate notifications are important
priorities in managing a terrorist incident.
Remember Remember
Force protection is an extension of general
safety procedures. It refers to the safety
and security of both providers and
resources.
6/28/2011
907
How can I best protect myself from danger
and hazards during a terrorist incident?
What is my role in the incident response
plan for a terrorist incident?
You arrive at an office where multiple
patients are complaining of the same
symptoms. They state their office received
several threats due to its role in a
controversial foreign relations incident.
You and your partner recognize the similar
symptoms and decide these may be
linked.
continued
What is your best course of action next?
Should you remove yourself from the
scene at this point or remain with your
patients?
6/28/2011
908
11
Topics Topics
Before Beginning Resuscitation
Rescue Breathing
CPR
Clearing Airway Obstructions
Applying ECG Electrodes
Post Cardiac Arrest Care
6/28/2011
909
Before Beginning Before Beginning
Resuscitation Resuscitation
When Death Occurs When Death Occurs
Clinical deathwhen patients breathing
and heartbeat stop
May be reversible through CPR, other
treatments
Biological deathwhen brain cells die
Not reversible
Usually within 10 minutes of clinical death
Cardiopulmonary Cardiopulmonary
Resuscitation (CPR) Resuscitation (CPR)
Actions taken to revive person by keeping
heart and lungs working
Teamwork is essential to success
Effort must be tailored to suit specific
circumstances of the patient
Team must adapt the approach to the
apparent cause of cardiac arrest
6/28/2011
910
Assessing the Patient Assessing the Patient
Determine unresponsiveness
Determine breathlessness
Determine pulselessness
Determine Unresponsiveness
First action when you encounter a
patient who has collapsed
Tap or gently shake patient
Shout Are you okay?
Activate EMS Activate EMS
If patient is unresponsive, immediately
activate EMS
Unless condition is likely caused by a problem
other than heart disease (submersion, injury,
drug overdose)
If child or infant, activate EMS after
2 minutes of resuscitation
Unless reason to think the condition is caused
by heart disease
6/28/2011
911
Determine Breathlessness Determine Breathlessness
Occurs almost simultaneously with
determining pulselessness
Place ear beside patients nose and
mouth; face toward patients chest
Look for chest rise and fall
Listen and feel for escape of air from
mouth or nose
Determine Pulselessness
Done at same time as evaluating breathing
Feel carotid artery in adult or child
Feel brachial artery in infant
Assessing ABCs
If problems found, take appropriate steps
Proper treatment not necessarily in ABC order
continued
6/28/2011
912
Assessing ABCs Assessing ABCs
Is patients airway open?
Is patient breathing?
Does patient have circulation of blood
(pulse)?
Activating EMS Activating EMS
Activate EMS as soon as patient is
discovered in collapse
If you have assistance, have the other
person activate EMS
continued
Activating EMS Activating EMS
If alone and patient is an adult
First determine unresponsiveness and
breathing
Activate EMS before initiating next steps
If patient is a child or infant
Perform two minutes resuscitation before
activating EMS
6/28/2011
913
Positioning the Patient Positioning the Patient
Lay patient supine
before attempting
to open airway and
assess breathing
and circulation
Consider spinal
precautions
Opening the Airway
Head-tilt, chin-lift
Jaw-thrust
Initial Ventilations Initial Ventilations
and Pulse Check and Pulse Check
Heart stoppage is the reason most apneic
adults are not breathing
Oxygen often still in patients bloodstream
Start CPR with chest compressions, not
ventilations under ordinary circumstances
continued
6/28/2011
914
Initial Ventilations and Initial Ventilations and
Pulse Check Pulse Check
When cause of cardiac arrest is respiratory, you
may start CPR with ventilations
Deliver 2 breaths, each over 1 second and enough
volume to make chest rise
Frequently laypeople are taught a slightly
different approach to CPR than that taught
to health care providers. How might a
laypersons training be different with
regard to recognizing cardiac arrest?
Rescue Breathing Rescue Breathing
6/28/2011
915
Mouth Mouth--to to--Mask Breathing Mask Breathing
Use pocket face mask with one-way
valve
Seat mask firmly on patients face
Open patients airway; watch chest rise
Ventilate
If mask has oxygen inlet, provide
supplemental oxygen
Gastric Distention Gastric Distention
Rescue breathing can force air into
patients stomach, causing distention
Can cause two serious problems
Reduced lung volume
Regurgitation
continued
Gastric Distention Gastric Distention
Avoiding/preventing gastric distention
Position patients head properly
Avoid too forceful ventilations too quickly
delivered
Limit volume of ventilations delivered
6/28/2011
916
Appropriate position for patients
Who resume adequate breathing and pulse
after rescue breathing or CPR
Who do not require immobilization for
possible spinal injury
Roll patient onto side
Allows for drainage from the mouth and
prevents the tongue from falling backward
and causing an airway obstruction
CPR CPR
Checking for
Circulation
Before beginning
CPR, confirm
patient is pulseless
6/28/2011
917
Checking for Circulation Checking for Circulation
In adult or child (not infant), check carotid
pulse
Locate Adams apple
Place tips of index and middle fingers directly
over midline of this structure and slide
fingertips to side of patients neck closest to
you
continued
Checking for Circulation
Carotid pulse
typically found in
groove between
Adams apple and
muscles along side
of neck
continued
Checking for Circulation
In infant, check for
brachial pulse
If infant or child has pulse
slower than 60 beats per
minute, begin CPR
6/28/2011
918
How to Perform CPR How to Perform CPR
Chest compressions
Compressions cause increased pressure
inside the chest and possible actual
compression of the heart
Blood is forced out of the heart and into
circulation
When pressure is released, heart refills
Next compression sends fresh blood into
circulation and the cycle continues
continued
Providing chest compressions
Patient supine on hard surface
Place heel of hand on sternum between
nipples
Put other hand on top of first with fingers
interlaced.
Straighten arms and lock elbows
continued
Providing chest compressions
Deliver compressions straight down
Compress sternum of typical adult at least 2
inches
Fully release pressure
Do not bend elbows
Do not lift hands from sternum
6/28/2011
919
Providing
ventilations
Given between
sets of
compressions
Mouth-to-mask
technique preferred
continued
Adult Child Infant
Age Puberty and
Older
1 yrPuberty Birth1 yr
Compression
Depth
At least 2
inches
1/31/2 depth
of chest (2 in)
1/31/2 depth of
chest (1 1/2 in)
Compression
Rate
At least
100/min
At least
100/min
At least 100/min
Compression
to Ventilation
Ratio
30:2 30:2 (1 rescuer)
15:2 (2
rescuers)
30:2 (1 rescuer)
15:2 (2 rescuers)
3:1 (newborn)
CPR Techniques CPR Techniques
for Children (Age 1 Year for Children (Age 1 YearPuberty) Puberty)
CPR conducted as for an adult except use
heel of one hand for chest compressions
Two hands may be used if necessary to
achieve proper compression depth
6/28/2011
920
for Infants (Less Than 1 Year Old) for Infants (Less Than 1 Year Old)
Use two thumbs encircling technique for
compressions
Apply only a slight tilt when using head-tilt,
chin-lift to open airway
Adult Child Infant
Age Puberty and
older
1 yrpuberty Birth1 yr
Ventilation
Duration
1/sec 1/sec 1/sec
Ventilation
Rate
1012
breaths/min
1220
breaths/min
12-20
breaths/min
for Children and Infants for Children and Infants
How to Know How to Know
If CPR Is Effective If CPR Is Effective
Have someone else feel for carotid pulse
during compressions
Watch for chest rise during ventilations
Listen for exhalation of air
continued
6/28/2011
921
How to Know How to Know
If CPR Is Effective If CPR Is Effective
Other indications of effective CPR
Pupils constrict
Skin color improves
Heartbeat returns spontaneously
Spontaneous respirations
Arm and leg movement
Swallowing
Consciousness returns
Interrupting CPR Interrupting CPR
Once CPR is begun, you may interrupt
process for no more than a few seconds to
check for pulse and breathing or to
reposition yourself and patient
continued
May also interrupt CPR to:
Move, carry, or load patient into ambulance
Suction to clear vomitus or airway
obstructions
Defibrillate
Assess patient for signs of life
Switch positions to minimize fatigue
continued
6/28/2011
922
Whenever you interrupt compressions, do
it quickly to minimize time during which
patient is not circulating blood
When CPR resumes, begin with chest
compressions rather than ventilations
When Not to When Not to
Begin or to Terminate CPR Begin or to Terminate CPR
CPR should not be initiated when the
patient has a pulse
Patient may be unconscious and
unresponsive
Patient may not be breathing
continued
When CPR should not be initiated even
though patient has no pulse
Obvious mortal wounds
Rigor mortis
Obvious decomposition
A line of lividity
Stillbirth
continued
6/28/2011
923
Once CPR is started, continue until:
Spontaneous circulation and/or breathing
occurs
Another trained rescuer takes over
You turn care of the patient over to a person
with a higher level of training
Too exhausted to continue
Receive no CPR order
Clearing Airway Obstructions Clearing Airway Obstructions
Airway can be blocked by tongue and
foreign objects or materials
Obstruction can be partial or complete
6/28/2011
924
Mild Airway Obstruction Mild Airway Obstruction
Incomplete obstruction
Patient can speak, cough, exchange air
Encourage patient to cough to dislodge and
expel foreign object
Do not interfere with efforts to clear
obstruction by forceful coughing
continued
Mild Airway Obstruction Mild Airway Obstruction
Treat as severe airway obstruction if:
Patient cannot cough or has very weak cough
Patient is blue or gray or shows other signs of
poor air exchange
Severe Airway Obstruction Severe Airway Obstruction
Signs of severe airway obstruction
Inability to speak, breathe, cough
Unsuccessful ventilation attempts
6/28/2011
925
Abdominal Thrusts Abdominal Thrusts
Make fist
Place thumb side of fist against midline of
patients abdomen between waist and rib
cage
continued
Grasp properly positioned fist with other
hand and apply pressure inward and up
toward patients head in smooth, quick
movement
Deliver rapid thrusts until obstruction is
relieved
continued
Place patient in supine position and begin
CPR if:
Patient is unconscious adult or child
Patient is conscious but cannot sit or stand
You are too short to reach around patient to
deliver thrusts
6/28/2011
926
Chest Thrusts Chest Thrusts
Used in place of abdominal thrusts when:
Patient is in late stages of pregnancy
Patient is too obese for abdominal thrusts to
be effective
continued
Position yourself behind patient
Slide arms under patients armpits and
encircle patients chest
Form fist with one hand
Place thumb side of fist on midline of
sternum about 23 finger widths above
xiphoid process
continued
Grasp fist with other hand and deliver
chest thrusts directly backward toward
spine until obstruction is relieved
6/28/2011
927
Procedure Procedure
with Unconscious Patient with Unconscious Patient
Place patient in supine position
Perform CPR
Every time you open the airway, look in
mouth for object
Perform finger sweep if, and only if, you
see object
Adult Child Infant
Ask, Are you
choking?
Abdominal thrusts
maneuver until
obstruction is
relieved or patient
loses
consciousness
Ask, Are you
choking?
Abdominal thrusts
maneuver until
obstruction is
relieved or patient
loses
consciousness
Observe signs of
choking;
Series of 5 back
blows and 5 chest
thrusts
Summary of Actions Summary of Actions
Conscious Choking Patient Conscious Choking Patient
Adult Child Infant
Establish
unresponsiveness.
If alone, call for help.
Then open airway.
Attempt to ventilate.
If unsuccessful,
perform CPR.
Remove visible
objects (NO blind
finger sweeps).
Establish
unresponsiveness.
Open airway. Attempt
to ventilate. If
unsuccessful, perform
CPR. Remove visible
objects (NO blind
sweeps). After 2
minutes, call for help
if alone.
Establish
unresponsiveness.
Open airway. Attempt
to ventilate. If
unsuccessful, perform
CPR. Remove visible
objects (NO blind
sweeps). After 2
minutes, call for help if
alone.
Summary of Actions Summary of Actions
Unconscious Choking Patient Unconscious Choking Patient
6/28/2011
928
Results of Effective Results of Effective
Airway Clearance Sequence Airway Clearance Sequence
Patient re-establishes good air exchange
or spontaneous breathing
Foreign object expelled from mouth or
removed by rescuer
Unconscious patient regains
consciousness
Patients skin color improves
Procedures with Procedures with
Choking Child or Infant Choking Child or Infant
Very similar to procedure for an adult
For infant use a combination of back blows
and chest compressions
continued
Recognize and assess for choking
Give up to 5 back blows
Give 5 chest thrusts
continued
6/28/2011
929
If patient becomes unresponsive, open
airway and look for foreign body
If you see a foreign body, use finger
sweep to remove
Attempt to ventilate; if unsuccessful,
reposition head and try again
If not successful, start CPR
continued
If patient becomes unconscious, send
someone else to activate EMS system
If alone, wait until obstruction is relieved or
you have attempted airway obstruction
sequence for 2 minutes before activating
EMS system
Applying ECG Electrodes Applying ECG Electrodes
6/28/2011
930
Electrocardiograms (ECG) Electrocardiograms (ECG)
Provides data on hearts electrical activity
Alerts to life-threatening rhythm
disturbances
ECG interpretation traditionally is a
paramedic skill
EMT may be asked to assist to save time
Know the ECG Machine Know the ECG Machine
How to turn on
monitor
How to record
ECG strip
How to change
battery
How to change roll
of ECG paper
Types of Electrodes Types of Electrodes
Monitoring electrodes
Smaller pads
Most commonly used by paramedics
Combination monitoring/defibrillator
electrodes
Larger pads
6/28/2011
931
Preparing Skin Preparing Skin
Best connection is dry, bare skin
May have to shave excessive hair
Remove oil from skin with washcloth
Use antiperspirant on patients with very
sweaty skin
Applying Electrodes Applying Electrodes
Negative (white)
under center of right
clavicle
Positive (red) on left
lower chest
Ground (black or
green) under center
of left clavicle or right
lower chest
12 12--Lead ECG Lead ECG
Provides computerized interpretation
Easily transmitted to emergency
department
Used to assist in diagnosis of acute
myocardial infarction (AMI)
Reduces time to hospital treatment of AMI
with drugs or procedures
6/28/2011
932
Post Cardiac Arrest Care Post Cardiac Arrest Care
Respiratory Support Respiratory Support
May breathe less frequently
Adequacy and rate of breathing will
determine next steps
Inadequate: ventilate or assist ventilation with
oxygen
Adequate: administer high-concentration
oxygen by mask
Pulse Pulse
Monitor frequently
May be difficult to tell if patient has gone
back into arrest
If not sure of pulse, look for other signs of
circulation (movement)
If still not sure, ventilate, compress chest,
and have AED check rhythm
6/28/2011
933
Advanced Life Support Advanced Life Support
Get ALS assistance if available
ALS providers may use therapeutic
hypothermia
May increase patients chance of survival
with good neurological outcome
Supplemental Oxygen Supplemental Oxygen
If patient is perfusing sufficiently to get
pulse oximeter reading between 94% and
100%, reduce amount of oxygen
If you can do so without sacrificing other
important steps, do so in accordance with
local protocols
Be aware of hypoxia danger
Appendix Review Appendix Review
6/28/2011
934
CPR provides minimal circulation to delay
brain death.
Teamwork is essential to success in any
resuscitation.
For unconscious patients, determine
responsiveness, pulselessness, and
breathlessness before beginning
resuscitation.
continued
Activate EMS system immediately in
adults or after 2 minutes of resuscitation in
children and infants.
Consider using mouth-to-mask ventilations
during a resuscitation. Prevent gastric
distention: position airway properly and
limit force, rate, and volume of ventilations.
continued
Check for circulation by assessing carotid
pulse (adults, children) or brachial pulse
(smaller children, infants).
Quality chest compressions increase
pressure inside the chest and possibly
compress the heart.
continued
6/28/2011
935
Deliver compressions straight down,
compressing sternum 2 inches, with full
recoil between compressions.
Hand position, depth of compression, and
compression-to-ventilation ratios vary for
adults, children, and infants.
continued
Complete or severe airway obstruction is
indicated by patients inability to speak,
cough, or breathe.
Abdominal thrusts are used in conscious
adults and children.
Back blows and chest thrusts are used to
clear the airway in infants.
continued
Although the use of ECG is a paramedic
skill, EMT may be asked to help to save
time. Know the parts and function of the
ECG machine and how to place leads
Post cardiac arrest care is extremely
important because of the likelihood that
patient will arrest again.
6/28/2011
936
continued
Remember Remember
In a cardiac arrest patient, the primary
assessment is modified to first consider
circulation and the need for immediate
chest compressions.
continued
Remember Remember
If the patient is unresponsive and without a
pulse, chest compressions should be
initiated immediately.
Mouth-to-mask ventilations add a
component of oxygenation to the
sequence of CPR.
continued
Remember Remember
CPR provides circulation by changing the
pressure in the patients chest. This is
accomplished by compressing over the
sternum and allowing for full recoil.
Oxygenation occurs when ventilations are
delivered between compression cycles.
6/28/2011
937
continued
Remember Remember
The techniques of CPR for children and
infants must be modified to account for
differences in anatomy and physiology.
Once CPR has been initiated, interruptions
should be minimized and limited to a few
seconds.
continued
Remember Remember
Abdominal thrusts are used to relieve
severe airway obstructions in conscious
adults and children. CPR is used in
unconscious adults and children.
Back blows and chest compressions are
used to clear a severe airway obstruction
in an infant.
Remember Remember
If ALS is available, get assistance.
In the case of AMI, time is muscle. As
time passes, more and more heart muscle
becomes dysfunctional and finally dies in
the absence of oxygenated blood.
6/28/2011
938
What steps must be taken before
resuscitation when treating an
unconscious patient?
How can you differentiate between a mild
airway obstruction and a severe or
complete obstruction?
A 61-year-old female is found choking. You
find her awake and coughing. You note,
however, that she is unable to speak and
seems to be cyanotic. What immediate
actions must you take?
MEDICAL TERMINOLOGY
Common Terms and Definitions
1. Abdomen Area of the torso below the ribs and above the pelvis.
2. Abnormality That which is not normal.
3. Abrasion A scrape on the skin.
4. Abuse Misuse: excessive or improper use.
5. Accessory Auxiliary, assisting. Term applied to a lesser structure, which resembles in structure and function a
similar organ, as the pancreatic duct (of Santorini) or accessory suprarenal glands. An organ or
structure, which assists other organs in performing their functions as accessory reproductive organs.
6. Acute Sudden onset, or severe. Usually of short duration and not chronic.
7. Afebrile Without fever.
8. Allergy An abnormal reaction of body tissues in response to a specific substance, characterized by broncho
spasm, swelling and rash: also known as anaphylaxis.
9. Anatomy Study of the structure of the body.
10. Anemia Reduction in the number of circulating red blood cells.
11. Asymptomatic Without symptoms.
12. Ataxic Muscular in coordination
13. Bifurcation A separation into 2 branches.
14. Bradycardia Slow heart rate. <60 (less than 60 beats per minute)
15. Catheter Tube for evacuating or injecting fluids.
16. Comatose Deep unconsciousness, patient does not respond to external stimuli.
17. Congenital Present at birth.
18. Consciousness Being aware and having perception.
19. Contusion Bruise.
20. Criteria Standards for judging.
21. Cyanosis Bluish, grayish discoloration of the skin in response to decreased oxygen.
22. Deficiency A lack of.
23. Deformity A distortion or alteration in the natural form.
24. Dermis Pertaining to skin.
25. Diaphoresis/
Diaphoretic
Profuse sweating.
26. Diastole When the heart chambers refill after muscular contraction, pressure against arterial walls
27. Diffuse Scattered, spread out.
28. Dilate Expansion of a vessel or orifice.
29. Distend Stretch or expand.
30. Dysrhythmia/
Arrhythmia
Dysrhythmia is an abnormal or disturbed rhythm other than sinus. Arrhythmia is an irregularity or loss
of rhythm.
31. Emesis Vomit.
32. Etiology Cause of a disease or symptom.
33. Febrile Fever or elevation of temperature.
34. Gastric Pertaining to stomach.
35. Hematoma Swelling which contains blood.
36. Hemoglobin An iron containing pigment of the red blood cells that carry oxygen.
37. Hemorrhage Bleeding.
38. Hypertension Blood pressure above normal.
39. Hypoxia An inadequate amount of oxygen.
40. Imminent Likely to happen without delay.
41. Infarct/ Infarction Infarct is an area of tissue in an organ that dies (necrosis) after the blood supply is blocked. Infarction is
the formation of an infarct most commonly seen as cardiac (Myocardial Infarction) or pulmonary
infarction.
42. Infection An invasion of microorganisms that causes injurious effects on the body or specific tissues.
43. Inflammation Tissue reaction to infection or injury characterized by redness, pain, swelling or heat.
44. Inhibit To repress or restrain an action.
45. Injection Introduce a fluid into a vessel, cavity or muscle via a syringe and needle.
46. Intermittent Coming and going.
47. Involuntary Independent or contrary to ones conscious will.
48. Ischemia Temporary decrease or lack of the oxygen circulation to a part.
49. Malignant Tending or threatening to produce death.
50. Monitor To observe closely.
51. Mortality The state of causing death.
TERMINOLOGY
Common Terms and Definitions
52. Myocardium Heart muscle.
53. Necrosis Tissue death.
54. Nocturnal Pertaining to or occurring at night.
55. Objective Can be observed by others.
56. Origin The source of anything, the starting point.
57. Pallor Lack of color, pale.
58. Palpitation The feeling of fluttering or throbbing of the heart.
59. Patent Open.
60. Pedal Pertaining to the foot.
61. Peripheral Pertaining to the outer parts or surface of the body; away from the center.
62. Potential Possibility.
63. Potentiate To increase in potency or expected actions.
64. Postural Pertinent to, or affected by body position.
65. Precipitating factor A trigger factor.
66. Prognosis Prediction of the course and outcome of a disease or injury.
67. Prone Lying horizontal face down.
68. Sphygmomanometer An instrument used to indirectly measure arterial blood pressure.
69. Stenosis Constriction or narrowing of a passage or orifice.
70. Sterile Free of germs.
71. Subjective Not perceptible to an observer.
72. Symptom Any perceptible change in the body or its functions that indicates disease or the kind or phases of
disease. Symptoms may be classified as objective, cardinal, and sometimes as constitutional. However,
another classification considers all symptoms as being subjective with objective indications being
called signs.
73. Syncope A brief loss of consciousness.
74. Systemic Affecting the whole body, not just a part.
75. Systole / Systolic When the heart chambers empty by muscular contraction.
76. Tachycardia Rapid heart rate. >100 (More that 100 beats per minute.)
77. Thrombus A blood clot.
78. Titrate To adjust until desired effect
TERMINOLOGY
Common Abbreviations
1. - Negative findings
2. + Positive findings
3. a before
4. Ad Lib At pleasure or as much as is wanted, prescription abbreviation
5. AIDS Acquired Immune Deficiency Syndrome
6. ALS Advanced Life Support
7. AMA Against medical advice
8. AMI Acute Myocardial Infarction
9. AVPU Alert / Verbal Stimuli / Painful Stimuli / Unresponsive
10. Bid Twice a day
11. BLS Basic Life Support
12. B/P Blood Pressure
13. c With
14. CAD Coronary Artery Disease
15. c.c. Cubic Centimeters
16. c/c Chief Complaint
17. CHF Congestive Heart Failure
18. CNS Central Nervous System
19. CO Carbon Monoxide
20. c/o Complains Of
21. CO
2
Carbon Dioxide
22. COPD Chronic Obstructive Pulmonary Disease
23. CVA Cerebrovascular Accident
24. DC Discontinue
25. DOA Dead on arrival
26. Dx Diagnosis
27. ECG, EKG Electrocardiogram
28. ER Emergency Room
29. ED Emergency Department
30. ETT Endotracheal tube
31. ETA Estimated Time of Arrival
32. ETOH Alcohol Intoxicated
33. FB Foreign Body
34. FROM Full range of motion
35. Fx Fracture
36. GCS Glasgow Coma Scale
37. GI Gastrointestinal
38. Gm. Gram
39. Gr. Grain
40. GSW Gun Shot Wound
41. Gtt (s) Drop (s)
42. HAM History / Allergies / Medications
43. HBD Has Been Drinking
44 Hgb Hemoglobin
45. HHN Hand Held Nebulizer
46. HIV Human Immunodeficiency Virus
47. Hr. Hour
48. Hx History
49. ICP Intracranial pressure
50. IM Intramuscular
51. IV Intravenous
52. IVPB Intravenous piggy back
53. JVD Jugular vein distention
54. KVO Keep vein open
55. L Liter
56. LLQ Left Lower Quadrant of abdomen
57. LMP Last Menstrual Period
58. LUQ Left Upper Quadrant of abdomen
59. MEQ Milliequivalent
60. Mg Milligram
61. MI Myocardial Infarction
62. MICN Mobile Intensive Care Nurse
63. MICP Mobile Intensive Care Paramedic
64. ml milliliters
65. NKA No Known Allergies
66. NPO Nothing by mouth
67. NTG Nitroglycerin
68. O
2
Oxygen
69. OB Obstetrics
70. PEARL or PERL or
PERLA
Pupils Equal And Reactive to Light
71. p After
72. PE Pulmonary Embolus
73. PO By mouth
74. PRN As needed, as circumstances may require, as necessary
75. q Every, Quantity
76. QD Every day
77. qid 4 times per day
78. RBC Red blood cell or red blood count
79. R/O Rule Out
80. RX Prescription or treatment
81. s Without
82. SAMPLE Signs and Symptoms / Allergies / Medications / Past Pertinent History / Last Oral Intake / Events
leading up to this event
83. SIDS Sudden infant death syndrome
84. SQ Subcutaneous
85. SL Sublingual
86. SOB Short of breath
87. ss Signs and symptoms
88. stat Immediately
89. tid 3 times per day
90. TIA Transient Ischemic Attack
91. TKO To Keep Open
92. TM Transmucosal
93. TPR Temperature, Pulse, Respiration
94. VS Vital Signs
95. WNL Within Normal Limits
96. y.o. Year Old
Building Words, Roots and Combining Forms
1 algesia Sensitivity to pain, A form of hyperesthesia
2 brachia Arm (upper)
3. broncho relating to bronchi (wind pipes)
4. cardio Heart
5. cervico Neck
6. cephalo Head
7. costo Rib
8. cutane Skin
9. derm Skin
10. emia Blood
11. esthesia sensations, feelings
12. gastro Stomach
13. glyco Sugar
14. hem, hemia, hema Blood
15. hepa Liver
16. laryngo Larynx
17. lateral Side
18. lingual Tongue
19. myo Muscle
20. neuro Nerve
21. noc Night
22. opthalm Eye
23. osteo Bone
24. oto Ear
25. path disease
26. pedi foot
27. pharyngo throat, pharynx
28. phasia speech
29. phlebo vein
30. plegia paralysis
31 pnea breathing
32 pneumo air, lung
33. psych mind
34 renal kidney
35. scleros hardening
36. thermo heat
37. uro urnine,
Suffixes and Combining Forms (Appearing as the Last Part of a Word)
Suffix Meaning
1. -able able to - capable of
2. -al indicating connection/ with as in abdominal
3. -algia pain
4. -an belonging to - pertaining to
5. -cide destructive - killing
6. -cule little
7. -cyte cell
8. -ectomy surgical removal of any organ or gland
9. -emia blood
10. -esis action
11. -form shaped like - having the form of
12. -genetic formation - origin
13. -gram a tracing or mark
14. -graph instrument used in recording data
15. -iasis state - condition of particularly a pathological condition
16. -ism condition - or theory of; principle or method
17. -ite of - nature of
18. -itis inflammation of
19. -logy science of - study of
20. -megaly enlargement
21. -meter measure
22. -oid likeness - resemblance
23. -osis disease - condition - Usually denotes increase in the condition
24. -ostomy to form an opening or outlet
25. -phobia fear or aversion to a subject
26. -plasty repair of - reconstruction
27. -plegia paralysis or stroke
28. -rhage hemorrhage, bleeding, profuse discharge
29. -rhea to flow
30. -scope an instrument for visual examination
31. -scopy examination
32. -stomy to form an opening or outlet
33. -tomy incision of
34. -uria urine
PREFIXES, SUFFIXES AND COMBINING FORMS
Prefix Meaning
1. an- without or not
2. bi- twice - two
3. brachio- arm
4 brady- slow
5. broncho- bronchi
6. cardio- heart
7. centi- hundred - a hundredth
8. cervico- neck
9. chole- gall or bile
10. cholecysto- gallbladder
11. circum- around
12. co- together
13. con- together - with
14. contra- against - opposite
15. costo- ribs a rib
16. cysto urinary bladder or a cyst
17. de- down - from
18. dec/deca Ten
19. deci- Tenth
20. derma- the skin
21. dermat- the skin
22. dextro to the right
23. di- double - twice -apart from
24. dorso- Back
25. dys- abnormal - bad - difficult -painful - unlike
26. electro relation to electricity
27. en- in - into - within
28. endo- Within
29. entero- pertaining to the intestine
30. eni- in addition to - upon
31. eoui- Equal
32. eryth- Red
33. ey- out - out of - away from
34. eyo- outward
35. extra- outside of - in addition of
36. fibro- Fibers
37. fore- Before - in front of
38. gastro- stomach
39. glosso- tongue
40. glyco- Sugar
41. gyneco- Female
42. hem- Blood
43. hemi- Half
44. hemo- Blood
45. hepa- Liver
46. heptato- Liver
47. heredo- hereditary
48. hexa- Six
49. homeo- similarity
50. homo- same
51. hydro- water
52. hyper- above - increased - beyond
53. hypo- under - decreased
54. hystero- uterus
55. ileo- ileum
56. ilio- ilium
57. in- in - within - inside - into
58. inter- between
59. intra- within
60. intro- in - within - into
61. ischio- ischium
62. iso- equal
63. juxta- nearness - close proximity
64. kilo- one thousand
65. laryngo- the larynx
66. latero- side
67. levo- left
68. macro- big - large
69. mal- bad - poor
70. medi- middle
71. melano- black - dark
72. meso- middle
73. micro- small
74. milli thousand - a thousandth
75. multi- many
76. myelo- spinal cord - bone marrow
77. myo- muscle
78. narco- numbness - stupor
79. neo- new - recent
80. neuro- Nerve, Neural
81. nitro- nitrogen
82. non- not
83. oculo- the eye
84. opthalmo- eye
85. opo- juice - serum
86. ortho- straight - normal - correct
87. os- mouth - bone
88. osteo- bone
89. oto- ear
90. pan- all
91. para- beside - accessory to - apart from - against
92. path disease
93. ped- child or foot
94. per- by - through
95. peri- around
96. pharyngo- pharynx
97. phlebo- vein
98. photo- light
100. phren- diaphragm or mind
101. pneumo- air or lungs
102. pod- foot
103. poly- much - many
104. post- after
105. pre- before
106. pro- before - for - on account of
107. pseudo- false
108. psych- the mind
109. pyo- pus
110. quadri- four
111. radio- radiation
112. re- back - again - contrary
113. retro- backward
114. rhin- nose
115. roetgeno- roetgen or x-rays
116. sacro- sacrum
117. sarco- flesh
118. sclero- hard - hardening
119. semi-- half
120. skeleto- skeleton
121. sodio- containing sodium
122. steno- narrowing - constriction
123. sub- under - beneath
124. super- above - excess
125. supra- above
126. syn- union - together
127. tachy- fast
128. tarso- flat of the foot - edge of the eyelids
129. ter- thrice - threefold
130. tetra- four
131. thermo- heat
132. thyro- thyroid gland
133. trans- across - over
134. tri- three
135. ultra- beyond - excess
136. un- not - back - reversal
137. uni- one
138. uro- urine
139. vaso- a vessel
140. ventro- the abdomen
141. xero- dry
142. xipho- xiphoid cartilage
COMMONLY PRESCRIBED DRUGS
DRUG INDICATIONS FOR USE
1 Acetominophen fever, pain, inflammation
2 Adapin depression
3 Aldactone high B/P
4 Aldonet high B/P
5 Alupent bronchospasms, asthma COPD
6 Aminophylline bronchospasms, asthma COPD
7 Amitriptyline depression
8 Antivert nausea, vomiting, vertigo
9 Apresoline high B/P
10 Asendin depression
11. Aspirin fever, pain, inflammation
12 Atarax anxiety, tension, sedation
13 Benadryl allergic reactions, sedation
14 Blocadren angina, high B/P
15 Bricanyl asthma, bronchospasms
16 Bronkosol asthma, COPD
17 Cafergot migraine headaches
18 Calan asthma, bronchospasms
19 Capaten CHF, hypertension
20 Cardizem angina, coronary artery spasm
21 Catapres high B/P
22 Centrax anxiety
23 Cimetidine ulcers
24. Clinaril arthritis, inflammatory disease
25 Clonopin seizures
26 Corgard angina, hypertension
27 Coumadin blood thinner
28 Datmane sedation
29 Darvocet pain
30 Darvon pain
31 Depakene seizures
32 Diabinese diabetes
33 Diazepam anxiety, seizures
34 Digoxin CHF, arrhythmias
35 Dilantin seizures
36 Dimetap allergic reactions, colds
37 Diphenhydramine allergic reactions, colds
38 Dipyridamole angina
39 Diuril high B/P
40 Donnatol gastric hyperactivity
41 Dyazide high B/P
42 Dymelor diabetes
43 Elavil depression
44 Endep depression
45 Enduron CHF
46 Feldene pain, inflammation, arthritis
47 Furosemide high B/P, CHF, edema
48 Gaviscon ulcers
49 Halcion sedation
50 Haldol psychosis, sedation
51 Heparin blood thinner
52 Hydralazine high B/P
53 Hydrodiuril high B/P, CHF
54 Hydrochlorothiazide high B/P, CHF
55 Hygraton high B/P, CHF
56 Ibuprofen inflammation, asthma
57 Imipramine depression, migraines
58 Inderol angina, arrthymias, high B/P
59 Indocin arthritis, inflammation
60 Isordil angina
61 Lanaxin CHF, arrhythmias
61 Lasix high B/P, edema, CHF
62 Librium anxiety
63 Lithium manic depression
64 Lopressor high B/P
65 Meclazine allergic reactions (see Antivert)
66 Mellaril psychosis,anxiety
67 Meprobamate anxiety, tension, sedation
68 Methadone drug addiction, pain, sedation
69 Miltown anxiety, tension, sedation
70 Minipress high B/P
71 Moduretic high B/P, CHF
72 Motrin arthritis, inflammation
73 Mylanta ulcers
74 Mysoline seizures
75 Nardil depression
76 Navane psychosis
77 Nifedipine angina, coronary artery spasm
78 Nitrobid, paste angina
79 Nitroglycerine angina
80 Norpoce arrthymias
81 Norpromin depression
82 Orinase diabetes
83 Parafon Forte muscle cramps
84 Parnate depression
85 Pavabid angina, arrhythmias
86 Percodon pain
87 Percogesic pain
88 Phenobarbitol seizures, sedation
89 Presantine angina
90 Procainamide arrhymias
91 Procardia angina, hypertension
92 protxin psychosis
93 Pronestyl arrhythmias
94 Propranoiol angina, arrhythmias, high B/P
95 Prozac depression
96 Quinidex arrhythmias
97 Quinidine arrhythmias
98 Reserpine CHF, high B/P
99 Riopan ulcers
100 Serox anxiety, sedation
101 Sinequan depression
102 Stelazine psychosis
103 Tagamet ulcers
104 Tegretol seizures
105 Tenocmin angina, high B/P
106 Theo-dur bronchospasms, asthma, COPD
107 Theophylline bronchospasms, asthma, COPD
108 Thiazide high B/P
109 Thorazine psychosis
110 Timolol angina, high B/P
111 Tofronil depression, anxiety
112 Tolectin arthritis, inflammation
113 Tolinase diabetes
114 Tranxene anxiety
115 Triavil depression
116 Tylax pain
117 Tylenol pain, fever, inflammation
118 Valium anxiety, seizures
119 Ventolin bronchospasm, asthma, COPD
120 Veropam angina, coronary artery spasm, arrhythmias
121 Vistanil see Atarax
122 Vivactil depression
123 Warfarin blood thinner
124 Xanax sedation
125 Zarontin seizures
126 Zyloprim Gout
GLOSSARY
1 Abandonment Legal term for the cessation in the delivery of care without making provisions for ongoing care or
Evaluation of the patient
2 ABCs Basic components of primary survey. ABC's are comprised of Airway, Breathing, Circulation
3 Abdominal
Aneurysm
Tear between layers of the descending aorta creating a balloon effect which may rupture causing
massive Internal bleeding
4 Abrasion A scrape to skin or mucus membrane which results in damage to the epidermis and portion of the
dermis
5 Acute Dissecting
Aortic Aneurysm
Defect in wall of aorta leading to shearing and balloon effect which obstructs blood flow
6 AEIOU TIPS Acronym which helps define the reasons for a decreased L.O.C. or seizure
A Alcohol (consider any depressant or in the case of seizure withdrawal from depressants), Arrhythmia,
Apnea, Anaphylaxis
E Epilepsy, Environment
I Insulin, (consider hypoglycemia)
O Overdose
U Uremia, Under dose
T Trauma
I Infection
P Psychological
S Stroke, Shock
7 Aerobic metabolism Normal cellular metabolism using oxygen and glucose which results in the production of carbonic acid
(a Weak acid which is broken down to CO2 and H2O)
8 ALS Abbreviation for Advanced Life Support. This is a level of care reserved for patients requiring
paramedic or higher scope of practice
9 Altered level of
Consciousness
Condition indicated by lack of alertness or full concentration
10 Amniotic Sac A fluid filled membrane located in the pregnant uterus that cushions and protects the fetus
11 Alveoli Small sac-like structure of the lungs where the exchange of gases (diffusion) occurs
12 AMA Abbreviation meaning "Against Medical Advice," usually used for medical legal purposes
13 Anaerobic
metabolism
Abnormal cellular metabolism caused by a lack of oxygen creating lactic acid (a strong acid which is
Difficult for body to excrete)
14 Anatomical
Obstruction
Obstruction due to body tissue osculating airway
15 Angina Pectoris Medical condition caused by a decreased blood supply to a portion of heart muscle leading to ischemia
and chest pain
16 Anoxia Total lack of oxygen
17 Aorta Largest artery in body transporting oxygenated blood away from the left ventricle
18 Aphasic Inability to speak
19 APGAR Scoring system used to evaluate the status of newborns. Named after Dr. Virginia Apgar
20 Apnea Absence of respirations
21 Appendicitis Inflammation/infection of appendix
22 Arterial bleeding Bleeding from an artery which usually appears as bright red in color and may pulsate with heart beat
23 Arteries Blood vessels that carry blood away from heart
24 Asymptomatic Meaning without signs or symptoms
25 Ataxic respirations Irregular respiratory rate and tidal volume
26 Atria The upper chambers of the heart
27 Autonomic nerves Nerves that constrict involuntary functions of body
28 AVPU Mnemonic for assessing level of consciousness. AVPU stands for A- Alert, V- Responsive to verbal
Stimuli, P - responds to painful stimuli, U Unresponsive
29 Avulsion A tearing away of a body tissue or structure. May range from a simple flap of skin to complete
amputation
30 Bag-Valve-Mask /
BVM
A handheld device used in ventilating patients. A BVM is comprised of three major components: an
Airtight mask sealed against the patient's mouth a one-way valve allowing air to enter the patient's
airway and exhaled air to be exhausted into the atmosphere; and an oxygen reservoir to be squeezed by
hand. These devices come in a variety of sizes to be matched to the patients size.
31 Battle's Sign Ecchymosis over the mastoid bone indicating a basal skull fracture
32 Biological death Permanent brain death due to lack of oxygen. Biological death is irreversible
33 Blood Pressure Pressure of the blood against the walls of the arteries. Blood pressure can be computed by the following
formula: blood pressure equals cardiac output X peripheral vascular resistance (BP= COxPVR)
34 Bradycardia Abnormally slow heart rate, heart rate of less than 60 beats/min
35 Brainstem A major division of the brain that consisting of the medulla oblongata, pons Varolii, and midbrain, that
connects the spinal cord to the forebrain and cerebrum
36 Bronchi Part of the respiratory system that connects each lung to the trachea
37 Capillary Microscopic blood vessel where exchange of gases and nutrients between the bloodstream and tissue
occurs
38 Capillary refill A measurement of distal perfusion. Capillary refill of greater than two seconds is considered delayed
and Indicates poor perfusion
39 Epiglottis Structure located at opening of the larynx which protects the airway from swallowed liquids and solids
40 Esophageal varices Enlarged (dilated) blood vessels in the esophagus which may be easily ruptured causing severe bleeding
Usually caused by liver disease or alcoholism
41 ETA Abbreviation for Estimated Time of Arrival
42 Eustachian tube Tube found between the ear and throat which equalizes pressure between middle ear and outside
Environment
43 Evaporation Heat loss which is the result of liquid cooling and dissipating into surrounding air
44 Evisceration A wound characterized by the profusion of internal organs through the wound wall
45 External Auditory
Canal
Part of the outer ear that channels sound waves to the middle ear
46 Fetus Unborn baby
47 5150
5585 (peds)
Section of the California Welfare and Institutions Code that allows a person meeting certain criteria to
be treated and/or transported without consent. A 5150 can only be originated by a peace officer or
designate of the County Health Officer
48 Flail Chest Detachment of a segment to the bones making up the thoracic cage
49 Flanks Portion of the body containing the lateral aspects of the femur, hips, pelvis, buttocks, extending from
the hips to the ribs
50 Fontanels or Fontanel The soft spot on an infants skull where the bone has not yet joined
51 Fowlers Position Patient care position characterized by placing the patient in a sitting position. This position is used for
Patients that are short of breath
52 Frontal Line or
Frontal Plane
Imaginary line dividing body into anterior and posterior
53 Frontal Lobe Portion of the cerebrum located behind the forehead that contains emotion, behavior, movement,
Motivation
54 Genitourinary System Body system that removes waste products, maintains salt, water and acid-base balance and is involved
in Reproduction
55 Glucose Source of energy required by all cells for normal metabolism
56 Gran(d) mal seizure Generalized tonic-clonic muscle contractions with loss of consciousness
57 Gravida Term meaning total number of pregnancies
58 Heart rate Number of cardiac compressions per minute
59 Hemapophyses The second element in each half of a hemal arch, corresponding to the sternal part of a rib.
60 Hematemesis Vomiting blood
61 Hematoma Latin for "bloody tumor". Simply stated, a bump caused by fluid between layers of tissue
62 Hemorrhoid Enlarged blood vessels near the anus
63 High flow 02 The administration of oxygen at 10 to 15 liters via non-rebreather facemask. To be effective the patient
must be breathing and have adequate tidal volume
64 History Part of the secondary survey that documents the patient's past illnesses and/or injuries
65 Homeostasis The state of equilibrium or balance of body functions
66 Horizontal Line or
Horizontal Plane
Imaginary line dividing body into Superior and Inferior segments
67 Host Organism which provides a nourishing environment for an infectious agent
68 Hyperglycemia Abnormally high blood glucose (blood sugar)
69 Hypertension Blood pressure greater than 140 systolic or 90 diastolic (High blood pressure
70 Hypoglycemia Inadequate glucose (blood sugar) level
71 Hypopharynx Area of the throat immediately above the larynx
72 Hypotension Blood pressure too low to meet needs of the body. Hypotension may be associated with
signs/symptoms of inadequate perfusion
73 Hypoventilation Inadequate respiratory rate and/or tidal volume
74 Hypoxia Decreased oxygen saturation in blood or tissue
75 Iliac Crests The lateral superior aspects of the pelvis
76 Implied Consent Legal concept involving the rules of consent. In "Implied consent", consent is assumed when the patient
has a diminished L.O.C. or is a minor (In the absence of parent or guardian). Law assumes patient
would consent if able
77 Incubation period Interval between exposure to a disease and the appearance of signs/symptoms
78 Informed consent Concept involving the rules of consent. A patient must understand the nature and possible
complications of any procedure and must be physically and mentally competent to make a decision
79 Insulin Hormone secreted by the pancreas which allow cells to use glucose
80 Intercostal Muscles Muscles between the ribs. The intercostal muscles are accessory muscles of respirations
81 Intracellular
Compartment
One of three generalized areas of the body containing fluid located within cells
82 Interstitial
Compartment
One of three generalized areas of the body containing fluid. The Intracellular compartment of the body
contains fluid located within cells
83 Intravascular
Compartment
One of three generalized areas of the body containing fluid. The intravascular compartment of the body
contains fluid located within blood vessels
84 Iris Sphincter muscle located in the eye that controls pupil size
85 Kussmaul Breathing Deep rapid respirations which is subdivided into three stages
86 Labor Final period of pregnancy which is subdivided into three stages
87 1st stage from onset of regular uterine contractions through full dilation of cervix. This s usually the longest
stage of labor
88 2nd stage From full dilation of cervix through delivery of infant
89 3rd stage From delivery of infant through delivery of placenta
90 Laceration A tear of the skin having jagged edges
91 Left Lateral Position Patient lying on left side. This is the position of choice for patients with a decreased L.O.C.
92 Lactic Acid Product of anaerobic metabolism. Lactic acid is difficult for the body to get rid of
93 Larynx Also called the voice box. Portion of the upper airway that contains the vocal cords
94 Lens Part of the eye which focuses light rays onto retina
95 Level of
Consciousness (LOC)
A measurement of orientation and alertness. The verbal patient is tested regarding their ability to
correctly indicate their name, location, the time, and what happened (person, place, time, and purpose).
Patients that cannot respond verbally can be assessed by their reaction to painful stimuli
96 Low flow 02 The administration of oxygen at 2 to 6 liters via nasal cannula
97 Lower airway From the epiglottis to the alveoli
98 Lungs Organ of respiration where the exchange of oxygen and carbon dioxide occurs
99 M.A.C. (Medical Alert Center) Communications system in Los Angeles County used during multiple casualty
Incidents. M.A.C. coordinates efforts of prehospital care with hospital resources
100 Mechanical
obstruction
Foreign body that occludes the airway. Common causes include food, small toys, vomitus
101 Melena Black, tarry stool. Melena indicates intestinal bleeding
102 Meninges The membrane surrounding the brain and spinal cord. It is made up of three layers; the dura mater, the
arachnid mater, and the pia mater
103 Meningitis Inflammation of the membrane covering the brain and spinal cord usually due to infection
104 Mid-Sagittal Line or
Mid-sagittal Plane
Imaginary line through the center of the body dividing body into lateral and medial aspects
105 Modified Jaw Thrust A maneuver used to open a patients airway with a suspected head or spinal injury. It is performed by
holding the patients head secure and lifting the lower jaw upward without moving the head or neck
106 Muscular System Body system responsible for movement, maintenance of posture, constriction of tubular structures (i.e..
intestines, blood vessels). The muscular system can be divided into three groups. Skeletal muscles,
smooth muscles, and Cardiac muscle
107 Myocardial Infarction Also called a heart attack, an M.I. or coronary. Decreased blood supply to a portion of the heart muscle
leading to death of tissue
108 Myocardium Heart muscle
109 Nasopharyngeal
airway
Also called an NP airway. A flexible tube which is inserted in the nose and rests above the
hypopharynx
110 Negligence A legal concept which is caused by a failure to conform to established standards of care resulting in
damage or injury
111 Nervous System Body system responsible for the storage and transmission of information
112 Nuchal Rigidity Stiff neck which may be the result of meningitis
113 Occipital lobe Portion of the cerebrum that controls vision. The occipital lobe is located in the posterior cerebrum
114 Oropharyngeal
airway
Also called and OP airway. Tube like device place in the mouth to assist in keeping the airway open
115 Osmosis The process of fluid moving from a higher to a lower concentration. Sodium is the electrolyte that is
normally involved in this process
116 Para Medical term meaning the number of previous births (not including miscarriages or abortions)
117 Paradoxical
Respirations
Movement of a detached segment of chest wall opposite the normal movements of expansion and
retraction. Indicate a frail chest.
118 Paraplegia Paralysis of the lower extremities
119 Parietal lobe Portion of the cerebrum that controls sensation. The parietal lobes are located on the lateral aspects of
the cerebrum
120 Periorbital Meaning the area of the face around the eye sockets
121 Partial airway
obstruction
An airway obstruction characterized by the patient being able to adequately exchange air. It should be
noted that a partial airway obstruction may evolve into a complete airway obstruction
122 Patent airway An airway that allows the unobstructed exchange of oxygen and carbon dioxide
123 Passive cooling Removal of the patients clothing to decrease body temperature
124 Pericardium An inelastic membrane that surrounds the heart
125 Peripheral nerves A subdivision of the nervous system. Peripheral nerves conduct impulses from brain and spinal cord to
tissue or from tissue to the spinal cord and brain
126 Peripheral resistance Also called peripheral vascular resistance (PVR). The amount of force produced by diameter of the
blood vessels, which regulates blood flow. Peripheral resistance is determined by the diameter of the
blood vessels. The larger the diameter of the blood vessel, the less the peripheral resistance
127 Peritoneum Membrane surrounding the abdominal and pelvic cavity
128 Pharynx The throat
129 Photophobia An intolerance to light which occurs as the result of disease
130 Pinna Outer part of the ear. The pinna collects sound waves
140 Placentia Organ that develops during pregnancy and is expelled during the last stage of labor. The placenta
embeds itself on the wall of the uterus. It provides oxygen and nutrients to the fetus through the
umbilical cord
141 Plasma Liquid component of blood which acts as the transport medium for blood cells
142 Platelets A solid irregular microscopic component of blood that is involved in blood clotting
143 Pleura Membrane of the thoracic cavity that provides a friction free surface for the movement of the lungs
within the thorax
144 Post-ictal Period of sleepiness and decreased level of consciousness following a grand mal seizure
145 Primary Patient
Assessment
Phase of patient assessment which establishes whether the patient needs immediate life=saving
intervention. It is comprised of ensuring the environment for safety, checking and correcting the
patients Airway, Breathing, and Circulation. Following that, the EMT will identify and correct life
threatening circulatory problems (i.e. shock, arterial bleeding) followed by spinal immobilization if
necessary
146 P.R.N. Latin (Pro Re Nata) meaning to administer when necessary
147 Prone Position Patient position laying face down
148 Pulmonary vein Artery that transports oxygenated blood from the lungs to the left atria
149 Pulse Rhythmic wave that travels from the heart through the arteries
150 Pulse pressure The difference between diastolic and systolic blood pressure
151 Puncture A hole in skin caused by a sharp object such as a nail. Puncture wounds are easily contaminated
152 Pupil A portion of the eye which allows light into inner eye
153 Quadriplegia Paralysis of all four extremities
154 Radiation Heat loss due to energy being transmitted from warm source to cooler environment
155 Rales Abnormal lung sounds heard on auscultation indicating fluid in alveoli. Rales can be described as a wet
crackling sound
156 Rapid or Active
cooling
The application of a substance such as water to the patients body in order to lower core temperature
157 Rapid transport The safe efficient transport of a patient using emergency lights and siren
158 RAS (Reticular
Activating System)
An area of the brain located in the brain stem that is responsible for awareness and alertness
159 Red Blood Cells
(R.B.C.)
Microscopic blood cells that transport oxygen to other body cells
160 Respiration The process of breathing
161 Respiratory System The respiratory system supplies oxygen to body cells and removes carbon dioxide. The respiratory
system also helps balance body PH
162 Retina Part of the eye that changes light into nervous impulse
163 Sclera A membrane that surrounds and protects the eye
164 Secondary Patient
Assessment
Thorough assessment of all body systems
165 Semi-Fowlers
Position
Patient position characterized by the patient supine with upper body raised 45 degrees (semi-reclining).
The semi-fowlers position is used for patients that are short of breath or who are having chest-pain.
166 Semi-circular canals Part of the inner ear that provides for balance and equilibrium
167 Shock Widespread inadequate tissue perfusion to vital organs. The four major categories of shock are;
Cardiogenic Pump failure
Distributive Widespread vascular dilation
Hypovolemic Inadequate fluid volume
Obstructive Physical obstruction (Types of shock ends here)
168 Shock position Patient supine with legs raised approximately twelve inches. Position of choice for patients in shock
169 Sign Objective observation assessed by EMT-1
170 Skeletal System Body System that provides support, protection of underlying organs, body structure, assists in
ambulation and produces blood cells
171 Skin signs Vital signs that describe skin color, moisture, and temperature
172 SOB Abbreviation meaning shortness of breath
173 Spinal Cord Component of the central nervous system that transmits impulses to and from the brain. As with the
brain, the spinal cord is covered by a membrane called the meninges
174 Status epilepticus A true medical emergency that is defined as any seizure lasting longer than 10 minutes, or repetitive
seizures without periods of consciousness, or three or more seizures occurring in an hour
175 START Triage protocol meaning Simple Triage And Rapid Treatment
176 Stridor Raspy, crowing sound caused by upper airway obstruction
177 Stroke volume Stroke volume or SV is the amount of blood pumped by the left ventricle in one contraction
178 Subdural hematoma Collection of blood between dura mater and brain. Subdural hematomas are usually venous in origin
179 Sudden Infant Death
Syndrome or SIDS
SIDS or crib death is the sudden and unexpected death of an apparently healthy infant, usually under
one year of age, which remains unexplained after a complete medical history, death scene investigation
and postmortem examination
180 Supine Patient position when the patient is lying flat on their back
181 Suspect Person whose history or signs/symptoms suggest that he/she may have of be developing a
communicable disease
182 Symptom Subjective complaint voiced by the patient
183 Symptomatic An illness or injury causing the patient to be in distress
184 Syncope Sudden loss of consciousness due to inadequate brain perfusion
185 Systole The period of time when the heart is contracted
186 Systolic blood
pressure
The pressure of the blood against the walls of the arteries when the heart is contracted
187 Tachycardia Abnormally fast hear rate, heart rate greater than 100/min
188 Tachypnea Abnormally fast respiratory rate, respiratory rate of greater then 20/min
189 Tonic Meaning the tightening of muscles usually seen in seizures
190 Temporal lobe Portion of the cortex that controls speech and hearing. The temporal lobes are located on the cerebrum
behind the ears.
191 Transient Ischemic
Attack or TIA
Temporary condition of inadequate perfusion to the brain resulting in neurological deficits (weakness.
Paralysis, speech disorders, etc. ) which resolves after minutes (usual) to hours
192 Trendelenburg Patient position seldom used in prehospital care. When placed in trendelburg, the patient is kept in-line
with the head maintained lower then the feet
193 Triage French word meaning to sort
194 Turgor The resistance of skin as a factor of hydration and age
195 Tympanic membrane
(eardrum)
Part of the ear that vibrates to conduct sound waves
196 Ulcer Erosion of mucus membrane such as the stomach or intestinal lining which causes pain and/or bleeding
197 Umbilical Cord Cord found in the pregnant uterus that attaches the placenta to the fetus
198 Universal precautions Method of avoiding contamination by always handling blood and other body fluids as if they were
infectious
199 Upper airway Part of the respiratory system from nose and mouth to epiglottis
200 Uterus Muscular organ that holds and nourishes the fetus
201 Vasovagal response Syncope, which results from a temporary, fall in blood pressure or heart rate leading to inadequate brain
perfusion. Common causes include straining during bowel movement, vigorous suctioning and
vomiting
202 Veins Blood vessels that carry blood toward heart
203 Vena cava Largest veins in body returning deoxygenated blood to right atria
204 Ventricles Lower chambers of the heart
205 Venous bleeding Bleeding from veins usually dark red in color and occurring at a steady rate
206 Vital Signs Measurements of body system status. Vital signs includes; respirations, pulse, L.O.C., skin color, skin
moisture, temperature, pupils, and blood pressure
207 Wheezing Whistling (dry sound) sound heat most often makes on expiration indicating bronchospasm
208 White blood cells
(WBCs)
A solid microscopic blood component that is important in fighting infection
209 Xyphoid Process Cartilage located at the lower end of the sternum
COUNTY OF VENTURA
EMERGENCY MEDICAL SERVICES AGENCY
EMT-I STUDENT INFORMATION AND SKILLS SHEETS
These skills were originally developed by the
ALS/BLS skills Sub-Committee
Of the
Education Advisory Committee
Of the
Los Angeles County EMS Commission
Last update August 2005
VENTURA COUNTY EMS AGENCY
BASIC LIFE SUPPORT SKILL
AIRWAY EMERGENCY I AIRWAY MANAGEMENT
NASOPHARYNGEAL AIRWAY (NPA)
PERFORMANCE OBJECTIVES
The examinee will demonstrate proficiency in sizing, inserting, and removing a nasopharyngeal airway.
CONDITION
The examinee will be requested to insert a nasopharyngeal airway in a simulated adult or child who is breathing and has a gag reflex, but
has difficulty maintaining a patent airway. The adult or child manikin will be placed supine on the floor. The infant may be placed on a
table. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Adult and pediatric airway manikin, various sizes of nasopharyngeal airways, silicone spray, water-soluble lubricant, goggles, masks,
gown, gloves.
PERFORMANCE CRITERIA
1000/0 accuracy required on all items designated by a box (.) for skills testing and must manage successfully all items indicated by
double asterisks (**). Items identified by the symbol ($) must be practiced but is not a required test item.
Appropriate body substance isolation precautions must be instituted.
NAME
IPASS I I FAIL I 1st
2nd
DATE __/__/__
3rd (final)
EXAMINER(S) _
INSERTION OF NASOPHARYNGEAL AIRWAY
PREPARATION
Skill Component Yes No Comments
Take body substance isolation precautions
Assess for partial or complete airway obstruction
** Suction - if indicated
** Administer foreign body airway maneuvers - it
indicated
Select the largest and least deviated or obstructed
nostril
Select appropriate size nasopharyngeal airway by
measuring:
Diameter - size of the patient=s nostril or tip of little
finger
Length - nostril to tip of the tragus, ear lobe or angle
of the lower jaw
Hold the NPA in a pencil-grip fashion near the flange or
depth point and lubricate with a water-soluble lubricant
PROCEDURE
Open the airway:
Medical - head-titUchin-lift
Trauma - jaw-thrust
Gently pus h the tip of the nose upward and maintain the
head in a neutral position
Airway Emergency / Airway Management: Nasopharyngeal Airway (NPA)
Pa e 2 of 3
Insert the NPA with the bevel towards nasal septum:
Right nostril- NPA' S natural curve down toward chin
OR
Left nostril- NPA's natural curve up toward forehead
Advance NPA by directing tip along floor of nasal cavity:
Right nostril
- advance 2/3 of the measured length while
maintaining chin-lift or jaw-thrust position
- Continue to advance NPA until flange is seated
against outside of nostril or marked area is reached
W nostril
- insert approximately 1" or until resistance is met
- rotate 180
0
into position
- advance 2/3 of the measured length while
maintaining chin-lift or jaw-thrust position
- advance until flange is seated against outside of
nostril or marked area is reached
Confirm proper position of the NPA:
Patient tolerates airway
Feel at proximal end of airway for airflow on expiration
Check nostril for blanching
Reassess airway patency and breathing:
Skin color
Rise and fall of chest
Upper airway sounds
** Reposition head, check position of NPA, or suction it
indicated
** Administer oxygen via mask or ventilate with BVM at
the appropriate rate - if indicated
REMOVAL OF NASOPHARYNGEAL AIRWAY
PROCEDURE
Remove airway by grasping the flange and guiding the
NPA out while directing the NPA down toward the chin
** Suction oropharynx - if indicated
Administer 100
%
oxygen via mask, nasal cannula, or
BV device
Reassess airway and breathing
Dispose of contaminated equipment using approved
technique
ONGOING ASSESSMENT
$ Assess airway and breathing:
Continuously or at least every 5 minutes
Changes in airway sounds
Changes in respiratory status
St._Airway-Management-NPA
Airway Emergency / Airway Management: Nasopharyngeal Airway (NPA)
Pa e 3 of 3
DOCUMENTATION
$ Verbalize/Document:
Indication for insertion
Indication for removal- if applicable
Patient tolerance
Size of NPA used
Respiratory assessment:
- rate
- effort/quality
- tidal volum e
Oxygen administration - If needed
- airway adjunct/ventilatory devices used
- oxygen Iiter flow
- ventilation rate
St. _Airway-Managem ent-N PA
AIRWAY EMERGENY / AIRWAY MANAGEMENT
NASOPHARYNGEAL AIRWAY (NPA)
INDICATIONS:
Conscious or unconscious patients, with or without a gag reflex, who are unable to maintain a patent airway
Teeth are clenched and oropharyngeal airway cannot be inserted
Oral trauma when an oropharyngeal airway is contraindicated
CONTRAINDICATIONS:
Infants < 12 months due to small diameter of nostril and adenoidal tissue
Head injury when clear fluid drains from the nose or ears (Basilar skull fracture)
Head injury with suspected facial fractures
COMPLICATIONS:
Vomiting
Laryngospasm
Injury and pressure necrosis to nasal mucosa
Laceration of adenoids or tissue lining the nasal cavity
Severe nosebleed
Airway obstruction if kinked or clogged
NOTES:
Too short of an airway will not extend past the tongue.
Too long of an airway may pass into the esophagus and cause hypoventilation and gastric distention.
A nasopharyngeal airway does not protect the lower airway from vomitus or secretions or hold the tongue forward.
Never force a nasopharyngeal airway into nostril. If an obstruction or deviated septum is encountered, remove the NPA
and try the other nostril.
Use soft, flexible NPAs rather than the rigid, clear plastic NPAs less likely to cause soft-tissue damage or nose bleeds.
A second rescuer is needed to maintain in-line axial stabilization if spinal immobilization is required.
Info._Airway- Management-NPA
Page 1 of 1
AIRWAY EMERGENCY / AIRWAY MANAGEMENT
OROPHARYNGEAL AIRWAY (OPA)
The examinee will demonstrate proficiency in sizing, inserting and removal of an oropharyngeal airway.
CONDITION
The examinee will be requested to insert an oropharyngeal airway in a simulated unconscious adult, child or infant who is breathing, has
no gag reflex, and has difficulty maintaining a patent airway. The adult or child manikin will be placed supine on the floor. The infant may
be placed on a table. Necessary equipment witl be adjacent to the manikin.
EQUIPMENT
Adult, infant or child airway manikin, various sizes of oropharyngeal airways (0-#6), tongue blade or equivalent, pediatric resuscitation
tape, goggles mask, gown, gloves.
l
100
0
/0 accuracy required on all items designated by a box (.) for skills testing and must manage successfully all items indicated by
NAME DATE __1__1__ EXAMINER(S) _
i PASS i i FAIL I 1st 2nd 3rd (final)
INSERTION OF OROPHARYNGEAL AIRWAY
PREPARAliON
Assess for partial or complete airway obstruction
** Suction - if indicated
** Administer foreign body airway maneuvers - it
indicated
Select appropriate size by measuring the OPA from:
Corner of the mouth to the tragus or earlobe
OR
Center of the mouth to the angle of the lower jaw
PROCEDURE
Open the airway:
Medical - head-tilt/chin-lift
Trauma - jaw-thrust
Open the mouth by applying pressure on the chin with
your thumb
** Remove visible obstruction or suction - if indicated
Airway Emergency / Airway Management: Oropharyngeal Airway (OPA)
Pa e 2 of 2
Insert the airway into the pharynx by inserting the tip:
Toward the hard palate and rotate 180
0
when tip
passes the soft palate
OR
Straight while displacing the tongue anteriorly with a
tongue blade or equivalent device
OR
Sideways while displacing the tongue anteriorly with
a tongue blade or equivalent device and rotate 90
0
when tip passes the soft palate
Advance the airway until the flange rests on the lips or
teeth
Reassess airway patency and breathing:
Skin color
Rise and fall of chest
Upper airway sounds
** Reposition head, check position of OPA, or suction it
indicated
** Administer oxygen via mask or ventilate with BVM - it
indicated
REMOVAL OF OROPHARYNGEAL AIRWAY
PROCEDURE
Remove airway:
Grasp flange and guide the OPA out by directing
airway down toward chin
**5uction oropharynx - if indicated
**Administer oxygen - if indicated
technique.
ONGOING ASSESSMENT
Skill Component Yes
No Comments
$ Assess airway and breathing:
DOCUMENTATION
$ VerbaIize/Document
Indication for insertion
Indication for rem oval - if applicable
Patient tolerance/effect
Size of OPA used
- rate
- effort/quality
- tidal volume
Oxygen administration - If needed
- oxygen liter flow
- ventilation rate
St._Airway-Management-OPA
OROPHARYNGEAL AIRWAY (OPA)
INDICATIONS:
Unconscious patient without a gag reflex who has difficulty maintaining a patent airway.
When a Bag-valve-mask device is used to ventilate an unconscious patient.
CONTRAINDICAliONS:
Conscious or semi-conscious patient
Gag reflex
Clenched teeth
Oral trauma
COMPLICATIONS:
Vomiting
Laryngospasm
Injury to hard or soft palate (tearing, bleeding, etc)
Airway obstruction
NOTES:
A noisy airway is a partially obstructed airway.
Purpose of an OPA is to prevent obstruction of the upper airway by the tongue and allows for air exchange.
An oropharyngeal airway does not protect the lower airway from vomitus or secretions.
Too small of an airway will not adequately hold the tongue forward.
Too long of an airway can press the epiglottis against the opening of the trachea and result in an airway obstruction.
Improper positioning or insertion of the airway can push the tongue against the oropharynx and result in airway obstruction.
DO NOT secure an OPA with tape. This may result in an airway obstruction or aspiration if the patient vomits and the airway
cannot be removed rapidly.
A second rescuer is needed to main'tain in-line axial stabilization if spinal immobilization is required.
Info. _Ai rway-M a nagement-0PA
Page 1 of 1
SUCTIONING - ENDOTRACHEAL TUBE
The examinee will demonstrate proficiency in suctioning a patient with an endotracheal tube (consistent with scope of practice) while
maintaining aseptic technique.
CONDITION
The examinee will be requested to suction a simulated patient that is having copious secretions and difficulty breathing. The patient has
an endotracheal tube and is being ventilated with a bag-valve device. The adult or child manikin is supine on a simulated bed or on the
floor. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Simulated adult and pediatric airway management manikin, endotracheal tube, oxygen tank with connecting tubing, suction device with
connecting tubing, or hand-powered suction device with adaptor, sterile flexible suction catheter, sterile normal saline irrigation solution,
sterile container, sterile and unsterile gloves, goggles, masks, gown, waste receptacle, timing device.
100
0
Must maintain aseptic technique.
NAME DATE __/__,__ EXAMINER(S) _
2nd 3rd (final)
PREPARATION
Assess patient for the need to suction tracheal
secretions
Open suction kit or individual supplies
Open/unfold sterile container and fill with irrigation
solution
Ensure suction device is working
** Set appropriate suction setting:
Adult - between 80-120 mmHg
Pediatric and the elderly- between 50-100mmHg
PROCEDURE
Hyper-oxygenate patient - if indicated
Remove oxygen source
Apply sterile gloves
Connect sterile catheter to suction tubing/device
** Keep one (dominant) hand sterile
Airway Emergency I Airway Management: Suctioning - Endotracheal Tube
Pa e 2 of 2
Suction small amount of irrigation solution to:
Lubricate tip of catheter
Insert catheter into endotracheal tube without applying
suction
Advance catheter gently until resistance is met
Withdraw catheter slightly before applying suction
Suction while withdrawing using a rotating motion
** Maximum suction time of 5-15 seconds from
insertion to withdrawal of catheter.
Adults maximum 10-15 seconds
Peds maximum of5-10 seconds
Ventilate patient at approximate rate of:
Adult - 12/minute
Peds - 20/minute
Evaluate airway patency and heart rate - repeat
procedure if needed
Suction remaining water into canister, discard container
and change gloves
Discard contaminated catheter:
Coil contaminated catheter around sterile (dominant)
hand and pull glove over catheter
Pull glove from other hand over packaged catheter
and discard in approved waste receptacle
ONGOING ASSESSMENT
$ Assess airway, breathing and heart rate:
DOCUMENTATION
$
Skill Component
Verbalize/Document
Indication for suctioning
Oxygen liter flow
Patient=s tolerance of procedure
Problems encountered
Type of secretions:
- color
- consistency
- quantity
- odor
Respiratory assessment and heart rate:
- respiratory rate
- effort/qual ity
- tidal volume
- lung sounds
Yes No Comments
.C:::t
SUCTIONING - ENDOTRACHEAL TUBE
INDICATIONS: To maintain a patent airway in patients with an endotracheal tube
Rattling mucus sound from endotracheal tube (nois y respirations)
Bubbles of mucus in endotracheal tube
Coughing up secretions
Respiratory distress due to airway obstruction.
COMPLICATIONS:
Hypoxia Tracheal trauma
Bronchospasm Infection/sepsis
Cardiac dysrhythmias Cardiac arrest
Hypotension
NOTES:
Aseptic technique must be maintained throughout suctioning procedure to prevent infection.
Over suctioning should be avoided to decrease potential for tracheal damage and increase in mucus production.
Catheter size should not exceed 1/2 the inner diameter of the airway. Larger catheters may cause suction induced hypoxial lung
collapse and damage to tracheal tissues.
Establish and maintain a sterile field. Use the inside of the wrapper to establish a field for equipment.
Keep suction settings between 80-120 mmHg and decrease to a lower setting for pediatric and elderly patients (50-1 OOmmHg).
Excessive negative pressures may cause significant hypoxia and damage to tracheal mucosa. Too little suction will be ineffective.
Battery operated suction machine or hand powered suction devices may be used as long as they have an adaptor for a flexible
catheter.
Hyper-oxygenation may be required depending on patient's condition. This offsets volume and oxygen loss during suctioning.
To hyper-oxygenate, increase oxygen liter flow for a brief period of time or ventilate the patient 3-4 times with a bag-valve device.
Rotating the catheter prevents the direct suctioning of the tracheal mucosa and suctions secretions from sides of the tube. Roll the
catheter between thumb and forefinger for rotating motion.
Suctioning longer than recommended time will result in hypoxia. Maximum suction time depends on patient=s age and tolerance
and is timed from the insertion to withdrawal of the catheter.
- Adults maximum 10-15 seconds
- Peds maximum of 5-10 seconds
Info._Airway-Management-Suction-ETT_0507
Page 1 of 1
AIRWAY EMERGENCY - AIRWAY MANAGEMENT
SUCTIONING - OROPHARYNGEAL
The examinee will demonstrate proficiency in performing oropharyngeal suctioning using a rigid and flexible suction catheter and a bulb
syringe.
CONDITION
The examinee will be requested to suction a simulated patient who is either conscious or unresponsive and is unable to maintain a
patent airway due to copious oral secretions. The adult or child manikin is supine on a simulated bed or on the floor. Necessary
equipment will be adjacent to the manikin.
EQUIPMENT
Simulated adult and pediatric airway management manikin! oxygen tank with connecting tubing, suction device with connecting tubing, or
hand-powered suction device with adaptor, hard and flexible suction catheters, bulb syringe, normal saline irrigation solution, container,
gloves. goggles, masks, gown, waste receptacle, timing device.
100
%
accuracy required on all items designated by a box (.) for skills testing and must manage successfully all items indicated by
double asterisks (**). Documentation and procedure identified by the symbol ($), must be practiced but is not a required test item.
A clean technique must be maintained throughout suctioning procedure.
NAME DATE __/__/__ EXAMINER(S) _
2nd 3rd (final)
PREPARATION
Assess patient for the need to suction oral secretions
Fill container with irrigation solution
Adult - between 80-120 mmHg
Measure depth of catheter insertion from corner of mouth
to edge of earlobe
RIGID CATHETER (TONSIL TIP, YANKAUER)
PROCEDURE
Remove oxygen source - if indicated
Connect rigid catheter to suction tubing/device
Open patient=s mouth by applying pressure on the chin
with your thumb
Airway Emergency - Airway Management: Suctioning - Oropharyngeal
Pa e 2 of 4
Insert rigid catheter into mouth without applying suction
Advance catheter gently to depth measured
Suction while withdrawing using a circular motion
around mouth, pharynx and gum line
** Maximum suction time of 5-15 seconds:
Peds maximum of 5-10 seconds
Replace oxygen source or ventilate patient at
approximate rate of:
Adult - 12/minute
Peds - 20/minute
procedure if needed
and change gloves
Discard or secure contaminated catheter in a clean
area:
Discard into an approved receptacle
OR
Return used catheter to package and place in clean
area for future use
FLEXIBLE CATHETER (WHISTLE STOP, FRENCH)
PROCEDURE
Connect flexible catheter to suction tubing/device
with your thumb
Insert 'nexible catheter along the roof of the mouth without
applying suction
Advance catheter gently to depth measured
Suction while withdrawing moving catheter from side to
side around mouth, pharynx and gum line
** Maximum suction time of5-15 seconds:
Children maximum of5-10 seconds
Infants - no longer than 5 seconds
Adult - 12/minute
Child - 20/minute
Infant - 20/minute
Neonate -30/minute
procedure if needed
St. _Ai rway-M anagement -5uct ion-Oropharyn9eaI
Pa e 3 of 4
and change gloves
Discard or secure in a clean area contaminated catheter:
Discard into an approved receptacle:
- Coil contaminated catheter around sterile (dominant)
- Pull glove from other hand over packaged catheter
OR
Return used catheter to package and place in clean
area for future use
BULB SYRINGE
PROCEDURE
Prime bulb (squeeze out air) and hold in depressed
position
with your thumb
Insert tip of primed syringe into mouth and advance gently
to back of mouth
Slowly release pressure on bulb to draw secretions into
syringe
Remove syringe from mouth
Empty secretions into designated container by squeezing
bulb several times
Adult - 12/minute
Child - 20/minute
Infant - 20/minute
Neonate - 3D/minute
procedure if needed
Rinse bulb syringe with irrigation solution
Return used bulb syringe to package/container and place
in clean area for future use
Discard irrigation solution into designated container
and change gloves
ONGOING ASSESSMENT
$ Assess airway, breathing and heart rate
$ Continuously or at least every 5 minutes
$ Changes in airway sounds
$ Changes in respiratory status
St._Airway-Management-Suction-Oropharyngeal
Pa e 4 of 4
DOCUMENTATION
$
Skill Component
Verbal ize/Document
Oxygen liter flow
Patient's tolerance of procedure
Type of secretions:
- color
- consistency
- quantity
- odor
- respiratory rate
- effort/quality
- tidal volume
- lung sounds
Yes No Comments
St. _AiIWay-M anag e me nt-S uct ion-OropharyngeaI
SUCTIONING -OROPHARYNGEAL
INDICATIONS: To maintain a patent airway in patients who are unable to maintain a patent airway due to oral secretions.
Excessive oral secretions (noisy respirations)
Respiratory distress due to oral secretions/vomitus
Prevent aspiration of secretions/vomitus
COMPLICATIONS:
Hypoxia Oral trauma/broken teeth
Bronchospasm Infection/seps is
Cardiac dysrhythmias Vomiting
Hypotension Aspiration
CONTRAINDICATION:
Infants less than 1 year of age
NOTES:
A clean technique must be maintained throughout suctioning procedure to prevent infection.
Use rigid catheters with caution in conscious or semiconscious patients. Put the tip of the catheter in only as far as can be
visualized to prevent activating the gag reflex.
Rigid catheters are best for suctioning large amount of secretions or large particles.
Keep suction settings between 80-120 mmHg and adjust lower for pediatric and elderly patients (50-100mmHg). Excessive
negative pressures may cause significant hypoxia and damage to tracheal mucosa. Too little suction will be ineffective.
Hand-powered suction devices may be used as long as they have an adaptor for a flexible catheter.
Pre-oxygenation may be required depending on patient=s condition. This offsets volume and oxygen loss during suctioning.
Suctioning longer than recommended time will result in hypoxia. Maximum suction time depends on patient=s age and tolerance:
- Adults maximum 10-15 seconds
- Children maximum of 5-10 seconds
- Infants - no longer than 5 seconds
If vagal stimulation occurs, the patient may experience bradycardia, especially pediatric patients.
Info. _Airway-M anagernent-Suction-Oropharyngeal
Page 1 of 1
SUCTIONING - TRACHEOSTOMY TUBE AND STOMA
The examinee will demonstrate proficiency in suctioning a patient with a tracheostomy tube (consistent with scope of practice) while
maintaining aseptic technique.
CONDITION
The exarrlinee will be requested to suction a simulated patient that is having copious secretions and difficulty breathing. The patient has
a tracheostomy tube (with or without an inner cannula) and is receiving supplemental oxygen (through aT-bar device or tracheal mask).
The adult or child manikin is supine on a simulated bed. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Simulated adult and pediatric tracheostomy manikin, tracheostomy tube (metal/plastic) with an inner cannula, oxygen tank with
connecting tubing, T-bar or tracheal mask} suction device with connecting tubing or hand-powered suction device with adaptor, sterile
flexible suction catheter, sterile normal saline irrigation solution, sterile container, plastic saline irrigation vial/ampule, vial of normal
saline, Scc syringe, removable needle} sterile and unsterile gloves, goggles, masks, gown, waste receptacle, timing device.
100
0
Must maintain aseptic technique.
2nd 3rd (final)
PREPARAliON
Assess patient for the need to suction tracheal
secretions
Open/unfold sterile container and fill with irrigation
solution
Adult- between 80-120 mmHg
PROCEDURE
Hyper-oxygenate patient - if indicated:
Increase Oxygen liter flow
OR
Ventilate with Bag-valve device 4-5 times
Unlock and remove inner cannula - if indicated
Airway Emergency I Airway Management: Suctioning - Tracheostomy Tube And Stoma
Pa e 2 of 3
Apply sterile gloves
Connect sterile catheter to suction tubing/device
** Keep one (dominant) hand sterile
Suction small amount of irrigation solution to:
Lubricate tip of catheter
Insert catheter into tracheostomy tube/stoma without
applying suction
Advance catheter gently to appropriate level:
Shallow suctioning - opening of trach tube/stoma
OR
Measured suctioning - length of trach tube
OR
Deep suctioning - past trach tube to carina
Withdraw catheter slightly before applying suction
if beyond (rach tube
Suction while withdrawing catheter using a rotating
motion and observe patient=s response:
** Maximum suction time of 5-15 seconds from insertion
to withdrawal of catheter.
Adults maximum 15 seconds
Children maximum of 5 seconds
Infants - no longer than 5 seconds
Place patient on oxygen or replace oxygen source
if indicated
procedure if needed
** If secretions are thick and unable to clear
tracheostomy tube. instill sterile saline and repeat
previous stQPS
Suction remaining irrigation solution into collection
canister and discard appropriately
Discard contaminated catheter:
Coil contaminated catheter around sterile (dominant)
Pull glove from other hand over packaged catheter
REPLACE INNER CANNULA
Check for spare or clean the inner cannula - if needed
Remove oxygen source
Replace clean inner cannula and lock
Replace oxygen source
St._Airway-Management-Suction-rach_Tube
Airway Emergency / Airway Management: Suctioning - Tracheostomy Tube And Stoma
Pa e 3 of 3
ONGOING ASSESSMENT
$ Assess airway I breathing and heart rate:
Continuously or at least every S minutes
DOCUMENTATION
$ Verbalize/Document
Oxygen liter flow
Patient=s tolerance of procedure
Type of secretions:
- color
- consistency
- quantity
- odor
- respiratory rate
- effort/quality
- tidal volume
- lung sounds
INSTILLATION OF NORMAL SALINE
Normal Saline is only instilled if absolutely necessary
$ Prepare saline irrigation solution - if indicated
Check saline for:
- drug name
- integrity of container/medication
- concentration/dose
- clarity
- expiration date
Twist off top of saline irrigation vial/ampule
OR
Prepare a syringe with Scc normal saline and remove
needle - if within scope of practice
$ Instill 1-5ml of sterile saline down tracheostomy tube
3-5mI for ad uIts
1-2 ml for pediatric patients
$ Repeat suction procedure
St._Airway-Management-Suction-rach_Tube
SUCTIONING - TRACHEOSTOMY TUBE AND STOMA
DEFINITIONS:
Inner cannula - a Asleeve@ which fits inside the tracheostomy tube and may be removed for cleaning
Hyper-oxygenation - increasing oxygen liter flow for a brief period of time or ventilating the patient 3-4 times with a bag-valve devicE to
increase the blood oxygen level
Tracheotomy- a surgical incision into the trachea to establish an airway that may be temporary or permanent
Tracheostomy (trach) - a tracheal stoma (opening) that results from a tracheotomy
Tracheostomy (trach) tube - a plastic or metal tube inserted below the 2
nd
or 3
rd
tracheal ring bypassing the epiglottis
INDICATIONS: To maintain a patent airway in patients with a tracheostomy tube or stoma.
Rattling mucus sound from tracheostomy (noisy respirations)
Bubbles of mucus in trach
Coughing up secretions
Patient requests to be suctioned
Respiratory distress due to airway obstruction
COMPLICATIONS:
Hypoxia
Bronchospasm
Cardiac dysrhythmias
Hypotension
Tracheal trauma
Infection/sepsis
Cardiac arrest
Airway Emergency/Airway Management: Suctioning-Tracheostomy Tube and Stoma
Page 2 of 2
NOTES:
Aseptic technique must be maintained throughout suctioning procedure to prevent infection.
Excessive suctioning should be avoided to decrease potential for tracheal damage and increase in mucus production.
Catheter size should not exceed 2 the inner diameter of the airway. Larger catheters may cause suction-induced hypoxia, lung
collapse and damage to tracheal tissues.
Establish and maintain a sterile field. Use the inside of the wrapper to establish field for equipment.
Hand-operated vacuum suction devices may be used as long as they have an adaptor for a flexible catheter.
Keep suction setting between 80-120 mmHg and adjust setting lower for pediatric and elderly patients (50-100 mmHg). Excessive
negative pressures may cause significant hypoxia, damage to tracheal mucosa or lung collapse. Too little suction is ineffective.
Pre-oxygenation may be required depending on patient's condition. This offsets volume and oxygen loss during suctioning.
Patient mayor may not be on oxygen and have either aT-bar or tracheal mask for humidification.
Oxygen should be maintained until ready to suction. Flow rate may need to be adjusted to prepare patient for suctioning.
Rotating the catheter prevents the direct suctioning of the tracheal mucosa. Roll the catheter between thumb and forefinger for
rotating motion.
Suctioning longer than recommended time will result in hypoxia. Maximum suction time depends on patient's age and tolerance and
is timed from the insertion to withdrawal of the catheter:
- adults maximum 15 seconds
- children maximum of 5 seconds
- infants - no longer than 5 seconds
Inner Cannulas:
Not all tracheostomy tubes have inner cannulas.
The inner cannula does not need to be removed for routine suctioning. However, if the patient is in respiratory distress the inner
cannula must be removed in order not to push the thick secretions back down the trachea and to immediately open the airway.
Sometimes just removing the inner cannula corrects the problem. The cannula may only need to be cleaned and replaced.
Procedure for cleaning the inner cannula:
- Rinse the inner cannula with saline/tap water by dipping the cannula into solution and tipping cannula upside-down to allow
solution to run through it.
- Suction or use a pipe cleaner (if available) to remove secretions.
- Gently tap the cannula to remove excess solution before reinsertion.
Normal Saline Irrigations:
Instilling normal saline into the tracheostomy tube does NOT liquify or loosen tenacious secretions by breaking the mucus bond.
The only effect instillation of saline has is to make the patient cough strongly and thus loosen secretions.
EMTs &paramedics may instill normal saline into the tracheostomy tube if needed to loosen secretions. However, this procedure
poses a great risk for pneumonia and should only be done if absolutely necessary.
Each patient must be evaluated early to determine the need for irrigation to thin or loosen secretions.
EMTs & paramedics may use the prepared saline irrigation vial/ampule. Caution - the rescuer must ensure that the vial/ampule
contains norm a/ saline and not a medication such as A/butera/. Paramedics may use a syringe to draw up saline and instill into the
tracheostomy tube after removing the needle.
Instill 1-5ml of sterile saline down tracheostomy tube. Amount of satineinstilled depends on patienfs age and tolerance: 3-5ml for
adults and 1-2 ml for pediatric patients
- Pediatric patients falling into a color zone on the Broselow tape should have only 1-2 ml of solution instilled. Those longer than the
Broselow tape may tolerate 3-5 ml of solution.
Info. _Airway-M anagement-Suction-Trach_Tube_0507
AIRWAY EMERGENCY / AIRWAY OBSTRUCTION
ADULT - UNRESPONSIVE
The examinee will demonstrate proficiency in clearing a foreign body airway obstruction from an adult who is unrespons ive.
CONDITION
The examinee wilt be requested to assess and clear a foreign body airway obstruction in an adult patient who is found unresponsive.
The manikin will be placed supine on the 'floor. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Adult CPR manikin, bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator, oropharyngeal and nasopharyngeal
airways appropriate for manikin, silicone spray, water-soluble lubricant, 1Occ syringe, goggles, masks, gown, gloves, timing device.
100
%
double asterisks (**). Actions and documentation, identified by the symbol ($), must be practiced but are not required test items.
Ventilations must be at least at the minimum rate required.
NAME DATE __,__,__
EXAMINER(S) _
2nd 3rd (final)
PREPARAliON
Skill Component No Comments Yes

Assess scene safety
Determine if patient sustained possible traumatic injury
** Consider spinal immobilization - if indicated
PROCEDURE
Skill Component Comments Yes No

Establish unresponsiveness
Activate the emergency response system or call for
additional EMS personnel - if indicated

Open/Maintain a patent airway:
Medical - head-tilt/chin-Iift
Trauma - jaw-thrust
** Clear/suction airway - if indicated
** Consider nasopharyngeal or oropharyngeal airway
if indicated
Airway Emergency / Airway Obstruction: Adult - Unresponsive
Pa e 2 of 3

Assess for breathing (5-10 seconds):
Look
Listen
Feel

Manage ventilations:
If breathing is adequate:
- medical - place in recovery position
- trauma - initiate spinal immobilization
If breathing is absent or inadequate
- give 2 slow breaths with BVM device or pocket
mask:
** If unable to ventilate:
- reposition head and chin
- repeat attempt to ventilate
** If able to ventilate. check pulse:
- provide rescue breathing (10-20/minute) - it
indicated
- attach AED - if available/indicated
- start compression cycle - if indicated

Perform up to 5 abdominal or chest thrusts - if unable
to ventilate:
Place patient supine
Straddle patient=s thighs
Place heel of one hand midline of abdomen, above
umbilicus and below xiphoid
Place other hand on top of 15t hand
Press both hands into abdomen with quick, upward
thrusts

Open the patient=s airway using a tongue-jaw lift

Perform a finger sweep to remove the foreign body

Repeat sequence until obstruction is cleared or
advanced procedures are available - if indicated:
Attempt to ventilate
Abdominal or chest thrusts
Tongue-jaw lift
Finger seep
** If able to ventilate 1 give 2 breaths and check pulse:
- if no pulse - start cardiac compressions and attach
AED - if available /indicated
- if pulse - start rescue breathing (10-20/minute)
ONGOING ASSESSMENT

Repeat an ongoing assessment every 5 minutes:
Initial assessment
Relevant portion of the focused assessment
Evaluate response to treatment
Compare results to baseline condition and vital signs
St._Airway-Obst_Airway-Adult
Airway Emergency I Airway Obstruction: Adult - Unresponsive
Pa e 3 of 3
DOCUMENTATION
Skill Component

Verbalize/Document:
Cause of obstruction - if possible identify foreign
body
Signs of obstruction
- skin signs
- absent or inadequate respirations
Response to maneuver
Reassessment of airway
Additional treatment provided
Yes No Comments
St._Airway-Obst_Airway-AduIt
ADULT - UNRESPONSIVE
DEFINITIONS:
Complete airway obstruction - unable to speak, breathe, or cough forcefully, may clutch neck (universal choking sign) and no air
movement.
Partial airway obstruction - weak, ineffective cough, high-pitched noise or no sounds when inhaling, increased respiratory difficulty
and possibly cyanosis.
INDICATIONS:
Patients who are unresponsive, apneic and unable to be ventilated.
CONTRAINDICATIONS:
None when above conditions apply.
COMPLICATIONS:
Gastric distention
Rib fractures
Sternal fractures
Separation of ribs from sternum
Laceration of liver or spleen
Pneumothorax
Hemothorax
Lung and heart contusion
Fat emboli
NOTES:
Adult Obstructed Airway technique is indicated for patients 8 years of age and older.
The tongue is the most common cause of airway obstruction due to decreased muscle tone. Other causes include foreign body
and swollen air passages
The tongue and epiglottis may obstruct the entrance of the trachea due to inspiratory efforts creating negative pressure in the
airway.
A second rescuer is needed to maintain in-line axial stabilization jf spinal immobilization is required.
If the patient is in a prone position with suspected trauma, the patient should be turned using log-roll method to avoid flexion or
twisting of the neck or back.
If the patient is breathing adequately and has no signs of trauma, place in recovery position as soon as initial assessment is
completed. This prevents airway obstruction by the tongue, mucus or vomitus.
To prevent airway obstruction, remove dentures only if they cannot be kept in place. Fitted dentures maintain form for a good seal.
Other signs of circulation - breathing, coughing or movement in response to rescue breaths. This is done while checking for a
pulse.
An alternative to checking the carotid pulse is checking a femoral pulse.
Info._Airway-Obst_Airway-AduIt_ (Unresp)
Page 1 of 1
CHILD - RESPONSIVE
The examinee will demonstrate proficiency in recognizing and clearing an airway obstruction in a child who is choking.
CONDITION
The examinee will be requested to assess and attempt to clear an airway obstruction in a child who is choking and showing signs of
respiratory distress. The manikin may be seated in a chair or on a persons lap or placed on a raised surface or on the floor. Necessary
equipment will be adjacent to the manikin.
EQUIPMENT
Child manikin, bag-valve-mask device
1
O
2
connecting tubing
1
oxygen source with flow regulator
1
nasopharyngeal and oropharyngeal
airway appropriate for manikin
1
silicone spraY1 water-soluble lubricant, 1Occ syringe, goggles
1
masks
1
gown, gloves, timing device.
I PASS I I FAIL I 1st 2nd 3rd (final)
PREPARATION
Skill Component

Yes No Comments

Assess scene safety

Determine if patient sustained possible traumatic
injury
** Consider spinal precautions - if indicated
Skill Component

Establish that child is choking on a foreign body:
Partial Obstruction:
- sudden onset of respiratory distress
- coughing
- gagging
- stridor/wheezing
Complete Obstruction:
- increased respiratory distress
- cough ineffectual (loss of sound)
- stridor/apnea
- cyanosis
Attempt to remove foreign body obstruction:
Partial obstruction --- Encourage child to cough
Complete obstruction - Perform abdominal thrusts
(Heimlich maneuver)
? Stand behind the victim and place thumb side of
fist above child's umbilicus
? Grab fist with other hand and give quick upward
thrusts -- as many times as needed
PROCEDURE
Yes No Comments
Airway Emergency I Airway Obstruction: Child - Responsive
Pa e 2 of 2
additional EMS personnel - if obstruction not relieved
after 1 minute or child becomes unresponsive
** If responsive but still obstructed after 1 minute-
continue abdominal thrusts.
** If unresponsive -- start sequence for airway
obstruction of unresponsive child.
Manage ventilations after removal of foreign body:
If breathing is restored and adequate:
- medical - place in recovery position if unresponsive
If breathing is absent or inadequate:
mask:
** If able to ventilate, check pulse:
- if no pulse, start cardiac compressions
- if pulse, start rescue breathing with 100%
supplemental oxygen
ONGOING ASSESSMENT
Comments Yes No Skill Component
$ Repeat ongoing assessment every 5 minutes:
Initial assessment
Compare results to baseline condition and vital
signs
DOCUMENTATION
Comments Yes Skill Component No
$ VerbaIize/Document:
Cause of obstruction - identify foreign body
Observed/reported signs of obstruction:
- skin signs
Response to obstruction maneuver
St._Airway-Obst_Airway-Child (Resp)
CHILD - RESPONSIVE
DEFINITIONS:
Complete airway obstruction - unable to speak, breathel or cough forcefully, may clutch neck (universal choking sign) and no air
movement is detected.
Partial airwav obstruction - weak, ineffective cough, high-pitched noise or no sounds when inhaling, increased respiratory
difficulty
Phone fast - for breathing difficulties. In children, the most common cause of arrest is an inadequate airway. Complete one
sequence to remove obstruction and if successful and no pulse, provide 1 minute of CPR, before leaving the child to call for
EMS personnel.
Phone first - for sudden cardiac arrest - usually not applicable in infants and children.
Recovery position - ideal position that maintains a patent airway and spinal stability, minimizes risk of aspiration and limits
pressure on bony prominences and nerves. It also must allow for visualization of respirations and skin color and provide
access for interventions. Due to the varied ages and sizes in pediatric patients, there is no universal recovery position for
children.
INOleATIONS:
Children who are choking with signs of partial or complete airway obstruction
CONTRAINDICATIONS:
COMPLICATIONS:
Gastric distention
Rib 'fractures
Sternal fractures
Pneumothorax
Hemothorax
Fat emboli
NOTES:
Child Obstructed Airway technique is indicated for patients 1-8 years of age.
Some signs of inadequate breathing are: respiratory distress, fast/slow respirations, bradycardia, stridor, cyanosis, poor
perfusion, and altered LOC.
Obstruction may have been relieved prior to EMS arrival. Patient should be transported for medical evaluation.
DO NOT interfere if child has an effective cough.
An additional rescuer is needed to maintain in-line axial stabilization if spinal im mobilization is required.
If the child is in a prone position with suspected trauma, the child should be turned using log-roll method to avoid flexion or twisting
of the neck or back.
If the child is breathing adequately and has no signs of trauma, place in recovery position as soon as initial assessment is
DO NOT perform a blind finger sweep, this may force object further down trachea. Onlv perform finger sweep if object is visible.
Supplemental oxygen should always be used after spontaneous breathing has resumed.
Info._Airway-Obst_Airway-Child_ (Resp)
Page 1 of 1
CHILD - UNRESPONSIVE
The examinee will demonstrate proficiency in recognizing and clearing an airway obstruction in a child who is unresponsive.
CONDITION
The examinee will be requested to assess and attempt to clear a foreign body airway obstruction in a child who is found unresponsive.
The manikin may be placed on a raised surface or on the floor. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Child manikin, bag-valve-mask device. O
2
connecting tubing, oxygen source with flow regulator, nasopharyngeal and oropharyngeal
airway appropriate for manikin, silicone spray, water-soluble lubricant, 1Occ syringe, goggles, masks, gown, gloves, timing device.
100
0
NAME DATE __,__/__ EXAMINER(S) _
I PASS I I FAIL I 1st 2nd 3rd (final)
PREPARAliON

Assess scene safety
Determine if patient sustained possible traumati c
injury
PROCEDURE

Establish un responsiveness

Trauma - jaw-thrust
Suspected obstruction - tongue-jaw lift
** Clear/suction airway if indicated
if indicated

Look
Listen
Feel
Airway Emergency I Airway Obstruction: Child - Unresponsive
Pa e 2 of 3

- give 2 slow breaths with BVM device/pocket
mask:
* If unable to ventilate:
- if pulse, start rescue breathing with 100%
supplemental oxygen

Perform up to 5 abdominal thrusts - if unable to
ventilate:
StraddIe patient=s th ig hs
Place heel of one hand above umbilicus and below
xiphoid
Place other hand on top of 1st hand
Press both hands into abdomen with quick, upward
thrusts


Remove the foreign body - if object is visible

after 1 minute

Reposition head - if unable to ventilate
Abdominal thrusts
Tongue-jaw lift
Finger sweep - if object is visible
** If able to ventilate, give 2 breaths and check pulse:
- if pulse, start rescue breathing (20/minute)

Manage ventilations - if obstruction is relieved and
Dulse is present
- provide rescue breathing at 20 breaths/minute
with BVM device or pocket mask:
St._Airway-Obst_Airway-ChiId_(Unresp)
Airway Emergency I Airway Obstruction: Child - Unresponsive
Pa e 3 of 3
ONGOING ASSESSMENT
$ Repeat an ongoing assessment every 5 minutes:
Initial assessment
signs
DOCUMENTATION
Signs of obstruction:
- skin signs
Response to obstruction maneuver
St. _Airway-Obst_Airway-Chi Id_(Unresp)
CHILD - UNRESPONSIVE
DEFINITIONS:
Complete airway obstruction - unable to speak, breathe, or cough forcefully, may clutch neck (universal choking sign) and no air
movement is detected.
Partial airway obstruction - weak, ineffective cough, high-pitched noise or no sounds when inhaling, increased respiratory
difficulty
Phone fast - for breathing difficulties. In children, the most com mon cause of arrest is an inadequate airway. Complete one
sequence to remove obstruction and if successful and no pulse, provide 1 minute of CPR, before leaving the child to call for
EMS personnel.
Phone first - for sudden cardiac arrest - usually not applicable in infants and children.
Recovery position - ideal position that maintains a patent airway and spinal stability minimizes risk of aspiration and limits
children.
INDICATIONS:
Children who are unresponsive, apneic and unable to be ventilated.
CONTRAINDICATIONS:
COMPLICATIONS:
Gastric distention
Rib fractures
Sternal fractures
Pneumothorax
Hemothorax
Fat emboli
NOTES:
Child Obstructed Airway technique is indicated for patients 1-8 years of age.
The tongue is the most common cause of airway obstruction due to decreased muscle tone. Other causes include foreign body and
swollen air passages.
The tongue and epiglottis may obstruct the entrance of the trachea due to inspiratory efforts creating negative pressure in the airway.
An additional rescuer is needed to maintain in-line axial stabilization if spinal immobilization is required.
Some signs of inadequate breathing are: respiratory distress, fast/slow respirations, bradycardia, stridor, cyanosis, poor perfusion,
and altered LOC.
If the child is in a prone position with suspected trauma, the child should be turned using log-roll method to avoid flexion or twisting
of the neck or back.
If the child is breathing adequately and has no signs of trauma, place in recovery position as soon as initial assessment is
DO NOT perform a blind finger sweep, this may force object further down the trachea. Q.!:lli! perform finger sweep if object is visible.
Other signs of circulation - breathing, coughing or movement in response to rescue breaths. This is done while checking for a pulse.
Supplemental oxygen should always be used after spontaneous breathing has resumed.
Info._Airway-Obst_Airway-Child_(Unresp)
Page 1 of 1
INFANT - UNRESPONSIVE
The examinee will demonstrate proficiency in clearing a foreign body airway obstruction from an infant who is unresponsive.
CONDITION
The examinee will be requested to assess and clear a foreign body airway obstruction in an infant who is found unresponsive. The
manikin may be placed on a raised surface or on the floor. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Infant manikin, bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator, oropharyngeal airway appropriate for
manikin, silicone spray, water-soluble lubricant, 1Occ syringe, goggles
1
masks, gown, gloves, timing device.
100
%
NAME DATE __,__/__ EXAMINER(S) _
2nd 3rd (final)
PREPARAliON
Assess scene safety
PROCEDURE
Trauma - jaw-thrust
Suspected obstruction - tongue-jaw lift
** Consider oropharyngeal airway- if indicated
Look
Listen
Feel
Airway Emergency / Airway Obstruction: Infant - Unresponsive
Pa e 2 of 3

- give 2 slow breaths with BVM device or pocket mask:
- if no pulse start cardiac compressions
- if pulse start rescue breathing

Perform up to 5 back blows - if unable to ventilate:
Place infant prone on forearm
Support jaw and face
Use heel of hand
Deliver blows in rniddle of back between shoulder
blades

Place infant supine:
Turn onto opposite arm
Maintain support of the head and neck

Perform up to 5 chest thrusts:
Find lower 2 of sternum (1 finger width below nipple
line)
Use 2 fingers
Compress at a depth of a to 2 of chest


Remove the foreign body - if object is visible

after 1 minute

Back blows
Chest thrusts
Tongue-jaw lift
Finger sweep - if object is visible
** If able to ventilate, give 2 breaths and check pulse:
- if no pulse start cardiac compressions
- if pulse start rescue breathing

Manage ventilations - if obstruction is relieved and
pulse is present
- provide rescue breathing at 20 breaths/minute with
BVM device or pocket mask:
St._Airway-Obst_Airway-lnfant_(Unresp)
Airway Emergency / Airway Obstruction: Infant - Unresponsive
Pa e 3 of 3
ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION
Signs of obstruction:
- skin signs
Response to maneuver
St _Airway-Obst_Airway-1 nfant_(Unresp)
INFANT - UNRESPONSIVE
DEFINITIONS:
Complete airway obstruction - unable to make verbal sounds, breathe, or cough forcefully, and there is no air movement, and
cyanosis.
Partial airway obstruction - weak, ineffective cough, high-pitched noise or no sounds when inhaling, increased respiratory
difficulty. sternal retractions, altered level of consciousness, and cyanosis.
Phone fast - for breathing difficulties. In infants and children, the most common cause of arrest is an inadequate airway, complete
1 sequence to remove obstruction or provide 1 minute of CPR, before leaving the pediatric patient to call for EMS personnel.
Phone first - for sudden cardiac arrest - usually not applicable in infants.
Recovery position - ideal position that maintains a patent airway and spinal stability minimizes risk of aspiration and limits
pressure on bony prominences and nerves. It also must allow for visualization of resprations and skin color and provide access
for interventions. There is no universal position for children.
INDICATIONS:
Infants who are unresponsive, apneic, and unable to be ventilated.
CONTRAINDICATIONS:
COMPLI CATIONS:
Gastric distention
Rib fractures
Sternal fractures
Pneumothorax
Hemothorax
Fat emboli
NOTES:
Infant Obstructed Airway is defined as a neonate to 1 year of age.
The tongue is the most common cause of airway obstruction due to decreased muscle tone. Other causes include foreign body
and swollen air passages
The tongue and epiglottis may obstruct the entrance of the trachea due to inspiratory efforts creating negative pressure in the
airway.
Move the infant no more than necessary to ensure an open airway. A second rescuer is needed to maintain in-line axial
stabilization if spinal immobilization is required.
If the patient is in a prone position with suspected trauma, the infant should be turned using log -roll method to avoid flexion or
If the infant is breathing adequately and has no signs of trauma, place in recovery position as soon as initial assessment is
DO NOT PERFORM A BLIND FINGER SWEEP. this may force object further down trachea. Onlv perform finger sweep if object
is visible.
Other signs of circulation - breathing, coughing or movement in response to rescue breaths.
Info._Airway-Obst_Airway-lnfant_(Unresp)
.Page 1 of 1
BREATHING EMERGENCY
BAG-VALVE-MASK VENTILATION
UNPROTECTED AIRWAY
The examinee will demonstrate proficiency in ventilating a simulated patient utilizing a bag-valve-mask device.
CONDITION
The examinee will be requested to ventilate a simulated adult, child, or infant in a non-traumatic respiratory arrest with an unprotected
airway. The examinee will be required to ventilate for a minimum of 1 minute. The adult or child manikin will be placed supine on the
floor. The infant may be placed on a table. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Adult, child, and infant manikin, adult and pediatric bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator,
oropharyngeal and nasopharyngeal airways appropriate for manikin, silicon spray, water-soluble lubricant, 1Gee syringe, pediatric
resuscitation tape, goggles, masks, gown, gloves, timing device.
100
0
double asterisks (**). Items identified by the symbol ($) must be practiced but is not a required test item .
Ventilation must be at least at the minimum rate required for the situation given.
NAME _ DATE __/__/__ EXAMINER(S) _
IPASS I 1 FAIL I 1st
2nd 3rd (final)
PREPARATION
Select appropriate size mask and bag
Assemble bag-valve-mask device
Connect bag-valve-mask device to oxygen source
Turn oxygen on to deliver 15L/min
PROCEDURE
Open the airway:
Medical - head-tilt/chin-Iift
Trauma - jaw-thrust
Insert Oropharyngeal/N asopharyngeal airway
** Remove visible obstruction or suction - if indicated
Breathing Emergency: Bag-Valve-Mask Ventilation/Unprotected Airway
Pa e 2 of 2
Place mask over mouth and nosel maintaining a tight
seal and patent airway:
Place thumb on apex of mask and index finger on
mask over chin area - forming letter AC@
Place remaining 3 fingers on mandible and bring the
jaw up toward the mask - forming letter AE@
Ventilate patient with appropriate tidal volume:
Observe for effective rise and fall of chest
Allow for adequate exhalation between ventilations
Ventilate patient at approximate rate of:
Adult - 12/minute
Child - 20/minute
Infant - 20/minute
Neonate - 30/minute
Re-assess:
Lung compliance
Airway patency
Skin color
Heart rate
**Suction - if indicated
Clean or dispose of contaminated equipment using
approved technique.
ONGOING ASSESSMENT
Repeat an ongoing assessment every 5 minutes:
Initial assessment
DOCUMENTATION

VerbaIize/Document:
Percent of oxygen/Liter flow
Ventilation rate
Size of nasopharyngeal or oropharyngeal adjunct
Resistance encountered (lung compliance)
Gastric distention - if developed
Dentures and location - if removed
Response to ventilation
- chest rise and fall
- color
- level of consciousness
St._Breathing-BVM-Unpro_Airway
BREATHING EMERGENCY / AIRWAY MANAGEMENT
BAG-VALVE-MASK VENTilATION
UNPROTECTED AIRWAY
INDICATIONS:
Respiratory arrest
Respiratory compromise (hypoxia)
COMPLICATIONS:
Gastric distention
Vomiting
NOTES:
A second rescuer is needed to maintain in-line axial stabilization if spinal immobilization is required, but may initially be performed by
one rescuer by stabilizing the head between the rescuer's legs and anterior thighs.
BVM device should have either no pressure-relief (pop-off) valve or a valve with an override feature to permit use of high pressures
which may be necessary to achieve visible chest rise and effective ventilation.
Squeezing the bag too forcefully will result in gastric distension and vomiting. Use only the force and tidal volume needed to achieve
visible chest rise.
In cases of gastric distension} continue ventilations using appropriate airway maneuvers.
Using a bag-valve-mask device with an oxygen reservoir attached to an oxygen source that delivers 15Urrlinute can provide a 90% or
greater concentration of inspired oxygen. However, the effectiveness of the BVM device depends on the volume of gas that is
squeezed out of the bag and if a proper seal is maintained.
In pediatric patients, hypoxia results in bradycardia which may lead to asystole. Reassess heart rate in neonates every 30-60
seconds and in infants and children every 1-2 minutes.
It is important to maintain a neutral position in pediatric patients to prevent hyperflexion of the neck which may inhibit ventilations or
occlude the airway (head is relatively large for size of the body). Appropriate airway alignment is achieved by placing approx. 2" of
padding under the shoulders or entire torso if necessary.
Info._Breathing-BVM-Unprotected_0507
Page 1 of 1
BREATHING EMERGENCY
MOUTH - MASK VENTILATION WITH SUPPLEMENTAL OXYGEN
The examinee will demonstrate proficiency in ventilating a patient using a pocket face mask with supplemental oxygen.
CONDITION
The examinee will be requested to assess and ventilate a patient that requires pulmonary resuscitation and/or rescue breathing by
using a pocket face mask and providing supplemental oxygen. During the initial assessment, the patient is found unresponsive
who is either apenic or has depressed respirations. The manikin will be placed supine on the floor. Necessary equipment will be
adjacent to the manikin.
EQUIPMENT
Adult CPR manikin, pocket face mask with an O
2
outlet and a one-way valve, O
2
connecting tubing, oxygen source with flow regulator,
oropharyngeal airway, nasopharyngeal airway, goggles, gown, gloves, timing device.
100
%
accuracy required on all items designated by a box (.) for skills testing and must manage successfully all items indicated
by double asterisks (**). Documentation, identified by the symbol ($), must be practiced but is not a required test item.
1st 2nd 3rd (final)
IPASS I I FAIL!
PREPARATION

Assess scene safety/scene size -up
** Consider spinal injury - if indicated
Assess breathing

Connect one-way valve to pocket mask opening

Connect oxygen tubing to mask and oxygen source

Turn oxygen on to deliver 15L/min
PROCEDURE

Position self at the head or side of the patient

Open the airway using head tilt-chin lift or jaw-thrust
maneuver

Place the mask securely over the patient's nose
and mouth:

Narrow tip seated on the bridge of the nose

Broader portion fit into the groove between the
lower lip and the chin

Seal the mask on the patient's face
Breathing Emergency: Mouth - Mask Ventilation With Supplemental Oxygen
Pa e 2 of 2
Maintain an open airway us.ing head-tilt/jaw -thrust
maneuver
Place mouth around the one-way valve and deliver
appropriate number of slow breaths:
Adult - each breath over 2 seconds
Infant and child - each breath 1-1.5 seconds
Watch for rise and fall of chest
** Reposition head if unable to ventilate
** Start obstructed airway maneuvers - If still unable
to ventilate
** Consider an oropharyngeal or nasopharyngeal
airway - if indicated
Continue to ventilate at the approxi mate rate of:
Adult - 12/minute
Child - 20/minute
Infant - 20/minute
Neonate - 3D/minute
** After 30 seconds attach oxygen to face mask- if
not alreadv done
** Consider Sellick's maneuver (cricoid pressure) to
prevent gastric distention
ONGOING ASSESSMENT
Initial assessment
signs
DOCUMENTATION
$
Skill Component
Verbalize/Document:


Ventilation rate


Response to ventilation
- chest rise and fall
- color
- level of consciousness
Yes No Comments
St._Breathing-Mouth-Mask_Ventilation
BREATHING EMERGENCY / AIRWAY MANAGEMENT
MOUTH - MASK VENTILATION WITH SUPPLEMENTAL OXYGEN
INDICATIONS:
Patients who are unresponsive, apneic, or have depressed respirations
CONTRAINDICATIONS:
COMPLICATIONS:
Gastric distention
NOTES:
Do not start resuscitation if the patient meets the criteria in VCEMS Policy #606 - Determination / Pronouncement of Death in the
Field
The tongue is the most common cause of airway obstruction due to decreased muscle tone.
Move the patient no more than necessary to maintain an open airway. A second rescuer is needed to maintain in-line axial
stabilization if spinal imn10bilization is required.
Adequate ventilation is indicated by good chest rise and hearing and feeling air escape doing exhalation.
Improper positioning of head a nd chin is the most common cause of inadequate ventilations.
Only remove dentures if they cannot be kept in place to prevent airway obstruction. Fitted dentures maintain form for a good seal.
Improper positioning of head and chin is the most common cause of inadequate ventilations.
Adequate ventilation is indicated by good chest rise and hearing and feeling air escape doing exhalation.
Mouth-mask rescue breathing provides the same tidal volume as mouth-to-mouth rescue breathing, and is easier to use and
produces a larger tidal volume than the bag-valve-mask device since the rescuer uses both hands to maintain a seal.
Using a mouth -to-mask device without supplemental oxygen, breaths should be delivered at 1OrTlI/kg or average of 700-1000ml over
a 2 second period.
Using a mouth -to-mask device with supplemental oxygen, breaths should be delivered at 8-7ml/kg or average 400-6COni over a 1-2
second period which reduces the chance of gastric inflation.
In pediatric patients, breaths should be delivered a 6-7ml/kg (no average available since weight range varies significantly).
Info._Breathing-Mouth-Mask_Ventilation
Page 1 of 1
BREATHING EMERGENCY
OXYGEN ADMINISTRATION
The examinee will demonstrate proficiency in the administration of oxygen utilizing an oxygen tank and regulator and utilizing an
oxygen mask and nasal cannula, and providing oxygen by the blow-by method.
CONDITION
The examinee will be requested to administer oxygen to a patient who is either awake or has an altered level of consciousness
whose condition requires supplemental oxygenation by a mask, cannula, or blow-by method. The manikin will be placed supine on
the floor or upright in a chair or simulated bed. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Adult CPR manikin, O
2
connecting tubing, simple O
2
mask, non-re-breather mask, nasal cannula, oxygen source with flow regulator,
oropharyngeal and nasopharyngeal airways appropriate for manikin, silicone spray, water-soluble lubricant, goggles, masks, gown,
gloves, timing device.
100
0
/0 accuracy required on all items designated by a box (.) for skills testing and must manage successfully all items indicated
by double asterisks (**). Documentation, identified by the symbol ($), must be practiced but is not a required test item.
I
1st 2nd 3rd (final)
I FAIL
PREPARATION
Assess scene safety/scene size-up
SETTING UP OXYGEN CYLINDER (TANK) AND REGULATOR
PROCEDURE
Check for and confirm that tank contains "medical
grade" oxygen
Check that O-ring is in place on either cylinder or
regulator opening
Clear dust from opening
Align the pin index from the regulator into cylinder
holes
Tighten clamp with hand pressure to ensure an
adequate seal
Open valve and read pressure gauge
** If cylinder leaks, turn off valve and check
connections
** If cylinder in use, change cylinder if less than 500
1000 psi.
Breathing Emergency: Oxygen Administration
Pa e 2 of 4
Attach tubing or delivery device to regulator and
adjust flow
Remove oxygen delivery device from patient and
regulator
Turn off valve at top of cylinder
Open flow meter device to bleed oxygen out of
system
Detach regulator by loosening the clamp
Store oxygen cylinder appropriately
DISCONTINUING OXYGEN CYLINDER (TANK) AND REGULATOR
PROCEDURE
Remove oxygen delivery device from patient and
regulator
Turn off valve at top of cylinder
Open flow meter device to bleed oxygen out of
system
Detach regulator by loosening the clamp
Store oxygen cylinder appropriately
NASAL CANNUALA (NC)
PROCEDURE
Attach oxygen supply tubing to oxygen source
Set oxygen to appropriate liter flow (2-6 Liters/minute)
Check for oxygen flow through NC
Place the nasal cannula prongs into the nostrils
(nares)
Secure tubing by:
Hold loop of tubing anterior to face and neck and
slip tubing around the patient's ears and under
the chin
Adjust fit of the NC under the chin
Evaluate patient comfort
St. _Breathi ng-Oxygen_Administrati on_0507
Pa e 3 of 4
MEDIUM CONCENTRATION OXYGEN MASK (SIMPLE FACE MASK)
PROCEDURE
Set oxygen to appropriate liter flow (10-15
Liters/minute)
Check for oxygen flow through mask
~ . Never apply an oxygen mask without oxygen
flowing
Place mask on patient's face covering both nose and
mouth with narrow end over the bridge of the nose
Slip elastic band over patient's head and either above
or below ears
Gently pull ends of the elastic strap until mask is
secure
Mold the metal strip over the bridge of the nose for a
secure fit
Evaluate patient comfort
HIGH CONCENTRATION OXYGEN MASK (NON-REBREATHER MASK)
PROCEDURE
Unroll oxygen reservoir bag and attach to mask
Ensure oxygen tubing is attached to oxygen source
and reservoir bag
Set oxygen to appropriate liter flow (10-15
Liters/minute)
Inflate reservoir bag by holding finger over the valve
located inside the mask above the reservoir bag
insertion
Check for oxygen flow through mask
Place mask on patient's face covering both nose and
mouth with narrow end over the bridge of the nose
Slip elastic band over patient's head and either above
or below ears
Gently pull ends of the elastic strap until mask is
secure
Mold the metal strip over the bridge of the nose for a
secure fit
St. _8 reat hi n9-0xygen_Admini strati on _0507
Pa e 4 of 4
Evaluate patient comfort and that the reservoir bag
does not collapse completely.
** If reservoir bag collapses completely, increase
oxygen by 2-Liter increments until bag remains
partially inflated at end of each breath.
** If the oxygen reservoir bag dislodges, replace the
oxygen mask.
** If lower oxygen concentration is needed, convert
the non-rebreather mask to a simple face mask.
~ ' If the reservoir bag collapses completely, the
patient is unable to inhale and hypoxia and/or death
will occur.
BLOW-BY OXYGEN ADMINISTRATION)
PROCEDURE
Set oxygen to appropriate liter flow:
Adult-10-15 Liters/minute
Infant/Child - 6 Liters/minute
Neonate - maximum of 5 Liters/minute
Check for oxygen flow through tubing
Administer oxygen by appropriate method:
Infant/Child
- place oxygen tubing through small hole in the
bottom of a 6-8 oz paper or Styrofoam cup
- Hold cup approximately 1"_2
Jl
from child's nose
and mouth
Neonate - hold tubing 1"_2" from nose and
mouth
ONGOING ASSESSMENT
Initial assessment
signs
DOCUMENTATION
$
Skill Component
Verbalize/Document:

Oxygen administration device used



Respiratory rate and tidal volume

Skin color

Level of consciousness

Response to oxygen administration
Yes No Comments
St._Breathing-Oxygen_Administration_0507
BREATHING EMERGENCY
Definitions:
Minute volume - Total volume inhaled in a minute calculated by multiplying tidal volume and respirations per
minute. Therefore, adequate tidal \Olume and respirations are important to evaluate.
Respiratory distress - Condition in which the patient needs to work harder to breath. SIS include: increased
respiratory rate, accessory muscle use, nasal flaring, and difficulty speaking in complete sentences. The patient
may assume a bold upright or a tripod position to aid respiratory muscles.
Respiratory failure - Condition in which there is inadequate ventilation to support life and requires positive
pressure ventilations. The patient develops an altered mental status, loses muscle tone and has inadequate
minute volume to move air in and out of the lungs for adequate oxygen exchange. This condition develops when
there is respiratory muscle fatigue after prolonged respiratory distress or there is an obstruction of the upper or
lower airway.
~ Warning:
Patients with cellular hypoxia will develop irreversible cell death leading to vital organ death and
ultimately to death of the patient.
Never apply an oxygen mask without oxygen flowing, this will result in hypoxia and possible death.
If the reservoir bag from a non-rebreather mask collapses completely the patient is unable to inhale and
hypoxia and/or death will occur. Increase oxygen by 2-Liter increments until the bag remains partially inflated
at the end of each inhalation.
Notes:
Room air (21 % oxygen) is sufficient for normal metabolism of healthy individual. However, if they suffer with a
condition resulting in inadequate cellular metabolism, they need to be supplemented with enriched levels of
oxygen. Patients with cellular hypoxia will develop irreversible cell death leading to vital organ death and
ultimately to death of the patient.
High-flow oxygen should NOT be withheld from patients with chronic obstructive pulmonary disease (CaPO).
These patients also sustain significant trauma or other acute medical emergencies that lead to hypoxia and
hypoperfusion. If the respiratory drive becomes inadequate then ventilate the patient with a bag-valve-mask as
necessary.
Supplemental oxygen with a mask or cannula in patients with inadequate minute volume may progress to cellular
hypoxia unless the patient is properly ventilated.
Oxygen Source:
Medical grade oxygen is labeled "Oxygen U.S.P.". This oxygen is more carefully cleaned and refined than
commercial types of oxygen.
To confirm cylinder contains medical grade oxygen:
check color of cylinder-green and white, solid green, or unpainted aluminum with a green ring around top of
cylinder
pin index groupings line up with oxygen regulator
Compressed O
2
tanks for prehospital use come in 4 sizes: "D" and ItE" are small and portable, 11M" and "H" or
sometimes labeled 11K" are significantly larger and used on-board the ambulance.
Cylinders ideally should be changed at 750 psi and not put into service if less than 500 psi. If the cylinder is in use, it should
never be allowed to go below 200 psi, but must be changed immediately.
Never leave cylinders standing in an upright position unless properly secured. Large tanks must be held in place
by a chain or metal strap. If cylinder is dropped and the valve breaks off, the cylinder will act as a missile
projectile.
Portable tanks should be placed on their side on the floor, in a case or other secure carrier. When
transporting a patient on a gurney, the tank should be secured between the patient's lower legs.
Page 2 of 2
BREATHING EMERGENCY
Nasal Cannula
Nasal cannula is a low-flow, low-oxygen concentration delivery device that delivers 24%-40% of oxygen at flow
rates of 2-6 Liters/minute. The patient breathes in room air with the oxygen delivered by the nasal cannula.
Mouth breathers do not benefit from nasal cannula oxygen administration.
Indications - any condition in which low - medium oxygen concentrations is needed.
patient with chronic obstructive pulmonary disease who is not in distress and only requires low liter flow
patients with asthma
patients with uncomplicated chest pain
patients who cannot tolerate restrictive feeling of a mask
patients who are vomiting
DO NOT deliver more than 6 L/min through nasal cannula because this will dry out the mucosa or cause oxygen
burns to nostrils and will not increase oxygen delivery.
Curvature of the prongs should be oriented so that the tips will face upward and slightly posterior once inserted.
Never place the tubing behind the head since this may decrease the flow of oxygen or the patient may strangle if the cannula
slips around the neck.
Medium Concentration Oxygen Mask (Simple Face Mask)
Simple face mask delivers approximately 60% of oxygen at flow rates of 10-15 Umin.
Elastic straps placed above the ears may result in patient discomfort. However, the mask is more secure in prehospital care if
it is applied above the ears.
Ensure that mask fits properly since leakage around the mask decreases the delivery of oxygen.
High Concentration Oxygen Mask (Non-rebreather Mask)
A non-rebreather mask is a low-flow, high-oxygen concentration device that can achieve approximately 90% at
flow rates of 10 -15 L/min. It consists of a reservoir bag beneath a one-way valve that prevents the patient from
exhaling into the bag and re-breathing their CO
2
.
Indication - when a patient requires high oxygen concentration.
respiratory distress
shock
poor tissue perfusion
Place the elastic strap either above or below the ears. Elastic strap placed above the ears may result in patient
discomfort, but is more secure for prehospital transport.
Assure that mask fits properly because leakage around the mask decreases the delivery of oxygen.
If the reservoir bag collapses completely the patient is unable to inhale and hypoxia and/or death will occur.
Increase oxygen by 2-Liter increments until bag remains partially inflated at the end of each inhalation.
During inhalation - exhalation valves located at the sides of the mask close, valve above the reservoir bag opens,
and reservoir bag deflates slightly.
During exhalation - exhalation valves at the sides of the mask open, valve above the reservoir bag closes, and
reservoir bag expands fully
Assure that there is adequate and uninterrupted oxygen flow to patient or patient may not be able to inhale
adequate volume or oxygen needed.
Never connect the oxygen connector in mask directly to and endotracheal or tracheostomy tube.
Never decrease the liter flow of oxygen if a lower concentration is needed. High flow rates are needed to keep
reservoir bag inflated. Convert the non-rebreather mask to a simple face mask
To convert non-rebreather mask to simple face mask:
Remove reservoir bag, connector with baffle, and rubber discs on sides of mask
Insert oxygen connector (supplied in packaging) and reconnect oxygen tubing.
Info._Breathing-Oxygen_Administration
CARDIAC EMERGENCY
AUTOMATED EXTERNAL DEFIBRILLATION (AED)
The examinee will demonstrate proficiency in performing external defibrillation using a semi-automated external defibrillator.
CONDITION
The examinee will be requested to manage an adult patient who is found unresponsive with no signs of trauma. CPR mayor may not be
in progress. The manikin will be placed supine on the floor. The examinee will be required to br.ing the necessary equipment to the
scene.
EQUIPMENT
Adult and pediatric CPR manikin, AED trainer, adult and pediatric defibrillator pads, cables, towel, safety razor, bag-va\.e-maskdeviCE, O
2
connecting tubing. oxygen source with flow regulator, 1-2 assistants (optional), goggles, masks, gown, gloves, timing device.
100
%
double asterisks (**). Documentation, identified by the symbol ($), must be practiced but is not a required test item.
NAME DATE __,__,__ EXAMINER(S) _
2nd 3rd (final)
PREPARATION
Skill Component
Yes No Comments
** Consider spinal immobilization if indicated

Assess patient and initiate BLS procedures:
Unwitnessed Arrest (unwitnessed by EMS
personnel):
- stop CPR if in progress
- establish unresponsiveness
- open the airway
- assess breathing - ** give 2 breaths - if indicated
assess pulse
= Adult
- activate appropriate resource - 9-1-1 or ALS
- perform CPR for 1% minutes - if indicated
- - apply AED
EMS Witnessed Arrest:
- establish unresponsiveness
- open the airway
- assess breathing - ** give 2 breaths - it
indicated
- assess pulse
:::::
Adult
- apply AED
- activate ALS - if indicated
Cardiac Emergency: Automated External Defibrillation (AED)
Pa e 2 of 2
PROCEDURE
Position AED next to patient
Turn on AED
Bare the chest and prepare pad sites for secure pad
contact
Apply defibrillator pads (minimum of % It apart):
Adult
- ~ - right sternal border directly below the
clavicle
- Lower - left midaxillary line! 5th - 6th intercostal
space with top margin below the axilla
Analyze rhythm
** Ensure no one touches patient
Follow AED voice prompt untililno shock advised" is
given
** Ensure no one touches patient- if shocks are to be
delivered
Reassess patient for:
Unresponsiveness
Breathing
Pulse
** Start/Resume CPR - if indicated
** Provide rescue breathing at approx. 12 breaths/min
if indicated
** Place in recovery position if indicated
Reassess patient after 1 minute/follow AED voice
prompt
ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION
Patient assessment
Analysis result - shock vs no shock advised
Time and number of shocks - if applicable
Patient response to shocks - if applicable
Pad Placement
Adult: Anterior/Anterior
St._Cardiac-AED_0507
CARDIAC EMERGENCY
AUTOMATED EXTERNAL DEFIBRILLATION (AED)
INDICATIONS:
Unresponsive, pulseless, non-breathing patient
Children 8-year-of-age or older
CONTRAINDICAliONS:
Patients who are awake, have a pulse, or are breathing.
Patients who meet conditions outlined in VCEMS Policy #606 - Determination/Pronouncement of Death in the Field.
Traumatic full arrest - relative contraindication, may apply if arrest appears to be related to medical causes.
COMPLICATIONS:
Burns to chest
Inappropriate shocks or failure to shock
NOTES:
Defibrillation should be done immediately when the arrest is witnessed by EMS Personnel or an AED Service Provider. EMS
Personnel are defined as EMTs and paramedics who respond to a 9-1-1 call. This does not include law-enforcement unless they are
an AED Service Provider.
Never use the AED to triage or monitor patients who complain of chest pain and are awake, breathing or have a pulse.
If EMS Personnel did not witness the arrest, it is considered an unwitnessed arrest.
CPR for 1% minutes prior to defibrillation results in improved survival rates.
The only shockable rhythms are ventricular fibrillation and ventricular tachycardia.
Defibrillation stops all chaotic electrical impulses in the heart and allows for the normal pacemaker to re-establish a viable heart
beat.
The AED may be used in children 8-year-of-age and older.
The initial priority for pediatric resuscitation is to provide oxygenation and ventilation. BLS procedures should be initiated upon
arrival before the AED is placed.
The AED will prompt steps after being turned on.
The AED will re-analyze at regular intervals.
The AED operator is responsible to make sure that no one touches the patient when AED is analyzing or when shocks are to be given.
The arcing of electricity, if pads are not applied securely, results in burns to the chest and/or the myocardium not receiving an
appropriate electrical charge.
DO NOT defibrillate in free standing water. Remove patient from water and dry chest thoroughly before applying pads.
DO NOT apply pads over medication patches. Remove medication patches with gloves and clean area before applying pads.
Medication patches may block energy delivery to the heart and cause minor burns due to arcing. Gloves should be worn to
protect provider from exposure to medications which may be absorbed through the skin.
DO NOT place pads over pacemaker or implanted cardiac defibrillator. Place pads inferior to the medical device or to the side of the
medical device. Pacemakers and implanted cardiac defibrillators (ICDs) may reduce energy delivery to the heart if pads are placed
over them.
Metal surfaces do not pose a hazard to either the patient or the provider.
Water conducts electricity and may provide a pathway for energy from the AED to the provider or bystanders or from one electrode
pad to another.
Excessive chest hair may interfere with electrode pad placement. Use safety razor or if no razor is available apply initial pads then
remove them quickly to remove hair then apply a second set of pads.
Electrical devices may create wave forms that could be misinterpreted by the AED. Reduce electrical interference by
reducing/eliminating stray electrical energy (electric blanket, TV, radio wireless phones, pagers, etc.).
l
For children, use specific pediatric defibrillator, specific pediatric pads, or adult pads with an attenuator as per manufacturer's
direction.
Some manufacturer's recommend that pads are placed on specific sides. Always follow manufacturer=s directions.
If a child '5 older than 8 years-of-age or more than 55 pounds (NREMT Scope), use adult defibrillation pads. DO NOT delay
treatment to determine child's age or weight. If pads are applied in an anterior-anterior position, the pads must be at least 2
inch apart to prevent arcing and/or burns.
Cardiac Emergency: AED
Page 2 of 2
Only use the anterior-posterior position in small children.
Ensure that pads NEVER TOUCH in either the adult or child. Pads must be at least % inch apart. If the pads touch, this may cause
arcing and/or skin burns. If pads overlap, the AED is unable to read the rhythm and will result in no shock being delivered when
indicated.
Body piercing jewelry, such as nipple rings, may cause arcing and skin burns. However, the jewelry should not be removed since
special technique is required for removal. Use caution to prevent injury to patients and healthcare providers.
Info._Cardiac-AE 0
CARDIAC EMERGENCY / CARDIOPULMONARY RESUSCITATION
ADULT - 1 RESCUER CPR
The examinee will demonstrate proficiency in performing cardiopulmonary resuscitation andlor rescue breathing.
CONDITION
The examinee will be requested to assess and perform cardiopulmonary resuscitation and/or rescue breathing for an adult patient who is found
unresponsive. The manikin will be placed supine on the floor. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Adult CPR manikin, device, O
2
connecting tubing, oxygen source with flow regulator, oropharyngeal and nasopharyngeal airways
appropriate for manikin, silicone spray, water-soluble lubricant, 1Dcc syringe, goggles, masks, gown, gloves, timing device.
100
%
accuracy required on all items designated by a box (_) for skills testing and must manage successfully all items indicated by double
asterisks (**). Action and documentation, identified by the symbol ($), must be practiced but are not a required test items.
Ventilations and compressions must be at least at the minimum rate required.
IPASS II F_AIL___
1st 2nd 3rd (final)
PREPARAliON

PROCEDURE


additional EMS personnel - if indicated

Look
Listen
Feel

mask
- insert an oral airway or nasopharyngeal airway
- allow 2 seconds per breath
- ensure adequate chest rise
- allow for exhatation between breaths (2-3
seconds)
[squeeze-release-release]
** If unable to ventilate, reposition head, attempt
ventilation and initiate obstructed airway
procedures - if indicated
- - - - - - -
Cardiac Emergency I Cardiopulmonary Resuscitation: Adult - 1 Rescuer CPR
Pa e 2 of 2
Check for carotid pulse and other signs of circulation
(5-10 seconds):
** Provide rescue breathing (10-20/minute) it
indicated
** Attach AED - if available/indicated
** Start compression cycle - if indicated
Perform chest compressions - if indicated:
Lower half of sternum
Heel of one hand on sternum with other hand on
top
Depth: 1% - 2 inches
Rate: approximately 1DO/minute
Ratio cycle: 15 compressions to 2 ventilations
Complete 4 compression cycles of 15:2
[end with ventilations]
Reassess carotid pulse and other signs of
ulation:
Circulation present but breathing absent or
inadequate - continue with 1D-20
ventilations/minute
No circulation present - continue CPR cycle of 15:2
[begin with compressions]
ONGOING ASSESSMENT
Initial assessment
signs
DOCUMENTATION
Witnessed arrest
- EMS vs citizen
- time last seen to onset of CPR
Citizen CPR
Approximate time patient was without CPR
Pulses palpated/not palpated with compressions
Response to CPR
Organ/Tissue Donor - if able to obtain information
St._Cardiac-CPR-Adult-1_Rescuer_OS07
ADULT -1 RESCUER CPR
INOICATIONS:
Patients who are unresponsive, apneic, and pulseless.
CONTRAINDICATIONS:
COMPLICATIONS:
Gastric distention
Rib fractures
Sternal fractures
Pneumothorax
Hemothorax
Fat emboli
NOTES:
Adult CPR technique is indicated fo r patients 8 years of age and older.
Field.
Move the patient no more than necessary to maintain an open airway. A second rescuer is needed to maintain in-line axial
If the patient is breathing adequately with no signs of trauma, place in recovery position as soon as initial assessment is completed
and have suction immediately available. This prevents airway obstruction by the tongue, mucus or vomitus.
Remove dentures only if they cannot be kept in place to prevent airway obstruction. Fitted dentures maintain form for a good seal.
Other signs of circulation - breathing, coughing or movement in response to rescue breaths. This is done while checking for a pulse.
An alternative to checking the carotid pulse is checking the femoral pulse.
Four compression cycles should take approximately 1 minute.
Continue CPR until AED or additional EMS personnel arrive.
CPR cycle ends with ventilations and begins with compressions.
Current law allows for emergency medical personnel to perform a reasonable search for organ donor documentation in
unresponsive patients who may die prior to arrival at a hospital. HOWEVER, IN NO EVENT SHOULD A SEARCH BE CONDUCTED IF
THAT EFFORT WILL DELAY LIFE-SAVING CARE OR TRANSPORT.
Info. _Cardiac-C PR-Ad uIt-1_Rescuer
Page 1 of 1
I
CARDIOPULMONARY RESUSCITATION
Two examinees will demonstrate proficiency in performing two (2) rescuer cardiopulmonary resuscitation and/or rescue breathing.
CONDITION
Examinee #1 will be requested to direct examinee #2\ assess and perform cardiopulmonary resuscitation and/or rescue breathing
for an adult patient who is found unresponsive. The manikin will be placed supine on the floor. Necessary equipment will be
adjacent to the manikin.
EQUIPMENT
Adult CPR manikin, bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator, oropharyngeal and
nasopharyngeal airways appropriate for manikin, silicone spray, water-soluble lubricant, 1Dcc syringe, goggles, masks, gown,
gloves, timing device.
100
%
double asterisks (**). Documentation: identified by the symbol ($), must be practiced but is not a required test item.
2nd 3rd (final)
PREPARATION
** Consider spinal immobilization if indicated
PROCEDURE
Direct Rescuer #2 to activate the emergency
response system/call for additional EMS personnel
if indicated
Trauma - jaw-thrust
** Clear/suction airway if indicated
if indicated
Look
Listen
Feel
I
Skill Component
- give 2 slow breaths with BVM device or pocketmask:
- insert an oral airway
- allow for exhalation between breaths (2-3 seconds)
[squeeze-release-release
ventilation and initiate obstructed airway procedures
- if indicated
** If able to ventilate unresponsive patient, consider
applying cricoid pressure (Sellick Maneuver) - if 3
rescuers are available
Check for carotid pulse and other signs of circulation
(5-1 0 seconds):
** Provide rescue breathing (10-20/minute) - if indicated
** Direct Rescuer #2 to perform 1-Rescuer CPR while
attaching the AED - if available and indicated
** Start compression cycle- if indicated
Direct Rescuer #2 to perform chest compressions - it
indicated:
Lower half of sternum
Heel of one hand on sternum with other hand on top
Depth: 1 1/2 - 2 inches
Ratio cycle: 15 compressions to 2 ventilations
Ventilate:
Patient not intubated - perfo rm synchronized
ventilations with a Bag-Valve-Mask device with a ratio
of 2 ventilations/15 compressions
Patient intubated with an ET, ETC - perform
asynchronized ventilations with a Bag-Valve device
with a ratio of 1 ventilation/10 compressions
Monitor carotid pulse for adequacy of compressions
Reassess carotid pulse and other signs of circulation
after 1 minute [end with ventilations]:
inadequate - continue 10-20 ventilations/minute
No circulation present - continue CPR cycle of 15:2 or
synchronized ratio

Cardiopulmonary Resuscitation: Adult - 2 Rescuer CPR
Page 2 of 3'1
Yes No Comments
_
SWITCH
Skill Component
Call for switch on the next cycle
Complete ventilations and move to the chest
Direct rescuer #2 to move to the head of the patient
Direct Rescuer #2 to reassess carotid pulse and other
signs of circulation after 1 minute [end with ventilations]:
Circulation present but breathing absent or inadequate
- continue 10-20 ventilations/minute
No circulation present - continue CPR cycle of 15:2 or
synchronized ratio
Yes No Comments
$ Repeat an ongoing assessment every 5 minutes: $ The initial and focused examination is repeated every 15 minutes
for stable patients and every 5 minutes for priority patients.
Initial assessment
$ Every patient must be re-evaluated at least every 5 minutes, if any Relevant portion of the focused assessment
treatment was initiated or medication administered, unless Evaluate response to treatment
changes in the patient=s condition are anticipated sooner.
Priority patients are patients who have abnormal vital signs,
signs/symptoms of poor perfusion or if there is a suspicion that the
patient=s condition may deteriorate.
DOCUMENTATION
Comments No Skill Component Yes
Witnessed arrest
- EMS vs citizen
Citizen CPR
Response to CPR
St._Cardiac-CPR-Adult-2 _Rescuer_0507
INOICATIONS:
Patients that are unresponsive, apneic! and pulseless.
CONTRAINDICATIONS:
COMPLICATIONS:
Gastric distention
Rib fractures
Sternal fractu res
Pneumothorax
Hemothorax
Fat emboli
NOTE:
Adult CPR is defined as 8 years of age and older
Do not start resuscitation if the patient meets the criteria in Ref. No. 606 Determination /Pronouncement of Death in the Field or
The tongue is the most common cause of airway obstruction due to decreased muscle tone .
Move the patient no more than necessary to ensure an open airway. A second rescuer is needed to maintain in-line axial
If the patient is in a prone position with suspected trauma! the patient should be turned using log-roll method to avoid flexion or
If the patient is breathing adequately and no signs of trauma, place in recovery position as soon as initial assessment is completed.
This prevents airway obstruction by the tongue! mucus or vomitus.
Remove dentures only if they cannot be kept in place to prevent ailWay obstruction. Fitted dentures maintain form for a good seal.
Other signs of circulation - breathing, coughing or movement in response to rescue breaths. This is done in conjunction with
checking for a pulse.
Four compression cycles should take approximately 1 minute.
Continue CPR until AED or additional EMS personnel arrive.
CPR cycle ends with ventilations and begins with compressions.
Cricoid pressure prevents air from entering the esophagus and stomach during ventilations. It requires 3 rescuers in order to use
the Sellick Maneuver when performing CPR:
- 1 rescuer to perform bag-valve-mask ventilations
- 1 rescuer to perform compressions
- 1 rescuer perform the maneuver.
The Esophageal-Tracheal-Combi Tube (ETC) seals off the oropharyngeal and nasopharyngeal airways allowing for air to enter the
lungs and prevents escape through the oropharynx and nasopharynx.
Synchronized ventilations - pause during compressions to allow for breaths to be delivered.
Asynchronized ventilations - DO NOT pause during compressions for breaths to be delivered.
Current law allows for emergency medical personnel to perform a reasonable search for organ donor documentation in unresponsive
patients who may die prior to arrival at a hospital. HOWEVER! IN NO EVENT SHOULD A SEARCH BE CONDUCTED IF THAT EFFORT
WILL DELAY THE PATIENT OF LIFE-SAVING CARE OR TRANSPORT.
Info,_Cardiac-CPR-Adult-2 Rescuer-0507
Page 1 of 1
CHILD - 1 RESCUER CPR
The examinee will demonstrate proficiency in performing cardiopulmonary resuscitation and/or rescue breathing for a child.
CONDITION
The examinee will be requested to assess and perform cardiopulmonary resuscitation and/or rescue breathing for a child who is found
unresponsive. The manikin will be placed on a raised surface or on the floor. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Child CPR manikin! bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator, oropharyngeal and nasopharyngeal
airway appropriate for manikin! silicone spray! water-soluble lubricant! 1ace syringe! goggles! masks, gown, gloves! timing device.
100%> accuracy required on all items designated by a box (.) for skills testing and must manage successfully all items indicated by
double asterisks (**). Actions and documentation, identified by the symbol ($)t must be practiced but are not required test items.
NAME DATE __,__/__
EXAMINER(S) _
I PASS I I FAIL I
1st 2nd 3rd (final)
PREPARATION
Skill Component Yes Comments No


Assess scene safety
Determine if patient sustained possible traumatic
injury
** Institute spinal precautions - if indicated
PROCEDURE
Comments No Skill Component Yes


Trauma
- jaw-thrust
- neutral position (tragus of ear level with top of
shoulder)
** Clear/suction airway- if indicated
- if indicated

Look
Listen
Feel
Cardiac Emergency / Cardiopulmonary Resuscitation: Child - 1 Rescuer CPR
Pa e 2 of 3

If breathing is absent inadequate:
mask
(CONTINUED)

Manage ventilations (CONTINUED)
ventilation and initiate obstructed airway
procedures - if indicated
** If ventilating with a BVM device, insert an oral or
nasopharyngeal airway

Check for a carotid pulse and other signs of
circulation
(5-10 seconds):
** Provide rescue breathing (20/minute) - if indicated
- no pulse or signs of circulation
- pulse < 60 beats/minute with signs of poor
systemic perfusion

Landmark: heel of one hand on the lower half of
sternum
Depth: ? to % of anterior-posterior chest
measurement (approximately 1-1 % inches)
Ratio cycle: 5 compressions to 1 ventilation

Complete 1 minute of CPR cycles of 5: 1
(end with ventilations)

additional EMS personnel- if indicated

Reassess carotid pulse and other signs of
circulation:
inadequate - continue with 20 ventilations/minute
No circulation present - continue CPR cycle of 5: 1
(begin with compressions)
St._Cardiac-CPR-Child-1_ResGuer
Cardiac Emergency / Cardiopulmonary Resuscitation: Child - 1 Rescuer CPR
Pa e 3 of 3
ONGOING ASSESSMENT
Initial assessment
signs
DOCUMENTATION
Witnessed arrest
- EMS vs citizen
Citizen CPR
Pulses palpated or not palpated with compressions
Response to CPR
St._Cardiac-CPR-Child-1_Rescuer
CHILD -1 RESCUER CPR
DEFINITIONS:
Phone fast - for breathing difficulties. In children, the most common cause of arrest is an inadequate airway. Complete 1
sequence to remove obstruction or provide 1 minute of CPR before leaving the pediatric patient to call for EMS personnel.
Recovery position - ideal position that maintains a patent airway and spinal stability minimizes risk of aspiration and lim its
children.
INOleATIONS:
Children that are unresponsive, apneic, and pulseless
CONTRAINDICATIONS:
COMPLICATIONS:
Gastric distention
Rib fractures
Sternal fractures
Pneumothorax
Hemothorax
Fat emboli
NOTES:
The viability of organs is directly affected by perfusion and oxygenation and the longer a patient is without CPR, the greater the damage to vital
organs.
Child CPR technique is indicated for patients 1-8 years of age.
Do not start resuscitation if the patient meets the criteria in VCEMS Policy #606 - Determination I Pronouncement of Death in the Field
Move the child no n10re than necessary to maintain an open airway. An additional rescuer is needed to maintain in-line axial stabilization if spinal
immobilization is required.
If the child is in a prone position with suspected trauma, the child should be turned using the log-roll method to avoid flexion or twisting of the neck
or back.
If the child is breathing adequately with no signs of trauma, place in recovery position as soon as initial assessment is completed and have suction
immediately available. This prevents airway obstruction by the tongue, mucus or vomitus.
Some signs of inadequate breathing are: respiratory distress, fast/slow respirations, bradycardia, stridor, cyanosis, poor perfusion, and
altered LOC.
Observe other signs of circulation - breathing, coughing or movement in response to rescue breaths. This is done while checking for a pulse.
An alternative to checking the carotid pulse is checking the femoral pulse.
Place appropriate padding under the shoulders to maintain proper airway and spinal alignment.
CPR cycle begins with compressions and ends with ventilations.
Insert an oropharyngeal or nasopharyngeal airway when using a BVM for ventilation.
Current law allows for emergency medical personnel to perform a reasonable search for organ donor documentation in unresponsive patients who
may die prior to arrival at a hospital. HOVVEVER, IN NO EVENT SHOULD A SEARCH BE CONDUCTED IF THAT EFFORT WILL DELAY
CARE OR TRANSPORT.
Info._Cardiac-CPR-Child-1_Rescuer
Page 1 of 1
INFANT - 1 RESCUER CPR
The examinee will demonstrate proficiency in performing cardiopulmonary resuscitation and/or rescue breathing.
CONDITION
The examinee will be requested to assess and perform cardiopulmonary resuscitation and/or rescue breathing for an infant who is found
unresponsive. The manikin will be placed on a raised surface or on the floor. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Infant CPR manikin, bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator, oropharyngeal airway appropriate
for manikin, silicone spray, water-soluble lubricant, 1Dcc syringe, goggles, masks I gown, gloves, emergency resuscitation tape, timing
device.
100
0
I PASS I I FAIL I
1st 2nd 3rd (final)
PREPARAliON
Assess scene safety
** Institute spinal immobilization - if indicated
PROCEDURE
Medical - head-tiltlchin-lift
Trauma
- jaw-thrust
- neutral position (tragus of ear level with top of
shoulder)
** Consider oropharyngeal airway- if indicated
Look
Listen
Feel
Cardiac Emergency / Cardiopulmonary Resuscitation: Infant - 1 Rescuer CPR
Pa e 2 of 3

- give 2 slow breaths with BVM device or pocket mask:
- insert an oral airway
ventilation and initiate obstructed airway procedures
- if indicated

Check for brachial pulse and other signs of circulation
(5-10 seconds):
** Provide rescue breathing (20-30/minute) - if indicated
- no pulse or signs of circulation
- newborn/neonate/infant - pulse < 60 beats/minute

Lower 1/2 of sternum (1 finger width below nipple
line)
2 finger technique
Depth: 1/3 to 1/2 of chest
Rate: at least 1DO/minute
Ratio cycle: 5 compressions to 1 ventilation

Complete 1 minute of CPR cycles of 5: 1
(end with ventilations)

additional EMS personnel

Reassess brachial pulse and other signs of circulation:
inadequate - continue 20-30 ventilations/minute
No circulation present - continue CPR cycle of 5: 1
(begin with compressions)
ONGOING ASSESSMENT
Initial assessment
St._Cardiac-CPR-lnfant-1_ Rescuer_0507
Cardiac Emergency / Cardiopulmonary Resuscitation: Infant - 1 Rescuer CPR
Pa e 3 of 3
DOCUMENTATION
Witnessed arrest
- EMS vs citizen
Citizen CPR
Response to CPR
St._Cardiac-CPR-lnfant-1_ Rescuer_0507
INFANT -1 RESCUER CPR
DEFINITIONS:
Newborn - neonate in the first minutes to hours after birth.
Neonate - infants in first month after birth (28 days).
Infant - includes the neonate period to 1 year (12 months).
Phone fast - for breathing difficulties. In infants and children, the most common cause of arrest is an inadequate airway, complete
1 sequence to remove obstruction or provide 1 minute of CPR, before leaving the pediatric patient to call for EMS personnel.
Phone first - for sudden cardiac arrest - usually not applicable in infants.
Recovery position - ideal position that maintains a patent airway and spinal stability, minimizes risk of aspiration and limits pressure
on bony prominences and nerves. It also must allow for visualization of respirations and skin color and provide access for
interventions. There is no universal recovery position for children.
INDICATIONS:
Patients who are unresponsive, apneic, and pulseless.
CONTRAINDICATIONS:
COMPLICATIONS:
Gastric distention
Rib fractures
Sternal fractures
Pneumothorax
Hemothorax
Fat emboli
NOTES:
Field
Start compression cycle if an infant has no pulse or signs of circulation or if a newborn has a pulse < 60 beats/minute. Even
though the newborn or infant has a pulse, the low rate and cardiac output is insufficient to provide for adequate perfusion.
Use shoulder padding to maintain proper airway and spinal alignment.
Move the infant no more than necessary to ensure an open airway. A second rescuer is needed to maintain i n ~ i n e axial
If the infant is in a prone position with suspected trauma, the patient should be turned using log-roll method to avoid flexion or
If the infant is breathing adequately and has no signs of trauma, place in recovery position as soon as initial assessment is
Other signs of circulation - breathing, coughing or movement in response to rescue breaths. This is done in conjunction with
checking for a pulse.
An alternative to checking the brachial pulse is checking a femoral pulse.
The CPR cycle ends with ventilations and begins with compressions.
Info._Cardiac-CPR-lnfant-1 Rescuer
Page 1 of 1
--------------
CIRCULATION EMERGENCY
BLEEDING CONTROL
The examinee will demonstrate proficiency in controlling external venous and/or arterial bleeding.
CONDITION
The examinee will be requested to assess and control external venous and/or arterial bleeding by appropriate methods. A simulated
patient was involved in a traffic collision sustaining a large laceration to an extremity which is actively bleeding. Necessary equipment will
be adjacent to the patient.
EQUIPMENT
Manikin or live model, bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator, stethoscope, blood pressure cuff,
pen light, timing device, 4"x4" dressings, roller gauze, kerlex, elastic wraps, constricting band and dowel or commercial tourniquet. tape,
clipboard, pen, goggles, masks, gown, gloves.
1000/0 accuracy required on aU items designated by a box (.) for skills testing and must manage successfully all items indicated by
2nd 3rd (final)
PREPARATION
Assess type of bleeding:
Arterial
Venous
Capillary
Remove enough clothing to expose entire wound
PROCEDURE
Control bleeding (initial attempt):
Apply direct pressure to wound - if indicated
Elevate extremity - if indicated
Apply pressure dressing - if indicated
Control continued bleeding (additional attempt):
Compress appropriate pressure point
- brachial
- femoral
Splint extremity - if indicated
Apply pneumatic pressure device - if indicated
(NREMT Scope onlv not used in California)
Control continued bleeding (last-resort attempt):
Apply a tourniquet as distal as possible on the extremity
- inflated blood pressure cuff
OR
- constricting band and dowel
** Administer 100% oxygen via mask
** Institute shock management - if indicated
ONGOING ASSESSMENT
Skill Component . Yes
No Comments
Initial assessment
DOCUMENTATION
Mechanism of injury
Description of injury
Treatment provided
Pulse/Circulation before and after treatment
Motor movement before and after treatment
Sensation before and after treatment
Time tourniquet applied - if indicated
St._Circulation-Bleeding-Control-0507
CIRCULATION EMERGENCY
BLEEDING CONTROL
DEFINITION:
Dowel - stick, rod, or any object that can be inserted under loop of tourniquet and used to twist tourniquet tight
TYPES OF BLEEDING:
Arterial
Blood is bright red in color and oxygen rich.
Arterial bleeding is the most difficult to control due to the pressure that is within the arteries.
Blood spurts from the wound, but as the blood pressure drops, the spurting becomes less forceful.
Venous
Blood is dark red in color and oxygen poor.
Venous bleeding is easier to control than arterial bleeding due to lower venous pressure.
Blood flows at a steady stream and may be minor or profuse depending on the size of the vessel.
Capillary
Blood is dark red in color; site of oxygen and carbon dioxide gas exchange.
Blood oozes from capillaries and usually clots spontaneously.
TOURNIQUET FACTS:
A tourniquet is used when all other methods have failed. It has the potential to cause damage to nerves, muscle, blood vessels,
and soft tissue resulting in loss of the extremity.
DO NOT apply tourniquet over a joint, but as close to the injury as possible.
Use a wide bandage and secure tightly to prevent cutting into the skin and underlying tissue.
Once a tourniquet is applied, it should not be loosened or removed without approval of a physician.
Apply tourniquet proximal to bleeding site as distal as possible on extremity.
TOURNIQUET APPLICATION:
Pad skin by wrapping 6-8 layers of a 4" bandage around the extremity twice
Tie another dressing loosely around extremity
Insert dowel under last loop of last dressing applied
Rotate the dowel (to tighten tourniquet) until the bleeding stops
Secure the dowel in position when the bleeding stops
NOTES:
Direct pressure may involve just the finger tips or may require hand pressure.
Elevation of an extremity may be used secondary to and in conjunction with direct pressure.
Continue to reinforce dressing if bleeding does not stop. DO NOT remove original dressing. Removing the original dressing will
increase bleeding if clot formation has begun.
Pressure points for bleeding control are only found in the extremities. The most commonly used points are the brachial and
femoral.
Motion reduction of bone ends will reduce amount of tissue damage and bleeding associated with a fracture.
Pneumatic pressure devices include air splints, blood pressure cuff, and the pneumatic antishock garment (PASG). Air splints do
not have enough pressure to control an arterial bleed. Blood pressure cuffs often leak air and thus may be ineffective.
EMTs are able to use the pneumatic antishock garment (PASG) as a pneumatic device on a lower extrernity for bleeding control.
(NREMT Scope ONLY). Not used in California
Info._Circulation-Bleeding_Control
Page 1 of 1
MEDICATION ADMINISTRATION
BRONCHODILATOR METERED DOSE INHALER (MOl)
The examinee will demonstrate proficiency in recognizing the indications, contraindications, criteria, and assist the patient with the
administration of a prescribed bronchodilator inhaler.
CONDITION
The examinee will be requested to establish that a simulated patient who is complaining of difficulty breathing meets the criteria for
administration of a bronchodilator inhaler. The examinee will assist the patient with administering the medication with or without using a
spacer device. Necessary equipment will be adjacent to the simulated patient.
EQUIPMENT
Simulated patient: oxygen tank with a flow meter, oxygen mask, blood pressure cuff, stethoscope, placebo bronchodilator inhaler
cartridge and plastic mouthpiece case, spacer device, timing device, clipboard, pen, goggles, masks, gown] gloves.
NAME DATE __,__,__
EXAMINER(S) _
2nd 3rd (final)
PREPARATION

Complete an initial assessment
General impression
Life-threatening condition
Assess mental status/stimulus response (AVPU)
Assess/Manage airway
Assess/Manage breathing
** Administer 100% oxygen
Verbalize the criteria for assisting patients with
medications:
Medication prescribed by a physician
Medication prescribed for patient
Meets indication for administration
No contraindications present for administration

Verbalize the indications for assisting the patient with a
bronchodilator inhaler:
Symptoms of respiratory distress
- shortness of breath
- wheezing
- coughing
- difficulty speaking.
Medication Administration: Bronchodilator Metered Dose Inhaler (MOl)
Pa e 2 of 3
Verbalize the contraindications for administration of a
bronchodilator inhaler:
Patient does not meet indication or criteria for
administration
Patient has taken maximum prescribed dose before
EMS arrival
Patient is unable to follow directions or use the
inhaler
PROCEDURE
Check medication for:
Drug name
Integrity of container/medication
Concentration/Dose
Clarity
Expiration date
Prepare Medication:
Remove the mouthpiece cover
Shake inhaler 5-6 times
** Insert cartridge into plastic mouthpiece case - if not
done previously
** Attach spacer - if needed
Instruct patient to breath out normally (not forcefully)
Position the inhaler:
Hold inhaler 2 finger-widths in front of open mouth
OR
Place inhaler inside of mouth, past the teeth, above
the tongue
OR
Attach a spacer to the mouth piece and close lips
around spacer
Instruct patient to take a slow, deep breath and take in as
much air as possible on command
Instruct patient to inhale:
Without Spacer
Inhale for 5-7 seconds and press the inhaler 1 time
(1 spray or puff)
With Spacer
Press inhaler 1 time and have patient breath in and out
normally 3-4 breaths
** May repeat sprays as prescribed - if needed
Instruct patient to hold breath for as long as comfortable
or up to 10 seconds before breathing out slowly through
pursed Ijps
Remove inhaler and replace oxygen
Reassess respiratory function, breath sounds and
patient=s response after 3 minutes
Monitor pulse periodically for irregularity
St._Medication-Admin-Bronchdilator-MDI-0507
Pa e 3 of 3
ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION

Assessment findings before and after administration

Drug
- name
- dose
- route
- site
- time
- who administered medication

Repeat dose - if indicated

Patient=s response to medication

Respi ratory status

Cardiovascular status

Mental status

Vital signs
St._Medication-Admin-Bronchdilator-MDI-0507
BRONCHODILATOR METERED DOSE INHALER (MOl)
ASSESSMENT: RESPIRATORY DISTRESS:
Onset - gradual vs sudden (when it began)
Provokes - causative eventj i.e. allergy, exertion, drugs, etc
Quality - effective ventilations, tidal volume, difficulty getting air in or air out
Rate - fast, slow, normal, respiratory pattern
Recurrence - initial vs repeated episodes, time of last episode
Relief - constant vs intermittent; what makes it better or worse
Severity - mild, moderate, severe - used to rate initial event or compare to previous episode or ongoing assessment accessory
muscle use, stridor, position, etc.
Time - duration
Distress level considerations for chief complaint of shortness of breath (SOB)
Mild = tachypnea, normal position, answers in full sentences
Moderate =tachypnea, upright position if possible, answers in partial sentences
Severe =tachypnea, tripod position, answers in 2-3 words only
INDICATIONS:
Bronchospasm caused by:
- asthma
- COPD
- bronchitis
CONTRAINDICATIONS:
Patient does not meet indication or criteria for administration
Medication not prescribed for patient
Maximum inhalation dose taken before EMS arrival
ADVERSE EFFECTS:
Cardiovascular - tachycardia, hypertension
Neurological- tremors, nervousness, headache, dizziness
Respiratory - cough, wheezing
Gastrointestinal - nausea
ADMINISTRATION:
Adult - 1 spray with or without spacer. May repeat sprays as prescribed - if needed
< 12 years - Not recommended for prehospital care
> 12 years - Same as adult
DEFINITIONS:
Hypoxemia - decreased oxygen level in arterial blood
Pursed lips -lips made smaller by puckering. This decreases resistance to air flow by dilating small bronchi.
Page 2 of 2
NOTES:
EMTs may not a carry bronchodilator inhaler, they may onlv assist with administration of a patient=s prescribed bronchodilator
inhaler.
In life-threatening situations, an ALS Unit must be enroute or BLS should consider transport if ALS arrival is longer than transport
time.
Symptoms of asthma include: shortness of breath, wheezing, coughing (usually dry and irritative), distressed breathing, and difficulty
speaking.
When in a cold environment, warm the caniste r by rolling it between your hands before use. This results in smaller particles of
medication being inhaled and better distribution and absorption by the lungs.
Patient should not stop inhaling once the dose is delivered, but continue to inhale as long as possible (usually 5-7 seconds). This
time frame mixes the medication with the incoming air and pulls it into the lungs slowly.
If using a spacer, there may be a whistling sound if the patient inhales too rapidly.
Avoid spraying into patient=s eyes or vision will be temporarily blurred
Info._Medication_Admin-Bronchdilator_MDI_0507
EPINEPHRINE
adm inistration of the prescribed epinephrine using an auto-injector device.
CONDITION
The examinee will be requested to establish that a simulated patient complaining of a severe allergic reaction with respiratory distress
meets the criteria for administration of epinephrine and will assist the patient by administering O.3mg 1M using an auto-injector device.
Necessary equipment will be adjacent to the simulated patient.
EQUIPMENT
Simulated patient, oxygen tank with a flow meter, oxygen mask, blood pressure cuff, stethoscope, placebo epinephrine in an auto-.tnjector
device or auto-injector trainer, biohazard container, alcohol wipes, adhesive bandage, timing device, clipboard, pen, goggles, masks,
gown, gloves.
100
%
2nd 3rd (final)
PREPARAliON
Comments Skill Component Yes No

Complete an initial assessment:
General impression
Assess mental status/stimulus response (AVPU):
Assess/Manage airway:
Assess/Manage breathing:

Verbalize the criteria of assisting patients with
medications:
No contraindications present for administration

Verbalize the indications for assisting the patient with
Severe anaphylaxis with symptoms of either shock
and/or respiratory distress
Verbalize the contraindications for administration of

epinephrine:
administration
PROCEDURE
Drug name
Concentration/Dose
Clarity
Expiration date
Identify location of injection site:
Remove clothing from thigh area
Locate site - upper-outer thigh
Cleanse injection site with alcohol wipe
Remove the safety cap from auto-injector
Place tip of auto-injector hard against injection site
Hold the injector in place for 10 seconds until the
medication is injected
Remove the injector and place in biohazard container
Massage injection site for 10 seconds with alcohol
wipe
** Apply adhesive bandage - if indicated
Evaluate response to epinephrine administration:
Respiratory status
- rate
- tidal volume
- lung sounds
- pulse
- blood pressure
- skin vitals
Mental status
** Treat for shock - if indicated
** Initiate BLS Procedures (CPR, AED) - if indicated
ONGOING ASSESSMENT
Initial assessment
St._Medication-Admin-Epinephrine-0507
DOCUMENTATION


Drug
- name
- dose
- route
- site
- time

Patient=s response to medication

Respiratory status


Mental status

Vital signs
St._Medication-Admin-Epinephrine-0507
EPINEPHRINE
DEFINITIONS:
Anaphylaxis - an allergic reaction that may present as a mild allergic reaction to cardiovascular collapse and respiratory arrest.
Patient assist - assisting patients with medications means that the EMT may:
- allow the patient to self-administer prescribed medications in the presence of BLS providers
- assist the patient in taking prescribed medications if the patient has difficulty with self-adm inistration
- administer the prescribed medication to the patient if the patient is physically incapable of administering the medication
ASSESSMENT: ALLERGIC REACTION I ANAPHYLAXIS I ENVIRONMENTAL EMERGENCY:
Onset - history of allergy
Substance - type of substance
Exposure - ingestion, inhalation, absorption, envenomization
Time - duration
Effect - general vs local rash, hives, itching, respiratory problems, nausea, vomiting, etc
Progression - initial symptom to current condition
Relief-treatment initiated prior to EMS
ASSESSMENT: RESPIRATORY DISTRESS:
Onset- gradual vs sudden (when it began)
Provokes - causative event (e.g. allergy, exertion, drugs, etc)
Severity - mild, moderate, severe - used to rate initial event or compare to previous episode or ongoing assessment, accessory
Time - duration
Moderate =tachypnea, upright position if possible, answers in partial sentences
Severe =tachypnea, tripod position, answers in 2-3 words only
INDICATIONS:
Severe anaphylaxis with either shock and/or respiratory distress
CONTRAINDICATIONS:
ADVERSE EFFECTS:
Cardiovascular - tachycardia, hypertension, chest pain, ventricular fibrillation
Neurological-seizures, cerebral hemorrhage, headache, tremors, dizziness, anxiety
Gastrointestinal- nausea, vomiting
ADMINISTRATION:
Adult - (Epinephrine auto-injector) O.3mg 1M in the upper-outer thigh as a 1 time dose. May NOT repeat.
Pediatric -(Epinephrine auto-injector junior) O.15mg 1M in the upper-outer thigh as a 1 time dose. May NOT repeat.
NOTES:
EMTs may not carry epinephrine; they may ~ assist with administration of a patient's prescribed epinephrine auto-injector.
In life-threatening situations, an ALS Unit I!lJJ..! be enroute or BLS should consider transport if ALS arrival is longer than transport time.
Anaphylaxis may be caused by insect stings or bites, foods, drugs, other aHergens, exercise, or may be spontaneous.
Signs/symptoms of anaphylaxis: flushed skin, nervousness, syncope, tachycardia, thready or unobtainable pulse, hypotension, convulsions,
vomiting, diarrhea. abdominal cramps, urinary incontinence, wheezing, stridor, difficulty breathing, itching, rash, hives, and generalized edema.
Patients may have been instructed that they can use EpiPen through clothing. This is not recommended for healthcare providers.
DO NOT inject into buttocks hands feet or intravenously (IV). Injection into the buttocks, hands or feet may result in loss of blood flow to these
areas and result in delayed absorption and tissue necrosis. IV injection may cause an acute myocardial infarction or cerebral hemorrhage. Deltoid
injection is NOT recommended in Los Angeles County.
The EpiPen contains 2ml (2mg) of epinephrine. The auto-injector delivers O.3ml (O.3mg) approximately 1.7ml remains in the pen after activation.
Info._Medication_Admin-Epinephrine_0507
Page 1 of 1
NITROGLYCERIN
administration of the prescribed medication nitroglycerin.
CONDITION
The examinee will be requested to establish that a simulated patient complaining of substernal chest discomfort meets the criteria for
administration of nitroglycerin and will assist the patient by administering either the nitroglycerin spray or tablet or two different patients
may be selected to demonstrate both methods of administration. Necessary equipment will be adjacent to the simulated patient.
EQUIPMENT
Simulated patient, oxygen tank with a flow meter, oxygen mask, blood pressure cuff, stethoscope, placebo nitroglycerin spray and tablets,
timing device, clipboard, pen, goggles, masks, gown, gloves.
100
%
2nd 3rd (final)
PREPARAliON


Complete an initial assessment and pertinent vital
signs:
General impression
Assess mental status/stimulus response (AVPU)
Assess/Manage airway
Assess/Manage breathing
Blood pressure
** Obtain blood pressure

Verbalize the criteria for assisting patients with
medications:
No contraindications are present for administration

Verbalize the indications for assisting the patient with
nitroglycerin:
Symptoms of chest pain/discomfort
Systolic blood pressure> 100mm/Hg

Verbalize the contraindications for administration of
nitroglycerin:
administration
Patient has taken 3 doses before EMS arrival within
the last 5 minutes
Last dose was < 5 minutes ago
Systolic blood pressure < 100mm/Hg
Administration of Sildenafil citrate (Viagra") or similar
medication within 24 hours
PROCEDURE

Drug name
Concentration/Dose
Clarity
Expiration date

Prepare Medication:
Tablet
Remove tablet from container and check that it is
intact
Spray
Remove top of spray canister

Remove oxygen mask and instruct patient to open mouth
and lift tongue

Administer medication:
Tablet
Place tablet under patient's tongue
Instruct patient to allow tablet to dissolve and NOT to
swallow
~
Deliver one spray sublingually or transmucosal
Instruct patient NOT to inhale spray

Replace oxygen mask

Reassess blood pressure and pain response in 5
minutes
** Place patient in shock position - if indicated
St._Medication-Admin-Nitroglycerin-0507
ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION


Blood pressure before administration

Drug
- name
- dose
- route
- site
- time

Patient's response to medication

Blood pressure 5 minutes after administration
St._Medication-Admin-Nitroglycerin-0507
NITROGLYCERIN
DEFINITIONS:
Sublingually - medication administration under the tongue
Transmucosal - medication route on top of tongue or mucus membrane in the mouth (buccal cavity)
ASSESSMENT: PAIN I DISCOMFORT
Onset- when the pain/discomfort first began (minutes - weeks); what makes it better or worse
Provokes - causative event or what increases pain/discomfort
Quality - type of pain, i.e. sharp, ache, squeezing, burning, etc
Region - area Ifocal vs diffuse pain/discomfort
Radiation, - pain moves to another area away from its origin;
Relief-constant vs intermittent; what makes it better or worse
Severity - mild, moderate, severe or 1-10 scale used to rate initial event or compare to previous episode or ongoing assessment
Time - duration
INDICATIONS:
Chest pain/discomfort
CONTRAINDICATIONS:
Patient has taken 3 doses before EMS arrival within the last 5 minutes
Last dose was < 5 minutes ago
Systolic blood pressure < 100mm/Hg
Administration of Sildenafil citrate (Viagra7) or similar medication within 24 hours
ADVERSE EFFECTS:
Cardiovascular - hypotension, bradycardia, reflex tachycardia, rebound hypertension
Neurologica/- throbbing headache, dizziness/faintness, confusion, blurred vision
Gastrointestina/- nausea, vomiting, dry mouth
General- flushed skin, sublingual burning
ADMINISTRAliON:
Adult -1 tablet or 1 spray as a 1 time dose of O.4mg. May not repeat.
Pediatric - Not recommended for prehospital care
NOTES:
EMTs may not carry nitroglycerin, they may onlv assist with administration of a patienfs prescribed nitroglycerin.
In life-threatening situations, an ALS Unit must be enroute or BLS should consider transport if ALS arrival is longer than transport
time.
Nitroglycerin may cause hypotension due to vasodilation. Always take blood pressure before administration and 5 minutes after
administration.
Instruct patient not to swallow the nitroglycerin tablet, it will change the absorption rate and the amount of drug absorbed. Sublingual
absorption is faster than gastrointestinal absorption.
Instruct patient not to inhale nitroglycerin spray, it will change the absorption rate and the amount of drug absorbed. Sublingual
absorption is faster and more accurate than inhaling medication into lungs.
DO NOT shake nitroglycerin spray container or dose delivered will be altered. One spray delivers O.4mg of nitroglycerin.
Info._Medication_Admin-Nitroglycerin_0507
Page 1 of 1
MUSCULOSKELETAL INJURY / SPLINTS
RIGID I CONFORMING SPLINT
The examinee will demonstrate proficiency in applying either a rigid or conforming splint.
CONDITION
The examinee will be requested to apply either a rigid or a conforming splint on a patient who has sustained an isolated closed or open
fracture of the wrist, forearm or lower extremity. The patient is awake and able to answer all questions and follow instructions. There are
no contraindications present for the application of a splint. The manikin or live model will be placed in an appropriate position that is
consistent with the injury sustained. Necessary equipment will be adjacent to the manikin or live model or brought in by the examinee.
EQUIPMENT
Adult CPR/trauma manikin or live model, various rigid and conforming splints, long spine board, all necessary straps, sterile dressings,
2"-3"roller gauze, 1" tape, goggles, masks, gown, gloves.
100
0
NAME DATE __1__1__
EXAMINER(S) _
2nd 3rd (final)
PREPARATION
Skill Component Yes No omments
Assess scene safety
Determine if patient sustained possible spinal injury
Stabilize and expose the injured extremity:
Cut clothes away - if indicated
Remove shoes and socks - if indicated
Remove extremity and toe/finger jewelry
Assess extremity distal to injury for:
Pulse/Circulation
Motor movement
Sensation
** Consider realignment of extremity- if distal part of
extremity is pulse/ess and cyanotic
Cover wound with sterile dressing and secure in place
if indicated
Determine if splint should be applied
** Consider rapid transport - if patient is critical
Select the proper sptint for stabilization and
immobilization
Prepare and pad the splint - as needed
Musculoskeletal Injury / Splints: Rigid / Conforming Splint
Pa e 2 of 2
PROCEDURE
Support the fracture site and maintain manual
immobilization:
** Insert a 2"_3" wide roller bandage into patient=s
cupped palm - if indicated
Lift the extremity
Slide the splint under the extremity
Lower the extremity into the splint
Secure the splint:
Bone - immobilize the joint above and below the
fracture site
Joint - immobilize the bones above and below the
injured joi nt
Make sure extremity is properly shimmed
** Elevate extremity slightly above the level of the heart
** Consider application of ice packs - if swelling is
present
Re-assess extremity distal to injury for:
Pulse/Circulation
Motor movement
Sensation
ONGOING ASSESSMENT
$ Repeat an ongoing assessment every 5-15 minutes:
Initial assessment
DOCUMENTATION
$ Verbalize and document
Mechanism of injury
Treatment provided
Type of splint
Pulse/C irculation before and after splinting
Motor movement before and after splinting
Sensation before and after splinting
St._Musculoskeletal-RigidConf-Splint-0507
MUSCULOSKELETAL INJURY / SPLINTS
RIGID & CONFORMING SPLINTS
INDICATIONS:
Protect and maintain the position of an injured extremity:
- fracture
- sprain/strain
- dislocation
COMPLICATIONS:
Neurovascular compromise if splint is applied incorrectly.
SPLINTING PRINCIPLES:
Priorities in managing a patient with extremity fractures:
- 1st - life-threatening conditions
- 2
nd
-limb-threatening conditions
3
rd
- _ all other conditions
General management for suspected fractures:
- stop bleeding and treat for shock
- support area of injury
- immobilize joints above and below injury site
General splinting principles:
- pad rigid splints to adjust for anatomic shapes and patient comfort
- remove jewelry to prevent neurovascular compromise with increased swelling
- evaluate extremity before and after immobilization for nerve and vascular function
SPLINTING ERRORS:
Splinting before life-threatening injuries are addressed - (Treat life-threatening injuries first, then splint.)
Delaying transport of critical patients in order to splint an extremity.
Improper splinting technique:
- Splints applied too tight will compromise circulation and can cause nerve and muscle damage.
- Splints applied too loosely may result in further soft-tissue damage or convert a closed fracture into an open fracture.
Applying an incorrect splinting device, that is inappropriate for the severity of the patient's condition, and method of transport.
Not realigning long bones when an extremity is pulseless and cyanotic.
Attempting to realign joints - (May increase damage to soft tissue, neNes, and muscles.)
NOTES:
Rigid splints include: board splints (wood, plastic or metal), air splints, traction splints, pre-formed specific area splints, and spine
board (long board).
Conforming splints include: cardboard splints, ladder splints, SAM splints, vacuum splints, malleable metal finger splints, blanket
rolls, and pillows.
There are two situations when an extremity must be splinted in the position found:
- Dislocations
- When resistance or extreme pain is encountered during the attempt to realign a long bone fracture
Splinting minimizes pain, reduces hemorrhage and the risk of converting a closed fracture into an open fracture, prevents blood
vessel and nerve damage, and fat emboli.
Immobilizing the joint above and below the fracture site ensures stabilization of the fracture.
Shimming involves padding the extremity in the splint to decrease any movement of the extremity. Make sure there is even pressure
and contact. Pad all bony prominences.
For lower extremity fractures, patient should be supine and the extremity elevated about 6'1 to minimize swelling.
Always apply a layer of protection between an ice pack and the skin to reduce the possibility of frostbite or further injury to underlying
tissue.
Always splint the hand in the position of function. DO NOT tape fingers flat or cause angulation of the wrist.
Info._Musculoskeletal-RigidConf_Splint_0507
Page 1 of 1
MUSCULOSKELETAL INJURY
BIPOLAR TRACTION DEVICE - HARE SPLINT
The examinee will demonstrate proficiency in applying a bipolar traction device - Hare splint.
CONDITION
The examinee will be requested to apply a traction splint on a patient who has sustained an isolated lower extremity fracture. The patient
is awake and able to answer all questions and follow instructions. There are no contraindications for application of a tracti on splint The
manikin or live model will be placed supine on the floor. Necessary equipment will be adjacent to the manikin or live model.
EQUIPMENT
Adult CPR/trauma manikin or live model , assistant Hare splint, long spine board, all necessary straps, sterile dressings, 1
11
tape,
goggles, masks, gown, gloves.
100
%
2nd 3rd (final)
IPASS i I FAIL I 1st
PREPARAliON

Assess scene safety

Direct assistant to stabilize lower extremity

Expose the injured extremity:
Remove shoes and socks
Remove extremity and toe jewelry

Assess extremity distal to injury for:
Pulse/C irculation
Motor movement
Sensation

Cover wound with sterile dressing and secure in place-
if indicated

Determine if traction splint should be applied
Musculoskeletal Injury: Bipolar Traction Device - Hare Splint
Pa e 2 of 3
PROCEDURE

Apply the ankle harness above the ankle with the 3rd
flap under the heel:
Bring side flaps of harness up
Cross one end over the other
Pull side flaps down the lateral edge of the foot
Hold all 3 O-rings in one hand
Adjust harness to ensure a snug fit

Direct assistant to take the 3 O-rings and apply and then
maintain manual traction:
Hold the rings in one hand
Place other hand under the lower leg over the harness
OR
Place one hand on anterior surface of the lower leg
over the harness
Place other hand under the lower leg over the harness

Fold down heel stand and lock in place

Unlock collet sleeves

Measure splint for length:
Place against lateral aspect of the uninjured lower
extremity
Extend splint approximately 8"-12" beyond the heel

Relock collet sleeves

Place sptint next to the injured lower extremity and
prepare support straps:
1st above fracture site
2
nd
above knee
3
rd
below knee
4
th
above ankle

Support the fracture site from under the thigh

Oirect assistant to lift the lower extremity on command
while maintaining manual traction
(both rescuers must lift lower extremity at the same
time)

Slide the splint under the affected lower extremity until it
seats against the ischial tuberosity

Give the command and lower the lower extremity onto
the splint

Pad the groin area

Secure the groin strap high around the upper thigh of
the injured lower extremity

Hook the 3 O-rings into the US" hook

Adjust the traction by turning the winch until manual
traction has been equaled

Direct assistant to release manual traction slowly
Pa e 3 of 3
Secure the 4 support straps:
1st above fracture site
2
nd
above knee
3
fd
below knee
4
th
above ankle
Re-assess extremity distal to injury for:
Pulse/Circulation
Motor movement
Sensation
Secure the patient and splint to the backboard
ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION
Treatment provided
Pulse/Circulation before and after splinting
BIPOLAR TRACTION DEVICE - HARE SPLINT
INDICATIONS:
Single long bone fracture of the lower extremity:
- Mid-shaft femur
- Proximal and middle 3
rd
of the tibia and fibula with neurovascular compromise
CONTRAINDICATIONS:
Pelvic fracture
Hip injury
Knee injury
Lower third (near the ankle) of a lower extremity injury
Ankle and foot fractures
Distal end of femur fracture
Partial amputation or avulsion of the lower extremity
More than one fracture of the same extremity
COMPLICATIONS:
Neurovascular compromise if traction splint is applied incorrectly.
Injury to genitals if groin strap is not positioned correctly.
Priorities in managing a patient with an extremity fractures:
2
rd
- - limb-threatening conditions
3
rd
- - all other conditions
- evaluate extremity before and after immobilization for neurovascular function
SPLINTING ERRORS:
Splinting before life-threatening injuries are addressed. (Treat life-threatening injuries first, then splint.)
Delaying transport for critical patients in order to splint extremity.
Improper splinting extremity:
Applying an incorrect splint device - not appropriate to the severity of the patient's condition and method of transport.
Attempting to realign joints. (May increase damage to soft tissue, nerves, and muscles.)
Page 2 of 2
NOTES:
Traction splints may be used on open or closed femur fractures, especially when there is neurovascular compromise,
uncontrollable bleeding and severe pain due to muscle spasm.
Femur fractures result from major force and in children is commonly the result of child abuse.
Purpose of traction splint is to prevent overriding of the bone ends! decrease pain, relax muscle spasm, reduces blood loss.
There can be a significant blood loss with a femur fracture, 500-1000 or even more if it is an open fracture.
The Hare splint is a bipolar device because it uses two (2) pole-like sides to initiate countertraction against the ischial
tuberosity. It elevates and stabilizes the extremity when the patient is moved.
DO NOT secure straps before traction has been established. This may interfere with pulling traction along the entire length of
the lower extremity and can cause angulation and excessive tightening of the strap resulting in compromised circulation.
Adequate traction is applied when the injured lower extremity is the same length as the other lower extremity or the patient feels
relief.
Never apply a Pneumatic Anti -shock Garment (PASG) over a rigid splint. The metal shaft of the splint produces a void between
the PASG and the extremity allowing for continued internal or external bleeding. This may also press the splint into the extremity
causing tissue damage, circulatory compromise, or puncture the PASG resulting in sudden dangerous deflation. (PASG is not
used in California! only in NREMT scope)
Never release the mechanical traction unless manual traction is re-established. The release of traction may cause additional
injury to the lower extremity.
Info,_Musculoskeletal-Tx_Splint-Hare_OS07
UNIPOLAR TRACTION DEVICE - SAGER SPLINT
The examinee will demonstrate proficiency in applying a unipolar traction device - Sager splint.
CONDITION
The examinee will be requested to apply a traction splint on a patient who has sustained an isolated lower extremity fracture. The patient
is awake and able to answer all questions and follow instructions. The patient has no contraindications for application ofatradionsplint
The manikin or live model will be placed supine on the floor. Necessary equipment will be adjacent to the manikin or live model.
EQUIPMENT
Adult CPR/trauma manikin or live model, Sager splint, long spine board, all necessary straps/cravats, sterile dressings, 1" tape, goggles,
masks, gown! gloves.
100
0
double asterisks (**). Documentation! identified by the symbol ($), must be practiced but is not a required test item.
IPASS I I FAIL I 1st 2nd 3rd (final)
PREPARATION


Assess scene safety


Stabilize and expose the injured lower extremity:
Remove shoes and socks
Remove extremity and toe jewelry

Assess lower extremity distal to injury for:
Pulse/Circulation
Motor movement
Sensation

Cover wound with dry sterile dressing and secure in
place - if indicated

Determine if traction splint should be applied

Place Sager on ground with the top of the padded IIT_
bar" in-line with the patient's groin
Musculoskeletal Injury: Unipolar Traction Device - Sager Splint
Pa e 2 of 3
PROCEDURE

Measure splint for length:
Place against medial aspect of the injured or
uninjured lower extremity
Extend pole to the level of the heel

Seat the padded liT-bar" firmly against:
Pelvis (ischial tuberosity)
Medial side of the thigh between injured lower
extremity and genitalia
OR
Outside of the injured lower extremity

Pad the groin area and between lower extremity and
pole of splint - if indicated

Secure the groin strap high around the upper thigh of

Size the ankle harness just above the ankle for a
secure fit
Fold the extra ankle pads out - if not needed

Tighten the ankle harness above the ankle:
Bring end of harness up
Cross Velcro closures one end over the other
Pull strap down to the sale of the foot
Attach the ankle harness to the splint and tighten - if not
alreadvattached

Extend the splinfs inner pole to apply traction of about
10
%
of body weight to maximum of 15 Ibs:
Hold the upper portion of the metal pole while pUlling
traction
Apply counter traction to the groin
Align red arrow with the proximal weight marker
Stabilize upper part of splint to prevent movement of

Release pull on distal section and ensure ratchet is
locked

Check groin strap and tighten as needed for snug fit

Secure the splint to 'ower extremity(s) with cravats
(elastic straps)at the level of the:
Thigh(s)
knee(s)
Lower leg(s) - above the ankle harness
Both extremities together - if extra long strap is
available

Secure both feet together with figure 8 strap - if not
alreadv secured:
Place strap under ankles
Cross straps and bring between both feet
Bring crossed straps under soles of feet
Bring straps over top of feet
Secure straps
Pa e 3 of 3
Secure patients to long spine board
Re-assess both extremities distal to injury for:
Pulse/Circulation
Motor movement
Sensation
ONGOING ASSESSMENT
Skill Component Teaching Points
Initial assessment
The initial and focused examination is repeated every 15 minutes
for stable patients and every 5 minutes for priority patients.
Every patient must be re-evaluated at least every 5 minutes) if any
treatment was initiated or medication administered, unless
changes in the patient=s condition are anticipated sooner.
Priority patients are patients who have abnormal vital signs,
signs/symptoms of poor perfusion or if there is a suspicion that the
patient=s condition may deteriorate.
DOCUMENTATION
Mechanism of injury
Treatment provided
Pounds of traction applied
Pulse/Circulation before and after splinting
UNIPOLAR TRACTION DEVICE - SAGER SPLINT
INDICATIONS:
Long bone fracture of the lower extremity:
- Mid-shaft femur
- Proximal and middle 3rd of the tibia or fibula with neurovascular compromise
CONTRAINDICATIONS:
Pelvic fracture
Hip injury
Knee injury
Lower third (near the ankle) of a lower leg injury
Ankle and foot fractures
Distal end of femur fracture
Partial amputation or avulsion of the leg
More than one fracture of the same extremity
COMPLICATIONS:
Neurovascular compromise if traction splint is applied incorrectly.
Injury to genitals if T-bar and groin strap are not positioned correctly.
Priorities in managing a patient with an extremity fractures:
2
nd
- - limb-threatening conditions
3
rd
- _ all other conditions
- evaluate extremity before and after immobilization for neurovascular function
SPLINTING ERRORS:
Splinting before life-threatening injuries are addressed - (Treat life-threatening injuries first, then splint.)
Delaying transport of critical patients in order to splint an extremity.
Improper splinting technique:
Applying an incorrect splinting device, that is inappropriate for the severity of the patienfs condition and method of transport.
Attempting to realign joints - (May increase damage to soft tissue, nerves, and muscles.)
Page 2 of 2
NOTES:
Traction splints may be used on open femur or closed fractures, especially if there is neurovascular compromise, uncontrollable
bleeding and severe pain due to muscle spasm.
Femur fractures result from major force and in children is commonly the result of child abuse.
Purpose of traction splint is to prevent overriding of the bone ends, decrease pain, relax muscle spasm, and reduce blood loss.
There can be a significant blood loss with a femur fracture, 500-1000 or even more if it is an open fracture.
The Sager splint is a unipolar device because it uses a single pole to initiate countertraction against the ischial tuberosity. It does
not elevate or stabilize the lower extremity when the patient is moved. Additional support and splinting is required which is
accomplished by securing both legs together.
The Sager allows splinting of both legs with one splint if needed. Attach groin strap and ankle harness to the most serious fracture if
only one ankle harness is available.
The Sager splint may be applied by a single rescuer, the 2nd rescuer generally stabilizes the lower extremity to prevent movement. It
does not require manual traction and elevation of the leg.
DO NOT secure cravats (elastic straps) before traction has been established. This may interfere with pulling traction along the entire
length of the leg and can cause angulation and excessive tightening of the strap resulting in compromised circulation.
Never apply a Pneumatic Anti-shock Garment (PASG) over a rigid splint. The metal pole of the Sager splint produces a void between
the PASG and the lower extremity allowing for continued internal or external bleeding. This may also press the splint into the
extremity causing tissue damage, circulatory compromise, or puncture the PASG resulting in sudden dangerous deflation. (PASG is
used only in the NREMT Scope, not in California)
The spring within the pole of the Sager splint allows for some automatic self-adjustment to maintain the proper level of traction once
the splint has been applied when changes in muscle spasms occur.
Never release the mechanical traction unless manual traction is re-established. The release of traction may cause additional injury
to the leg.
An Infant traction splint is used for neonates and children up to 6-years-of-age.
Info._Musculoskeletal-Tx_Splint-Sager_OS07
NEUROLOGICAL EMERGENCY / SPINAL IMMOBILIZATION
LONG SPINE BOARD
The examinee will demonstrate proficiency in performing and directing team members in spinal immobilization using a long spine board.
CONDITION
The examinee will be requested to perform and direct team members to apply a cervical collar, log roll and secure a patient onto a long
spine board. The patient was ejected from a car and found lying supine on the ground. The patient is alert and complaining of neck and
back pain. Necessary equipment will be adjacent to the manikin.
EQUIPMENT
Live model or manikin, various sizes of rigid collars, long spine board, straps or binders, head-neck immobilizer, padding material, 2-3
11
cloth tape, 2-3 assistants, goggles, masks, gown, gloves.
100
%
accuracy required on all items designated by a bar (.) for skills testing and must manage successfully all items indicated by
Appropriate body substance isolation precautions must be instituted as required for scenario given.
Maintain axial stabilization of neck and body alignment at all times.
IPASS I I FA ! W
2nd 3rd (final)
PREPARATION
Assess environment for safety
PROCEDURE
Place patient's head in neutral in-line position and
maintain axial stabilization throughout procedure
unless contraindicated
- If team leader initiates C-spine immobilization first
relinquish position to an assistant as soon as
possible
- If an assistant is irrlmediately available - direct
assistant to initiate C-spine immobilization
Assess all extremities for:
Circulation
Sensation
Motor function
Assess neck for:
Accessory muscle use Tenderness
Neck vein distention Crepitus
Tracheal deviation Pulse quality
Medical alert tags
Penetrations/lacerations
Contusions/bruises/abrasions
Deformities (visible and palpated)
Neurological Emergency / Spinal Immobilization: Long Spine Board
Pa e 2 of 3
Apply appropriately sized extrication collar
** Ensure that collar does not obstruct the airway, or
hinder mouth opening, ventilation or circulation

Direct one assistant to position long board parallel to the
patient (opposite side of rescuers)

Position team members appropriately to turn patient:
4 team members
- Team leader - At head - in charge of counting for roll
- 1
st
assistant - near midchest with one hand on
patient's shoulder and the other on patient's hip
and securing near arm with knees
_2
nd
assistant - by hips with one hand above patient's
waist and the other below patient's knee and
securing far arm to lateral upper thigh
_3
rd
assistant - by knees with one hand on patient's
mid-thigh and the other below patient's calf
3 team members
- Team leader - At head - in charge of counting for roll
- 1
st
assistant - near midchest with one hand on
shoulder and other hand on upper thigh and
securing near arm with knees
- 2
nd
assistant - near upper legs with one hand on hip
and other hand below knee and securing far arm to
lateral upper thigh

Give the signal and roll patient towards team members
while maintaining body alignment

Assess back:
Slide hand holding shoulder to center of back to
stabilize patient
Use other hand to palpate for injuries, tenderness
and deformity

Direct assistant near patient's hips to slide board into
position next to patient

Give signal to roll patient onto board maintaining body
alignment

Center patient vertically on board angling the patient
towards center by sliding patient towards foot of board
then towards the head of board

Fill in spaces between the body and the board or straps
with padding - if indicated
Occipital padding for an adult or older child
Shoulder padding for a young child, toddler or infant
Shimming padding for spaces between torso, hips,
and legs and the edge of the board or straps
Secure chest, hips and legs to board with straps or binder
** Ensure chest expansion is not compromisedandintra
abdominal pressure is not increased
St. _Neuro -5pinaI-I mmob-Lon9-Board -0507
Neurological Emergency / Spinal Immobilization: Long Spine Board
Pa e 3 of 3
Immobilize head and neck with an approved immobilizing
device and securing technique
** Ensure that device does not compromise patient=s
airway, carotid arteries or neck veins
Check:
Airway
Chest expansion
Ensure arms are secured prior to transport
Reassess all extremities for:
Circulation
Sensation
Motor function
ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION
$ Report and document neuro and circulatory findings of all
4 extremities before and after spinal immobilization
St._Neuro -5pinaI-I mmob-Long-Board -0507
NEUROLOGICAL EMERGENCY / SPINAL IMMOBILIZATION
LONG SPINE BOARD
INDICATIONS:
Suspected spinal injury when:
Unresponsive or history of loss of consciousness
Not alert / disoriented with GCS <15
Suspected ETOH/Drug use
Spinal pain with or without motion
Spinal deformity
Neurological deficit
Painful or distracting injury
Mechanism of injury - if high suspicion of spinal injury with negative findings or communication barrier
CONTRAINDICATIONS FOR ATTEMPTING NEUTRAL IN-LINE POSITION OF THE HEAD:
Head is grossly misaligned (no longer extends from midline)
Moving the head into a neutral in-line position results in:
- compromising airway or ventilation
- initiating or increasing muscle spasms of the neck
- increasing neck pain
- initiating or increasing neurological deficits
- encountering resistance when attempting to move the head of an unconscious patient
COMPLICATIONS:
Aspiration
Positional asphyxia
COMMON MISTAKES:
Inadequate immobilization - torso or head not sufficiently secured.
Immobilization with the head hyperextended in adults and older children - caused by lack of appropriate padding under occiput.
Immobilization with the head hyperflexed in toddlers and infants - caused by lack of appropriate padding under shoulders and torso.
Readjusting the torso straps after the head has been secured - results in movement of the head and neck.
Failure to immobilize penetrating trauma of the head, neck or torso - may result in neuro deficits due to injury to the spinal cord.
Failure to reassess patients for circulation, sensation, motor movement, airway compromise and inadequate chest expansion -may
result in increased neuro deficits or death.
Taping or placing straps across chin - may cause airway obstruction.
NOTES:
Cervical collars DO NOT immobilize, they allow for 25-30% of motion by flexion and extension and up to 50% for other type of motion.
Occipital padding is required for adults and older children. Shoulder or torso padding is required for young children, toddlers and infants.
When log rolling, the patient=s arms should be kept at the side to help splint the body. Placing the patient=s arm above the head interferes with head
and neck alignment.
To prevent aspiration and airway compromise, tape should never be directly applied to chin or collar and then secured to the board without a head
neck immobilizer device in place.
Securing the torso before securing the head prevents angulating the cervical spine.
Shim patients well to prevent lateral movement in situations when the patient must be turned on their side:
- Vomiting
3
rd
- trimester pregnancy the board must be propped 45 toward the left side to prevent compression of the vena cava and thereby prevent
compromised venous return to the heart.
Only approved immobilization devices such as commercial immobilizers. towels, blanket rolls, etc. should be used. Sand bags, IV bags and other heavy
objects should not be used as head immobilizing devices which may shift and result in further spinal injury.
Prolonged backboard immobilization is frequently associated with headache, back pain, mandibular pain and pressure sores. Symptoms develop at
point of contact between a bony prominence and the board or cervical collar.
Helmets should be removed in the field if they are loose, unstable, and if they compromise the ability to control the airway. Sports helmets should not be
removed unless necessary and then the patient must be padded appropriately if shoulder pads are in place.
Patients> 64 years of age have a higher incident of spinal injury; therefore, mechanism of injury should be taken into consideration when deciding if
spinal immobilization should be instituted.
Too much padding under the head or shoulders will result in neck extension and too little padding results in neck flexion.
Restriction of chest movement and increasing intra-abdominal pressure may result in positional asphyxia. Pediatric patients are especially susceptible
to this.
Inmobilize the head and neck in or near the position it was initially found if contraindications for instituting neutral in-line position of the head are
present.
Info._Neuro-Spinal_lmmob-Long_Board
Page 1 of 1
OBSTETRICAL EMERGENCY / EMERGENCY CHILDBIRTH
DELIVERY
The examinee will demonstrate proficiency in assisting with an imminent delivery and perform initial interventions as necessary.
CONDITION
The examinee will be requested to assess and assist in the delivery of a newborn and initiate appropriate interventions as needed using
a simulated patient. The pregnancy is full term, the patient is having 'frequent contractions and the baby=s head is crowning. Required
equipment will be next to the patient or brought to the scene by the examinee.
EQUIPMENT
Obstetrical manikin with baby, placenta and umbilical cord, 1 assistant, obstetrical kit with cleansing towelettes and germicidal wipes,
4x4s, drapes, sheet, 8 towels, 2 cord clamps, 2 plastic ties, umbilical cord scissors, bulb syringe, obstetrical pad, plastic bag, sterile
gloves, baby blanket, oxygen tank with flow meter, oxygen tubing, adult and neonatal oxygen mask, adult and neonatal bag-valve-mask
device, nasal cannula, stethoscope, goggles, masks, gown, gloves.
100
%
NAME DATE __1__' __ EXAMINER(S) _
2nd 3rd (final)
PREPARAliON

Assess mother's history:
Last menstrual period (LMP) and/or
expected due date (EDD)
Prenatal care
Diabetes
Drug use (street or prescribed)
Problems with this pregnancy
Vaginal discharge
- bleeding
- bloody discharge
- rupture of amniotic membranes (color and odor)
Number of pregnancies and births
Type of previous deliveries - if indicated
- vaginal
- cesarean

Assess contractions:
Frequency
Duration
Intensity

Determine if delivery is imminent:
Crowning present
Contractions 2-3 minutes apart
Mother has urge to push

Determine:
Additional resources
Specialized equipment
** Consider equipment needed for administration of
oxygen to the mother and/or baby

Put on protective equipment:
Gown with long sleeves
Face mask
Goggles
Gloves (non-sterile if not already applied)

Position mother:
Place in a semi-Fowler's position
Elevate buttocks with pillow or blanket 2
11
-4"
Remove clothing that obstructs perineum
Pull up knees and spread apart

Open Obstetrical kit

Cleanse perineum with cleansing towelette and
germicidal wipes

Put on sterile gloves

Drape mother and establish a sterile field around
vaginal opening
PROCEDURE
Comments Skill Component No Yes

Support the baby's head and apply gentle pressure to
perineum to prevent explosive delivery:
Keep one hand on baby's head
Apply pressure to perineum with sterile towel

Rupture the amniotic membranes and pull membranes
from baby's mouth and nose - if not ruptured previously
** Note color and odor of amniotic fluid - if membranes
were not ruptured previouslv
Check for umbilical cord around neck as soon as head
is delivered:
** If no nuchal cord- continue with delivery
** If nuchal cord- loosen cord with 2 fingers and slip
over baby's head
1\/\
if necessary B clamp in 2 places 2"_3" apart and
cut the cord

Clear the babis airway:
Suction mouth 2-3 times
Suction each nostril 1-2 times
St._Obstetrical_Emerg -ECB-Delivery-0507

Assist in releasing the shoulders:
Upper shoulder - guide head downward - if indicated
Lower shoulder - guide head upward - if indicated

Assist in delivering the rest of the baby

Hold baby securely:
Place in Trendelenburg position
Support the head at the level of the mother=s perineum

Wipe and suction the baby's mouth and nose again
Stirn ulate the baby to breathe - if indicated
Vigorously rub the back with a towel
Flick the soles of the feet
** Ventilate baby with bag-valve-mask c if no response
after 5-10 seconds ofstimulation

Double clamp umbilical cord - if not clamped
previouslv;
1st clamp - 6"-8" from baby
2
rd
clamp - 2"-3" from the 1st clarrlp toward the mother
(10
11
-12" from the baby)

Cut the umbilical cord between the clamps - if not cut
previouslv;

Dry and wrap the baby in a blanket or towel

Direct assistant to monitor and complete initial care of
the baby

Assess mother's vital signs and check for vaginal
bleeding

Observe for signs of placental separation:
Lengthening of the umbilical cord
Contraction of the uterus (uterus raises into a
globular shape)
Gush of blood from the vagina

Prepare for delivery of the placenta:
Have mother bear down
Have basin ready to receive placenta
Expect a gush of blood after placenta is delivered

Deliver the placenta:
Grasp the placenta when it appears at the vaginal
opening
Rotate the placenta - DO NOT pull on cord
Guide the placenta and membranes from the vaginal
opening into basin or towel
** Check for integrity of the placenta and cord

Place the placenta into plastic bag and transport with
the mother

Check for perineal lacerations and apply pressure to
control bleeding - if indicted

Remove the soiled sheets and place in plastic bag
St. _Obstetrical_Emerg -ECB-Delivery-O507

Place 2 obstetrical pads over the vaginal and perineal
area:
Touch only the outer surface of the pads
Place pads from vagina down towards anus
Assist mother in putting thighs together to hold pads
in place

Assess the fundus every 5 minutes and massage if
indicated
Place one hand above pubic bone
Place other hand above contracted uterus
Massage (knead) over area using a circular motion
until the uterus is firm

Provide comfort and support to the mother and
transport

t h

ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION
Time of delivery of baby and placenta
LMP and/or EDD
Vaginal discharge
Number of pregnancies and births
Type of previous deliveries - if indicated
Estimated blood los s
Integrity of the placenta and cord
Condition of the baby
Fundal massage - if provided
St. _Obstetrical_Emerg -ECB-Delivery-O507
DELIVERY
DEFINITIONS:
Bab v - name used to indicate newborn
Newborn - neonate in the first minutes to hours after birth
Neonate - infants in first month after birth (28 days)
Infant - includes the neonate period to 1 year (12 months)
Bloody show - watery bloody discharge is normal through out the three stages of labor. During the 1st stage of labor it is the
displacement of the mucus plug as the cervix dilates
Crowning - bulging of the vaginal opening or when the presenting part of the baby is visible. This is the most reliable sign of
imminent delivery
Duration of the contraction - 'from the beginning of the contraction to its completion
Frequencv of contractions - from the beginning of one contraction until the onset of the next contraction
Labor pains - pain in addition to the discomfort of the contractions, usually felt in the lower abdomen and back
Meconium - fetal feces that is normally passed as the baby's first bowel movement. However, during fetal or maternal stress
defecation may occur before birth
Nuchal cord - umbilical cord wrapped around baby=s neck
Uterine inversion - uterus is inverted or turned inside-out. Caused by extensive pressure on the uterus or from pulling on the
umbilical cord before the placenta is delivered
COMPLICATIONS AND INTERVENTIONS:
Meconium -stained amniotic fluid
Problem - will cause pneumonia or other problems
Intervention - suction mouth and nose aggressively before delivery of the rest of the body
Nuchal cord
Problem - will choke the baby and the cord may tear during the deliver causing sever hemorrhage in baby and mother
Intervention - slip the cord around neck or double clamp and cut cord if unable to slip it
STAGES OF LABOR:
The three stages of labor are:
- 1
st
stage (dilation stage) - Starts with regular contractions and thinning and gradual dilation of the cervix
Ends with complete dilation of the cervix
- 2
nd
stage (expulsion stage) - Starts with baby entering the birth canal
Ends with the deliver of the baby
- 3
rd
stage (placental stage - Starts with the delivery of the baby
Ends with the delivery of the placenta
Contractions follow the following pattern:
- Latent (early) phase of 1st stage of labor - Active phase of 1st stage of labor
frequency -- every 15-30 minutes frequency -- every 2-3 minutes
duration -- 30-40 seconds duration -- average 60 seconds
intensity - mild intensity - moderate to strong
ABNORMAL DELIVERIES:
Prolapsed cord
Problem - cord presents through the birth canal before delivery of the head. This is a serious emergency which endangers the life of
the unborn fetus.
Intervention:
- Administer high flow oxygen to the mother to increase oxygen delivery to fetus
- Elevate mother=s pelvis on a pillow or inverted bed pan to reduce pressure on cord
Obstetrical Emergency/Emergency Childbirth: Delivery
Page 2 of 3
- Elevate presenting part of the baby off the cord to prevent compression of the cord and maintain fetal circulation
- Cover cord with a sterile moist dressings to minimize temperature change and reduce umbilical artery spasm
Limb presentation
Problem - either an arm or leg appears first instead of the head.
Intervention:
- Administer oxygen to the mother to increase oxygen delivery to the fetus
- Elevate mother's pelvis on a pillow or inverted bed pan to reduce pressure on the baby
- Transport immediately - delivery is impossible
ABNORMAL DELIVERIES (Continued):
Breech presentation
Problem - baby's feet or buttocks appear first instead of the head. Every attempt should be made to transport to the hospital. (/tis
not uncommon to have meconium in amniotic fluid with breech presentation.)
Intervenlion:
- Administer oxygen to the mother to increase oxygen delivery to the fetus
- Let delivery proceed
- If the head does not deliver within 3 minutes
- form an airway for the baby by placing the middle and index fingers along the infant=s face
- hold the vaginal wall away from the baby's nose and mouth
- hold baby's mouth open slightly with finger so that baby can breath
- transport rapidly
Multiple births
Problem - generally both babies are delivered norm ally, however about 113 of the second babies are breech
Intervention:
- When the 1st baby is born, cut the cord to prevent hemorrhage to the 2nd baby
- If the 2nd baby has not delivered within 10 minutes of the 1st, transport immediately
- Expect hemorrhage after the 2nd baby has delivered
- Deliver the placenta or placentas or transport if not delivered when mother and babies are stabilized and ready for transport
- Keep the babies warm, they are usually small and readily become hypothermic
Premature birth
Problem - baby is more susceptible to respiratory problems, infections and hypothermia
Intervention:
- Keep baby warm with extra insulation
- Administer supplemental oxygen by blow by
- Avoid contamination from birth process and DO NOT breath into baby's face
NOTES:
When the amniotic fluid is stained greenish or brownish-yellow, it indicates that either maternal of fetal distress during labor.
This is caused by the release of fetal feces released into the amniotic fluid.
Aspiration of meconium stained amniotic fluid may cause pneumonia or other breathing problems.
The mother and newborn should be transported to the same facility.
BLS units shall call for an ALS unit or transport to the most appropriate hospital
APGAR score is assessed at 1 minute and 5 minutes and if the score is less than 7, it is repeated every 5 minutes for 20 minutes.
Into. _Obstetrica1_Emerg -ECB-Delivery_0507
Obstetrical Emergency/Emergency Childbirth: Delivery
Page 3 of 3
DELIVERY
Evaluation Factor Findings Score
Appearance (color) cyanotic or pale
blue hands and feed with pink body
extremities and trunk pink
o points
1 point
2points
Pulse no pulse
< 100/ minute
> 1aO/minute
no reflex to stimulation
slight reflex to stimulation
grimace, cough, sneeze, or cry in
response to
stimulation
limp, no extremity movement
some flexion with no movement
actively moving
- no respiratory effort
- slow, irregular effort with weak cry
- good effort with strong cry
o points
1 point
2 points
Grimace (reflex irritability) o points
1 point
2 points
Activity (extremity movement, degree of
flexion and resistance to straightening them)
o points
1 point
2 points
Respirations a points
1 point
2 points
7-10 point =normal - provide routine care
4-6 points =moderately depress - provide stimulation and oxygen
0-3 points =severely depressed - provide CPR and BVM ventilations
Info. _ObstetricaLEmerg -ECB -Del ivery_0507
NEWBORN ASSESSMENT & MANAGEMENT
The examinee will demonstrate proficiency in assessing the newborn and performing initial care and interventions as necessary.
CONDITION
The examinee will be requested to assess and perform the initial care of the newborn and intervene as necessary using a simulated
patient. The newborn is full term with no major complications during pregnancy. The newborn was suctioned during the birth process,
the cord clamped and cut and the baby is wrapped in a blanket. Required equipment will be in the room readily accessible.
EQUIPMENT
Baby manikin with umbilical cord clamped, bulb syringe, baby blanket, oxygen tank with flow meter, oxygen tubing, neonatal oxygen
mask, neonatal bag-valve-mask device, stethoscope, goggles, masks, gown, gloves.
100
%
IPASS I I FAIL I
1st 2nd 3rd (final)
PREPARAliON
Determine:
PROCEDURE
Assessment of the newborn is performed after the baby is dried, wrapped, airway cleared, and stimulated
Assess and support body temperature:
Dry newborn completely - if not done Dreviouslv
Keep wrapped with head covered
Assess and support the airway:
Position on back or side with neck in a neutral
position
Suction with bulb syringe - if needed
Assess breathing:
If adequate - continue with assessment
If gasping or respirations are inadequate - ventilate
with bag-valve-mask at 40-60 breaths per minute
If respirations shallow or slow - administer oxygen
and stimulate by:
- vigorously rubbing back with a towel
- slapping or flicking the soles of the feet
Obstetrical Emergency / Emergency Childbirth: Newborn Assessment & Management
Pa e 2 of 2
Assess circulation:
Heart rate
If> than 120 beats/minute - conti nue assessment
If 100-120 beats/minute -administer oxygen
If < than 100 beats/minute - ventilate with bag-valve
mask device attached to 1000/0 oxygen
If < 60 beats/minute - start CPR @ 120
com pressions/min ute
Color
If pink or peripheral cyanosis of hands and feet - no
treatment indicated
If central cyanosis and good respirations and heart
rate> 100 beats/minute - administer oxygen
If generalized pallor or cyanosis and no response to
oxygen administration - ventilate with bag-valve-mask
device attached to 100
0
/0 oxygen
Assess umbilical cord for:
Bleeding - apply sterile dressing and direct pressure if
indicated
Security of clamps or ties - use additional clamps or
ties as indicated
ONGOING ASSESSMENT
Initial assessment
DOCUMENTATION
Time of delivery of baby
Presence of meconium
Integrity of the cord
Condition of the baby
St._Obstetrical_Emerg -ECB-Newborn
NEWBORN ASSESSMENT & MANAGEMENT
DEFINITIONS:
Baby - name used to indicate newborn
Newborn - neonate in the first minutes to hours after birth
Neonate - infants in first month after birth (28 days)
Infant - includes the neonate period to 1 year (12 months)
Central cyanosis - bluish color on trunk and face
Peripheral cyanosis - bluish color limited to hands and feet
Meconium - fetal feces that is normally passed as the baby's first bowel movement. However, during fetal or maternal stress,
defecation may occur before birth
Oxygen administration - administration of free-flow oxygen directly to baby1s face by either mask or blow-by method:
- mask - at least 5 Liters/minute, held loosely over baby's face
- blow-by with oxygen tubing - at least 5 Liters/minute, held near the nostrils
INDICATIONS FOR BAG-VALVE-MASK VENTilATIONS:
Apnea, gasping, or inadequate respirations
Heart rate less th an 100 beats/minute
Persistent central cyanosis unresponsive to administration of oxygen
INDICATIONS FOR CARDIOPULMONARY RESUSCITATION:
Pulseless
Heart rate less than 60.
NOTES:
The newborns must make three rapid transitions to the out side world from their protected environment in utero:
- changing their circulatory pattern
- emptying fluid from their lungs and beginning ventilation
- maintaining body temperature
Four main objectives in caring for the newborn:
- Provide and maintain warmth. Important to dry and wrap baby with only face exposed, they lose most of their heat from the
head area.
- Continually assess respirations, heart rate and color.
- Maintain adequate respirations by positioning, suctioning, administration of oxygen, and ventilate with a BVM if indicated
- Provide cardiac compressions for heart rate < 60
The mother and newborn should be transported to the same facility.
BLS units shall call for an ALS unit or transport to the most appropriate hospital.
Signs of poor perfusion are: weak cry, bradycardia (heart rate < 100 beats/minute), inadequate respirations 40 breaths/minute),
and cyanosis.
Hyperextension or flexion of neck may cause an airway obstruction. To maintain in position, place a folded blanket or towel
under the neck and shoulders.
If copious secretions are present, position the baby on the side and slightly extend the neck. This allows the secretions to
collect in the mouth and not in the posterior pharynx.
When ventilating with a BVM, use onlv enough force to allow for good chest rise. Over-inflation causes gastric distention which
will affect tidal volume by elevating the diaphragm
If ventilating with a bag-valve-mask device, heart rate must be re-assessed every 30 seconds.
Check pulse by one of the following:
- auscultate apical pulse
- palpate pulse at base of umbilical cord
- palpate brachial or femoral pulse
Normal newborn heart rate is 120-160 beats/minute.
Obstetrical Emergency I Emergency Childbirth: Newborn Assessment & Management
Page 2 of 2
Compression to ventilation ratio is 3 compressions to 1 ventilation.
APGAR score is assessed at 1 minute and 5 minutes and if the score is less than 7, it is repeated every 5 minutes for 20
minutes.
APGAR SCORE
Evaluation Factor Findings Score
Appearance (color) cyanotic or pale
blue hands and feed with pink body
extremities and trunk pink
no pulse
< 1001 minute
> 1aO/minute
no reflex to stimulation
- slight reflex to stimulation
- grimace, cough, sneeze, or cry in
response to
stimu lation
limp, no extremity movement
some flexion with no movement
actively moving
- no respiratory effort
- slow, irregular effort with weak cry
- good effort with strong cry
a points
1 point
2points
Pulse o points
1 point
2 points
Grimace (reflex irritability) o points
1 point
2 points
Activity (extremity movement, degree of
flexion and resistance to straightening them)
o points
1 point
2 points
Respirations o points
1 point
2 points
7-10 point = normal - provide routine care
4-6 points = moderately depress - provide stimulation and ox ygen
0-3 points = severely depressed - provide CPR and BVM ventilations
The inverted pyramid - reflects the frequencies for neonatal
resuscitation in newborns without meconium stained
amniotic fluid.
STEPS
Step 1 - always needed
Step 2 - frequently needed
Step 3 - infrequently needed
1
2
3
Step 4 - infrequently needed
Step 5 - rarely needed
4
5
Always assess and manage:
Temperature (warm & dry)
Airway (position & suction)
Breathing (stimulate to cry)
Circulation (heart rate & color)
Info._ObstetricaLEmerg -ECB-Newborn_0507
INVERTED PYRAMID
DIy. \Varm, Position,
Suction. Sun'urate
Oxygen
Establish Effective Ventilation
Bag-val'/e mask
Endotrachtlal intubation
American Heart Association Pyramid
PATIENT ASSESSMENT & MANAGEMENT
SCENE SIZE-UP AND INITIAL ASSESSMENT
The examinee will demonstrate proficiency in performing an initial medical or trauma patient assessment involving scene size-up and an
initial assessment! and perform initial interventions as necessary.
CONDITION
The examinee will be requested to perform an initial medical or trauma assessment on a simulated patient and perform initial
interventions as necessary. Required equipment will be either next to the patient or brought to the scene by the prehospital provider.
EQUIPMENT
Live model or manikin, oxygen tank with flow meter! oxygen tubing! BVM device! oxygen mask! nasal cannula! stethoscope, blood
pressure cuff, pen light, timing device! clipboard! pen! long sleeves! goggles, masks, gown, gloves.
100
%
double asterisks (**).
2nd 3rd (final)
PREPARATION
SCENE SIZE-UP
CRITICAL DECISIONS
Skill Component
Yes No Comments
Assess:
Personnel/patient safety
Environmental hazards
Number of patients
Mechanism of injury
Determine:
Need for extrication/spinal immobitization
INITIAL ASSESSMENT
CRITICAL MANAGEMENT AND TRANSPORT DECISIONS
Consider:
General impression
Establ ish patient rapport:
Ask the right questions
Respond with empathy
Patient Assessment & Management: Scene Size-Up And Initial Assessment
Pa e 2 of 2

Awake/not awake and orientation to environment
Verbal stimulus response
Painful stimulus response
Unresponsive
** Consider blood glucose level - if unresponsive

Patent
Obstructed
** Open and clear/suction airway- if indicated
** Consider basic airway adjuncts - if indicated

Rate
Effort
Tidal volume
Breath sounds (rapid chest auscultation) - if difficultv
breathinalshortness of breath
** Consider O
2
therapy
** Consider BVM - if inadequate ventilation

Assess/Manage circulation:
Pulse - rate, rhythm! quality
Skin - color, temperature! moisture
Bleeding
Capillary refill - if appropriate
** Control severe bleeding
** Consider shock position - if hypotensive
** Consider monitor/AED - if indicated
** Consider venous access - if indicated

Assess major disability & deformities:
Neurological deficits
Abnormal body presentation (posture)

Determine:
Chief complaint/problem
Focused history and physical examination
Transport decision

Expose specific body area for detailed examination - if
pertinent
St. _Patient_Assessment-l nitiaI
I
The examinee will demonstrate proficiency in performing a complete medical or trauma assessment involving scene size-up, initial
assessment, focused history, physical examination, ongoing assessment, and perform initial interventions as necessary.
CONDITION
The examinee will be requested to perform a complete medical or trauma assessment on a simulated patient and perform initial
EQUIPMENT
Live model or manikin, oxygen tank with flow meter, oxygen tubing, BVM device, oxygen mask, nasal cannula, stethoscope, blood
pressure cuff, pen light, timing device, clipboard, pen, long sleeves, goggles, masks, gown, gloves.
100
%
2nd 3rd (final)
PREPARATION
SCENE SIZE-UP
CRITICAL DECISIONS
Assess:
Personnel/patient safety
Environmental hazards
Number of patients
Mechanism of injury
Determine:
Need for extrication/spinal immobilization
INITIAL ASSESSMENT
CRITICAL MANAGEMENT AND TRANSPORT DECISIONS
Consider:
General impression
Establish patient rapport:
Ask the right questions
Respond with empathy

Awake/not awake and orientation to environment
Verbal stimulus response
Painful stimulus response
Unresponsive
** Consider blood glucose level - if unresponsive
Patent
Obstructed
** Open and clear/suction airway- if indicated
** Consider basic airway adjuncts - if indicated
Rate
Effort
Tidal volume
Breath sounds (rapid chest auscultation) if difficultv
breathing/shortness of breath
** Consider O
2
therapy
Assess/Manage circulation:
Pulse - rate, rhythm, quality
Skin - color, temperature, moisture
Bleeding
Capillary refill - if appropriate
** Control severe bleeding
** Consider shock position - if hypotensive
** Consider monitor/AED - if indicated
** Consider venous access - if indicated
Assess major disability &deformities:
Neurological deficits
Abnormal body presentation (posture)
Determine:
Chief complaint/problem
Focused history and physical examination
Transport decision
Expose specific body area for detailed examination - if
pertinent
FOCUSED HISTORY AND PHYSICAL EXAMINATION
RESPONSIVE MEDICAL I MINOR TRAUMA PATIENT
Assess current problem:
Signs and symptoms
Assess pain - if pertinent
- onset
- provoking factor/relieving factor
- quality
- region/r/radiation/recurrence
- severity (mild-severe or 1-10 scale)
- time
St. _Pat ient-Assessment-Com prehensive-O 507
Skill Component
Assess current problem (Continued)
Assess difficulty breathing - if pertinent
- onset
- provoking factor
- quality
- recurrence and what treatment provides relief
- severity
- time
Events leading to iHness/mechanism of injury
Obtain personal and past medical history:
Age
Weight
Under physician=s care/Private medical doctor
Pertinent history
Allergies
Medications
Last oral intake - if pertinent
Assess vital signs:
Cardiac status
- Pulse - rate, rhythm, quality
- ECG reading - if indicated and available
Respiratory status
- Respirations - rate, effort, tidal volume
- Breath sounds
Blood pressure
Temperature - if indicated
Assess neurological status:
Comprehensive orientation level- person, place, time
Glasgow Coma Scale (GCS) - eyes, motor, verbal
Pupils - size, equality, reactivity, movement - j[
indicated
Extremities-circulation, movement, strength,
sensation
Examine injured or affected area
Yes No Comments
Perform detailed physical exam ination
** Manage specific problem or injury
Assess:
Current medical history
OPQRST for pain/respiratory - if indicated
Personal history
Vital signs
Neurological status
St. _Pat ient-Assessment-Com prehensi ve-O 507

ONGOING ASSESSMENT
STABLE AND PRIORITY (CRITICAL) PATIENTS
Repeat (every 5 minutes for priority patients and every 15
minutes for stable patients):
Initial assessment
Relevant portion of the focused examination
ELEMENTS FOR A DETAILED PHYSICAL EXAMINATION OR EXAMINATION OF A SPECIFIC BODY PART
MANAGEMENT OF SPECIFIC PROBLEM OR INJURY
HEAD - Skull, Eyes, Ears, Nose, Mouth, Face
Examine for:
- drainage
- deformity
- contusions (raccoon eyes
t
Battle's sign)
- abrasions
- punctures/penetrations
- bu rns/soot
- lacerations
- swelling
- scars
- eye movement
Palpate for:
- tenderness
- instability
- crepitus
** Maintain patent airway
NECK/CERVICAL SPINE
Examine for:
- deformity
- contusions
- abrasions
- burns
- lacerations
- swelling
- scars
- jugular vein distention (JVD)
- tracheal deviation
- accessory muscle use
medical alert tags
Palpate for:
- tenderness
- instability
- crepitus
- subcutaneous emphysema
- carotid pulses
** Maintain spinal immobilization - if indicated
** Apply occlusive dressing - if puncture wound to
neck
St_Patient-Assessment-Comprehensive-0507
CHEST - Clavicles Sternum, Ribs
Examine for:
- deformity
- contusions
- abrasions
- paradoxical movement
- burns
- lacerations
- swelling
- scars
- sucking chest wound

Palpate for:
- tenderness
- instability
- crepitus

AuscuItate:
- breath sounds
Percuss - if breath sounds unequal
** Apply occlusive dressing to sucking chest wound - it
indicated
** Splint flail segment - if paradoxical motion
** Decompress chest - if tension pneumothorax
ABDOMEN/PELVIS

Examine for:
- deformity
- contusions
- abrasions
- burns
- lacerations
- swelling
- scars
- distention
- pulsating mass
- incontinence
- priapism

Palpate for:
- rigidity/guarding
- tenderness
- femoral pulses
- crepitus
LOWER EXTREMITIES

Examine for:
- deformity - lacerations
- contusions - medical alert tags
- abrasions - scars
- punctures/penetrations - swelling
- burns

Palpate for:
- pedal pulses - instability
- tenderness crepitus
S1. _ Pati ent-Assessment-C om prehensive-O 507
UPPER EXTREMITIES

Examine for:
- deformity
- contusions
- abrasions
- burns
- lacerations
- swelling
- medical alert tags

Palpate for:
- brachial/radial pulses
- tenderness
- instability
- crepitus
BACK - posterior thorax, lumbar, buttocks

Examine for:
- deformity
- contusions
- abrasions
- burns
- lacerations
- swelling
- scars

Palpate for:
- tenderness
- instability
- crepitus
- sacral edema
St_Patient-Assessment-Comprehensive-OS07
NOTES:
Repeat initial and focused examination every 5 minutes for priority patients and every 15 minutes for stable patients.
Priority patients are patients who have abnormal vital signs, SIS of poor perfusion or if there is a suspicion that the patient=s
condition
may deteriorate.
Trauma patients with chest injuries, difficulty breathing and signs of shock should be assessed for bilateral breath sounds after
the initial assessment has been completed to determine possible tension pneumothorax.
The respiratory rate> 40 or < 10 may not provide adequate tidal volume. Be prepared to assist with bag-valve-mask ventilation if
level of consciousness is decreased.
Capillary refill can be taken at any skin area such as: fingernail bed, palm, chest, forehead, etc. (If using the ball of the foot in
pediatric patients, child must be in a supine position.)
Ideal scene time is < 10 minutes for critical (priority) trauma patients.
The order of a detailed physical exam should evaluate life-threatening injuries. Exam should start with the head, neck, torso, legs
and then progress to the arms and back.
ADDITIONAL ASSESSMENT AND QUESTIONS FOR SPECIFIC CONDITIONS:
ALLERGIC REACTION I ANAPHYLAXIS I ENVIRONMENTAL EMERGENCY
Onset - history of allergy
Exposure - ingestion, inhalation, absorption, envenomization
Time - duration
Effect - general vs local rash, hives, itching, respiratory problems, nausea, vomiting, etc
ALTERED LEVEL OF CONSCIOUSNESS I WEAKNESS I DIZZINESS I SYNCOPE
Onset - what happened
Time - duration of event
Responsiveness - GCS; response to stimuli -- awake, verbal, pain or unresponsive
Orientation - name, place, and time
Associated symptoms - neuro deficits, pupil response
Possible causes: (not all inclusive)
- A alcohol, anoxia, allergic reaction
- Eepilepsy, electrolyte imbalance
- I insulin (hyper-hypo glycemia)
- 0 overdose
- U uremia, under-dose
- Ttrauma
- I infection
- P psychiatric! post-ictal, poisoning (ingestion, inhalation), palpitation (dysrhythmias)
- 5 stroke
BEHAVIORAL EMERGENCY
Provokes - causative event; medical, psychiatric, traumatic event
History - medical history and medications and compliance with medications
Effect - type of behavior; danger to self or others
Patient Assessment & Management
Page 2 of 3
NAUSEA I VOMITING I DIARRHEA
Onset of problem
Skin temperature/fever
Pain/discomfort
Skin color
Signs of dehydration
- skin turgor/tenting
- absence tearing
- decreased urinary output
- quality of pulse
OBSTETRICAL I GYNECOLOGICAL EMERGENCY
Last menstrual period
Bleeding / discharge / amniotic fluid (rupture of membranes [ROM]) - color, odor, amount (# of saturated pads)
Pregnant - how far along, number of pregnancies and births
Pain/discomfort - duration, constant vs intermittent
Labor - time and length of contractions, crowning, urge to push
PAIN I DISCOMFORT (non-traumatic)
Onset- when the pain/discomfort first began (minutes - weeks); what makes it better or worse
Provokes - causative event or what increases pain/discomfort
Quality - type of pain, i.e. sharp, ache, squeezing, burning, etc
Region - area focal vs diffuse pain/discomfort
Radiation, - pain moves to another area away from its origin;
Relief- constant vs intermittent; what makes it better or worse
Severity - mild, moderate, severe or 1-10 scale used to rate initial event or compare to previous episode or ongoing assessment
Time - duration
POISONING I OVERDOSE
Amount / Exposure -- quantity and route (ingestion, inhalation, absorption, injection)
Effect- altered level of consciousness, respiratory problems, abdominal pain/discomfort, nausea, vomiting, etc
RESPIRATORY DISTRESS
Onset- gradual vs sudden (when it began)
Provokes - causative event, i.e. allergy, exertion, drugs, etc
Severity - mild, moderate, severe - used to rate initial event or compare to previous episode or ongoing assessment
l
accessory
Time - duration
Moderate = tachypnea, upright position if possible, answers in partial sentences
Severe = tachypnea, tripod position, answers in 2-3 words only
Info._Patient_Assessment_Mgmt
Patient Assessment & Management
Page 3 of 3
VAGINAL BLEEDING
Onset
Last normal menstrual period (LNMP)
Pregnant/how far along
Pain/cramping
Amount of bleeding (number of saturated pads/hour)
Passing clots/tissue
Nausea, vomiting
Dizziness
Onset of fever
Highest temperature obtained
Associates signs/symptoms: nausea, vomiting, diarrhea, pain, cough, urinary symptoms, stiff neck
Measures to reduce fever
Last dose of hyperpyrexic (fever reduction) medications such as Tylenol, Motrin, aspirin
Info. Patient Assessment Mgmt

ELEMENTS FOR A DETAILED PHYSICAL EXAMINAliON
OR
EXAMINATION OF A SPECIFIC BODY PART
The examinee will demonstrate proficiency in performing a detailed physical examination or examination of a specific area and perform
initial interventions as necessary_
CONDITION
The examinee will be requested to perform a detailed physical examination or examination of a specific area on a simulated patient and
perform initial interventions as necessary. Required equipment will be either next to the patient or brought to the scene by the prehospital
provider.
EQUIPMENT
Live model or manikin, oxygen tank with flow meter, oxygen tubing, BVM device! oxygen mask, nasal cannula, stethoscope, blood
100
%
2nd 3rd (final)
DETAILED PHYSICAL EXAMINATION OR EXAMINATION OF A SPECIFIC BODY PART
HEAD - Skull, Eyes, Ears, Nose, Mouth, Face
Examine for:
- drainage
deformity
contusions (raccoon eyes, Battle=s sign)
abrasions
punctures/penetrati ons
burns/soot
lacerations
swelling
scars
Palpate for:
- tenderness
- instability
- crepitus
** Maintain patent airway
Patient Assessment & Management: Elements For A Detailed Physical Examination or Examination Of A Specific Body Part
Pa e 2 of 4
NECK/CERVICAL SPINE

Examine for:
- deformity
- contusions
- abrasions
- punctures/penetrati ons
- burns
- lacerations
- swelling
- scars
- jugular vein distention (JVD)
- tracheal deviation

Palpate for:
- tenderness
- instability
- crepitus
- carotid pulses
** Maintain spinal immobilization - if indicated
** Apply occlusive dressing - if Quncture wound to neck
CHEST - Clavicles Sternum, Ribs

Examine for:
- deformity
- contusions
- abrasions
- paradoxical movement
- burns
- lacerations
- swelling
- scars
- sucking chest wound

Palpate for:
- tenderness
- instability
- crepitus

Auscultate:
- breath sounds

Percuss - if breath sounds unequal
** Apply occlusive dressing to sucking chest wound - it
indicated
** Splint flail segment - if paradoxical motion
** Decompress chest - if tension pneumothorax
St._Patient_Assessment-Detailed
Patient Assessment & Management Elements For A Detailed Physical Examination or Examination Of A Specific Body Part
Pa e 3 of 4
Skill Component No Yes Comments
ABDOMEN/PELVIS

Examine for:
- deformity
- contusions
- abrasions
- pu nctu res/penetrations
- burns
- lacerations
- swelling
- scars
- distention
- pulsating mass
- incontinence
- priapism

Palpate for:
- rigidity/guarding
- tenderness
- femoral pulses
- crepitus
LOWER EXTREMITIES

Examine for:
- deformity
- contusions
- abrasions
- burns
- lacerations
- swelling
- scars

Palpate for:
- pedal pulses
- tenderness
- instability
- crepitus
UPPER EXTREMITIES

Examine for:
- deformity
- contusions
- abrasions
- burns
- lacerations
- swelling
- scars
.Palpate for:
- brachial/radial pulses
- tenderness
- instability
- crepitus
5t ._Patient_Assessment-Detailed
Patient Assessment & Management: Elements For A Detailed Physical Examination or Examination Of A Specific Body Part
Pa e 4 of 4
BACK - Posterior Thorax, Lumbar, Buttocks

Examine for:
- deformity
- contusions
- abrasions
- punctures/penetrati on s
- burns
- lacerations
- swelling

Palpate for:
- tenderness
-instability
- crepitus
- sacral edema
St. Patient Assessment-Detailed

The examinee will demonstrate proficiency in performing a focused medical or trauma assessment involving history and a physical
examination and perform initial interventions as necessary.
CONDITION
The examinee will be requested to perform a focused medical or trauma assessment on a simulated patient and perform initial
EQUIPMENT
100
%
accuracy required on all items designated by a box (_) for skills testing and must manage successfully all items indicated by
2nd 3rd (final)
............................................................
_ Assess current problem:
Signs and symptoms
Assess pain - if pertinent
- onset
- provoking/relieving factor
- quality
- region/radiation/recurrence
- severity (mild-severe or 1-10 scale)
- time
Assess current problem (continued):
Assess difficulty breathing - jf pertinent:
- onset
- provoking factor
- quality
- recurrence and what treatment provides relief
- severity
- time
Events leading to illness/mechanism of injury
Patient Assessment & Management Focused History And Physical Examination/
Responsive Medical/Minor Trauma Patient
Page 2 of 2

Obtain personal and past medical history:
Age
Weight
Under physician's care/Private medical doctor
Pertinent history
Allergies
Medications
Last oral intake - if pertinent

Assess vital signs:
Cardiac status
- pulse - rate, rhythm, quality
- ECG reading - if indicated and available
Respiratory status
- respirations - rate, effort, tidal volume
- breath sounds
Blood pressure
Temperature - if indicated

Examine neurological status
Comprehensive orientation level- person, place,
time, and purpose
Glasgow Coma Scale (GCS) - eyes, motor, verbal
Pupils - size, equality, reactivity, movement - ;findicated
Extremities-circulation, movement, strength,
sensation

Examine injured or affected area
St._Patient_Assessment-Focused-Minor

UNRESPONSIVE MEDICAL I MAJOR TRAUMA PATIENT
The examinee will demonstrate proficiency in performing a focused medical or trauma assessment involving history and a physical
examination and perform initial interventions as necessary.
CONDITION
The examinee will be requested to perform a focused medical or trauma assessment on a simulated patient and perform initial
interventions as necessary. Required equ.ipment will be either next to the patient or brought to the scene by the prehospital provider.
EQUIPMENT
pressure cuff, pen light, timing device, clipboard, pen, long steeves, goggles, masks, gown, gloves.
100% accuracy required on all items designated by a box (.) for skills testing and must manage successfully all items indicated by
2nd 3rd (final)

UNRESPONSIVE MEDICAL I MAJOR TRAUMA PATIENT
Perform detailed physical examination
** Manage specific problem or injury
Assess:
Current medical history
OPQRST for pain/respiratory - if indicated
Personal history
Vital signs
Neurological status
St._Patient_Assessment-Focused_Major
Page 1 of 1
ONGOING ASSESSMENT
The examinee will demonstrate proficiency in performing an ongoing medical or trauma assessment and perform interventions as
necessary.
CONDITION
The examinee will be requested to perform an ongoing medical or trauma assessment on a simulated patient and perform interventions
as necessary. Required equipment will be either next to the patient or brought to the scene by the prehospital provider.
EQUIPMENT
Live model or manikin, oxygen tank with flow meter, oxygen tub.ing, BVM device, oxygen mask, nasal cannula, stethoscope, blood
100
0
2nd 3rd (final)
ONGOING ASSESSMENT

STABLE AND PRIORITY PATIENTS
Repeat (every 5 minutes for priority patients and every 15
minutes for stable patients):
Initial assessment
Relevant portion of the focused examination
St. _Patient_Assessment-0ngoin9
Page 1 of 1
PATIENT ASSESSMENT / VITAL SIGNS
BLOOD PRESSURE
The examinee will demonstrate proficiency in obtaining an accurate auscultated and palpated blood pressure reading.
CONDITION
The examinee will be requested to auscultate a systolic and diastolic blood pressure using a live model. The examinee will then be
asked to palpate a systolic blood pressure on a live model. Necessary equipment will be adjacent to the patient.
EQUIPMENT
Live model, large/medium/pediatric sphygmomanometer, stethoscope/dual teaching stethoscope, goggles, mask, gown, gloves.
100
%
Reading must be within +/- 6 mmHg (systolic and diastolic) of examiner=s determination.
2nd 3rd (final)
PREPARATION
Select appropriate size blood pressure cuff
Select an appropriate site:
Upper extremity
Lower extremity
Position the extremity at appropriate level
UPPER EXTREMITY AUSCULTATED BLOOD PRESSURE
PROCEDURE
Place cuff snugly around arm:
Approximately 1" above antecubital space
Center the bladder over the brachial artery
Ensure bulb and tUbing are at bottom of cuff - it
possible
Locate the brachial artery and palpate pulse
Insert the stethoscope earpieces into ears
Place the diaphragm/bell of the stethoscope over the
brachial artery
Inflate cuff rapidly 20-30mmHg above the level where
the pulse sound was obliterated
Deflate cuff 2-4 mmHg/second and note where the first
sound is heard (systolic pressure)
Patient Assessment I Vital Signs: Blood Pressure
Pa e 2 of 2
Continue to deflate cuff 2-4 mmHg/second and note
where the first change in tone is heard (diastolic pressure)
where the sound disappears entirely (absolute
diastole) - if sound continues to be heard
LOWER EXTREMITY AUSCULTATED BLOOD PRESSURE
PROCEDURE
Place cuff snugly around thigh:
Approximately 1
11
above knee
Center the bladder over the popliteal artery
Ensure bulb and tubing are at bottom of cuff it
possible
Locate the popliteal artery and palpate pulse
Insert the stethoscope earpieces into ears
Place the diaphragm/bell of the stethoscope over the
popliteal artery
Inflate cuff rapidly 20-30 mmHg above the level where the
auscultated pulse sound was obliterated
sound is heard (systolic pressure)
where the last distinct sound is heard (diastolic pressure)
PALPATED BLOOD PRESSURE
PROCEDURE
Place cuff snugly around arm:
1
11
above antecubital space
Center the bladder over the brachial artery
Ensure bulb and tubing are at bottom of cuff - it
possible
Locate and palpate pulse at the brachial or radial artery
Inflate cuff rapidly to 20-30mmHg above the level where
the palpated pulse is obliterated
beat is felt
ONGOING ASSESSMENT
$ Reassess auscultated or palpated blood pressure as
required:
Priority patients every 5 minutes
Stable patients every 15 minutes
DOCUMENTATION
Blood pressure reading
Site used
Patient' position
51. Patient Assessment-VS-BP
PATIENT ASSESSMENT /VITAL SIGNS
BLOOD PRESSURE
DEFINITIONS:
Blood pressure - measurement of force applied against the walls of the arteries as the heart pumps blood through the
body. Determined by stroke volume (amount of blood ejected into the arterial system with one ventricular
contraction)r heart rate, and peripheral vascular resistance (BP=combination of SV, HR, and PVR)
Pulse pressure - is defined as the difference in pressure between the systolic and diastolic pressure. This diagnostic information
is important in certain conditions:
- widening pulse pressure may indicate increased intracranial pressure
narrowing pulse pressure may indicate cardiogenic, hypovolemic and other forms of shock which have a
decreasing systolic pressure
Korotkoff's sounds - pulse sounds that are heard as sharp tapping or knocking sounds at each ventricular contraction. These
sounds are caused by an inflated blood pressure cuff partially occluding blood flow through an artery.
NOTES:
Blood Pressure Readings:
- The first sound is when blood initially flows through the artery and is called the systolic pressure.
- The second sound is when there is a change (muffled) in sound or the sound disappears. Th is occurs when the pressure in the cuff
falls below the pressure in the artery. This is considered the diastolic pressure.
- The third sound is when the sound disappears completely (if still heard beyond the diastolic change). This occurs when the blood
flows freely through the artery and is considered the Aabsolute diastole@.
A palpated blood pressure is NOT preferred. Only provides a systolic pressure and does not provide a diastolic pressure which may
provide important additional diagnostic information. Should only be used when environmental noise overrides auscultation. An
auscultated pressure should always be attempted initially and ASAP during the ongoing assessment.
Brachial artery provides the most accurate reading and can be palpated down to approximately 70mmg/Hg while the radial artery is no
longer palpable below 80mmHg.
Lower extremity systolic pressure may be 10-40 mm/Hg higher than upper extremities. The diastolic pressure may be the same or
lower than the arm. (Should be attempted if unable to use upper extremities.)
If the first sound is missed, deflate the cuff completely and wait 30 seconds before re-inflation to prevent venous congestion.
Sometimes the blood pressure should be taken in both arms, such as with the com plaint of chest pain radiating to the back, this might
provide information regarding a possible aortic dissection.
Hypertension in adults is when the systolic pressure is sustained> 140mmHg OR diastolic pressure> 90mmHg. However, patients
with chronic hypertension may be in shock when pressures drop below their normal and are considered adequate for non-hypet1ensive
patients.
Normal systolic blood pressure parameters Systolic blood pressures denoting hypotension when
associated with signs and symptoms of shock
Newborn
Infant
Child
Adult
50-70
80-100
80-110
90-140
Males
Females
Children
< 90 Systolic
< 80 Systol ic
< 70 Systolic
Common Pitfalls
Situation Results
Cuff is too large
Cuff is too small
Center of the bladder is not over the brachial artery
Cuff is deflated too slowly
Cuff is over inflated
false low reading
false high reading
inaccurate reading
causes venous congestion = false high reading
causes vasospasms/pain =false high reading
Patient Assessment I Vital Signs: Blood n " ' ~ " ' ~ '"
Page 2 of 2
Documentation
Readings Written
Two sound readings systolic/diastolic (120/72)
Three sound readings systolic/diastolic/final diastolic change (124/72/40).
Palpated reading systolic/palpated (90/P).
In some situations the diastolic sound may not disappear completely and is recorded as systolic/zero (72/0).
nfo._Patient_Assessment-VS-BP
ORTHOSTATIC
The examinee will demonstrate proficiency in obtaining accurate orthostatic vital signs.
SKILLS PREREQUISITE
The examinee must be proficient in taking a blood pressure and pulse w.ith the patient lying supine, sitting and standing.
CONDITION
The examinee will be requested to obtain accurate orthostatic vital signs on a 34 year old female who is complaining of abdominal pain
and vomiting for 2 days. Initial blood pressure and pulse are normal. Capillary refill is 3 seconds. The patient is pale and lying on the
couch with head propped up on 2 pillows. Necessary equipment will be adjacent to the patient.
EQUIPMENT
Live model, large/medium sphygmomanometer, stethoscope/dual teaching stethoscope, timing device, gloves.
100% accuracy required on all items designated by a box (_) for skills testing. Items identified by the symbol ($) must be practiced but
is not a required test item.
Reading must be within +/- 6 mm/Hg for blood pressure and +/- 4 beats/minute for pulse of examiner=s determination.
2nd 3rd (final)
Have patient lie supine for at least 1 minute:
Auscultate blood pressure
Assess pulse for rate, quality, and regularity
Have patient sit for 1 full minute:
Have patient stand for 1 full minute:
ONGOING ASSESSMENT
Reassess auscultated blood pressure as required:
DOCUMENTATION
Blood pressure site used
Blood pressure and pulse readings
(lying, sitting, standing)
St._Patient_Assessment-VS-Orthostatic
ORTHOSTATIC
PURPOSE:
To assess potential for hidden blood loss or decrease in circulating blood volume.
INDICATION:
Suspicion of possible hypovolemia in patients who have a normal blood pressure and pulse rate.
CONTRAINDICATIONS:
Hemorrhage/hypovolemia
Altered level of consciousness
Possible spinal injury
Signs of inadequate perfusion - weakness, dizziness, syncope
Signs of decreased circulating volume
Patients with irregular pulse or bradycardia
NOTES:
Orthostatic vital signs are also known as postural vital signs or tilt test. This is a diagnostic procedure and not pertinent
for field assessment.
Orthostatic vital signs are normally performed in 3 steps: lying =sitting =:standing.
A decrease of 10-20mm/Hg in either the systolic or diastolic pressure, or an increase of 10-20 beats/minute in the pulse
rate represents positive orthostatic changes. Physicians and text sources vary as to V\l1at values are considered
positive, therefore 10-20 range is given.
Only one factor, a decrease of the systolic or diastolic blood pressure or an increase in the pulse, is required to
determine a positive orthostatic change.
Patients with positive orthostatic changes should be suspected of having hidden blood loss and transported to the
hospital for further evaluation.
It is important to obtain a medical history as to medications because patients on calcium channel or beta blockers may
not have the ability to raise their pulse rate.
Info._Patient Assessment-VS-Orthostatic
Page 1 of 1
PATIENT ASSESSMENT I VITAL SIGNS
PULSE
The examinee will demonstrate proficiency in performing an accurate pulse assessment.
CONDITION
The examinee will be requested to perform an accurate pulse assessment on a patient who answers all questions and follows
commands. The patient may be either seated in a chair or lying supine. The examinee will assess the radial pulse while the examiner
assesses the opposite radia I or brachial pulse to determine the accuracy of the assessment. Necessary equipment will be adjacent to
the patient.
EQUIPMENT
Live model, timing device, stethoscope, goggles, mask, gown, gloves.
Appropriate body substance isolation precautions must be ins tituted.
Reading must be within +/- 4 beats/minute of examiner=s determination.
NAME DATE __/__/__
EXAMINER(S) _
2nd 3rd (final)
PREPARATION
No Comments Skill Component Yes
Locate the most common arterial points:
Central
- carotid
- femoral
- apical
Peripheral
- brachial
- radial
- ulnar
- popliteal
- tibial (posterior tibial)
- pedal (dorsalis pedis)
INITIAL ASSESSMENT
Yes No Comments Skill Component
Assess pulse:
Rate (normal, fast, slow)
Rhythm/Regularity
Quality/Strength
** Consider cardiac monitor - if pulse is irregular
FOCUSED ASSESSMENT
Assess pulse:
Rate (beats/minute)
Rhythm/Regularity
Quality/Strength
ONGOING ASSESSMENT
Skill Component
$ Repeat pulse assessment:
Every 5 minutes for priority patients
Every 15 minutes for stable patients
Yes No Comments
$ Re-assess pulse:
Rate (beats/minute)
Rhythm/Regularity
Quality/Strength
DOCUMENTATION
Rate (beats/minute)
Rhythm/Regularity
Quality/Strength
ECG reading - jf applicable
St._Patient_Assessment-VS-Pulse
PULSE
DEFINITIONS:
Rate - number of heart beats per minute:
Initial assessment - determine if fast or slow, rate is not counted during the initial assessment
- Focused/Ongoing assessment - rate can be calculated by counting for 15 seconds and multiplying by 4. A six (6) second pulse
count is NOT acceptable due to inaccuracy of the count and mathematical errors.
Rhythm/Regularity - heart rhythm may be either regular or irregular. The rhythm may be either regularly-irregular or irregularly
irregular.
- Regular rhythm - consistent interval between beats
- Irregular rhythm - a beat may be early, late or missed. An irregular pulse should be counted for 1 full minute.
* All irregular rhythms are considered abnormal rhythms until proven otherwise. The young and athletes have commonly
regularly-irregular pulses as a normal event called sinus arrhythmia. Pulse accelerates with inspiration and slows with expiration.
Quality/Strength - determines the feel of the pulse and described as: strong, full or bounding, weak or thready
Normal Pulse
Rate
Quality/Strength
Strong normal
Full/bounding stronger than normal
Weak/thready difficult to feel
Palpated Pulse in Relation to Blood Pressure
(Adults)
Radial approximately .2: 80 Systolic
Brachial approximately.2: 70 Systolic
Femoral approximately.2: 70 Systolic
Carotid approximately
~
60 Systolic
(pressure is lost in order indicated from radial to carotid)
Adult 60-100
Child 80-120
Infant 90-160
COMMON CAUSES OF ABNORMAL PULSE RATE OR RHYTHM
Tachycardia Bradycardia
I
Irregular Rhythm
Heart disease Electrolyte imbalance
Organophosphates Conduction defects
Calcium channel or beta blocking Cardiac damage (MI)
agents Drug/Chemical ingestion or exposure
Vagal response Hypoxia
Myocardial infarction Alteration in body temperature
Pain
Intracranial pressure
CNS depressing drugs/medications
Athletic conditioning
Hypothermia
Exercise
Hypoxia
Fever
Infection
Hypovolemia
Hyperthyroidism
Emotional upset
Stimulating drugs/medications
Myocardial infarction
Pain
Hyperthermia
Note:
10-15
%
of pedal pulses are difficult to find. Check other signs of circulation. Mark pulses with an "X" if located.
tnfo._Patient_Assessment-VS-Pulse_OS07
Page 1 of 1
RESPIRATIONS I BREATHING
The examinee will demonstrate proficiency in performing an accurate respiratory assessment.
CONDITION
The examinee will be requested to perform an accurate respiratory assessment for the initial, focused and/or ongoing assessment. The
patient is able to answer all questions and follow commands. The patient may be either seated in a chair or lying supine. The examiner
will assess respirations with the examinee to determine the accuracy of the assessment. Necessary equipment will be adjacent to the
patient.
EQUIPMENT
Live model, timing device, goggles, mask, gown, gloves.
100
%
Reading must be within +/- 2 breaths/minute of examiner=s determination.
IPASS I I FAIL I
PREPARAliON
** Place a mask on the patient - if suspected airborne
disease
** Place mask on patient and a HEPA respirator on
rescuer - if sus,pected tuberculosis
INITIAL ASSESSMENT

Observe or feel for rise and fall of chest or abdomen
Assess respirations/Manage breathing:
Rate (normal, fast, slow)
Effort/Quality
Tidal volume
** Consider O
2
therapy
Assess breath sounds (rapid chest auscultation) - it
difficultv breathing or shortness of breath
Patient Assessment I Vital Signs: Respirations / Breathing
Pa e 2 of 2
FOCUSED ASSESSMENT
Observe or feel for rise and fall of chest or abdomen
Rate (respi rations/m inute)
Effort/Quality
Tidal volume
Rhythm/Pattern (regular/irregular)
** Consider O
2
therapy
** Place a mask on the patient - if suspected airborne
disease and not alreadv done
** Place mask on patient and a HEPA respirator on
rescuer - if suspected tuberculosis and not alreadv
done
$ Repeat respiratory assessment:
Every 5 minutes for priority patients
Every 15 minutes for stable patients
$ Observe or feel for rise and fall of chest or abdomen
$ Re-assess/Manage breathing:
Rate (respirations/minute)
Effort/Quality
Tidal volume
Rhythm/Pattern (regular or irregular)
** Consider O
2
therapy
$ Re-assess breath sounds (3 bilateral anterior or
posterior fields) - if difficultv breathing or shortness of
breath
DOCUMENTATION
- rate (respirations/minute)
- effort/quality
- tidal volume
- rhythm/pattern (regular or irregular)
Breath sounds
Oxygen administration:
- oxygen fiter flow
- ventilation rate
St. _Patient_Assessment-VS-Respirati 0 ns
DEFINITIONS:
Accessory muscles - muscles used when a patient has difficulty breathing. They include the shoulder muscle (trapezius); neck
muscles (sternocleidomastoid and scalenus ); chest muscles (pectoralis and intercostals); and abdominal muscles.
Dyspnea - subjective feeling of shortness of breath - usually associated with heart or lung disease! but occurs normally with
intense physical activity or in high altitudes.
Inspiratory: Expiratory ratio (I:E ratio) - this ratio is time of inspiration to time of expiration. The active inhalation phase lasts 1/3
the time of the passive exhalation phase. It takes longer to exhale than to inhale. If the rate of breathing increases, the ratio may
change to 1:2 or 1: 1 depending on the rate. In patients with COPD and asthma! air trapping occurs and to exhale completely the
ratio may increase to 1:4.
Respiration (ventilations) - in normal breathing each breath includes 2 phases; inspiration and expiration
Tripod position - abnormal position to keep airway open. The patient is in a sitting position leaning forward on both arms and
demonstrates a conscious effort to breathe
NOTES:
The amount of air exchange that occurs is dependent on the rate and the tidal volume.
Respiratory rate can be calculated by counting for 30 seconds and multiplied by 2. Abnormal pattern should be counted for 1 full
minute.
Respiratory rate> 40 or < 10 may not provide adequate tidal volume. Be prepared to assist with bag-valve-mask ventilation if
level of consciousness is decreased.
An adult patient breathing slower than 10 breaths/minute or faster than 24 breaths/minute should be evaluated for inadequate
breathing.
Signs of respiratory distress:
- respiratory rate slower than 10 breaths/minute or greater than 24 breaths/minute
- intercostal and sternal retractions
- pale! cyanotic, or cool (clammy) skin
- abnormall:E ratio
- abnormal respiratory pattern
- decreased, unequal or abnormal lung sounds
- labored breathing
- shallow or uneven chest rise and fall
- unable to speak in complete sentences between breaths (only 2-3 words at a time)
Type of Respirations Characteristics Possible Cause
Normal/Adequate Breathing is ordinary - neither deep or shallow Normal respirations
Shallow Slight movement of the chest or abdomen Respiratory depression! chest wall injury, pleuritic
pain
Labored Increased effort of breathing, use of accessory
muscles! *nasal flaring, *intercostal retractions,
* sternal retraction
* mostly seen in infants and children
Respiratory insufficiency and failure
(In infants and children, cardiac arrest ;s most
commonly caused by respiratory arrest)
Noisy Snoring, wheezing! gurgling, crowing and stridor Partial airway obstruction from a foreign object!
swelling! neck position, fluid in the lungs, or
constriction of the airways
Patient Assessment/Vital Signs: Respirations I Breathing
Page 2 of 2
(Continued)
Tidal Volume Normal Respiratory Rates Accessory Muscles
Normal/Adequate
Increased
Shallow (decreased)
Adults 12-20
Child 15-30
Infants 25-50
Newborn 30-60
Adults
Trapezius (shoulder) {assist with inspiration]
Sternocleidomastoid (neck) [assist with inspiration]
Scalenus (neck) {assist with inspiration]
Abdominal [assist with expiration]
Pediatric
Intercostal retractions
Sternal retractions
Children retract in severity from the bottom up
Respiratory Patterns Respirations Definition
Norma!
Mf\fWVV\M
Air-tfOpplf1g
~
Eupnea Normal breathing
BrodyPfleo
Tachypnea
Hyperventilahon
lhyperpneoJ
fVVVV\
Cheyne-Stokes
~
~
..
Kussmaul
~
BioI's
!\f\-..-I\..J\.
Bradypnea Slower than normal rate
Apnea No breathing
Tachypnea Faster than normal rate
Hyperventitation
(hyperpnea)
Increased rate and/or depth
(faster and/or deeper than normal
respirations)
Ataxic Irregularly - irregular
Sighing
~
Alox;c
~
Biot's Irregular with periods of apnea
(similar to but not as regular as
Cheyne Stokes)
Cheyne-Stokes Regular increase and decrease in
depth followed by a period of
apnea
Kussmaul Rapid, regular deep respirations
caused by diabetic ketoacidosis or
other metabolic acidosis
Central Neurogenic Hyperventilation Pattern similar to Kussmaul but
caused by increased intracranial
pressure (head injury)
Air trapping Prolonged but inefficient expiratory
effort, commonly seen in COPO or
asthma
Sighing An occasional deep, audible
inspiration that is insignificant
Info. Patient Assessment-VS-Respirations
PATIENT ASSESSMENT
PEDIATRIC EMERGENCY TAPE - BROSELOW
The examinee will demonstrate proficiency in the use of a Pediatric Emergency Tape (within their scope of practice) to determine color
code, weight, drug dosages, and size of equipment for a simulated pediatric patient.
CONDITION
The examinee will be asked to determine the weight drug dosage, and/or correct size of equipment for a pediatric patient who is either in
a standing or supine position using the Pediatric Emergency Tape. Necessary equipment will be adjacent to the patient.
EQUIPMENT
Simulated pediatric patient or infant/child manikin, Pediatric Emergency Tape, goggles, masks, gown, gloves.
100
%
accuracy required on all items designated by a box (_) for skills testing. Items identified by the symbol ($) must be practiced but
NAME DATE __,__,__
EXAMINER(S) _
2nd 3rd (final)
PREPARATION
_ Place patient in position for optim al evaluation of body
length or height:
Supine
Standing
_ Remove tape from package
Locate red end of tape and measure from this end
PROCEDURE
Partially unfold tape with the multi-colored strips and kg
markings visible to rescuer
Place red end of tape even with the most stable end of
patient=s body:
Supine -- at top of head
Standing -- at the heel of the foot
Hold red end of tape even with the starting point unfurl
tape and stop at the:
Heel - if supine
Head - if standing
Note the colored strip and the colored zone that is even
with the top of the head or at the bottom of the heel.
Patient Assessment: Pediatric Emergency Tape - Broselow
Pa e 2 of 2
Skill Component
Read:
Color zone on the side of the tape
Kg weight
Use weight range to calculate correct drug dosages - it
a lie Ie and within S 0 e of raetice.
Use the colored zone to identify the correct size of
equipment - if applicable.
Yes No Comments
Color zone
Kg in color zone
Weight given by caregiver
St. Patient-Assessment-Broselow-0507
PATIENT ASSESSMENT
PEDIATRIC EMERGENCY TAPE - BROSELOW
PURPOSE:
To estimate weight, drug dosages and correct size of equipment for pediatric patients up to 36kg (79Ibs).
INDICATION:
All infants and children smaller or equal to length of tape.
NOTES:
The starting or ending point of the foot is the heel, not the extended foot or toes.
If the child is longer than the tape, stop and estimate weight by using other techniques, i.e.
Child's weight = 2kg x age in years + 10kg
Only pediatric resuscitation drugs for shock, hypoglycemia or cardiac arrest are listed on the tape. Other
emergency pediatric drugs are not listed.
PREHOSPITAL DRUGS ON TAPE PREHOSPITAL DRUGS NOT ON TAPE
Atropine
Calcium Chloride
D
2s
W
Diazepam
Dopamine Infusion
Epinephrine
Lidocaine
Naloxone
Sodium Bicarbonate
Albuterol
Adenosine
Charcoal
Dextrose (Oral)
Diphenhydramine
Epinephrine for Anaphylaxis and Asthma
Glucagon
Morphine
Info._Patient_Assessment-Broselow
Page 1 of 1
PATIENT ASSESSMENT
CHEST AUSCULTATION
The examinee will demonstrate proficiency in performing rapid and/or comprehensive auscultation of the anterior and posterior breath
sounds.
CONDITION
The examinee will be requested to auscultate anterior and posterior breath sounds and perform rapid chest auscultation in critical
situations using alive model or respiration simulator. Necessary equipment will be adjacent to the patient.
EQUIPMENT
Live model or respiration simulator, stethoscope/dual teaching stethoscope, goggles, mask, gown, gloves.
100
%
accuracy required on all items designated by a box (.) for skills testing. Items identified by the symbol ($) must be practiced but
NAME DATE __1__' __ EXAMINER(S) _
2nd 3rd (final)
PREPARATION
Direct patient to breathe deeply in and out through open
mouth when ready to listen at specific areas
Place diaphragm of stethoscope directly on patient=s
skin over auscultation site
RAPID AUSCULTATION
PROCEDURE
Listen for presence and equality of bilateral breath
sounds only:
Instruct patient to take a deep breath - if responsive
Listen at 5ttl - 6
th
intercostal space mid-axillary line
ANTERIOR CHEST AUSCULTATION
PROCEDURE
Yes No Comments Skill Component
Listen to a minimum of 3 bilateral anterior fields:
Apices - 1 inch below the clavicle at mid-clavicular
line
Mid-lung fields - 3rd-4th res at mid-clavicular line
Bases - 6
th
intercostal space at midaxillary line
POSTERIOR CHEST AUSCULTATION
PROCEDURE
Listen to a minimum of 3 bilateral posterior fields:
Apices - vertebral border at the level of T-3 (3
rd
rib)
Mid-lung fields - inferior angle of the scapula
Bases - 3 finger breadths below the inferior angle of the
scapula at the level of the diaphragm (approx. 10
th
rib)
ONGOING ASSESSMENT
$ Auscultate anterior or posterior breath sounds as
required:
DOCUMENTATION
Initial and ongoing breath sounds:
- type of sounds heard
- absent sounds
Location of auscultation (anterior or posterior)
Site of sounds heard - if abnormal
St. Patient-Assessment-Chest Auscultation-050?
PATIENT ASSESSMENT
CHEST AUSCULTATION
DEFINITIONS:
Adventitious - abnormal sounds. Result from obstruction of either the large or small airways and are most commonly heard on
inspiration - crackles, wheezes and rhonchi.
Atelectasis - a collapse or airless condition of the lung. May be caused by obstruction, hypoventilation, mucus plugs or
excessive secretions.
Bronchial -sounds heard over a major bronchus; harsh, high-pitched with an equal inspiratory and expiratory phase.
Death Rattle - Audible rales heard without a stethoscope. Usually heard as patient is dying.
Lobectomy- The surgical removal of a lobe of the lung or any organ.
Tracheal - sounds heard over the trachea; loud and high-pitched with a pause between inspiratory and expiratory phase
(expiratory phase slightly longer).
Vesicular - normal breath sounds heard all over the chest distal to the central airways; soft sound and is primarify an inspiratory
sound. May be diminished in older, obese, or very muscular patients. Harsher sounds heard if ventilations are rapid and deep
or in children due to their thin, elastic chest walls.
BREATH SOUNDS OTHER TERMS DESCRIPTION
Normal Clear Clear and quiet breath sounds heard during inspiration and expiration - louder
during inspiration.
Rales Crackles
Crepitation
Wet
Crackling, popping sound produced by air passing over airway secretions/fluid or
the sudden opening of collapsed airways. May be coarse or fine and heard usually
on inspiration but can be heard on expiration - louder during inspiration.
Rhonchi Sonorous rales
Congested
Low- pitched continuous rumbling, snoring sound produced by narrowing of the
larger airways due to thick secretions or muscle spasms. Sonorous wheezing
sound may be heard on inspiration or expiration (usually expiration). This often
clears or changes with coughing.
Wheezes Musical rales High-pitched continuous sound produced by narrowing of the smaller airways.
Whistling sound may be heard on inspiration or expiration - louder during
expiration. More severe if heard on inspiration.
Stridor Crowing Brassy, crowing sound produced by obstruction in the upper airways. May be
caused by epiglottitis, viral croup, or foreign body - most prominent on inspiration.
Heard best over the larynx or trachea.
NOTES:
Firm pressure is necessary to eliminate friction sounds of chest hairs rubbing against stethoscope.
Breath sounds are heard more prominently at the mid-lung field because the lungs are smaller at the apices and bases.
Compare sounds heard bilaterally and listen to both the inspiratory and expiratory phase.
DO NOT listen to breath sounds over clothing. This results in significant alteration of sounds heard.
If rales are suspected, but difficult to hear, have patient cough to clear secretions.
As patients become more severe, breath sounds may cross over and a combination of sounds may be heard or one sound
obliterated by another.
May combine auscultation of anterior and posterior fields as necessary to ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ y - - - " - - - - _
Patient Assessment: Chest Auscultation
Page 2 of 2
Auscultation sites:
Anterior:
Apices - 1 inch below the clavicle at mid-clavicular line
Mid-lung fields - 3rd-4th ICS at mid-clavicular line
Bases - 6
th
intercostal space at midaxillary line
Posterior:
Apices - vertebral border at the level of T-3 (3
rd
rib)
Mid-lung fields - inferior angle of the scapula
Bases - 3 finger breadths below the inferior angle of the scapula at the level of the diaphragm (approx. 10
th
rib)
Info._Patient_Assessment-Chest_Auscultation
Page 2 of 2
SOFT TISSUE INJURY I BANDAGING
ABDOMINAL EVISCERATION
The examinee will demonstrate proficiency in applying a dressing to an open abdominal injury with evisceration of intestines.
CONDITION
The examinee will be requested to assess and dress an open abdominal injury with evisceration of intestines. The patient has
sustained an open abdominal injury with evisceration of intestines. Necessary equipment will be adjacent to the patient.
EQUIPMENT
Manikin or live model, bag-valve-mask device, O
2
connecting tubing, oxygen source with flow regulator, stethoscope, blood pressure cuff,
pen light, timing device, 4
11
x4" dressings, large tap dressings, occlusive dressings, tape, clipboard, pen, goggles, masks, gown, gloves.
100
0
double asterisks (**) .. Documentation, identified by the symbol ($), must be practiced but is not a required test item.
2nd 3rd (final)
PREPARATION
Yes Skill Component No Comments
Assess type of bleeding:
Arterial
Venous
Capillary
Remove enough clothing to expose entire wound
PROCEDURE
Skill Component Comments No Yes
Soak large sterile dressing with sterile saline
Place moist dressing over wound
Apply an occlusive dressing over the moist dressing - if
time permits and available
** Consider rapid transport if patient is critical
Secure the dressing by:
Taping around all four sides
OR
Cravats tied above and below the position of the exposed
organ
Soft Tissue Injury I Bandaging: Abdominal Evisceration
Pa e 2 of 2
Maintain warmth of eviscerated organs by covering moist
or occlusive dressing with:
Layers of bulky dressings
Lint-free towels
Flex patient's legs and knees - if no suspected spinal
injury
ONGOING ASSESSMENT
Yes No Skill Component Comments
Initial assessment
DOCUMENTATION
S Verbalize/Document:
Mechanism of injury
Treatment provided
1St. Soft-Tissue-Evisceration-0507
SOFT TISSUE INJURY / BANDAGING
ABDOMINAL EVISCERAliON
NOTES:
The exposed organs must be covered with a moist dressing and kept warm because an open abdominal cavity radiates body heat
exposed organs lose fluid rapidly.
Sterile or tap water should never be used to wet dressings because the water is hypotonic and will draw water into cells resulting in
destruction.
Flexing the patient's legs and knees relieves pressure on the abdominal musculature.
Dry dressings adhere and dry out normally moist tissues which causes further destruction and necrosis of the exposed organs.
DO NOT touch or try to replace any eviscerated organ.
DO NOT delay transport to apply an occlusive dressing, this is only necessary if there is a possibility of long field or transport time.
healthcare provider should frequently check to see that dressings remain moist and if necessary wet them as needed.
DO NOT use any material that is adhering or loses substance when wet.
DO NOT use aluminum foil, this may cause laceration of the eviscerated organ. Occlusive dressings consist of clear plastic
nfo._Soft_Tissue-Evisceration_0507
age 1 of 1
------
------
Patient Assessment/Management - Medical
Start TIme:
Stop Time: Date:
Candidate's Name:
Evaluator's Name: Points Points
Possible Awarded
Takes. 01' verbalizes. body substance isolation precautions 1
SCENE SIZE.lJP
Determines the scene is safe 1
Determines the mechanism of injury/nature of illness 1
Determnes the number of patient. 1
Requests additional help if necessary 1
Considers stabilization of spine 1
INITIAL ASSESSMENT
Verbalizes general impression of the patient 1
Determines responsivenessltevel of consciousness 1
Determi nes chief complaint/apparent life threats 1
Assessment 1
Indicates appropriate oxygen therapy Assesses airway and breathing 1
Assures adequate ventilation 1
Assesses/controls major bleeding 1
Assesses pulse 1 Assesses circulation
Assesses akin (color, temperature and condition) 1
Identifies priority patients/make. transport decisions 1
FOCUSED ..STORY AND PHYSICAL EXAMINA110NIRAPID ASSESSMENT
Signs and symptoms (Assess hist 'KY d present illness) 1
Respiratory C.rdlac AlterN Mental Allergic Poisoning! Environmental Obstetrics Behavioral
Status R.actlon Ov.rdo Emergency
Onset? Onset? -Oesaiption of -History of -Substance? -Source? -Are you pregnant? -How do you feel?
-Provokes? Provokes? the episode. allergies? VVhen did you -Environment? -How long have you -Determine
Quality? -Quality? -Onset? -VJ'hat were ingestlbecome -Duration? been pregnant? suicidal
-Radiates? -Radiates? eDuration? you exposed exposed? -Loss of -Pain or tendencies.
-Seventy? -Severity? -Associated to? -How much did consciousness? contractions? -Is the patient a
-Time? -Time? Symptoms? -How were you ingest? -Effects -Bleeding or threat to self or
Interventions? -Interventions? -Evidence of you -Over what time general or discharge? others?
Trauma? exposed? period? local? -Do you feet the Is there a medicat
-'nterventions? -Effects? -Interventions? need to push? problem?
-Seizures? -Progression? -Estimated -Last menstrual Interventions?
-Fever? -Interventions? weight? I period?
Allergies 1
Medications 1
Past pertinent history 1
Last oral intake 1
1 Event leading to present illness (rule out trauma)
1
if indicated, complete. r a ~ d assessment)
Vitals (obtains baseline vital signs)
Performs fOQJsed physical examination (assesses affected body part/system or.
1
Interventions (obtains medical diredion or verbalizes standing order fOf' medication interventions 1
and verbalizes proper additional interventionltreatment)
,
Transport (re-evaluates the transport decision)
Verbafizes the consideration for completing 8 detailed physical examin8tfan 1
ONGOING ASSESSMENT (verblllzedl
Repeats initiaf assessment 1
Repeatl vital signs 1
,
Repeats focused assessment regarding patient complaint or injuries
30 Critical Crft8ri. Total:
______Did not take. or verbalize. body substance isol_ion precautions when necessary
______Did nol determine scene safety
______Did not obtain medicaJ diredion or verbalize standing orders for medical interventions
______Oid nol provide high concentration of oxygen
______Did not find or manage problems associated with airway, breathing, hemorrhage or shock (hypoperfusion)
______Did not differentiate patient's need for transportation versus continued assessment 81 the acene
______Oid detailed or focused histOf)'/physical examination before assessing the airway. breathing and drculation
______Oid not ask questions about the present illness
Adrnnistered a dangerous or inappropriate intervention
1
Patient Assessment/Management Trauma
Start Time:
Stop Time: Date:
Candidate's Name:
Evaluator's Name:
Points Points
Possible Awarded
Takes, or verbalizes. body substance isolation precautions
1
SCENE SIZE-UP
Determines the scene is safe
Determines the mechanism of injury
Determines the number of patients
Requests additional help if necessary
Considers stabilization of spine
INITIAL ASSESSMENT
Verbalizes general impression of the patient
1
1
1
1
1
1
Determines responsivenessllevel of consciousness 1
Determines chief complaint/apparent life threats 1
Assessment 1
Assesses airway and breathing Initiates appropriate oxygen therapy 1
Assures adequate ventilation 1
Injury management 1
Assesses/controls major bleeding 1
1 Assesses circulation Assesses pulse
Assesses skin (cofor. temperature and conditions) 1
Identifies priority patients/makes transport decision 1
FOCUSED HISTORY AND PHYSICAL EXAMINAnoNIRAPID TRAUMA ASSESSMENT
Selects appropriate assessment (focused or rapid assessment) 1
Obtains. or directs assistance to obtain, baseline vital signs 1
Obtains S.A.M.P.L.E. history 1
DETAILED PHYSICAL EXAMINAnON
Inspects and palpates the scalp and ears 1
1
Assesses the facial areas including oral and
Assesses the eyes Assesses the head
1
nasal areas
Inspects and palpates the neck 1
Assesses the neck Assesses for JVD 1
Assesses for tracheal deviation 1
Inspects 1
Palpates 1
Auscultates
Assesses the chest
1
1 Assesses the abdomen
1 Assesses the pelvis Assesses the abdomen/pelvis
1 Verbalizes assessment of genitalia/perineum
as needed
1 point for each extremity 4
includes inspection, palpation, and assessment
of motor, sensory and circulatory function
Assesses the posterior
Assesses the extremities
1 Assesses thorax
1
Manages secondary injuries and wounds appropriately
Assesses lumbar
1
1 point for appropriate management of the secondary InJurylwound
Verbalizes re-assessment of the vital signs 1
Tota,l: 40
Critical Criteria
Did not take, or verbalize, body substance isolation precautions
Did not determine scene safety
Did not assess for spinal protection
Did not provide for spinal protection when indicated
Did not provide high concentration of oxygen
Did not find, or manage. problems associated with airway, breathing, hemorrhage or shock (hypoperfusion)
Did not differentiate patient's need for transportation versus continued assessment at the scene
Did other detailed physical examination before assessing the airway, breathing and circulation
. . ....
D1d not transport patient wlth,n (10) minute time limit
--------
----
CARDIAC ARREST MANAGEMENT/AED
WITH BYSTANDER CPR IN PROGRESS
Start Time:
Stop Time: Date:
Candidate's Name:
Evaluators Name:
Points Points
Possible Awarded
ASSESSMENT
Takes, or verbalizes, body substance isolation precautions
1
Briefly questions the rescuer about arrest events
1
Turns on AED power
1
Attaches AED to the patient
1
Directs rescuer to stop CPR and ensures all individuals are clear of the patient
1
Initiates analysis of the rhythm
1
Delivers shock
1
Directs resumption of CPR
1
TRANSITION
Gathers additional information about the arrest event 1
Confirms effectiveness of CPR (ventilation and compressions) 1
INTEGRATION
Verbalizes or directs insertion of a simple airway adjunct (oraVnasal airway) 1
Ventilates, or directs ventilation of the patient 1
Assures high concentration of oxygen is delivered to the patient 1
Assures adequate CPR continues without unnecessary/prolonged interruption 1
Continues CPR for 2 minutes 1
Directs rescuer to stop CPR and ensures all individuals are clear of the patient 1
Initiates analysis of the rhythm 1
Delivers shock 1
1 Directs resumption of CPR
TRANSPORTATION
Verbalizes transportation of the patient 1
Total: 20
Critical Criteria
____Did not take, or verbalize, body substance isolation precautions
Did not evaluate the need for immediate use of the AED
____Did not immediately direct initiation/resumption of CPR at appropriate times
____Did not assure all individuals were clear of patient before delivering a shock
____Did not operate the AED properly or safely (inability to deliver shock)
____Prevented the defibrillator from delivering any shock
--------
----
----
SPINAL IMMOBILIZATION
SEATED PATIENT
Start Time:
Stop Time: Date:
Candidate's Name:
Evaluator's Name: Points
Possible
Points
Awarded
Takes. or verbalizes, body substance isolation precautions 1
Directs assistant to place/maintain head in the neutral in-line position 1
Directs assistant to maintain manual immobilization of the head 1
Reassesses motor, sensory and circulatory function in each extremity 1
Applies appropriately sized extrication collar 1
Positions the immobilization device behind the patient 1
Secures the device to the patient's torso 1
Evaluates torso fixation and adjusts as necessary 1
Evaluates and pads behind the patient's head as necessary 1
Secure the patient's head to the device 1
Verbalizes moving the patient to a long board 1
Total: 12
----
Critical Criteria
Did not immediately direct, or take, manual immobilization of the head
____Released, or ordered release of, manual immobilization before it was maintained mechanically
____Patient manipulated, or moved excessively, causing potential spinal compromise
____Device moved excessively up. down, left or right on the patient's torso
Head immobilization allows for excessive movement
____Torso fixation inhibits chest rise, resulting in respiratory compromise
____Upon completion of immobilization, head i ~ not in the neutral position
Did not assess motor. sensory and circulatory function in each extremity after voicing
immobilization to the long board
____Immobilized head to the board before securing the torso
----
SPINAL IMMOBILIZAliON
SUPINE PATIENT
Start Time:
Stop Time: Date:
Candidate's Name:
Evaluator's Name: Points
Possible
Points
Awarded
Takes, or verbalizes, body substance isolation precautions 1
Directs assistant to place/maintain head in the neutral in-line position 1
Directs assistant to maintain manual immobilization of the head 1
Applies appropriately sized extrication collar 1
Positions the immobilization device appropriately 1
Directs movement of the patient onto the device without compromising
the integrity of the spine
1
Applies padding to voids between the torso and the board as necessary 1
Immobilizes the patient's torso to the device 1
Evaluates and pads behind the patient's head as necessary 1
Immobilizes the patient's head to the device 1
Secures the patient's legs to the device 1
Secures the patient's arms to the device 1
Reassesses motor sensory and circulatory function in each extremity 1
Total: 14
Critical Criteria
____Did not immediately direct, or take. manual immobilization of the head
____Released, or ordered release of, manual immobilization before it was maintained mechanically
_____Patient manipulated, or moved excessively, causing potential spinal compromise
____Patient moves excessively up, down, left or right on the device
Head immobilization allows for excessive movement
____Upon completion of immobilization, head is not in the neutral position
____Did not assess motor, sensory and circulatory function in each extremity after immobilization
to the device
____'mmobilized head to the board before securing the torso
---------
---------
-----
BAG-VALVE-MASK
APNEIC PATIENT
Start Time:
Stop Time: Date:
Candidate's Name:
Possible Awarded
Voices opening the airway 1
Voices inserting an airway adjunct 1
Selects appropriately sized mask 1
Creates a proper mask-to-face seal 1
Ventilates patient at proper rate and adequate volume 1
(The examiner must witness for at least 30 seconds)
Connects reservoir and oxygen 1
Adjusts liter flow to 15 liters/minute or greater 1
The examiner Indicates arrival of a second EMT. The second EMT Is Instructed to
ventilate the patient while the candidate controls the mask and the airway
Voices re-opening the airway 1
Creates a proper mask-to-face seal 1
Instructs assistant to resume ventilation at proper rate and adequate volume 1
(The examiner must witness for at least 30 seconds)
Total: 11
Critical Criteria
_____Did not take.. or verbalize, body substance isolation precautions
_____Did not immediately ventilate the patient
Interrupted ventilations for more than 20 seconds
_____Did not provide high concentration of oxygen
_____Did not provide, or direct assistant to provide proper volume/breath or rate
(more than 2 ventilation errors per minute)
_____Did not allow adequate exhalation
--------
--------
----
----
----
BLEEDING CONTROUSHOCK MANAGEMENT
Start Time:
Stop Time: Date:
Candidate's Name:
Possible Awarded
Applies direct pressure to the wound 1
Note: The examiner must now Infonn the candidate that the wound continues to bleed.
Applies tourniQuet 1
Note: The examiner must now Infonn the candidate the patient Is now showing signs
and symptoms Indicative of hypoperfuslon
Properly positions the patient 1
1 Administers high concentration oxygen
1 Initiates steps to prevent heat loss from the patient
1 Indicates the need for immediate transportation
7 Total:
Critical Criteria
____Did not take, or verbaHze, body substance isolation precautions
Did not apply high concentration oxygen
Did not control hemorrhage using correct procedures in a timely manner
Did not indicate a need for immediate transportation
--------
--------
----
IMMOBILIZATION SKILLS
LONG BONE INJURY
Start Time:
Stop Time: Date:
Candidate's Name:
Evaluators Name: Points Points
Possible Awarded
Directs application of manual stabilization of the injury 1
Assesses motor, sensory and circulatory function in the injured extremity 1
Note: The examiner acknowledges "molor, sensory and circulatory function are
present and normal"
Measures the splint 1
Applies the splint 1
Immobilizes the joint above the injury site 1
Immobilizes the joint below the injury site 1
Secures the entire injured extremity 1
Immobilizes the hand/foot in the position of function 1
1
Note: The examiner acknowledges "motor, sensory and circulatory function are
present and normal"
Total
Reassesses motor, sensory and circulatory function in the injured extremity
10
Critical Criteria
____Grossly moves the injured extremity
____Did not immobilize the joint above and the joint below the injury site
Did not reassess motor. sensory and circulatory function in the injured extremity
before and after splinting
--------
-----
Start Time:
Stop Time: Date:
Candidate's Name:
Possible Awarded
Assembles the regulator to the tank 1
Opens the tank 1
Checks for leaks 1
Checks tank pressure 1
Attaches non-rebreather mask to oxygen 1
Prefills reservoir 1
Adjusts liter flow to 12 liters per minute or greater 1
Applies and adjusts the mask to the patient's face 1
Note: The examiner must advise the candidate that the patient is not tolerating the
non-rebreather mask. The medical director has ordered you to apply a nasal cannula
to the patient.
Attaches nasal cannula to oxygen 1
Adjusts liter flow to 6 liters per minute or less 1
1 Applies nasal cannula to the patient
Note: The examiner must advise the candidate to discontinue oxygen therapy
Removes the nasal cannula from the patient 1
Shuts off the regulator 1
Total:
1
15
Relieves the pressure within the regulator
Critical Criteria
_____Did not take, or verbalize, body substance isolation precautions
_____Did not assemble the tank and regulator without leaks
_____ Did not prefill the reservoir bag
Did not adjust the device to the correct liter flow for the non-rebreather mask
(12 liters per minute or greater)
_____Did not adjust the device to the correct liter flow for the nasal cannula
(6 liters per minute or less)
--------
AIRWAY, OXYGEN AND VENTILATION SKILLS
UPPER AIRWAY ADJUNCTS AND SUCTION
Start Time:
Stop Time: Date:
Candidate's Name:
Evaluator's Name:
OROPHARYNGEAL AIRWAY Points
Possible
Points
Awarded
Selects appropriately sized airway 1
Measures airway 1
Inserts airway without pushing the tongue posteriorly 1
Note: The examiner must advise the candidate that the patient is gagging a
becoming conscious
nd
1 Removes the oropharyngeal airway
SUCTION
Note: The examiner must advise the candidate to suction the patient's airway
Turns on/prepares suction device 1
Assures presence of mechanical suction 1
Inserts the suction tip without suction 1
Applies suction to the oropharynx/nasopharynx 1
NASOPHARYNGEAL AIRWAY
Note: The examiner must advise the candidate to insert a nasopharyngeal airway
Selects appropriately sized airway 1
Measures airway 1
Verbalizes lubrication of the nasal airway 1
Fully inserts the airway with the bevel facing toward the septum 1
Total: 13
Critical Criteria
_____Did not take, or verbalize, body substance isolation precautions
_____Did not obtain a patent airway with the oropharyngeal airway
_____Did not obtain a patent airway with the nasopharyngeal airway
_____Did not demonstrate an acceptable suction technique
_____'nserted any adjunct in a manner dangerous to the patient
IMMOBILIZAliON SKILLS
JOINT INJURY
Start Time:
Stop Time: Date:
Candidate's Name:
Possible Awarded
Takes, or verba.lizes, body substance isolation precautions 1
Directs application of manual stabilization of the shoulder injury 1
Note: The examiner acknowledges "motor, sensory and circulatory function are present
and normal."
Selects the proper splinting material 1
Immobilizes the site of the injury 1
Immobilizes the bone above the injured joint 1
Immobilizes the bone below the injured joint 1
Reassesses motor, sensory and circulatory function in the injured extremity 1
Note: The examiner acknowledges "motor, sensory and circulatory function are present
and normal."
Total: 8
Critical Criteria
____Did not support the joint so that the joint did not bear distal weight
_____Did not immobilize the bone above and below the injured site
_____Did not reassess motor, sensory and circulatory function in the injured extremity before
and after splinting
IMMOBILIZATION SKILLS
TRACTION SPLINTING
Start Time:
Stop Time:
Candidate's Name:
Date:
Possible Awarded
Directs application of manual stabilization of the injured leg 1
Directs the application of manual traction 1
present and normal"
Prepares/adjusts splint to the proper length 1
Positions the splint next to the injured leg 1
Applies the proximal securing device (e.g .. ischial strap) 1
Applies the distal securing device (e.g.. ankle hitch) 1
Applies mechanical traction 1
Positions/secures the support straps 1
Re-evaluates the proximal/distal securing devices 1
Reassesses motor, sensory and circulatory function in the injured extremity 1
present and normal"
Note: The examiner must ask the candidate how he/she would prepare the
patient for transportation
Verbalizes securing the torso to the long board to immobilize the hip 1
Verbalizes securing the splint to the long board to prevent movement of the splint 1
Total: 14
Critical Criteria
_____Loss of traction at any point after it was applied
_____Did not reassess motor, sensory and circulatory function in the injured extremity before
and after splinting
_____The foot was excessively rotated or extended after splint was applied
____Did not secure the ischial strap before taking traction
_____Final immobilization failed to support the femur or prevent rotation of the injured leg
_____Secured the leg to the splint before applying mechanical traction
Note: If the Sagar splint or the Kendricks Traction Device is used without elevating the patient's leg, application
of manual traction is not necessary. The candidate should be awarded one (1) point as if manual traction were
applied.
Note: If the leg is elevated at all, manual traction must be applied before elevating the leg. The ankle hitch may
be applied before elevating the leg and used to provide manual traction.
--------
MOUTH TO MASK WITH SUPPLEMENTAL OXYGEN
Start Time:
Stop Time: Date:
Candidate's Name:
Possible Awarded
Takes, or verbalizes
l
body substance isolation precautions 1
Connects one-way valve to mask 1
Opens patient's airway or confirms patient's airway is open 1
(manually or with adjunct)
Establishes and maintains a proper mask to face seal 1
Ventilates the patient at the proper volume and rate 1
Connects the mask to high concentration or oxygen 1
Adjusts flow rate to at least 15 liters per minute 1
Continues ventilation of the patient at the proper volume and rate 1
Note: The examiner must witness ventilations for at least 30 seconds
Total: 8
Critical Criteria
_____Did not take
l
or verbalize, body substance isolation precautions
_____Did not adjust liter flow to at least 15 liters per minute
_____Did not provide proper volume per breath
(more than 2 ventiliation errors per minute)
_____ Did not ventilate the patient at a rate of 10-12 breaths per minute
_____ Did not allow for complete exhalation

Fall 2011 EMT Lectures

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Fall 2011 EMT Lectures

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6/28/2011

Laryngeal Mask Airway (LMA)

Activate the emergency response system or call for

Take body substance isolation precautions

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