Alexanuia Bamilton SmaitReview EMT Review Package Alexandra Hamilton Smart Review Topics: 1. Anatomy and Physiology 2. Vital Signs and History 3. Lifting and Moving Patients 4. Airway Management 5. CPR 6. Scene Size up 7. Initial and Ongoing Assessment 8. Bleeding and shock 12. Dressing and Bandaging 13. Musculoskeletal Injuries 14. Head and Spinal Injuries 15. Allergic Reactions 20. Infants and Children 22. Geriatrics 23. HAZMAT
Alexanuia Bamilton SmaitReview EMT Review Package Alexandra Hamilton Smart Review Topics: 1. Anatomy and Physiology 2. Vital Signs and History 3. Lifting and Moving Patients 4. Airway Management 5. CPR 6. Scene Size up 7. Initial and Ongoing Assessment 8. Bleeding and shock 12. Dressing and Bandaging 13. Musculoskeletal Injuries 14. Head and Spinal Injuries 15. Allergic Reactions 20. Infants and Children 22. Geriatrics 23. HAZMAT
Alexanuia Bamilton SmaitReview EMT Review Package Alexandra Hamilton Smart Review Topics: 1. Anatomy and Physiology 2. Vital Signs and History 3. Lifting and Moving Patients 4. Airway Management 5. CPR 6. Scene Size up 7. Initial and Ongoing Assessment 8. Bleeding and shock 12. Dressing and Bandaging 13. Musculoskeletal Injuries 14. Head and Spinal Injuries 15. Allergic Reactions 20. Infants and Children 22. Geriatrics 23. HAZMAT
Alexanuia Bamilton SmaitReview EMT Review Package Alexandra Hamilton Smart Review Topics: 1. Anatomy and Physiology 2. Vital Signs and History 3. Lifting and Moving Patients 4. Airway Management 5. CPR 6. Scene Size up 7. Initial and Ongoing Assessment 8. Bleeding and shock 12. Dressing and Bandaging 13. Musculoskeletal Injuries 14. Head and Spinal Injuries 15. Allergic Reactions 20. Infants and Children 22. Geriatrics 23. HAZMAT
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The document discusses anatomy, vital signs, patient assessment, trauma care, and ambulance operations.
Supine, prone, right/left lateral recumbent, Fowler's position, and Trendelenberg position are discussed.
The skeletal system including bones of the skull, spine, arms, pelvis, legs, and feet as well as joints and muscles are covered.
Alexanuia Bamilton SmaitReview
EMT Review Package
Alexandra Hamilton
Smart Review
Topics: 1. Anatomy and Physiology 2. Vital Signs and History 3. Lifting and Moving Patients 4. Airway Management 5. CPR 6. Scene Size up 7. Initial and Ongoing Assessment 8. Trauma Assessment 9. Documentation 10. Communication 11. Bleeding and shock 12. Dressing and Bandaging 13. Musculoskeletal Injuries 14. Head and Spinal Injuries 15. Pharmacology 16. Respiratory Emergencies 17. Cardiac Emergencies 18. Diabetic and Altered Mental Status 19. Allergic Reactions 20. OBGYN 21. Infants and Children 22. Geriatrics 23. HAZMAT 24. Ambulance Operations Alexanuia Bamilton SmaitReview Anatomy and Physiology Anatomy: study of the structure of form of living things Physiology: normal functions of living organisms and their parts.
Knowledge of anatomy: Accurate patient assessment Locating body organs & systems Quality patient care.
Anatomical Position: best described as a person standing, facing forward with his palms facing forward Medial: refers to a position closer to the midline Lateral: refers to a position farther away from the midline Proximal: nearer to the point of origin Distal: farther from the point of origin Anterior: nearer to/or at the front of the body Posterior: nearer to or at the back of the body
Right Upper: liver, kidney, colon, pancreas & gallbladder Left Upper: liver, spleen, left kidney, stomach, colon, pancreas Right lower: right kidney, colon, small intestine, major artery and vein to the right leg, ureter and appendix. Left lower: left kidney, colon, small intestine, major artery and vein to the left leg, ureter.
Supine Someone in the supine position is lying on his or her back.
Prone Someone in the prone position is lying face down
Right Lateral Recumbent Patient is lying on their right side. *If injuries exist on left.
Left Lateral Recumbent (Recovery Position) Patient is lying on their left side
Fowler's Position Sitting straight up or leaning slightly back. Their legs may either be straight or bent. 30-45 degree angle. Trouble breathing = 90 degree.
Trendelenberg Position Lying supine with their head slightly lower than their feet. For patients that have lost a lot of fluid.
Alexanuia Bamilton SmaitReview Body Systems
Musculoskeletal System: Gives body shape, protects vital organs and provides for body movement
Skull and Facial Bones: Skull: 22 bones: 8-Cranial 14-Facial
Spinal Column: Spine: contains 33 bones called vertebrae Five sections: o Cervical (7)-base of skull to beginning of chest o Thoracic (12)- contains intact spinal cord and has ribs (12) attached. o Lumbar (5) o Sacral (5) o Coccygeal (4)
Skeletal system: 206 bones. Need to be able to identify: Spine: Skull, mandible, cervical/thoracic/ lumbar/sacral/coccyx spine, ribs. Arms: Hummers, radius, ulna, carpels, metacarpals, phalanges Pelvis: ilium, ischium, pubis, acetabulum (ball joint of femur fits into pelvis) *in elderly patients-broken hip could lead to death. Legs: femur, tibia, fibula Foot: tarsals, metatarsals, phalanges Shoulder: scapula, clavicle (collarbone)
Joints: Ball and Socket: pelvis Hinge: knees and elbows Capsule around joints in the shoulder, elbow, knee, hip and pelvis Cartilage: keeps bones from grinding against each other.
Muscle: Skeletal - voluntary. o Attaches to bones. o Responsible for movement/under conscious control o Forms the major muscle mass of the body o 700 skeletal muscles Cardiac- involuntary o Found in the heart o Has its own blood supply (coronary arteries) o Contracts on its own (automaticity) via electrical impulses Smooth involuntary Alexanuia Bamilton SmaitReview o Found in gastrointestinal tract, urinary system, blood vessels o Control the flow of materials through these structures. o Carries our automatic muscular functions o No conscious control (autonomic nervous system o Responds to stimuli such as heat, cold and stretching.
Thoracic Cavity:
Respiratory System: Stoke patients: lose ability to swallow. Epiglottis. Trachea: does not have capacity to constrict or expand Bronchi: left and right. (Left is a little bigger but shorter) 5 lobes in lung: (right: 3 / left: 2) Bronchiole lead to Alveolus: Alveolus are covered by capillary beds Capillary beds: sight of diffusion of Oxygen and CO2 across the membrane.
Inhalation- air flows into lungs o Diaphragm and intercostal muscles contract o Diaphragm moves downwards o Ribs more upward and outward o Size of chest cavity increases
Exhalation Alexanuia Bamilton SmaitReview o Diaphragm and intercostal muscles relax o Diaphragm moves upwards o Ribs move downward and inward o Size of chest cavity decreases
Adequate Breathing: must be breathing adequately o Normal Breathing Rates: ! Adults: 12-29 breaths/min " Between 20-30 is not as good. Take closer look. " Acidosis: condition of excessive acid in the body fluids Fix it! Supplemental oxygen. ! Children: 15-30 breaths/min ! Infants: 25-50 breaths/min
Inadequate breathing: breathing effort o Increased use of accessory muscles, especially in infants and children. o Intercostal contraction: can see space in between ribs. o Breathing fast: ! Indentation by clavicle# using extra muscles to get chest to expand o Pale or cyanotic (blue skin) assoc. with low oxygen content. ! Hypoxia parts of the body are deprived of oxygen. o Cool, clammy skin o Agonal respirations (occasional gasping, seen just before death) ! Nervous response, not ventilation. o Signs of Acute Respiratory Distress: nasal flaring, pursed lips on exhalation, coughing, crowing, high pitched bark, respiratory noise (wheezing, rattling), chest tightness, excessive use of accessory muscles, numbness tingling (hands and feet), impaired mentation, unconsciousness (dizziness, restlessness, anxiety, confusion, combativeness)
Pediatric Airway anatomy: Child has smaller nose and mouth. More space is taken up by tongue. Childs trachea is narrower. Cricoid cartilage is less rigid and less developed. Airway structures are more easily obstructed. Signs of Inadequate Breathing: nasal flaring, retractions, seesaw breathing, diaphragmatic breathing.
Circulatory System: Heart, blood vessels and blood.
Alexanuia Bamilton SmaitReview Vein: blood back to heart Artery: blood away from heart to other parts of body.
Cardiac Conduction System: Sinoatrial (SA) node: creates electrical impulses that are transmitted to other parts of the heart. Atrioventricular (AV) node: polarization and depolarization Bundle of His
Heart: Right Atrium: High in carbon dioxide, low in oxygen. Comes from vena cava. Tricuspid Valve: One way valve to prevent backflow Right Ventricle: Blood is pushed to the pulmonary artery Pulmonary artery: takes blood from heart to lungs. Diffusion of oxygen coming in, and carbon dioxide going out. Pulmonary vein: from the lungs back to the heart. High oxygen conc. Low carbon dioxide Left Atrium: High oxygen conc. Low carbon dioxide Bicuspid valve: prevents backflow Left Ventricle: pushed out through the aortic valve Aorta: vein that pushes blood from heart to the rest of the body.
Systolic: heart pumps blood out Diastolic: heart is resting
* Blood moves back to heart by skeletal muscular movement and 1-way valves.
Need to be able to recite: the flow of a red blood cell from right atrium to left ventricle
Coronary arteries: come off at root of Aorta. 3 big coronary arteries o Left Anterior Descending (LAD): supplies blood to the front portion of the heart and the septum (muscle in between ventricles) Alexanuia Bamilton SmaitReview o Circumflex (Circ): supplies the back (posterior) portion of the left ventricle o Right Coronary Artery (RCA): supplies the bottom portion of right ventricle
Arch of Aorta: Brachiocephalic artery: artery of medinisum that supplies blood to right arm, head and neck. o Right common carotid artery: supplies head and neck with oxygenated blood o Right subclavian artery: Left common carotid artery: supplies head and neck with oxygenated blood Left subclavian artery: supplies blood to left arm
Blood Composition: Red blood cells: give blood its color. Carries oxygen to organs. Carry carbon dioxide away from organs. White blood cells: provide defense against infection and produces antibodies.
Pulses: Carotid Pulse: under jaw, along trachea Femoral Pulse: deep inside the groin. Radial pulse: arm. Side of thumb Brachial Pulse: underside of arm or elbow Posterior Tibial Pulse: inside of ankle Dorsalis Pedis Pulse: midway top of foot
Blood Pressure: pressure exerted by circulating blood upon the walls of blood vessels Ideal: 120/80 *Blood pressure = [cardiac output (CO)] x [peripheral vascular resistance (PVR)] o Cardiac output= (heart rate) x (stroke volume) Alexanuia Bamilton SmaitReview Blood pressure = (heart rate) x (stroke volume) x (peripheral vascular resistance) o HR: # of heart beats per unit of time o SV: volume of blood pumped from one ventricle of the heart with each beat o PVR: size of lumen (open space of blood vessels) Pulse rate = if over 130 # could be losing blood ^
o Epinephrine: hormone and neurotransmitter ! Increasing induction through nervous system of heart ! Increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system.
Perfusion: delivery of oxygen and other nutrients to the cells of all organ systems and the removal of waste products. Hypoperfusion: lack of oxygen and nutrients
Nervous System- Controls the voluntary and involuntary activity of the body. Consists of the brain, spinal cord and nerves.
Central nervous system- controls all basic bodily functions and responds to external changes
Peripheral Nervous System- provides a complete network of motor and sensory nerve fibers connecting the central nervous system to the rest of the body Sensory nerves carry information from the body to the brain and spinal cord Motor nerves- carry information from the bran and spinal cord to the body Autonomic nervous system: parallels spinal cord but is separately involved in control of exocrine glands, blood vessels, viscera and external genitalia. Ex: digestion and heart rate.
Digestive System: Allows for food travel and breakdown. Main organs: stomach, large & small intestine
Mouth# salivary amylase breaks down carbohydrates. Saliva is added o pH between 6.5 and 7.5. Esophagus# food travels down the esophagus by peristalsis Stomach # breaks things down. Referred to as chime. o Gastric juice consists of enzymes such as pepsinogen(digest proteins) Duodenum# first part of small intestine o Chyme enters through a sphincter. Pancreas # an exocrine gland by producing pancreatic juice, which empties into the small intestine via a duct. o Secretes insulin (from beta cells of isles of Langerhans) Alexanuia Bamilton SmaitReview Liver # produces bile (stored in gallbladder) o Bile emulsifies fats (separates it into small droplets) so they can mix with water and be acted upon by enzymes. Spleen # plays a key role in bodys immune system. Small intestine # site of most digestion. # Of villi (projections) that assist with absorption. Approx. 15 feet of small intestine o Peptidases complete the digestion of peptides to amino acids. o Maltase completes the digestion of disaccharides Large intestine # 95% of water is reabsorbed o Appendix # beginning of large intestine. Role in body is unknown.
Abdominal Quadrants:
Note: anyone with a pelvic injury needs to be treated as a critical patient
Skin / Integumentary System: largest organ of the body Protects the body from the environment and organisms. o A barrier to keep out microorganisms, debris, and unwanted chemicals. Underlying tissues and organs are protected from environmental contact. This helps preserve the chemical balance of body fluids and tissues. Alexanuia Bamilton SmaitReview Fluid retention o Prevent water loss and stops environmental water from entering the body. Helps regulate body temperature o Blood vessels in the skin can dilate (increase in diameter) to carry more blood to the skin, allowing heat to radiate from the body. When the body needs to conserve heat, these vessels constrict (decrease in diameter) to prevent heat loss. The sweat glands found in the skin produce perspiration, which will evaporate and help cool the body. The fat that is part of the skin serves as a thermal insulator. Sense heat, cold, touch, pressure and pain a lot of sensory nerves. Excretion: Salts and excess water can be released through the skin. Shock absorption: The skin and its layers of fat help protect the underlying organs from minor impacts and pressures.
The skin has three major layers: the epidermis, dermis, and subcutaneous layer. The outer layer of the skin is called the epidermis. The layer of skin below the epidermis is the dermis, which is rich with blood vessels, nerves, and specialized structures such as sweat glands, sebaceous (oil) glands, and hair follicles. Specialized nerve endings are also found in the dermis. They are involved with the senses of touch, cold, heat, and pain. The layers of fat and soft tissue below the dermis are called the subcutaneous layers. Shock absorption and insulation are major functions of this layer.
Burns: 1 st degree skin 2 nd degree- burns down into the capillary bed. Causes blisters. 3 rd degree burn down to the nerves. Very black of waxy white. 4 th degree- burn down to the muscles 5 th degree- burn down to the bone People with 2 nd degree burn on greater than 15% of their body go to burn centers. Alexanuia Bamilton SmaitReview
Endocrine System: Secretes chemicals that regulate body activities and functions: Insulin Epinephrine
-Pineal gland: modulation of wake/sleep patterns and seasonal functions. -Hypothalamus: controls temperature control -Thyroid: metabolism -Parathyroid gland: calcium uptake -Thymus gland: development of T cells (immune system) -Pancreas: produces insulin -Kidney: eliminating and retention of body fluids -Adrenal glands: adrenaline -Sexual glands: ovaries and testes Alexanuia Bamilton SmaitReview Vitals Signs and Sample History
Baseline Vital Signs: Outward signs of whats going on inside the body. 1 st measurements you will take
Pulse: the number of beats per minute o Count for 30 seconds and multiply by 2. (Minute pulse rate) o Adults generally: 60-100/minute ! Tachycardia is pulse more than 100/minute " Result from sympathetic discharge + more ! Bradycardia is pulse less than 60/minute o Pulse quality: strong or week. Regular or irregular o Carotid pulse: for patients that are unresponsive o Brachial pulse: for babies o Radial pulse: for patients that are awake
Respirations: single breath is considered to be the complete process of breathing in followed by breathing out. o Count for 30 seconds and multiply by 2 o Adults generally at rest is between 12 and 20 breaths/minute o Keep in mind that age, sex, size, physical conditioning, and emotional state can influence breathing rates. o Quality: normal, shallow, labored, noisy (wheezing)
Skin: color, temperature and condition o The blood vessels of the skin will receive less blood when a patient has lost a significant amount of blood or the ability to adequately circulate blood o Abnormal skin colors: Constriction of the blood vessels causes the skin to become pale ! Pale: indicates poor circulation of blood. =Loss of blood ! Cyanotic: not getting enough oxygen to red blood cells ! Flushed: caused by exposure to heat ! Jaundiced: yellowish tint to the skin from liver abnormalities ! Mottling: a blotchy appearance in patients (esp. children) as a result of shock ! If it is hard to tell skin color: check inside lower lip, inner eyelid or palm of hand. o Temperature: hot, cool and cold ! Feel the patients skin with the back of your hand o Condition: wet or very dry. ! Can reveal problems with circulation
Alexanuia Bamilton SmaitReview Pupils: responds to light o Size: dilated or constricted o Equality o Reactivity: to light or nonreactive (fixed) o Pupils that are dilated, constricted to pinpoint size, unequal in size or reactivity, or nonreactive may indicate a variety of conditions including drug influence, head injury, or eye injury.
Blood pressure: force of blood against blood vessels walls. o Systolic: pressure created when the heart contracts and forces blood into the arteries ! Normally systolic is usually no more than 120 mmHg. " Hypertension: systolic greater than 140 mmHg o Diastolic: the left ventricle relaxes and refills, the pressure remaining in the arteries/ the heart at rest. ! Normally diastolic is normally 60-90 mmHg " Hypertension: diastolic greater than 90 mmHg o Adult females ! May be 8-10 mmHg lower than an adult male ! Hypertension considered at same level as in male adult. o Child ! 1- 10 years old: " (Childs age x 2) + 80 mmHg ! Child or adolescent older than age 10 " Minimum systolic of 90 mmHg
Auscultating Blood Pressure: AuscultationWith auscultation the EMT will listen for the systolic and diastolic sounds using a stethoscope. o Avoid placing the BP cuff over clothing o Palpate the brachial artery o Deflate the cuff at about 2 mmHg per second. When you hear the first sound, record the pressure (systolic). Continue releasing air. When you hear the last sound, record the pressure (diastolic) o Close the valve and pump until radial pulse is no longer felt. Note the number and deflate the cuff. Position the stethoscope over the brachial artery and inflate the cuff to 30 mmHg above the level where you previously stopped feeling the radial pulse.
Palpating Blood Pressure: the EMT will feel for the return of the pulse with deflation of the cuff. When the pulse returns, this becomes your systolic number. Apply the cuff and inflate rapidly to 30 mmHg above the level where you can no longer feel the radial pulse. Slowly deflate the cuff. Note the pressure at which the radial pulse returns (systolic). You will not be able to measure the diastolic pressure by palpation. Alexanuia Bamilton SmaitReview
Noninvasive Blood Pressure Device: in ambulances.
Pulse Oximetry: measures oxygen circulating in the blood Place sensor on nail bed. Algorithm will provide a reading as a percent of hemoglobin saturated with oxygen Results: o 96100% = normal o 9195% = mildly hypoxia o 8690% = significant hypoxia o < 85% = severe hypoxia Precautions: o Not accurate in shock or hypothermia: ! Not enough blood is flowing through the capillaries for the device to get an accurate reading. o False readings in carbon monoxide poisoning o Movement and nail polish can cause inaccurate readings. o Batteries must be in good condition. Note: Do not withhold oxygen from a patient who may need it because the oximeter reads normal.
SAMPLE History: S : signs and symptoms A : allergies M : medications P : pertinent past history L : last oral intake E : events leading to injury or illness
Signs and Symptoms: A sign is objectivesomething you see, hear, feel, and smell when examining the patient. Ex- vital signs. A symptom is subjectivean indication you cannot observe but that the patient feels and tells you about. Ex- chest pain, dizziness, and nausea.
Allergies: to medications, foods, and environment. Is there a medical tag?
Alexanuia Bamilton SmaitReview Medications: prescription and over the counter. Current and recent What medications are you currently taking or supposed to be taking (prescription, over- the-counter, or recreational)? Are you on birth-control pills? Or smoking? (Can cause blood clots) Is there a medical identification tag with the names of medications on it? Do you take any herbal supplements or medications? Epocrates.com # application stating all medications and what it does.
Pertinent Past History: Have you been having any medical problems? Have you been feeling ill? Have you recently had any surgery or injuries? Have you been seeing a doctor? What is your doctors name? Should include medical, surgical, and trauma factors.
Last Oral Intake: When did you last eat or drink? What did you eat or drink? Food or liquids can cause symptoms or aggravate a medical condition. Also, if a patient will need to go to surgery, the hospital staff must know when he last had anything to eat or drink, since stomach contents can be vomited while a patient is under anesthesia, which is a very dangerous occurrence.
Events leading to illness or injury: What sequence of events led up to todays problem? o For example, the patient passed out, then got into car crash versus got into car crash and then passed out?
Interview Strategies: Position yourself appropriately: o So the patient can see your face and it is at a level close to that of the patients face. This is especially important with children. Identify yourself and reassure the patient: o The patient knows he is in competent hands. Maintain eye contact with the patient and state your name that you are an Emergency Medical Technician, and the organization you represent. Speak in a normal voice: o When you ask a question, wait for a reply. Avoid inappropriate remarks like Dont worry, and Everything is all right. Use your patients name. o For adults, use the appropriate Mr., Mrs., Miss, or Ms. unless they introduce themselves by their first name.
Alexanuia Bamilton SmaitReview
Lifting and Moving Patients Lifting Patients:
Lift safely with proper body mechanics. Back injuries are a leading cause of long-term disability for EMTs. Lifting Considerations: o Consider the weight of object/patient. o Communicate with partner. o Identify the need for help before lifting. o Have a plan.
Guidelines: Use your legs to lift: not your back Have feet positioned properly: They should be on a firm, level surface and positioned shoulder-width apart. Keep weight close to body: or as close as possible. This allows you to use your legs rather than your back while lifting. Lift without twisting: Attempts to make any other moves while you are lifting are a major cause of injury. Person at the head of the patient call the shots Avoid reaching more than 1520 inches in front of your body.
Safe pushing and pulling: Push rather than pull Keep your back locked in and your knees bent Keep weight close to your body Keep the line of pull through the center of your body by bending your knees. Avoid pushing or pulling overhead. Keep elbows bent and arms close to sides. If weight is below waist level, push or pull from a kneeling position.
Types of Moves: Emergency Moves: Three situations# Scene is hazardous: o This may occur when there is uncontrolled traffic, fire or threat of fire, possible explosions, electrical hazards, toxic gases, or radiation. Life threatening condition requires move o You may have to move a patient to a hard, flat surface to provide CPR, or you may have to move a patient to reach life-threatening bleeding. Patient must be moved to reach a critical patient o When there are patients at the scene requiring care for life-threatening problems, you may have to move another patient to access them.
Alexanuia Bamilton SmaitReview Drags: Clothes Drag: the patient is dragged by the clothes, the feet, the shoulders, or a blanket. These moves are reserved only for emergencies, because they do not provide protection for the neck and spine Drag (headfirst): greatest danger is spine injury. o Hands under armpits and hold onto forearms. Firefighter carry One-Rescuer Assist- arm over shoulder Two-Rescuer Assist- arms over shoulders
Urgent Moves: Scene factors cause a decline in patient condition Treatment of patients condition requires a move o Spinal precautions
Non-urgent moves: Used when there is no threat to life Use when patients condition allows for assessment and care Typically utilize a carrying device Extremity Carry
Patient Carrying Devices:
Moving Patients to Carrying Devices: Carrying device choice: o What is the patients position? Is there a suspected spinal cord injury? Patient Positioning: o Part of patient care plan o Must not cause harm to patient o Must be safe Recovery Position: o Turn patient on left side. Position of Comfort Shock Position
Transferring the patient to a hospital stretcher: 1. Position raised ambulance cot next to hospital stretcher. o Hospital personnel then adjust stretcher (raise or lower the head) to receive patient. 2. You and hospital personnel gather the sheet on either side of the patient and pull it taut in order to transfer the patient securely. 3. Holding the gathered sheet at support points near patients shoulders, mid torso, hips, and knees, you and hospital personnel slide patient in one motion onto hospital stretcher. Alexanuia Bamilton SmaitReview 4. Make sure patient is centered on stretcher and stretcher rails are raised before turning him over to emergency department staff.
Alexanuia Bamilton SmaitReview
Airway Management
Major concern: to make sure they have a patent, working airway at all times. Without airway, within 3-4 minutes, everything will be bad
Anatomy: Upper Airway: Nose Mouth Pharynx Oropharynx Nasopharynx Uvula Epiglottis
Alexanuia Bamilton SmaitReview Gastric content- high in acid. When a patient loses consciousness, they lose control of the epiglottis, in which gastric content could be thrown up and worse case, reach the bronchioles and destroy the alveolus.
Lower Airway Larynx (voice box) Cricoid cartilage Trachea- main windpipe o Some degree of cilia Carina Bronchi (right and left main stem bronchus) o Bronchioles Lungs Alveoli (alveolar sacs)
Alexanuia Bamilton SmaitReview Lungs: Right has 3 lobes / Left has 2 lobes Covered by pleura o The visceral pleura is the innermost covering of the lung. o The parietal pleura is a thicker, more elastic layer that adheres to the inner portion of the chest wall. o Between the two layers is pleural space, a small space that is at negative pressure ! space contains a small amount of serous fluid that acts as a lubricant to reduce friction when the layers of the pleura rub against each other during breathing.
Gas Exchange: Oxygenation is the process by which the blood and the cells become saturated with oxygen. This happens as a result of respiration, the process in which fresh oxygen replaces waste carbon dioxide, a gas exchange that takes place between the alveoli and the capillaries in the lungs, and also between the capillaries and the cells throughout the body; this process is known as diffusion. Ventilation is the mechanical process of moving air in and out of the lungs.
Alexanuia Bamilton SmaitReview Inhalation and Exhalation Inhalation is an active process that requires energy expenditure due to muscular contraction. o Inhalation process: This action increases the size of the chest cavity, creating negative pressure inside the chest cavity. Exhalation is a passive process as the thorax and lungs recoil back to their normal anatomic position. o Exhalation process: This action decreases the size of the chest cavity, creating positive pressure inside the chest cavity.
Inhalation- air flows into lungs o Diaphragm and intercostal muscles contract o Diaphragm moves downwards o Ribs more upward and outward o Size of chest cavity increases Exhalation o Diaphragm and intercostal muscles relax o Diaphragm moves upwards o Ribs move downwards and inwards o Size of chest cavity decreases
Signs of Adequate Breathing Look: adequate and equal expansion of both sides of the chest when the patient inhales. Is there a chest rise or not? Listen: For air entering and leaving the nose, mouth, and chest Feel: For air moving out of the nose or mouth.
Normal Rates: o Adult: 12-20 breaths/min o Children: 15-30 breaths/min o Infants: 25-50 breaths/min Rhythm: regular or irregular o Agonal respirations patient is unconscious, sounds like breathing but no breathing. Quality: with use of stethoscope o Breath sounds: present and equal o Minimal effort Depth: chest expands adequately and equally
Alexanuia Bamilton SmaitReview Signs of Inadequate Breathings Hypoxia: Inadequate amount of oxygen being delivered to the cells, resulting in an oxygen deficiency. o can result from an occluded airway, inadequate breathing, inadequate delivery of oxygen to the cells by the blood (hypoperfusion or shock), inhalation of toxic gases (e.g., carbon monoxide), lung and airway diseases (e.g., asthma, emphysema), drug overdose that suppresses the respiratory center in the brain (e.g., morphine, heroin, and other narcotics), stroke, injury to the chest or respiratory structures, and head injury. There are, in addition, many more conditions or injuries that may create a blockage to the airway or produce inadequate breathing by depressing the respiratory centers in the brain, interfering with gas exchange at the level of the alveoli, or restricting the movement of the chest wall. o Position: tripod # hands on legs to increase chest cavity. o cyanosis : The patients skin, lips, tongue, ear lobes, or nail beds are blue or gray.
Mild/moderate Hypoxia: o Tachypnea rapid, shallow breathing o Dyspnea- shortness of breath o Tachycardia heart rate increases over 100 o Pale, cool, moist skin sympathetic discharge o Hypertension increase in blood pressure. o Restlessness o Disorientation o Headache o Combative eliminate hypoxia first.
Severe hypoxia o Tachypnea rapid shallow breathing o Dyspnea shortness of breath o Tachycardia (early) heart rate increases ! then bradycardia heart rate slows down o Pale, cool skin sympathetic discharge o Hypertension increase in blood pressure o Drowsiness o Confusion o Altered mental status- combative o Accessory muscle use to breath
Critical Findings: When the patients signs indicate inadequate breathing or no breathing (respiratory failure or respiratory arrest), a life-threatening condition exists and prompt action must be taken. o Respiratory distress: Patient struggling to breath. Start ventilation. o Respiratory failure: Oxygen intake not enough to support life o Respiratory arrest: Breathing stops completely Alexanuia Bamilton SmaitReview
Child vs. Adult Airway Head is disproportionally larger than body. Child has a larger tongue high tendency for choking Trachea: larynx narrows down.
Inadequate Breathing o Infants and children: nasal flaring, see saw breathing and retractions ! Due to the lack of muscle development in the chest, the infants count on the abdominal muscles and intercostal muscles to assist in the breathing effort.
Opening the airway: Goal is to establish and maintain a patent(clear and open) airway on EVERY patient that you encounter. A patient without a patent airway will die
Child: A towel behind the shoulder will help maintain an open airway.
Adult: No suspected head/spine injury # head tilt maneuver Suspected head/spine injury# jaw-thrust maneuver
Alexanuia Bamilton SmaitReview
Techniques of Artificial Ventilation Mouth to mask Two-person bag-valve mask Flow-restricted, oxygen-powered ventilation device One-person bag-valve mask
Mouth to mask: 16% oxygen concentration attach oxygen to mask at 15 lpm (if available) follow same steps as bag valve mask to obtain a seal with mask deliver each ventilation over 1 second, for every 5 seconds. (For all patients) o 3 seconds for children
Bag-Valve Masks (Adult, Child and Infant) Closed system. Consists of an oxygen reservoir, ventilation bag and exhalation port. Mask is clear Caution: adequate ventilation may require disabling the pop-off valve if the bag-valve mask unit is so equipped. Method o Select correct size mask. The top of the mask shouldnt pass the bridge of the nose and the bottom shouldnt pass the lower part of the chin. o Position yourself behind the patients head. o Hold the mask with your thumbs over the top half and your index and middle fingers over the bottom half. o Place the top of the mask over the patients nose and lower the bottom half of the mask over the mouth and chin. o If the mask has a large round cuff around the ventilation port, center the port over the patients mouth. o Use your ring and little fingers to lift the chin and maintain the head tilt. o Attach to oxygen at 15 liters per minute and have an assistant squeeze the bag once every 5 seconds (3 seconds for a child or infant).
Flow-Restricted, Oxygen-Powered Ventilation Device 40 liters per minute uses oxygen under pressure to deliver artificial ventilations through a mask placed over the patients face. This device is similar to the Alexanuia Bamilton SmaitReview traditional demand-valve resuscitator but includes newer features designed to optimize ventilations and safeguard the patient. pressure relief valve that opens at 60 cm water (audible alarm also sounds) Use on adult patients only.
If there is NO chest rise Reposition head Check for seal at mask and absence of air leaks Check for blockages in Bag Valve Mask or tubing If chest still does not rise, try a pocket mask or manually triggered device
Positive Pressure Oxygen Percentage: very important Pocket face mask o Without O 2 16% o With O 2 45%50% Bag-valve mask (BVM) o Without O 2 21% o With O 2 and without reservoir 45%50% o With O 2 and reservoir 90%100% Flow-restricted oxygen-powered ventilation device (FROPVD) o 100%
Ventilating through a Stoma or Tracheotomy Tube Patients with stomas who are found to be in severe respiratory distress or respiratory arrest frequently have thick secretions blocking the stoma. It is recommended that you suction the stoma frequently in conjunction with Bag Valve Mask-to-stoma ventilations. Ventilating a stoma: o Clear any secretions in stoma (most common problem). o Place head in a neutral position. o Choose a pediatric-size mask. o Ventilate at age-appropriate rate. If there is no chest rise: o air escapes from the mouth and/or nose when ventilating via stoma, consider sealing the stoma. o Attempt artificial ventilation through the mouth and nose
Airway Adjuncts: Rules Open airway manually first. Ensure there is no gag reflex for oral airway, no possible skull fracture for nasal airway. o Do not attempt the use of a nasopharyngeal airway if there is evidence of clear (cerebrospinal) fluid coming from the nose or ears. This may indicate a skull fracture in the area where the airway would pass. Maintain manual airway method even with airway in place. Do not force tongue into pharynx. Alexanuia Bamilton SmaitReview Have suction available. Remove adjunct if patient gags or regains consciousness. Maintain infection control.
Oropharyngeal Airways (OPA) An Oral Airway can help prevent the tongue from obstructing the airway of an unresponsive patient without a gag reflex Method: o Measure for correct size. o Open the mouth and insert the airway with tip towards roof of the mouth. o Insert airway along hard palate until you reach the soft palate, then rotate180.
Nasopharyngeal Airways (NPA) Method o Select the correct size. o Lubricate the airway. o Insert the airway posteriorly. ! If it does not advance, try the other nostril. Meant to go in the right nostril Has to be lubricated before use. Diameter: size of mid-section of pinky finger and size of nostril. Caution: NPA cannot be used if patients has suspected basilar skull fracture.
Techniques of Suctioning Purpose: To remove blood, other liquids, and food from the airway If you hear gurgling, suction
Type of Suction Units: Mounted on the ambulances. Run off of vacuum. Battery powered portable. Must check that it is charged. Oxygen powered nobody uses them anymore # eats oxygen. Manual suction really good. Hand powered with a trigger.
Suction Catheters: Hard - Useful for most secretions Soft - Useful for nasopharynx and when hard catheter wont work/fit
Rules of Suctioning Always use infection-control measures. Suction for no more than 15 seconds at a time (fewer in children and infants). o prolonged suctioning will cause hypoxia and death. If the patient continues vomit longer than 15 seconds, you must still continue to suction Alexanuia Bamilton SmaitReview o In short, suction quickly and efficiently for as short a time as possible. Place tip of catheter where you want to begin suctioning, and suction on way out. Suctioning Technique Inspect and test suction unit before you need it. Position the patient and yourself properly. Open the patients mouth while protecting your fingers. Without suctioning, insert hard catheter to base of tongue. If using a soft catheter, insert it only as far as the distance from the lips to the earlobe or angle of the jaw. Once tip of catheter is in the right place, apply suction, move tip, and remove fluid in airway.
Supplemental Oxygen:
Conditions Requiring Oxygen : Respiratory/cardiac arrest Stroke Shock Blood loss/fractures Many other conditions
Oxygen Cylinder: a seamless steel or lightweight alloy cylinder filled with oxygen under pressure, equal to 2,000 to 2,200 pounds per square inch (psi) when the cylinders are full. Pressure Gauge: pounds per square inch Flow meter: 0 -25 m per minute Sizes: o D cylinder contains about 350 liters of oxygen. o E cylinder contains about 625 liters of oxygen. o M cylinder contains about 3,000 liters of oxygen. ! Fixed systems on ambulances (commonly called on-board oxygen) include the M cylinder and larger cylinders: o G cylinder contains about 5,300 liters of oxygen. o H cylinder contains about 6,900 liters of oxygen.
Safety with Oxygen Inspect before using. Use nonsparking wrenches. Store and maintain cylinders properly. Do not drop cylinders or leave standing unsecured. Do not smoke or use near open flame. Stamp # indicates the test date of the tank. o Every 5 years, cylinders need to be tested. o Star present # testing can occur every 10 years. o Plus sign (+) present # hold 10% more per square inch Alexanuia Bamilton SmaitReview
Oxygen Delivery System: in a green tank Aluminum (portable) or steel(in ambulance) cylinders.
Administering Oxygen If the patient is not breathing, use artificial ventilations. If the patient is breathing and needs supplemental oxygen, use: o Nonrebreather mask o Nasal cannula
Nonrebreather mask: Can deliver up to 90% oxygen Must fill bag before placing mask on patient Use setting of 815 liters per minute Adult, child, and pediatric sizes Method: o Explain procedures to patient and attach tubing to regulator. o Open valve, adjust flow meter, fill bag of nonrebreather mask. o Place the mask on the patient and adjust the flow rate. o Secure the tank.
Nasal Cannula: Delivers low-concentration oxygen (2444%) Useful for patients who do not tolerate mask Use a setting of 26 lpm.
Supplemental Oxygen Percentage- Non rebreather mask o Without reservoir O 2 45%50% o With reservoir 90100% Nasal cannula o 1lpm O 2 24% 2lpm 28% o 3lpm O 2 32% 4lpm 36% o 5lpm O 2 40% 6 -lpm 44%
Special Considerations Facial Injuries: many blood vessels in the face make a seal so that there is no air leak Alexanuia Bamilton SmaitReview Can lead to two problems o Severe swelling from blunt injury o bleeding into the airway
Dentures: Leave in place under ordinary circumstances; remove if they block airway. If a partial plate becomes loose, leave it in place unless it causes a problem
Infants and Children: Avoid excessive hyperextension when opening the airway. Avoid excessive pressure when ventilating. Gastric distention may be common. Use properly sized BVM, nonrebreather, and suction equipment.
Oxygen Administration Administer high concentration oxygen First choice: non-rebreather mark at 12 LPM or greater so reservoir bag does not collapse during inhalation. If reservoir bag collapses and does not refill, increase to 15 LPM Second Choice: Nasal cannula at 6 LPM
Pediatric Oxygen Administration There is no contraindication to high concentration oxygen in pediatric patients in pre-hospital setting Administration of oxygen is best accomplished by allowing parent to hold the face mask, if tolerated, 6-8 inches from childs face Humidified oxygen is preferred.
Alexanuia Bamilton SmaitReview CPR - Recap
Regardless of if EMT has arrived: start chest compressions Chest compressions moves the blood around
6-10 mins # the brain will die due to lack of oxygen
Portable Defibrillator (AED) Shock # caused a depolarization and slows down other activity of the heart (electrical silence) so that the SA node will have an opportunity to fire. o After it defibrillates: it will tell you to start chest compression No shock indicated # check vitals o Really good or really bad
BLS : Basic Life Support
Adult Immediate recognition and activation of Emergency Response system Early bystander CPR Rapid of EMS Effective Advanced Life Support Integrated Post Cardiac Care
Pediatric Prevention of arrest Early bystander CPR Rapid of EMS Effective Advanced Life Support Integrated Post Cardiac Care
CAB (not ABC) Chest compressions # Airway # Breathing Rescuers can start chest compression earlier. Check victim for response and breathing With CAB, the rescuer should activate emergency response system if patient is unresponsive or barely breathing
Compression rate: at least 100/min
Training using a team approach Rescuer 1: activates system Rescuer 2: chest compression Rescuer 3: Bag valve mask Rescuer 4: setting up defibrillation Alexanuia Bamilton SmaitReview
In order to help assure the airway is open Find the Adams apple # half an inch below Press down on tricoid cartilage (1 st ring of trachea)
If within 10 seconds you dont feel a pulse, begin chest compressions Manual defibrillators are preferred to AED for infant patients
Maximum output of AED: 200-300 joules. = 2000-3000 volts.
AED measures transthoracic energy (how much energy does it take to get from one pad to another)
Critical elements of High Quality CPR Start compressions within 10 seconds Push hard and Rate of at east 100 compression/min Allow complete chest recoil Minimize interruption (less than 10 seconds) Efficient airways to make chest rise
Should be performed as a team Mask the individual skills of CPR
CPR 1 st step: check that the scene is safe = No water around 2 nd step: check for response and breathing 3 rd step: call for help 4 th : check for pulse. Adult and Child: carotid pulse Infant: brachial pulse 5 th : If there is no pulse, start chest compressions. Push hard and fast and allow complete chest recoil after each compression. Minimize interruptions 6 th : Ventilate twice
One cycle consists of chest compressions: 5 times ventilations: 5 times
Chest Compressions: Alexanuia Bamilton SmaitReview 1. Position yourself at victim side 2. Victim: supine on flat surface 3. Remove clothing from front of chest 4. Heal of one hand on center of bare chest 5. Heal of other hand on top 6. Shoulders right over your hand 7. Push hard and face a. 2 inches/ 5 cm down 8. Rate of at least 100 compressions/min
Opening the airway and giving breaths: Two-rescuer scenario: Bag Valve Mask One rescuer scenario: Pocket mask Pocket mask: place on patients face and seal mask. o Breath hard and look for chest compression o Each breath should be delivered over 1 second o If you have time, insert airway adjunct. Unresponsive and a Pulse # ventilations Unresponsive and No pulse # 30 compressions and 2 ventilations
When do you stop CPR? Someone comes and relieves you and starts doing CPR Physician tells you to stop Depended lividity (cells begin to break down#patient is dead) purple undertone. Patient wakes up DNR order # must call and get permission to stop
Bag Valve Mask: Dont pump forcefully: If too much air enters stomach # the patient may vomit
AED (automated external defibrillator) Open case and turn on AED will guide you Adult (8+) and pediatric pads Attach to bare chest o Side of left nipple o Below right collarbone No one touch the victim when shock is given (pause CPR) If no shock needs to be given: start chest compressions again
Circumstances 1. Water on chest# wipe chest and attach AED pads and move victim to dry area Alexanuia Bamilton SmaitReview 2. Pacemakers/Automated defibrillator(surgically) # do not put pad over lump a. Not going to hurt the device but if you place it over, the metal component will accumulate some current. 3. Hair on chest# shave off or pull off hard (Removing chest hair) then attach pads a. Do not set patients chest on fire 4. Get off the scene by 3 rd defibrillation
Puberty: anyone from 1 to puberty is considered a child Chest or underarm hair on males Chest/breast development on females
Single rescuer Compression to ventilation = 30:2 Hypoxia is a main reason why children go into cardiac arrest. If arrest is sudden, learn the child, activate emergency response system, get defibrillator and start compressions Children: A single rescuer should perform 5 cycles of CPR before leaving to activate the emergency response. o Compression: 1/3 of the chest ! If child is under 1 year old use two fingers for compression ! Hands wrapper around and thumbs in center of chest ! Then ventilate
Two rescuer Compression to Ventilation Ratio Adult= 30:2 Child= 15:2
Pop off valve: given pressures so that you wont give more pressure than needed
Review of Infant Basic Life Support Single rescuer Check for responsiveness and breathing If not breathing# shout for help If others present# tell them to activate emergency response system and get AED Check for pulse# brachial pulse for 5 secs 30 compressions then 2 breaths
When another rescuer comes compression to ventilation 15:2.
AED# can have appropriate adult and child shocks. If you have an infant, but dont have pediatric pads. Put a pad in front and pad in back between shoulder blades Alexanuia Bamilton SmaitReview
Advanced Airway
Rescue Breathing: ventilations with chest compressions. Ventilations every 6-8 seconds 1 breath every 3-5 seconds for children Check pulse every 2 minutes
Infant Site and kneel with infant in lap Infant prone on hand and support head and jaw with hand 5 back slaps between shoulder blades. And then start chest compressions. 1 per second Repeat back slaps and chest thrusts until object has removed.
Alexanuia Bamilton SmaitReview Scene Size Up
Evaluate the scene for safety hazards Yourself Crew Patients Bystanders
Danger Zone: minimum of 50 feet around scene Further if: fuel spill, fire, hazardous materials or downed power lines Note: o Do not enter unstable crash scenes. o Managing patients at crash scenes or on roadways and highways place the EMT at extreme risk of being struck by moving traffic. o Take extra precautions at crime scenes, suspected crime scenes, and scenes involving volatile crowd situations; wait for the arrival of police or, if a scene turns threatening, retreat and wait for the police. o Be sure to bring your portable radio with you when you leave the ambulance so that you can contact dispatch or medical direction from the scene for needed resources or advice. o Call for help from the appropriate agenciespolice, fire department, rescue squad, utility company, water rescue squad, hazmat team, or otherif a scene is outside your area of training or expertise. o Remove yourself if a scene turns hazardous. Crash or Rescue Scenes Toxic Substances or Hazmat Unstable Surfaces: slopes, ice or water Scene Violence: fighting, loud voices, alcohol/drug use, unusual silence, prior experience. Crime scenes and Violence: retreat to a position of safety, call for help, and return only after police has secured the scene. Be sure to document the danger and your actions.
Standard Precautions Take the necessary Standard Precautions: Body Substance Isolation Anticipate the need for Standard Precautions Always have Standard Precaution equipment available: gloves, mask and eye protection and gowns Use appropriate equipment to prevent exposure
Alexanuia Bamilton SmaitReview Mechanism of Injury vs. Nature of Illness Determine the Mechanisms of injury vs. nature of illness o Mechanism of injury (MOI) determines that the patient is a trauma patient o Nature of illness (NOI) determines that the patient is a medical patient. Number of patients: quick count o Each ambulance can carry 2 patients o Badly hurt patient= 1 patient/ambulance Need for additional resources
Mechanism of Injury - the physical event that caused the injury Determined from patient, family, bystander and observation of the scene
Motor Vehicle Collision
o (Head On): Two types of injury patterns are likely: the up-and-over pattern and the down-and-under pattern.
! Up and Over Pattern: the patient follows a pathway up and over the steering wheel, commonly striking the head on the windshield (especially when he was not wearing a seat belt), causing head and neck injuries. " Head leads + compression of cervical spine + chest/abdomen impacts steering wheel (compression of hollow and solid organs and shearing)
! Down and Under Pattern: the patients body follows a pathway down and under the steering wheel, typically striking his knees on the dash, causing knee, leg, and hip injuries. " Force is transmitted to lower extremities(tibial and femoral impact) + upper body rotates forward and strikes dash or steering wheel.
o (Rear Impact): common causes of neck and head injuries ! the head remains still as the body is pushed violently forward by the seat back(hyperextended), extending the neck backward, then the body will stop and the head will push forward(hyper flex)
o (Side Impact) or T-bone : have the most fatalities ! The head tends to remain still as the body is pushed laterally, causing injuries to the neck ! The head, chest, abdomen, pelvis, and thighs may be struck directly, causing skeletal and internal injuries. Alexanuia Bamilton SmaitReview o (Rotation Impact): involve cars that are struck, then went into a spin. ! a corner of the vehicle stops, the rest of the vehicle continues in forward motion until energy is transformed " Combination of front and lateral patterns
o (Rollover ): Rollover collisions frequently cause ejection of anyone not wearing a seat belt ! multiple impacts at various angles ! unrestrained driver: partial or full ejection with direct impact to ground/tree/outside the car. " 75% of totally ejected occupants die. Risk of death is 6x greater for ejected occupants.
o Vehicle Interior: spider web on windshield, deformed windshield, steering wheel, and vehicle deformity.
o Other Motorized Vehicles: motorcycles, all-terrain vehicles, snowmobiles and jet-ski
Falls: o Falls from heights of greater than three times the height of the patient are usually considered severe. o Consider ! Distance patient fell ! Part of body that struck surface ! Type of surface patient landed on ! Anything that interrupts/breaks the fall ! The force is also transmitted to adjoining parts of the body. ! When in doubt, assign the patient a high priority for rapid packaging and prompt transport.
Penetrating Trauma o Injury caused by an object that passes through the skin or other body tissue o These wounds are classified by the velocity, or speed, of the item that caused the injury. o Velocity: kinetic energy= mass x velocity^2 ! Low velocity injuries are usually limited to the area that was penetrated. (ex. Knife) ! Medium velocity wounds are usually caused by handguns and shotguns. (ex. Handgun or shotgun) ! High velocity: bullets are propelled by a high-powered or assault rifle. o Body Region Penetrated o Exit wounds o Bullets: can cause damage in two ways Alexanuia Bamilton SmaitReview ! Damage directly from the projectileThe bullet itself will damage anything in its path. The path of the bullet once it is inside the body is unpredictable since it may be deflected by bone or other tissue onto a totally different course. ! Pressure-related damage, or cavitationThis means that the velocity of the bullet as it enters the body creates a pressure wave that causes a cavity considerably greater than the size of the bullet. This cavity is temporary, but it may damage items in its path
Blunt force Trauma: is injury caused by a blow that strikes the body but does not penetrate the skin or other body tissues o The energy from a blunt-force blow will travel through the body, often causing serious injury to, even rupture of, internal organs and vessels. The resulting compromise of body functions, hemorrhage, or spillage of organ contents into the body cavity may have more severe consequences for the patient than a penetrating injury.
Nature of Illness: finding out what is or what may be wrong with the patient. Patient, when conscious and oriented, is a prime source of information about his or her condition. Family members or bystanders can also provide important information, especially for the unconscious patient. The scene. While you are sizing up the scene for safety, make note of other factors that may be clues to the patients condition. You may observe medications, of which you will make a mental note to examine later. You may be struck by dangerous or unsanitary living conditions for this particular patient.
Alexanuia Bamilton SmaitReview Adequacy of Resources: is determining if you have sufficient resources to handle the call. Note: Number of Patients, Hazardous materials, Fire or rescue , Unusual Situations Call for assistance before beginning care Triage procedures: to quickly assess all the patients and assign each a priority for receiving emergency care or transportation to definitive care.
Alexanuia Bamilton SmaitReview Initial Assessment
Components of Initial Assessment: Form a general impression Assess mental status Assess airway Assess breathing Assess circulation o (C-A-B) if unresponsive Identify priority patients
Form A General Impression: is based on your immediate assessment of the environment and the patients chief complaint and appearance # helps you to determine how serious the patients condition is and to set priorities for care and transport. Environment/scene clues Chief complaint Age o Child or infant o Adult o Over 50s Sex Look/Listen/Smell: alcohol? Obvious life threats: growing pool of blood?
Assess Mental Status - AVPU Alert: Patients who are oriented to person, place, time, and day, or date are considered alert and oriented Verbal stimulus: A patient who is awake but confused or disoriented is considered verbal Painful stimulus: At a lower level of responsiveness, the patient will respond only to painful stimuli, such as pinching Unresponsive: the lowest and most serious mental status is unresponsiveness, when the patient will not respond even to a painful stimulus.
Assess the Airway # Is patient able to maintain his own airway? If the patient is alert and talking clearly or crying loudly, the airway is open. o Assist with ventilations If the airway is not open or is endangered (patient is not alert, is supine, or is breathing noisily), o open the airway (jaw-thrust or head-tilt, chin-lift maneuver, suctioning, or insertion of an oropharyngeal or nasopharyngeal airway.) o If the airway is blocked, perform clearance procedures.
Alexanuia Bamilton SmaitReview If unable to, is patient a medical or trauma patient? Medical Patients: o Use head tilt, chin lift. o Suction and insert oral or nasal airway adjunct. Trauma Patients: o Immobilize the head manually o Use jaw thrust o Suction and insert oral or nasal airway as necessary
Assess Breathing If Breathing: Inspect Chest (DCAP-BTLS) o Deformities Contusions Abrasions - Punctures/Penetrations - Burns - Tenderness - Lacerations - Swelling Auscultate Chest (Breath Sounds): check with stethoscope
If not breathing
If he is not alert and his breathing rate is less than 8 or greater then 28 ventilations, ventilate with a BVM or Pocket Face Mask with 100% oxygen. If the patient is alert and his breathing is adequate, but the rate is greater than 20 breaths per minute, give high-concentration oxygen by non-rebreather mask.
AcronymOIPASS: o OxygenNasal Cannula or Nonrebreather vs. BVM or Pocket Face Mask o InspectOpen the shirt and visualize and breathing obstructions in the chest o Palpatecheck for symmetrical chest rise with your hands o AuscultateListen to lung sounds with a stethoscope bilateral o SealAny holes in the chest with an occlusive dressing o StabilizeAny flail segments in the chest with an bulky dressing
Alexanuia Bamilton SmaitReview Assess Circulation: Pulse, Bleeding and Skin Once any breathing problems are corrected, assess circulation.
VCR: Voids - CTC - Radial Pulse VoidsCheck for major bleeding at the arches such as: the neck, waist, knees, and ankles. CTCColor, temp, condition of the skin Radial pulseCheck for the presence and the quality of the radial pulse.
Pulse# between 60 - 100/min o In adults and children, check radial pulse first or carotid pulse. ! Infants: check brachial pulse o If no carotid pulse, start CPR and use AED as appropriate. Skin: color, temperature and condition o Colors: pink, pale, cyanotic, mottled ! Warm, pink, and dryindicating good circulation ! Pale and clammy (cool and moist)indicating poor circulation ! Dark-skinned, check the color of the lips or nail beds, which should be pink. ! Cyanotic # deprived of oxygen ! Mottled- blotchy o Condition: dry, wet, turgor o Temperature o Check capillary refill (for infants/children)
Identify Priority Patients Poor general impression Unresponsive patients Responsive but not following commands Difficulty breathing Shock (hypoperfusion) Complicated childbirth Chest pain with systolic BP lower than 90 Uncontrolled bleeding Severe pain anywhere # pay especial attention to older patients and diabetics
Which step is next? Medical assessment OR Trauma Assessment
Alexanuia Bamilton SmaitReview Ongoing Assessment
Steps of the Ongoing Assessment Repeat initial assessment: to check for life-threatening problems Reassess and record vital signs: comparing the results with the earlier baseline measurements and any other vital signs measurements you may have taken Repeat focused assessment Check on treatment in progress: This may help you to evaluate the adequacy of your interventions more objectively and to adjust them as necessary. o Always do the following: o Ensure adequacy of oxygen delivery and artificial ventilation. o Ensure management of bleeding. o Ensure adequacy of other interventions.
Ongoing assessment is done in the ambulance Except in the case of mass casualties Remember, life-threatening problems that were not present or were brought under control during the initial assessment may develop or redevelop before the patient reaches the hospital.
Reassessment Stable: Every 15 minutes for a stable patient, such as a patient who is alert, has vital signs in the normal range, and has no serious injury Unstable Every 5 minutes for an unstable patient, such as a patient who has an altered mental status, difficulty with airway, breathing, or circulation, including severe blood loss, or a significant mechanism of injury Note that a stable patient can quickly become an unstable patient.
Alexanuia Bamilton SmaitReview Assessment of a Trauma Patient
Focused History and Physical Exam # based on initial assessment May be called the secondary assessment or secondary survey. This exam takes a somewhat different path for trauma vs. medical patients.
Physical Exam: is there a significant mechanism of injury Two kinds of physical exam can be chosen for a trauma patient: o Rapid trauma assessment (a rapid head-to-toe exam) followed by prompt transport, or on-scene emergency care o Focused trauma assessment (an exam that is focused on a specific injury site) followed by on-scene emergency care
Significant Mechanism of Injury: the patient has a significant MOI, multiple injuries, AMS, or critical initial assessment findings: Mechanism of injury: o Adult: ejection from vehicle, death in same passenger compartment, fall of greater than 15 feet or 3 times the patients height, rollover of vehicle, high-speed vehicle crash, unresponsive or altered mental status, penetrating injury of head, chest or abdomen o Infants and children: falls greater than 10ft, bicycle collision, vehicle in medium speed collision o Interior of Vehicle: deformities to a vehicles interior may show where a person struck the surface and reveal and injury. ! Pay close attention to steering wheel, pedals, dashboard and rear-view mirror and airbags If significant mechanism of injury: o Reconsider mechanism of injury o Assess mental status o Continue spine stabilization o Perform a rapid trauma assessment
Rapid Trauma Assessment: DCAP-BTLS D deformity o Parts of the body that no longer have the normal shape C contusions o The medical term for bruise. The collection of blood under the skin A abrasions or scrapes such as road rash P punctures/penetrations o Are holes in the body, frequently the result of gunshot wounds and stab wounds. B burns o Be reddened, blistered, or charred-looking areas T tenderness o An area hurts when pressure is applied on it, as when it is palpated L lacerations Alexanuia Bamilton SmaitReview o Cuts or open wounds that sometimes cause significant blood loss S swelling o Result of injured capillaries bleeding under the skin
o Head: DCAP-BTLS + Crepitation: ! Crepitation: sound or feel of broken bones rubbing against each other ! Run your gloved fingers through the patients hair and palpate gently.
o Neck: DCAP-BTLS + Jugular Vein Distention and Crepitation ! Jugular vein distention is present when you can see the patients neck veins bulging. # If they are bulging when the patient is upright, it means that blood is backing up in the veins because the heart is not pumping effectively ! After you assess the head and neck, size and apply a rigid cervical spine immobilization collar.
o Chest: DCAP-BTLS + Crepitation + Breath sounds (presence and equality) ! Paradoxical motion, or movement of part of the chest in the opposite direction from the rest of the chest, " It usually occurs when a segment of ribs has broken at two ends and is floating free of the rest of the rib cage (obvious during respiration, moving inward when the lungs expand with air and outward when the lungs empty) ! Breath sounds: check if present and equal
o Abdomen: DCAP-BTLS + Firmness and Distention ! Distention is another way of saying the abdomen appears larger than normal. A distended abdomen could be a sign of internal bleeding or fluid collecting in the abdominal cavity
o Pelvis: DCAP-BTLS (Compress gently) ! Check for bleeding ! priapism, a persistent erection of the penis that can result from spinal cord injury or certain medical problems ! patient is awake, palpate the pelvis gently, stopping as soon as the patient identifies pain in the pelvis.
o Extremities: DCAP-BTLS +Distal Pulse, Sensation, Motor Function ! Is a pulse present Alexanuia Bamilton SmaitReview ! Can the patient move his hands and feet, ! Does the patient have feeling in his hands and feet.
o Posterior: DCAP-BTLS ! Roll the patient onto his side as a unit and assess the posterior body, inspecting and palpating for DCAP-BTLS in the area of the spine and to the sides of the spine, the buttocks, and the posterior extremities. ! Release back onto a long board
Significant Mechanism of Injury Assess baseline vital signs Obtain SAMPLE history Make CUPS determination o Critical (unconscious) o Unstable o Potentially unstable o Stable Consider requesting ALS Reconsider transport decision
If No Significant Mechanism of Injury Reconsider mechanism of injury Determine chief complaint Perform focused physical exam based on: chief complain and MOI
SAMPLE history: S- signs and symptoms A- allergies M- medications P- pertinent past history L last oral intake E events leading to injury or illness
Rules of Assessment: Explain to the patient what you are doing Expose areas before assessing Alexanuia Bamilton SmaitReview Assume spinal injury
Detailed Physical Exam Who needs a detailed physical exam? Determined by the patients condition After critical interventions for a patient with significant MOI Occasionally for a patient with significant MOI Rarely for a medical patient
Assess areas examined in rapid trauma assessment plus: Face, ears, eyes, nose and mouth o Eyes: DCAP-BTLS + Discoloration, unequal pupils, foreign bodies, blood in anterior chamber o Nose and mouth: DCAP-BTLS + discoloration. etc. Throat: tracheal deviation Neck: DCAP-BTLS + Crepitus Abdomen: look, listen and feel for crepitus and paradoxical movement. Reassess breath sounds, presence and equality. Abdomen, Pelvis and extremities may have already been assessed during rapid trauma assessment; if not yet done, assess these areas thoroughly.
Reassess Vital Signs: (this will be the 2 nd time vitals are being done) Respirations Pulse Skin color, temperature, condition Pupils Blood Pressure
Alexanuia Bamilton SmaitReview
Documentation
Pre-hospital Care Report (PCR): record of patient care, serves as a legal document, provides information for administrative functions, aids education and research, and contributes to quality improvement.
Functions: Continuity of care: The report you write will become a part of the patients permanent hospital record. Legal document: may be used as evidence in a legal case Quality improvement: become a valuable source for research on trends in emergency medical care and a guide for continuing education and quality improvement Education Billing Information: be used in preparing bills and in submitting records to insurance companies. Statistics Research: researchers might be looking to discover + or - effects of certain interventions at different stages of patient contact, others might be experts in administration studying documentation in an effort to deliver services in a more timely or cost-effective manner.
Type of Reports: Written Reports: are those that have portions with narrative areas, areas to record vital signs in written number form and check boxes Computerized Reports: those that are completed by shading boxes to record data; they are scanned for easy data storage and evaluation. Pen-Based Computer and PDA: laptop computers or PDAs that allow the EMT to enter information about a call directly into a database
PCR Data Set Individual box in the prehospital care report is called a data element. o Eg. Vital signs U.S. DOT defines minimum elements/minimum data set for a PCR: to aid in research across states. PCR can be broken down into several sections. The sections include run data, patient data, check boxes and the narrative section.
Minimum Data: Patient Information: EMTs initial contact with patient on arrival of scene, following all interventions and on arrival at facility. This section contains information about the patient, the patients condition throughout the call and the care given to the patient. o Chief complaint o Level of consciousness (AVPU), mental status Alexanuia Bamilton SmaitReview o Systolic BP for patents more than 3 years of age o Skin perfusion (capillary refill) for patients < 6 years of age o Skin color and temp o Pulse rate o Resp rate and effort Administrative Information o Time of incident reported o Time unit notified o Time of arrival at patient o Time unit left scene o Time of arrival at destination o Time of transfer of care
Data sections of the PCR:
Run Data: includes agency name, unit number, date, times, run or call #, crew member names, licensure levels and numbers. Time recorded must be accurate.
Patient Data Includes complaint, past medical history and vitals signs recorded
Treatment Given: Alexanuia Bamilton SmaitReview Stable patients vital signs should be taken every 15 minutes and an unstable patients should be taken every 5 minutes.
Narrative: It provides space to write information about the patient that cannot fit into fill-in blanks or check-off boxes. Avoid conclusions # be objective Include observations of the scene Include pertinent negatives: which are examination findings that are negative (things that are not true), but are important to note o for example, if a patient has chest pain, you will ask that patient if he has difficulty breathing. If the patient says he does not have difficulty in breathing, that is an important piece of negative information. Avoid slang and radio codes Use only standard abbreviations Use correct spelling Write legibly Unusual occurrences are documented on a separate Incident Report
Alexanuia Bamilton SmaitReview Pre-hospital Care Report Confidentiality: o Regulated by the Health Insurance Portability and Accountability Act (HIPAA) o Completed reports must be kept in a locked box Distribution of Copies o Determined by local and state regulations Falsification of PCR o Leads to poor patient care o May lead to revocation of certification/license: may also lead to the suspension or revocation of your certification/license o If an error in patient care occurs, document what did or didnt happen ! Note steps taken (if any) to correct the situation Correction of Errors o Draw single horizontal line through the error o Write the correct information beside it o Do not obliterate the error o If an error is discovered after the form is submitted: ! Complete a Supplemental Report attached to PCR " Use a different color of ink " Correct error with a single line cross out " Initial and date the correction Patient Refusal: make sure you get consent. o Competent adult patients may legally refuse treatment: age? Impaired by alcohol/drugs? Mentally competent? Impaired by medical condition? o Patient must be informed of the consequences of refusing care o Document all assessment findings o Have patient AND witness sign refusal form o Document attempts made to convince patient to go to hospital o Document actions taken to protect patient after you leave o Contact medical direction, if necessary
Special Documentation Issues
Special Reporting Situation Multiple casualty incident (MCI) o Insufficient time to fully complete a PCR o Use local forms or tags on the scene: chief complaint, vital signs, and treatment provided is recorded on a triage tag that is attached to the patient o Follow local MCI plan for documentation Infectious disease exposure Injuries to self/other providers Hazardous areas/scenes Alexanuia Bamilton SmaitReview Social service referrals Child/elder abuse Document unusual events o These reports are not made a part of the patients record Provide additional supplements to PCR Follow local guidelines for confidentiality.
Enrichment Alternative methods used for PCR charting o SOAP: subjective-objective-assessment-plan CHART: chief complain-history-assessment- Rx(treatment)- transport
Alexanuia Bamilton SmaitReview Communications
The three types of EMS Communication EMS Communication Radio Verbal reports: to convey information about your patient directly to the hospital personnel who will be taking over his care Interpersonal: are important in dealing with other EMTs, the patient, family and bystanders, medical direction, and other members of the EMS system.
Radio Communication System: Base station: A base station is a two-way radio at a fixed site such as a hospital or dispatch center. The base station can serve as a dispatch and coordination hub, and ideally is in contact with all other elements of the system. o base should be located on a suitable terrain, preferably a hill, and be in proximity to the hospital that serves as a medical command center. Two-way mobile radio Portable radio: useful when you are out of your vehicle and must stay in communication. Such portable units may also be used by medical direction when they are stationed at a hospital that has no radio. o Cell phones: transmit through the air instead of over wires so that the phones can be transported and used over a wide area. Cell phones allow EMS communications through an already established commercial system. Cell phones are not always a solution to the problem of radio communication because a cell phone needs to be able to reach a cell tower or site.
Radio System Maintenance: o Back up radio system in case of equipment failure o Daily radio checks and batter charging o Maintenance by qualified technicians
Radio system Components: o Radio frequencies are assigned and licensed by the Federal Communications Commission o This is to prevent two or more agencies from trying to use the same frequency and interfering with each others communications. There are also strict rules about interfering with emergency radio traffic and prohibiting profanities or offensive language
Communication Principles Radio reports must be concise, organized and pertinent Listen before transmitting Press Push to Talk (PTT) button one second before speaking Speak slowly and clearly with 2-3 inches from the microphone Alexanuia Bamilton SmaitReview Avoid slangs, codes and profanity Do not give a patients name over the air: it is a violation of HIPAA Consider using land line or cell phone for privacy Provide objective information
Communication with Medical Direction and Dispatch
Reasons to communicate with dispatch: Location of call and information When en route to scene Upon arrival at the scene When en route to hospital Request additional resources Advice when at hospital Advise when leaving hospital Report unusual situations Request assistance
Reasons to communicate with medical direction Consultation Obtain orders for medications/interventions
Medical Radio report: Provides patient information to hospital Allows hospital to prepare A quality report paint a picture of the patient with words
Radio Report Content Unit and level of provider Estimated time of arrival Patients age and sex (and race) Chief complaint Brief, pertinent history of present illness Major past illness Mental status Vital signs Pertinent findings of the physical exam Emergency medical care given Response to emergency medical care Questions/orders from medical directions o After receiving an order: ! Repeat the order back word-for-word ! Question orders that are unclear or appear to be inappropriate
Alexanuia Bamilton SmaitReview Example: Arrival in approx. 8 minutes. 64-year-old male: Caucasian. Was complaining of severe chest pains that have worsened. History of Diabetes and takes insulin for that. Currently patient is awake, conscious and very anxious. Blood Pressure is 110/70. Respiration: 20. Skin: cool and pale.
Verbal Communication: At the Hospital Introduce the patient by name (if known) Summarize information from the radio report Provide any additional information and changes since radio report
Interpersonal Communication Maintain eye contact: Make frequent eye contact. It shows interest and attentiveness. Positioning and Body Language: Position yourself at or below the patients eye level and use a more open stance Be honest Use language that the patent can understand: slowly and clearly and explain procedure before they are performed Use the patients proper name. Act and speak in a calm, confident manner. Allow the patient enough time to answer each question and LISTEN Be aware of disabilities that impair communication. Ex. mental disabilities. Interpreters may be needed for language barriers Visual or auditory deficits: o For the visually impaired person, you will want to take extra effort to explain anything that is happening that he cannot see. o Elderly patients Pediatric note: best to involve parents when communicating with a child
Alexanuia Bamilton SmaitReview Bleeding and Shock
Circulatory System Responsible for the distribution of blood Components o Heart: muscular organ that lies within the chest, behind the sternum. ! pump blood, which supplies oxygen and nutrients to the cells of the body. To provide a sufficient supply of oxygen and nutrients to all parts of the body, the heart must pump at an adequate rate and rhythm. o Blood o Blood vessels: ! Arteries: carry oxygen-rich blood away from heart " Except for pulmonary artery " thick muscular wall that constricts and dilates ! veins: microscopically small and carry oxygen rich blood to supply every cell ! capillaries: carry deoxygenated blood back to the heart " less pressure than blood in artery
Taking the patients blood pressure is a means of measuring arterial pressure. Where capillaries and body cells are in contact, a vital exchange takes place. o Oxygen and nutrients are given up by the blood and pass through the extremely thin capillary walls into the cells. At the same time, carbon dioxide and other waste products given up by the cells pass through the capillary walls and are taken up by the blood. Veins have one-way valves that prevent the blood from flowing in the wrong direction.
Hypo means low, so hypoperfusion means low perfusion. inadequate perfusion of the bodys cells will eventually lead to the death of tissues and organs. Patient will start losing blood pressure
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Function of the Blood: Transportation: oxygenated and deoxygenated blood o Blood carries inhaled oxygen from the lungs to the bodys cells, and it carries carbon dioxide from the body cells back to the lungs where it is then exhaled. Nutrition: from intestines or storage tissues (such as fatty tissue, the liver, and muscle cells) to the other body cells. Excretion: carries waste products from the cells to organs, such as the kidneys, that excrete (eliminate) them from the body. Protection: antibodies and white blood cells, which help fight disease and infection. Regulation: Blood carries substances that control the functions of the body, such as hormones, water, salt, enzymes, and chemicals. Blood also helps regulate body temperature by carrying body heat to the lungs and skin surface where it is dissipated.
Bleeding: Classification: internal or external bleeding Hemorrhage: severe bleeding, major cause of shock Most sensitive: o Brain: major nutrients are glucose and oxygen o spinal cord o kidneys
Classification Arterial: Most difficult to control o bright red, rich in oxygen o high pressure. # blood spurts out Venous: dark red(low in oxygen), maroon color o Lower that atmospheric pressure o Large veins may actually suck in debris or air bubbles Capillary: minor and is easily controlled o slow and oozing, low pressure o clots spontaneously with minimal treatment
External Bleeding
The severity of the bleeding is somewhat dependent on the amount of blood lost in relation to the physical size of the patient. Alexanuia Bamilton SmaitReview
Patient assessment Estimate amount of external blood lost Triage (prioritize) Predict potential shock Control external blooding
Patient Care 1. Standard precautions. 2. Open airway. 3. Monitor respirations. 4. Ventilate if necessary. 5. Control bleeding. Assess circulation by taking a radial pulse; assessing skin color, temperature, and condition; and controlling external bleeding.
Controlling External Bleeding Direct pressure and hemostatic gauze: o Apply pressure to wound o Hold pressure firmly. o Bandage o Dont remove dressing Apply tourniquet: o Device that closes off blood flow to and from an extremity o Controls life-threatening bleeding o Commonly used in military and tactical settings o Direct pressure and elevation are usually successful o Hemostatic gauze in areas where tourniquet is appropriate: trunk, neck, head o Use: ! Extremity injuries only ! Once applied, do not remove or loosen Alexanuia Bamilton SmaitReview ! Material: 4in wide, 6-8 layers, cravats frequently used, ! never use narrow material such as rope or wire o Application: ! Select site, no farther than two inches from wound. " Should be between the wound and the heart ! Tighten to the point where bleeding is controlled ! Attach a notation to the patient: show other rescuers that it has been used and the time of application ! Blood pressure cuff may be used, temporarily, as a tourniquet to control life threatening arterial bleeding from an extremity while a pressure dressed is applied. Inflate to approx. 150 mmHg. ! Contact medical direction Alternative Bleeding o pressure point is a site where a large artery lies close to the surface of the body and directly over a bone ! four sites (two on each side) used as pressure points to control profuse bleeding in extremities: " the brachial arteries for bleeding from the upper extremities, " femoral arteries for bleeding from the lower extremities o Splinting: ! Stabilization ! Various types: " Inflatable splints, also called air splints, may be used to control internal and external bleeding from an extremity. " Air splints are useful if there are several wounds to the extremity or one that extends over the length of the extremity. Air splints are most effective for venous and capillary bleeding ! Not effective for arterial bleeds ! Maintains pressure
Special Situations Head injuries: increased pressure within the skull, which forces fluid out of the cranial cavity o Fracture skull o Bleeding or loss of cerebral spinal fluid from ears or note o Do not attempt to stop bleeding: Doing so may increase the pressure in the skull. Do not apply pressure to the ears or nose. Allow the drainage to flow freely, using a gauze pad to collect it. Nose bleed o Epistaxis o Direct trauma: Tiny capillaries in the nose may burst because of increased blood pressure, sinus infection, or digital trauma (nose picking) Alexanuia Bamilton SmaitReview o Increased blood pressure o Patients at risk o Controlling Nosebleeds: ! Have patent sit down and lean forward ! Apply or instruct patient to apply direct pressure ! Keep patient quiet and calm ! Position patient on side(recovery position) if unconscious. Prepare to suction
Internal Bleeding Damage to internal organs and large blood vessels: o can result in loss of a large quantity of blood in a short period of time. Blood loss cannot be seen Sharp bone ends of a fractured femur can cause enough tissue and blood vessel damage to cause shock (hypoperfusion)
Mechanism of: Blunt Trauma o Falls o Motor vehicle/motorcycle crashes o Auto-pedestrian collisions o Blast injuries
Penetrating Trauma o Gunshot wounds o Stab wounds o Impaled objects
Signs of Internal Bleeding Injuries to surface of body Bruising, pain, swelling or deformed extremities (especially in the chest and abdomen) Bleeding from mouth, rectum, vagina, etc. Tender, rigid, or distended abdomen Vomiting Dark, tarry stools and bright red blood o Red blood # new o Dark blood # old Signs and symptoms of shock
Patient Care Maintain ABCs# airway, breathing, circulation Administer high concentration oxygen via nonrebreather mark Control external bleeding Prompt transport
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Shock: the inability of the circulatory system to supply cells with oxygen and nutrients.
Hypoperfusion also causes the inadequate removal of waste products from the cells. Causes: o Inability of heart to pump o Decreased supply of blood o Lack of integrity in blood vessels o Failure of vessels to dilate and constrict. Development o Heart fails as a pump o Blood volume is lost o Blood vessels dilate
Classification of Shock Compensated shock. o increased heart rate (to increase blood flow) and increased respirations (to increase oxygenation of the blood). o Constriction of the peripheral circulation (to redirect blood to the vital core organs) o results in pale, cool skin and, in infants and children, increased capillary refill time. Decompensated shock. o At the point when the body can no longer compensate for the low blood volume or lack of perfusion, decompensated shock begins. Irreversible. o Cell damage occurs, especially in the liver and kidneys. o Even if adequate vital signs can be restored, the patient may die days later due to the failure of irreparably damaged organs o Unable to maintain perfusion of vital organs
Types of Shock Hypovolemic: o uncontrolled bleeding or hemorrhage ! also may be caused by burns or crush injuries, where plasma is lost o Internal, external or combination Cardiogenic o Myocardial infarction or heart attack o Inadequate pumping of blood o Electrical system malfunctioning o 50% change of living if at hospital Neurogenic Alexanuia Bamilton SmaitReview o Uncontrolled dilation of blood vessels # increases the capacity of the circulatory system to the point where the available blood can no longer adequately fill it. o Sepsis (massive infection) or an anaphylactic (severe allergic) reaction may also cause neurogenic shock. Obstructive o Blocking blocks blood to heart (vena cava) from the heart o Cardiac tamponade: compression of the heart that occurs when blood or fluid builds up in the space between the myocardium (heart muscle) and the pericardium (outer covering sac of the heart) o Tension pneumothorax: progressive build-up of air within the pleural space o Pulmonary embolism: blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream Signs and Symptoms Restlessness, changes in mental status Pale, cool, and clammy skin Nausea and vomiting Vital sign changes o Pulse and respiration increase o Blood pressure drops o Inaccurate pulse oximetry Other signs of shock include thirst, dilated pupils, and sometimes cyanosis around the lips and nail beds.
Emergency Care for Shock: Increasing the oxygen saturation of the blood will improve oxygen supply to the tissues. You must also attempt to stop what is causing the shock, such as external bleeding, and attempt to maintain perfusion. Remember that transportation is an intervention. Maintain airway: Oxygenation Transport (intervention) o Maximum time on scene ten minutes, unless extrication involved. This time limit is often called the platinum ten minutes.
Pediatric notes Efficient compensating mechanism: o they can maintain a normal blood pressure until over half of their blood volume is gone. Blood pressure drops # serious o they are already near death Consider shock and treat early
Cultural considerations Skin color: This is best evaluated where the outer layer is thinnest. Alexanuia Bamilton SmaitReview Fingernails and lips Mouth: The color of the mucous membranes inside the mouth. Eyelids: Note the color of the conjunctiva Palms of hands and Soles of feet: Look for yellowish color or jaundice or small round purplish spots called petechiae that are a result of capillary bleeding. Ask the family: Ask if the patients skin color is normal.
Trending Vital Signs Elevated pulse Elevated respiratory rates Identifies patients condition Unstable- vital signs taken every 5 minutes
Normal, Shock or Excited? On Scene # ventilate, administer oxygen, compensated shock o Pulse : 96 Weak/regular o Respirations 8 and Shallow o Skin Cool/moist o BP 90/60 5 Minutes # ventilate, decompensated shock o Pulse: 100 Weak/regular o Respirations 10 and Shallow o Skin Cool/moist o B/P 82/56 10 Minutes # o Pulse : 112 Weak/regular o Respirations 6 and Shallow o Skin Cool/moist o B/P 74/50
Treatment of Shock: Supine Administer oxygen (airway management) Control bleeding Use PASG if necessary. Elevate extremities 810 inches. Prevent heat loss. Transport rapidly.
Alternative Bleeding- Control Methods Pneumatic Anti Shock Garment o Systolic BP < 50 mmHg and signs of inadequate perfusion, inflate all sections Alexanuia Bamilton SmaitReview o Systolic BP < 90 mmHg and signs of inadequate perfusion and unstable pelvic fracture, inflate all sections o Never inflate just the abdominal section o Never apply PASG if bleeding is above level of the garment o Never apply to children
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Dressing and Bandaging
Dressing: Material applied to a wound in an effort to control bleeding and prevent further contamination should be sterile, meaning that all microorganisms and spores that can grow into active organisms have been killed. Dressings also should be aseptic, meaning that all dirt and foreign debris have been removed Occlusive dressing: used to form an airtight seal on open wounds Aluminum foil or saran wrap Pressure dressing: self adherent roller bandage wrapped rightly over dressing Bandage: material used to hold a dressing in place
Do NOT: Dont wrap anything around airway Do not cover tips of fingers and toes Do not bandage too tightly or loosely Do not leave loose ends Cover all edges of dressing
Types of bandaging Used for ear or forehead
Joints roller gauze works well Alexanuia Bamilton SmaitReview
Forearm:
Hand: figure 8
Shoulder(including blade), scapula and armpit Alexanuia Bamilton SmaitReview
Pelvis- rollergauze works well
Dressing Open Wounds Take standard precautions. Expose wound: Cut away any clothing so the entire wound is exposed Use sterile or very clean materials. Cover entire wound. Control bleeding. Do not remove dressings once applied.
Two special problems occur when bandaging an extremity. First, point pressure can occur if you bandage around a very small area. o It is best to wrap a large area, ensuring a steady, uniform pressure. o Apply the bandage from the smaller diameter of the limb to the larger diameter (distal to proximal) to help ensure proper pressure and contact. Second, the joints have to be considered. You can bandage across a joint, but do not bend the limb once the bandage is in place. To do so may restrict circulation, loosen the dressing and bandage, or both.
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Chest Injuries Blunt trauma- blow to chest o can fracture the ribs, the sternum, and the costal (rib) cartilages. o Whole sections of the chest can collapse. o the lungs and airway can be damaged and the great vessels (aorta and venae cava) and the heart may be seriously injured. Severe blunt trauma: damaging internal organs and impairing respiration Penetrating objects: bullet, knives, steel rods Compression motor vehicle collision
Closed chest injuries Closed skin is not broken Open- skin is broken Flail chest- fracture of two or more consecutive ribs in two or more places Paradoxical motion- opposite movement of flail verses chest cavity.
Patient Care- Flail chest Perform initial assessment. Administer oxygen; assist ventilations as needed. Apply bulky dressing to stabilize flail segment.: tape should not encircle the chest or interfere with chest expansion o Ed says place hand over area and apply pressure # will stabilize them. Monitor respiratory rate and depth
Open Chest Injuries: Sucking chest wound open to atmosphere Signs of severe difficulty breathing o Wound to the chest o Characteristic sucking sound o Gasping for air
Patient Care-Open Chest Wound Maintain open airway. Seal open chest wound o Ed says: put hand over hole and release according to patient status Apply occlusive dressing. Administer high concentration oxygen Treat shock. Transport
Occlusive and Flutter Valves involve taping the dressing in place, leaving a side or corner of the dressing unsealed. Alexanuia Bamilton SmaitReview As the patient inhales, the dressing will seal the wound. As the patient exhales, the free corner or edge will act as a flutter valve to release air that is trapped in the chest cavity.
Management-Sucking Chest Hand pressure Reseal dressing: tape also may not stick well to bloody skin or to skin that is sweaty from shock Improvised occlusive dressing- IV bag or aluminum foil
Injuries within the chest cavity: Pneumothorax: air enters the chest cavity, possibly collapsing the lung. o The air can enter through an external wound or through a punctured lung or both. Signs of shock will also be present. o Air enters chest cavity # diminished or absent lung sounds # can progress to a tension pneumothorax Alexanuia Bamilton SmaitReview Tension pneumothorax: trapped air builds up in the chest cavity and puts pressure on the heart, great blood vessels, and the unaffected lung, reducing cardiac output and the ability of the lungs to oxygenate the blood. o Most often with closed chest injury after sealing a sucking chest wound o Lung punctured by broken ribs or other cause o Air cannot escape and builds up in chest o Jugular veins distend (unless blood volume is low) o Reduces cardiac output o Tracheal deviation Hemothorax: caused when lacerations within the chest cavity are produced by penetrating objects or fractured ribs o Chest cavity fills with blood # caused by laceration within chest # blood flows in and around lungs # signs of shock Hemopneumothorax: combination of blood and air, usually producing the same results: a collapsed lung and loss of blood leading to shock. o blood will flow into the space around the lung# lung may collapse # patient will experience a loss of blood and/or added pressure # shock Traumatic asphyxia: result of crush injury/sudden severe compression to chest o Sternum and ribs exert severe pressure exerted on heart and lungs forcing blood out of right atrium into jugular veins in neck o Blood vessels rupture # extensive bruising to face and neck o Neck and face darker color (red, purple or blue) o Bulging eyes, distended neck veins Cardiac tamponade: injury to the heart causes blood to flow into the surrounding pericardial sac o The hearts unyielding sac fills with blood and compresses the chambers of the heart to a point where they will no longer fill adequately, backing up blood into the veins. o Blood in pericardial sac # sac fills with blood # compresses chambers of heart # blood backs up into veins Signs: distended neck veins, weak pulses, low blood pressure and decreasing pulse pressure ! Pulse pressure : systolic diastolic pressure " Normal : 120-80 = 40 Aortic injury and dissection: inner layer of the wall of the aorta begins to tear. Blood from the interior of the vessel leaks into the outer layers and eventually causes a balloon-like protrusion (aneurysm). o Damage to this large, high-pressure vessel causes massive, often fatal bleeding. Penetrating trauma can cause direct damage to the aorta. Blunt trauma, such as deceleration from a severe motor-vehicle collision (e.g., head-on), can sever or tear the aorta. o Largest artery in body # high pressure vessel # fatal bleeding # blunt trauma # degeneration secondary to hypotension. o Signs: ! tearing chest pain radiating to back and chest Alexanuia Bamilton SmaitReview ! Differences in pulse and blood pressure between right and left arms and legs ! Cardiac arrest
Patient Care- Chest Injuries Maintain an open airway. Administer high -low oxygen. Follow local protocols. Care for shock. Transport as soon as possible. Consider ALS intercept.
Critical Decision Making Determining serious underlying problems Not necessary to diagnose Knowledge of signs and symptoms
Abdominal Injuries Closed or open Blunt trauma Internal bleeding Protruding organs(evisceration)
Signs and Symptoms- Abdominal Pain, cramps, nausea Weakness, thirst Lacerations and punctures Bruising, developing shock o Shock may present with restlessness; pale, cool, and clammy skin; rapid shallow breathing; a rapid pulse; and low blood pressure. Coughing up or vomiting blood o The vomitus may contain a substance that looks like coffee grounds (partially digested blood). o Rigid and/or tender abdomen Distended abdomen
Patient Care- Closed and Open Stay alert for vomiting and keep airway open. Patient supine with legs flexed to reduce pain by relaxing abdominal muscles. Administer high-flow oxygen. Care for shock. Apply anti-shock garments. Nothing by mouth. Alexanuia Bamilton SmaitReview Monitor vital signs. Transport .
Additional Steps Control external bleeding Do not touch or try to replace any eviscerated or exposed organs o Apply a sterile dressing moistened with sterile saline over the wound site before you apply an occlusive dressing. Maintain warmth by placing layers of bulky dressing or a lint-free towel over the occlusive dressing ! Saline: 0.9% sodium chlorine dissolved in water Do not remove impaled objects o stabilize it with bulky dressings that are bandaged in place. Leave the patients legs in the position in which you found them to avoid muscular movement that may move the impaled object
Burns may involve structures below the skin including muscles, bones, nerves, and blood vessels. .Burns can injure the eyes beyond repair. Respiratory system structures can be damaged, producing airway obstruction due to tissue swelling, and even respiratory failure and respiratory arrest. When caring for a burn patient, always think beyond the burn. For example, a medical emergency or accident may have led to the burn. fire or burn may aggravate a medical condition or injury o Someone trying to escape a fire may fall and suffer spinal damage and fractures. The EMT should not only detect the burn but detect the spinal damage and fractures as well.
Classification of Burns: Agent or source o Agent ! Chemical ! Electrical ! Thermal o Source: ! Dry lime ! Alternating current Depth o Superficial (1st degree) ! Epidermis ! Reddening of skin ! Swelling o Partial thickness (2nd degree) ! Through the dermis only Alexanuia Bamilton SmaitReview ! Intense pain and blistering o Full thickness (3rd degree) ! All layers damaged, including nerves ! Severe pain from 1st and 2nd degree burns Severity: o Agent or source o Body region involved o Depth o Extent o Age o Other illnesses or injuries
Area: Rule of Nines o Each major area represents 9% of body surface area. Rule of Palm o Palm of patients hand equals 1% body surface area.
leg 18% each arm 9% each Note: burns of airway, genitalia, hands, feet #go to burn center Partial thickness burns of >30% body surface area # burn center
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leg 14% each arm 9% each head- 18%
Pediatric Note: Greater risks BSA difference Higher risk of shock Severity differs in less than 5 years old Consider child abuse
Geriatric Note Minor to moderate in young adult = fatal for an aged person. Tissue healing is lessened. Time of healing is increased. Consider other illnesses and injuries. Moderate burns = critical when >55 years old.
Critical Burns Burns with respiratory injury Full-thickness burns >10% Body surface area Partial-thickness burns >30% Body Surface Area Burns with painful, swollen, or deformed extremity Moderate burns in young or elderly Burns to face, hands, or feet Burns to genitalia Alexanuia Bamilton SmaitReview Burns encircling any body part (arm, chest, etc.)
Patient Carethermal burns Dry sterile dressings EMS medical directors decision Considerations o All partial and full thickness = dry dressing or burn sheet vs. o Moist dressing for partial thickness burns less than 10% and dry for more severe cases Never apply ointments, sprays, or butter (which would trap the heat against the burn site and have to be scraped off by the hospital staff). Do not break blisters. Do not apply ice to any burn (it can cause tissue damage).
Patient Carechemical burns Requires immediate care Wash away chemical with water. If chemical is dry, brush away. Apply sterile dressing or burn sheet. Treat for shock. Transport.
Specific Chemicals: Dry lime: do not wash with water-brush away Carbolic acid (phenol) does not mix with water Sulfuric acid # heat is produced when water is added Hydrofluoric acid # flood with water Inhaled vapors # give high concentration oxygen
Electrical Burns Can cause severe damage to body Entry and exit burns
cover up with dry sterile dressing
Alexanuia Bamilton SmaitReview Musculoskeletal Injuries Anatomy: Bones are formed of dense connective tissue Provide bodys framework Support and protection Production of red blood cells Bones articulated into joints Classified: Long Short Flat Irregular
Physiology Bones provide framework. Joints allow for bending. Muscles allow for movement. Cartilage provides flexibility. Tendons connect muscle to bone. Ligaments connect bone to bone.
Periosteum Strong, white, fibrous material surrounding bone Blood vessels and nerves pass through Obvious when bone exposed Impaled objects Do not remove
Joints
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Muscles: the tissues or fibers that cause movement of body parts or organs Skeletal o Voluntary o Gives body shape o Connected to bones o Tongue, pharynx o Upper esophagus Smooth o Involuntary o Walls of organs o Digestive Cardiac o Walls of the heart
Cartilage: connective tissue that covers the outside of the bone end (epiphysis) and acts as a surface for articulation, allowing for smooth movement at joints. Connective tissue outside of the bone (epiphysis) Surface for articulation Smooth movement at joints Less rigid Forms flexible structures: , o Cartilage is less rigid than bone, forms or helps to form some of the more flexible structures of the body ! Septum of nose ! External ear ! Trachea ! Connections between ribs and sternum
Tendons and Ligaments Tendons o Bands of connective tissue o Binds muscles to bones o Power of movement o MTB = muscle-tendon-bone Ligaments o Connective tissue o Supports joints by attaching the bone ends and allowing for a stable range of motion. o Connects bone to bone Alexanuia Bamilton SmaitReview o BLB = bone-ligament-bone.
Mechanism of Injury Direct force: is a person being struck by an automobile, causing crushed tissue and fractures. o MVC o Crushed tissue o Fractures Rotational forces: can cause stretching or tearing of muscles and ligaments, as well as broken bones, such as occur when a ski digs into the snow while the skiers body rotates. o Football, basketball o Soccer Indirect force o Falls from heights
Types of Injury Fracture: Bones break Dislocation: Joints come apart Sprain: Stretching and tearing of ligaments Strain: Overexertion of muscle
Patient Assessment
Assessment: Pain and tenderness Deformity or angulation Grating or crepitus Swelling Bruising Exposed bone ends Joints locked in position Nerve and blood vessel compromise
Fractures: a !"#$%& %()*%+,)- ,./0*- is one in which the skin is not bioken. An #1%. %()*%+,)- ,./0*- is one in which the skin has been bioken oi toin thiough fiom the insiue by the injuieu bone oi fiom the outsiue by something that has causeu a penetiating wounu with associateu injuiy to the bone. o An open injuiy is a seiious situation because of the incieaseu likelihoou of Alexanuia Bamilton SmaitReview infection.
Patient Care
Injuries: Standard Precautions Initial assessment (ABCs) Rapid trauma exam Apply cervical collar Splint Apply dressing to wounds Cold pack/elevate Note: For a low-priority (stable) patient, splint individual injuries before transport. For a high-priority (unstable) patient, immobilize the whole body on a long spine board, then load and go. If time and the patients condition permit, you may be able to splint a specific injury en route.
Load and Go Initial assessment reveals unstable patient. Address ABCs. Use long spine board. Do not splint individual extremities.
Splinting Immobilize adjacent joints and bone ends. Decreases pain and movement Prevents additional injuries such as nerves, arteries, veins, and muscles. splinting minimizes the movement of disrupted joints and broken bone ends, and it decreases the patients pain. It can prevent a closed fracture from becoming an open fracturea much more serious conditionand it can help to minimize blood loss. In the case of the spine, splinting on a backboard prevents injury to the spinal cord and helps to prevent permanent paralysis
Realignment: Restores effective circulation Splint may be ineffective otherwise. Decreases circulatory compromise: o If the extremity is not realigned, the chance of nerves, arteries, and veins being compromised increases. When distal circulation is compromised or shut down, tissues beyond the injury become starved for oxygen and die. Reduction in pain Alexanuia Bamilton SmaitReview o Pain is increased for only a moment during realignment under traction. Pain is reduced by effective splinting.
General rule-realignment Grasp distal extremity for support Splint in position found o Realign if extremity cyanotic or lacks pulse Manual traction o Resistance: ! Stop realignment and splint in position found. o No resistance: ! Maintain traction until splint applied. Generally, injured joints should be splinted in the position found unless the distal extremity is cyanotic or lacks pulses. If so, an attempt should be made to align the joint to a neutral anatomical position using gentle traction, provided that no resistance is felt.
General rule- immobilization Treat life-threatening problems first Expose Assess distal PMS before and after Align long-bone to anatomical position Choose method to be used Do not push protruding bones Immobilize both injury site and adjacent joints Pad voids
Hazards of Splinting First address life-threatening conditions. Ensure airway, breathing, and circulation. Method dictated by severity of patient. Compression of nerves, blood vessels, and muscles Inappropriate splinting: o Cause further soft-tissue injury o Cause open fracture to occur
Procedure-Splinting Standard Precautions Expose Stabilize the injury site. Assess pulses and circulation, motor function, and sensation. Check for disability. Realign if deformed or if the distal extremity is cyanotic or pulseless Measure or adjust the splint. Maintain manual stabilization or traction. Alexanuia Bamilton SmaitReview Apply and secure the splint. Reassess PMS distal to the injury.
Traction Splint: Indications o Painful, swollen, deformed thigh with no joint or lower-leg pain Amount of traction to pull o 10% of patients body weight o Do not exceed 15 pounds Guidelines: o Standard Precautions o Manual stabilization and traction o Assess PMS. o Adjust splint to proper length. o Apply proximal securing device (ischial strap). o Apply distal securing device (ankle hitch). o Apply mechanical traction. o Position and secure support straps. o Re-evaluate o Secure torso and traction splint to long board.
SignsLower Extremity Injuries Pain in pelvis, hips, groin, or back Painful reaction when pressure applied to iliac crest Inability to lift legs when supine Lateral rotation (outward) Unexplained pressure on bladder
Patient care-pelvic injuries Limit patient movement. Determine PMS function distally. Straighten and stabilization lower limbs. Apply pneumatic anti-shock garment (PASG) when B/P <90. Immobilize on long spine board. Reassess. Provide oxygen and treat shock. Transport. Monitor vital signs.
Pelvic Wrap: wrap should be performed on patients who have pelvic deformity or instability (movement upon palpation) whether or not signs of shock are present. o Pelvic deformity or instability o Mechanism of injury indicates pelvic injury. Alexanuia Bamilton SmaitReview o Follow local protocols.
Hip dislocation: occurs when the head of the femur is pulled or pushed from its pelvic socket. It is difficult to tell a hip dislocation from a fracture of the proximal (uppermost portion of the) femur. Conscious patients will complain of intense pain with both types of injury. Patients who have had a surgical replacement of the hip joint are at increased risk of hip dislocation. The hip can be dislocated either anteriorly or posteriorly.
Signs and Symptoms-Hip dislocation Anterior o Lower limb rotated outward o Hip flexed Posterior o Lower limb rotated inward o Hip flexed o Knee bent o Foot may hang loose.
Patient CareHip o Assess distal PMS. o Apply long spine board o Immobilize limb with pillows or blankets o Secure patient o Reassess distal PMS. o Treat shock and provide oxygen. o Transport.
Signs and SymptomsHip fracture Localized pain (sometimes in the knee) Sensitive to pressure laterally (greater trochanter) Discolored tissues Swelling Unable to move limb Unable to stand Foot rotated outward Injured limb appears shorter
Patient Care-Hip fracture o Bind legs together o Padded boards o Apply PASG
Femoral Shaft Fracture Pain Alexanuia Bamilton SmaitReview Open or closed fracture with deformity Injured limb shortened
Patient Care-Femoral Shaft Fracture o Control any bleeding by applying direct pressure . o Manage the patient for shock . o Assess distal PMS function. o Apply a traction splint. o Reassess distal PMS function.
Knee Injury Pain and tenderness Swelling and deformity with obvious swelling The knee is a joint and not a single bone. Fractures can occur to the distal femur, to the proximal tibia and fibula, and to the patella (kneecap).
Patient Care- Knee injury o Assess distal PMS function. o Padded board splints o Pillow o Reassess distal PMS function. o Immobilize with padded board splint. o Pad the voids o Reassess distal PMS function. o
Alexanuia Bamilton SmaitReview Head and Spinal Injuries
Anatomy and Physiology Human Body Skeletal system o Support Protection Nervous system o Control of thought o Sensations o Motor function Subsystems o Central nervous system o Peripheral nervous system
Central nervous system Brain Spinal cord
Peripheral Nervous system the nerves that enter and exit the spinal cord between each pair of vertebrae the 12 pairs of cranial nerves that travel from the brain without passing through the spinal cord all of the bodys other motor and sensory nerves. o Messages from the body to the brain are carried by sensory nerves. Messages from the brain to the muscles are carried by motor nerves. These nerves control voluntary movements, or those we consciously control such as running or grasping. As the nerves exit the brain, prior to traveling down the spinal cord, they cross over to the opposite side of the body. This is why an injury to the left side of the brain may produce effects such as weakness or lack of sensation on the right side of the body.
Autonomic Nervous system Controls involuntary functions: o heart beat, breathing, and control of diameter of vessels, sphincter muscles, muscles controlling bladder and bowel and digestion.
Alexanuia Bamilton SmaitReview Brain Master organ Receives and sends messages (which determines the bodys response) Susceptible to injury The brain is held within the skull. The spinal cord exits the base of the brain and leaves the skull through a large hole where the spinal column is attached. The brain is bathed in a fluid called cerebrospinal fluid (CSF). This fluid also circulates down the spine around the spinal cord. Dura matter - tough connective tissue that covers brain Arachnoid - lies underneath dura matter and provides some added connective features. Pia matter - interlining membrane and very fragile.
Head Skull (29) o Cranium (8) o Facial bones(14) o Auditory bones (6) o Hyoid bone (1) Cranium: portion of the skull that encloses the brain o Forehead o Top o Back o Upper sides of skull Cranial Bones o fused Face o Fused except for mandible o 14 bones o temporal bone o temporomandibular joint Upper Jaw o Fused o Maxillae: made of two fused bones known as a maxilla. Nasal o Bridge o 2 bones o Cheek o Malar o Zygomatic o Forms portion of orbits Alexanuia Bamilton SmaitReview
Spine 33 vertebrae o 7 cervical o 12 thoracic o 5 lumbar o 5 sacral o 4 coccygeal spinous process o bony bump Every vertebra has a hollow space like the hole in a donut. These hollow spaces form a channel that runs the length of the spinal column and contains the spinal cord, which is cushioned by the cerebrospinal fluid.
Alexanuia Bamilton SmaitReview Injuries to the Head
Scalp: Blood vessels = bleeds profusely Control bleed Dress and bandage o Do not apply pressure if the injury site shows bone fragments or depression of the bone or if the brain is exposed. Instead, use a loose gauze dressing. Caution when applying pressure Skull Cranium and facial fractures Open or closed o assume that there may be an open head injury beneath any contusion or laceration of the scalp Brain Direct: to the brain can occur in open head injuries, with the brain being lacerated, punctured, or bruised by the broken bones or by foreign objects. Indirect: the shock of impact on the skull is transferred to the brain. Indirect injuries to the brain include concussions and contusions.
Brain Injuries: Concussion: when a person strikes his head in a fall, or is struck by a blunt object, a certain amount of the force is transferred through the skull to the brain. Usually there is no detectable damage to the brain and the patient may or may not become unconscious. o Mild o No detectable damage o May or may not lose consciousness o Headache Contusion: caused by a collision or blow that causes the brain to hit the inside of the skull, bounce off the opposite side, and then rebound to strike the first side of the skull again. o Occurs with closed head injuries o Bruising on opposite side of blow o Contrecoup bruising on the opposite side of the blow o Coup bruising of the brain occurs on the side of blow Laceration o Cut o Open head injury o Caused by sharp, bony ridges o Object penetrates cranium Hematoma Alexanuia Bamilton SmaitReview o Collection of blood within tissue o Named based on location in brain o Subdural: a collection of blood between the brain and the dura o Epidural : blood between the dura and the skull. o Intracerebral: when blood pools within the brain.
Skull and Brain Injury- Signs Visible bone fragments Altered mental status Deep laceration or severe bruise Alexanuia Bamilton SmaitReview Hematoma Depression or deformity Severe pain Bruising behind ear (late sign) Unequal pupils Raccoon eyes (late sign) Bleeding from ears and/or nose CSF from ears and/or nose Personality change Increased BP and decreased pulse Irregular breathing Temperature increase Blurred or multiple vision Hearing impairment Equilibrium problems Projectile vomiting Posturing Paralysis or disability Seizures Deteriorating vitals
Patient Care Standard Precautions Stabilize C Spine Evaluate breathing Administer oxygen Control bleeding Keep patient at rest Emotional support Treat shock Transport
Cranial Injuries: Impaled Objects # lengthy impaled object can make transporting the patient impossible until the object is cut or shortened Do not remove. Stabilize in place. Pad around object. Use hacksaw if needed Consult medical control.
Injuries to Face and Jaw Fractures Bone fragments: Bone fragments may lodge in the back of the Alexanuia Bamilton SmaitReview pharynx and cause airway obstruction. So may blood, blood clots, dislodged teeth, or a separated palate. Dislocations: mandible is subject to dislocation as well as to fracture Airway management Suction Jaw thrust Control bleeding C spine precautions Treat shock
Nontraumatic Brain Injuries Caused by an internal brain event Hemorrhage Blood clot Signs of nontraumatic (not caused by external trauma) brain injury Same as those for a traumatic injury No evidence of trauma No mechanism of injury
Glasgow coma scale EMS agencies use the GCS in addition to AVPU, for ongoing neurological assessment. Some systems would immediately transport a patient with a score of 8 or less directly to the trauma center if they are within 30 minutes transport time.
Eye Opening: Spontaneous Open your eyesnormal tone Shout command if normal tone unsuccessful Note eye injuries. Verbal Response Oriented o Who he is o Where he is o Day of the week Confused o Cannot answer questions Inappropriate words o Words do not fit situation Incomprehensible sounds o Mumbling o Moans o Groans o No verbal response Alexanuia Bamilton SmaitReview Motor Response Obeys command o Carry out request Localizes pain o Apply pressure to nail bed Withdraws o Pulls away from pain o Posturing in flexion o Elbows flex o Appearance of stiffness Posturing in extension o Legs and arms extend o Internal rotation of shoulder and forearm No motor response WithdrawsNote if the elbow flexes, if the patient moves slowly, if there is the appearance of stiffness, if he holds his forearm and hand against the body, or if the limbs on one side of the body appear to be paralyzed (hemiplegic position).
Posturing A) decorticate # sign of spinal reflex. Consciousness can still be salvaged. Upper extremities in towards the body B) decerebrate # cerebral cortex no longer intact (brain dead) extended upper extremities and rotated outwards.
Alexanuia Bamilton SmaitReview Injuries to the Spine
Mechanism of Injury to Upper Body
A simple rule of thumb is, if the mechanism of injury exerts great force on the upper body or if there is any soft-tissue damage to the head, face, or neck due to trauma (such as from being thrown against a dashboard), assume possible cervical- spine injury. Any blunt trauma above the clavicles may damage the cervical spine.
Patient Assessment-Spinal Injury Paralysis: Most reliable Pain without movement: Not always constant Pain with movement: Dont ask patient to move Tenderness along spine: Gentle palpation Impaired breathing: Watch patient breathe o If there is only a slight movement of the abdomen, with little or no movement of the chest, it is safe to assume that the patient is breathing with the diaphragm alone (diaphragmatic breathing) o nerves that control the diaphragm are located high in the cervical area (the third, fourth, and fifth cervical nerves) and are often unharmed, but the intercostal (between-the-ribs) nerves that control the chest muscles are often damaged in cervical and thoracic injuries. Deformity: Remove clothes and check Priapism: Persistent erection Posturing: Motor-nerve pathway interrupted Loss of bowel control Loss of bladder control Nerve impairment to extremities Soft-tissue injuries o Traumatic soft-tissue injuries to the head and neck may signal injury of the cervical spine. Traumatic soft-tissue injuries to the shoulders, back, or abdomen may signal injury of the thoracic or lumbar spine. Traumatic soft-tissue injuries to the lower extremities may signal injury of the lumbar or sacral spine. Severe spinal shock: Failure of the nervous system o (neurogenic shock) can be caused by the failure of the nervous system to control the diameter of blood vessels. The pulse rate may be normal because a message to speed up the heart may be prevented from getting to the heart due to the cord injury. Alexanuia Bamilton SmaitReview
Questions: What happened? Where does it hurt? Does your neck or back hurt? Can you move your hands and feet? Can you feel me touching (fingers and toes)? Do you feel pins and needles?
Strategiesresponsive patient Mechanism of Injury Bystander information DCAP-BTLS PMS Palpation
Assessment: Inspect DCAP-BTLS Palpate for tenderness. o Abdomen o Chest wall Assess extremities. o Pulses o Motor o Sensation Bystander information o What happened? o What did you see?
Patient Care-Spinal injury Manual in-line stabilization Assess ABCs. Rapid trauma exam Assess sensory and motor function. Apply spinal immobilization device. Oxygen Reassess motor and function.
Cervical Spine Injuries in Perspective 2.4% blunt trauma patients experience some degree of musculoskeletal injury to spine approx. 20,000 spinal cord injuries a year in US $1.25 million to care for a single patient with permanent SPI 15,000-20,000 SCI per year higher in men between ages of 16 30 Alexanuia Bamilton SmaitReview common causes: motor vehicle crashes, falls, etc.
Positive MOI- forces of impact suggest a potential spinal injury His speed MVC Falls greater than 3x body height Axial loading Violent situations near the spine : gun shots, stabbing Sports injuries o Infants 4 y.o. bones have not calcified efficiently. o Elders with osteoporosis Other high impact situations Consideration to special persons population o Pediatrics, geriatrics, history of Downs, spinal bifata, etc.
Normal Procedure-Immobilization Head and neck manually stabilized C collar applied after assessment Secure to short spine board or extrication vest. o Extrication vest: Flexible piece of equipment useful for immobilizing patients with possible injury to the cervical spine. It can be used when the patient is found in a bucket seat, in a short compact car seat, in a seat with a contoured back, or in a confined space. ! KED ! Kansas Backboard ! XP-1 ! LSP Halfback Vest
Technique-Rapid Extrication Bring the patients head into a neutral in-line position. This is best achieved from behind or to the side of the patient. Perform an initial assessment and rapid trauma assessment; then, apply a cervical spine immobilization collar. Support the patients thorax. Rotate the patient until his back is facing the open car door. Bring the patients legs and feet up onto the car seat. Bring the board in line with the patient and against the buttocks. Stabilize the cot under the board. Begin to lower the patient onto the board.
Logroll and Immobilization Establish and maintain in-line stabilization. Apply a rigid cervical spine immobilization collar. Place a long spine board parallel to the patient. If possible, pad the voids under the head and torso. Three rescuers kneel at the patients side opposite the board, leaving space to roll the patient toward them. Secure the patient to the board with straps. Loosely tie the wrists together. Alexanuia Bamilton SmaitReview Using a head/cervical immobilizer, secure the patients head to the spine board. Transfer the patient and the spine board as a unit. Secure the patient and the spine board to cot.
Other options Another option for securing the patient is using an X strap method that secures the torso to the backboard. Also apply one strap at the hip, one above the knee, and one below the knee. Blanket rolls and tape can also be used to secure the head of the patient to the backboard
Pediatric Note 6 years old or younger: When immobilizing a 6-year-old or younger child, provide padding beneath the shoulder blades to compensate for the large head. Pad from shoulders to toes as needed to establish a neutral position. Padding beneath shoulder blades Pad from shoulders to toes Practice immobilization with adult equipment.
Helmet Removal Injuries Face Neck Spine Airway management Resuscitation
Indication-helmet in place Helmet is snug No impending airway or breathing problems No resuscitation needed Removal would cause further injury Immobilization can be done with it in place No interference with airway and breathing assessment
Removal or Helmet Interferes with assessment Airway and breathing issues Improperly fitted Interferes with immobilization Cardiac arrest Per Medical Direction Alexanuia Bamilton SmaitReview Pharmacology
Pharmacology study of drugs their sources, characteristics, effects, etc. Usually refer to them as medicines or medications, because the public often thinks of drugs as illegal drugs EMT-Bs carry some medications, and can assist the patient take some of their prescribed medications.
Medications EMTs can Administered (carried on ambulance) Routinely carried: o Activated charcoal o Oral glucose o Oxygen o Baby aspirin May be carried o Albuterol mini0nebulizer o Epi-pen
Medications EMTs can assist with Prescribed inhaler (patients) Nebulized albuterol (can be carried on ambulance w/NYSDOH approval) Nitroglycerin (patient's) Epi-pen (epinephrine)
Definitions Pre prescribed medications# are those that are prescribed for a specific patient prior to the emergency
Medication Names Generic: the name listed in the US pharmacopoeia a governmental publication listing of all drugs in the US. o Name assigned to a drug before it becomes officially listed. Usually a simple form of the chemical name ! Ex: nitroglycerin, epinephrine. Trade: brand name is the name a manufacturer uses in marketing the drug o Ex. Epinephrine = adrenalin
Actions: the desired effects a drug has on the patient and/or his body systems ExampleNitroglycerin o Dilation of coronary arteries and subsequent increase of blood flow and oxygen to the heart muscle o Causes general dilation of systemic arteries, causing a drop in blood pressure
Indications for use Alexanuia Bamilton SmaitReview The indication for a drugs use includes the most common uses of the drug in treating a specific illness Specific signs, symptoms or circumstances under which it is appropriate to administer the drug to a patient.
Contraindications Situation in which a drug should not be used because it may cause harm to the patient or offer no effect in improving the patients condition or illness Example Nitroglycerin o Should not be given if the patient has a low blood pressure, because nitroglycerin, in dilating the arteries can cause a drop in systolic blood pressure o Should not be given if the patient has taken any erectile dysfunction medication in the last 72 hours.
Side Effects - Any actions of a drug other than those desired Some side effects may be predictable Ex: nitroglycerin o Hypotension, headache and pulse rate changes
Dose: how much of a drug should be given Usually given in milligrams
Routes of Administration- Route by which a drug is administered affects the rate that the medication enters the blood stream and arrives at its target organ. Oral or swallowed Sublingual or dissolved under the tongue Inhaled, or breathed into the lungs, usually in tiny aerosol particles as from an inhaler or as a gas such as oxygen Injected, through skin Absorption through the skin
Various Forms Suspensions # such as activated charcoal suspension or liquid-char Gels or paste # such as glucose to treat hypoglycemic Tablets or Spray # such as nitroglycerin tablets or spray. Gases
When do you give medication? Scene size up Initial assessment Sample history (OPQRST) Focused physical/vital signs Medication administration On going assessment Alexanuia Bamilton SmaitReview o Evaluate response to treatment *give oxygen in initial assessment
Administration Procedure Five Rights of medication administration o Right patient o Right medication o Right dose o Right route o Right time (timing; expiration date)
Bronchodilators
Bronchodilator Inhalers actions Dilates (enlarges) bronchioles, reducing airway resistance Ventolin or proventil (albuterol) Bronkosol or bronkometer (isoetharine) Alupent or metaprel (metaproternol)
Indications Patient exhibits signs and symptoms of a respiratory emergency (asthma) Patient has physician-prescribed hand held nebulizer
Contraindications Patient is unable to use device (not alert) Inhaler is not prescribed for the patient Patient has already taken maximum prescribed dose prior to EMT-Bs arrival Patient cannot hold nebulizer
Medical form Hand held metered close inhaler o Note: assure inhaler is at room temperature or warmer, and shake it up a little
Side effects: increased pulse rate, tremors and nervousness
Nebulized Albuterol Age range: 1year to 65 years Patient must be experiencing an exacerbation of their previously diagnosed asthma 2.5 mg unit dose administered nebulized albuterol o Standing Order! you do not need permission from hospital ! you can give 3 doses (5-10 minute intervals ! Contact medical control for further doses. Alexanuia Bamilton SmaitReview reassess patient: vital signs o you should not hear wheezing
Epinephrine Auto-Injections (Patients Own or Carried on Ambulance with NYSDOH approval)
dilates the bronchioles
Indications: Patient indicated signs of severe allergic reaction including either respiratory distress or shock (hypoperfusion) Medication is prescribed for the patient by a physician Administer as Standing Order, once, when assisting with patients own Epi. If patients own epinephrine is not available or expired, contact Medical Control for order to administer EMS Epinephrine.
Contraindications there are no contraindications when used in a life-threatening anaphylaxis in cases of an allergic reaction, as opposed to anaphylaxis, the patient should be able to participate in the decision and delivery of epinephrine.
Doses Adult-one adult auto injector (0.3mg) Infant and Child one infant/child auto injector (0.15mg)
Reassessment Strategies: Continue focused assessment of airway, breathing and circulatory status If patients condition continues to worsen (decreasing mental stat, increased breathing difficulty, decreasing BP) Meet ALS ASAP Obtain medication direction for an additional dose of epinephrine Treat for shock Prepare to initiate basic life suppose procedures (CPR/AED)
Hypoglycemia low blood sugar Alexanuia Bamilton SmaitReview Use a glucose supplement
Indications: patients with altered mental status with a history of diabetes controlled by medications
Contraindications: Decreased level of consciousness Cannot swallow or protect own airway
Side effects: None when given properly
Dosage: (1 tube) 30 grams
Vital Signs Assure S/S of AMS and Hx of diabetes o Assure that patient is conscious an can swallow and can protect own airway
Signs and Symptoms Nausea Vomiting Diarrhea Abdominal pain Burns around the mouth Unusual breath odors Difficulty breathing Altered mental status
Initial assessment History: o What substance? o When? o How much? o Over what time? o Patient interventions? o Weight of patient? Alexanuia Bamilton SmaitReview o Vital sings
Action: binds to certain toxins and prevents absorption
Contraindictions: ingestion of acids or alkalines
Side effects: Nausea/vomiting Black stools
Form: pre mixed in water in plastic container of 12.5 Gm or 25 Gm Dosage: 1Gm/Kg of body weight adult 25-50 Gm
Administration Shake container vigorously for at least 30 seconds. Repeat shaking if ingestion of activated charcoal takes longer than 10 minutes Persuasion Fill empty container with water after administration and have patient drink contents to assure proper dosing Do not delay transport
Documentation Requirements All assisted administration of medications must be documented on PCR Comments section o name of medication, dosage, route, time administered, response to medication, EMT# of technician who assisted with administration Treatment section o Check medication administered o Write the word assisted PCR distribution o White copy- retained by EMS o Yellow copy- retained by EMS agency o Pink Copy- left for patient at hospital
Pediatric Anatomy Airway structure differences Larger tongue The mouth and nose, in children, are smaller than those in adults and are more easily obstructed by even small objects, blood, or swelling. The tongue Smaller more flexible trachea: Because the head of an infant or young child is quite large relative to the body, it is necessary to place a folded towel or similar item about one inch thick under the shoulders to keep the trachea aligned and open cricoid cartilage is less developed and much less rigid. Therefore, the maneuver of pressing on the cricoid cartilage to help in placing a tube into the trachea, often used on adults, is not appropriate for an infant or child, since it can depress the soft cartilage and result in obstruction. Abdominal breaths
Alexanuia Bamilton SmaitReview Reasons for Breathing InspirationThe active process that uses the contraction of several muscles to increase the size of the chest cavity is called inspiration. The intercostal (rib) muscles and the diaphragm contract. The diaphragm lowers and the ribs move upward and outward. The expanding size of the chest cavity causes air to flow into the lungs. Another term for inspiration is inhalation. ExpirationA passive process, expiration, involves the relaxation of the rib muscles and diaphragm. The ribs move downward and inward, while the diaphragm rises. This movement causes the chest cavity to decrease in size and causes air to flow out of the lungs. Another term for expiration is exhalation.
Process of Breathing Inspiration Diaphragm and intercostal (rib) muscles contract. Diaphragm moves downward. Ribs move upward and outward, expanding chest cavity size. Larger chest size allows air to flow into lungs. Exhalation Diaphragm rises. Ribs move downward and inward, decreasing chest cavity size. Smaller chest size allows air to flow out of lungs.
Adequate Breathing Adequate breathing falls within certain ranges that are considered normal. The patient will not appear to be in distress. Adequate breathing is breathing that is sufficient to support life. RateRates of breathing that are considered normal vary by age. o adult, a normal rate is 1220 breaths per minute. o child, it is 1530 breaths per minute. o infant, it is 2550 breaths per minute. RhythmNormal breathing rhythm will usually be regular. Breaths will be taken at regular intervals and will last for about the same length of time. QualityBreath sounds, when auscultated with a stethoscope, will normally be present and equal when the lungs are compared to each other. o both sides should move equally and adequately o The depth of the respirations must be adequate. Skin color normal Normal mental status Evaluate rate, rhythm, and quality
Inadequate breathing Inadequate breathing is breathing that is not sufficient to support life. If left untreated, this condition will surely lead to death. Ratea breathing rate that is out of the normal ranges. o Very slow breaths and very rapid breaths Alexanuia Bamilton SmaitReview o Agonal respirations (dying respirations) are sporadic, irregular breaths o They are shallow and gasping with only a few breaths per minute. Rhythm irregular. o However, rhythm is not an absolute indicator of adequate or inadequate breathing. QualityWhen breathing is inadequate, breath sounds may be diminished or absent. o The depth of respirations (tidal volume) will be inadequate or shallow. o Chest expansion may be inadequate or unequal and respiratory effort increased. o the use of accessory muscles (muscles other than the diaphragm and the intercostal muscles, such as the muscles of the neck and abdomen) in breathing.
Inadequate Breathing in Pediatrics Most prominent signs: Nasal flaring Grunting Retractions and see-saw breathing you may observe a slight increase in pulse early, but soon the pulse will drop significantly. A low (or bradycardic) pulse in infants and small children in the setting of a respiratory emergency usually means trouble Leading killer of children Rapid deterioration and crashing of these patients rapid treatment and assessment is critical!
Evaluation of Breathing Frequent chief complaint. May also complain of chest tightness, anxiety, or restlessness Do not rely completely on patients perception, but rather on full patient assessment. May be a chronic problem or an acute onset Signs: o Increased or decreased pulse rate o Pale, cyanotic skin o Noisy breathing (gurgling, snoring, wheezing, etc.) o Accessory muscle use o Change in mental status o Flared nostrils, pursed lips o Positioning (tripod)
Respiratory Rate and Rhythm and Quality Rate: o Normal rates: ! Adult: 1220/min. ! Child: 1530/min. Alexanuia Bamilton SmaitReview ! Infant: 2550/min. o Critical finding: ! Very slow or very fast rates Rhythm o Breaths taken at regular intervals o Breaths last for approximately same length of time o May be influenced by talking, coughing, etc. o Critical finding: ! Irregular (not an absolute indicator) Quality o Measure by watching for equal chest rise. o Measure by feeling chest wall for equal expansion during inspiration. o Listen with stethoscope for abnormal noises. o Critical findings: ! Shallow or gasping ! Noisy lung sounds ! Unequal expansion ! Accessory muscle use ! Pale, cyanotic, or clammy skin
Pulse Oximetry oximeter reading in a normal, healthy person is typically 96 to 100 percent. o 91 to 95 percent indicates hypoxia, o 86 to 90 percent indicates significant hypoxia o 85 percent or less indicate severe hypoxia.
Causes of Respiratory Distress May be result of an acute problem o Trauma (chest injuries, head injuries) o Medical condition (heart attack, allergic reaction) o Other conditions (drowning, vomiting) o Anxiety, stress Respiratory condition o COPD ! Chronic bronchitis ! Emphysema Asthma
Chronic Obstructive Pulmonary Disease (COPD) Includes emphysema, chronic bronchitis, and black lung Generally affects older patients Affects patient continuously Causes include cigarette smoking, chemical exposure, and pollution
Chronic Bronchitis: involves inflammation, swelling, and thickening of the lining of the bronchi and bronchioles and excessive mucus production. Alexanuia Bamilton SmaitReview Inflamed and swollen bronchioles and thick mucus restricts airflow to the alveoli o Causing respiratory distress and possible hypoxia. Recurrent infections leave scar tissue that further narrows the airway.
Signs: o Typically overweight o Chronic cyanotic complexion (Chronic bronchitis patients are often called blue bloaters.) o Difficulty in breathing, but less prominent than with emphysema o Coarse rhonchi usually heard upon auscultation of the lungs o Vigorous productive cough with sputum (material that is coughed up) o Wheezes and, possibly, crackles at the bases of the lungs
Emphysema: the lung tissue loses its elasticity, the alveoli become distended with trapped air, and the walls of the alveoli are destroyed. Breakdown of alveolar walls Reduced surface area for exchange of oxygen and carbon dioxide Reduced elasticity of lungs Distal airways also involved have a greatly increased airway resistance.
Signs: o Thin, barrel chest appearance o Coughing, but with little sputum ! (Material that is coughed up) o Prolonged exhalation o Diminished breath sounds o Wheezing and rhonchi (rattles) on auscultation o Pursed-lip breathing o Extreme difficulty of breathing on minimal exertion o Pink complexion (Emphysema patients are often called pink puffers.) o Tachypnoeabreathing rate usually greater than 20 per minute at rest o Tripod position o May be on home oxygen
Asthma: Episodic disease with the narrowing of bronchioles and overproduction of mucus Typically one-directional, allows air into lungs but requires forceful exhalation (wheezing) Episodic # a disease that only affects the patient at irregular intervals). Alexanuia Bamilton SmaitReview The small bronchioles that lead to air sacs of lungs become narrowed due to muscle contractions that make up airway. PLUS there is an overproduction of thick mucus. o The combined effects of the contractions and the mucus cause the small passages to practically close down, severely restricting air flow Causes: o Allergic reactions to something inhaled, swallowed, or injected into the body o Pollutants o Exercise and stress
Lung Sounds Stridor: caused by a blockage in the throat or larynx (voice box), and it is typically heard when the patient inhales. Rhonchi: snoring or rattling noises heard upon auscultation. o Can indicate obstruction by thick secretions of mucus. o Often heard in chronic bronchitis, emphysema, aspiration, and pneumonia. Crackles: bubbly, popping sounds heard upon inhalation. o Associated with fluid that has surrounded or filled the alveoli or small bronchioles. o Crackles may indicate pulmonary edema or pneumonia. o Fine: Crackles are intermittent popping sounds. o Coarse: crackles are lower pitched and longer in duration than fine crackles. Wheezes: high-pitched musical sound heard upon inhalation and exhalation. o Usually due to swelling or spasms along the lower airway. o But is common in asthma and sometimes in chronic obstructive lung diseases such as emphysema and chronic bronchitis.
Artificial Ventilation Alexanuia Bamilton SmaitReview Pocket face mask with supplemental oxygen Two-rescuer bag-valve mask with supplemental oxygen One-rescuer bag-valve mask with supplemental oxygen Flow-restricted, oxygen-powered ventilation device (FROPVD) Ensure chest rise and fall. Rate of 12 breaths per minute for adults o 20 breaths per minute for children Monitor for a return to normal pulse rate and improved skin color.
BVM BVM with reservoir and 15 lpm of oxygen# patient receives 90100% of oxygen BVM without reservoir and 15 lpm of oxygen # patient receives 4550% of oxygen. BVM without oxygen # patient received 21% of oxygen.
Supplemental Breathing Provide for patients with adequate respirations. Deliver oxygen through o Nonrebreather mask (12 to 15 liters per minute) o Nasal cannula (2 to 6 liters per minute). Carefully monitor to ensure that ventilations are adequate.
Patient Interview Conduct after initiation of oxygen therapy. Use OPQRST and SAMPLE as guides for questions. o OOnset. When did it begin? o PProvocation. What were you doing when this came on? o QQuality. Can you describe the feeling you have? o RRadiation. Does the feeling seem to spread to any other part of your body? Do you have pain or discomfort anywhere else in your body? o SSeverity. On a scale of 1 to 10, how bad is your breathing trouble? ! (10 is worst, 1 is best.) o TTime. How long have you had this feeling? If patient has difficulty breathing, use family/friends to help with answers. Medications that the patient takes may influence treatment options. Alexanuia Bamilton SmaitReview
Prescribed Inhaler Inhalers contain a drug that dilates, or enlarges, the air passages, making breathing easier. Medication name: o Generic: albuterol, isoetharine, etc. o Trade: Proventil, Ventolin, Alupent, etc. Act immediately in an emergency to reverse airway constriction o E.g. Ventolin, Proventil, albuterol. Not for use in emergencies; used daily to help reduce inflammation and prevent attacks o Beclomethasone, Advair # should not be used to reverse an acute attack or in the event of breathing difficulty. Indications: Signs/symptoms of breathing difficulty Prescribed by physician Specific authorization by medical direction Patient must meet all criteria.
Contraindications: Inability of patient to use device Inhaler not prescribed No permission from medical direction Patient has used maximum dose
Medication form: Metered-dose inhaler
Dosage: Number of inhalations based on physician order
Side effects: Increased pulse rate Tremors Nervousness
Note: Check the expiration date. Make sure the patient is alert and able to use device. Be sure inhaler is at room temperature or warmer. Alexanuia Bamilton SmaitReview Determine if patient has already used inhaler and the number of times it has been used.
Step by Step Instructions 1. This permission from medical direction may be by phone/radio or by standing order, depending on your local protocols. 2. Check the medication to assure it is for the patient, it is the correct medication for the problem, and that it has not expired. 3. Shake the inhaler vigorously for at least 30 seconds. 4. Instruct the patient to then exhale slowly through pursed lips. 5. Instruct the patient to inhale deeply, and, as they do so, depress the canister. 6. Remove inhaler and instruct the patient to hold their breath for 10 seconds a. (or as long as possible). 7. Replace the oxygen to the patient. Reassess the breathing status and vital signs.
Spacer devices make the exact timing necessary to use an inhaler less critical. The inhaler is activated into the spacer device (sometimes called an Aerochamber). The medication stays airborne inside the chamber and can then be inhaled directly into the lungs.
Small-Volume Nebulizer The medications used in metered-dose inhalers can also be administered by small-volume nebulizer (SVN). produces a continuous flow of aerosolized medication that can be taken in during multiple breaths over several minutes, giving the patient a greater exposure to the medication.
The human heart is a muscular organ located in the center of the thoracic cavity. The heart has four chambers: two upper chambers called atria and two lower chambers called ventricles. The atria both contract at the same time. When they contract, blood is forced into the hearts lower chambers, the ventricles. Both ventricles contract simultaneously to pump the blood out of the heart. one-way valve to prevent blood in the ventricle from being forced back up into the atrium when the ventricle contracts. o The pulmonary artery has a one-way valve so that blood in the artery does not return to the right ventricle. o The aorta also has a one-way valve to prevent backflow to the left ventricle.
Four Chambers of the heart Right atrium. The venae cava (the superior vena cava and the inferior vena cava) are the two large veins that return blood to the heart. The right atrium receives this blood and, upon contraction, sends it to the right ventricle. Tricuspid valve# prevents backflow
Right ventricle. Alexanuia Bamilton SmaitReview The right ventricle receives blood from the chamber above it, the right atrium. When the right ventricle contracts, it pumps this blood out to the lungs via the pulmonary arteries. o Tricuspid will close from added pressure (preventing backflow) blood is very low in oxygen and is carrying waste carbon dioxide that was picked up as the blood circulated through the body. While this blood is in the lungs, the carbon dioxide is excreted (taken out of the blood and when the person exhales, carried out of the body), and oxygen is obtained (taken into the blood from air the person has inhaled). The oxygen-rich blood is now returned to the left atrium via the pulmonary veins.
Left atrium. The left atrium receives the oxygen-rich blood from the lungs. When it contracts, it sends this blood to the left ventricle. o Bicuspid valve
Left ventricle. The left ventricle receives oxygen-rich blood from the chamber above it, the left atrium. When it contracts, it pumps this blood into the aorta, the bodys largest artery, for distribution to the entire body. o Since the blood must reach all parts of the body, the left ventricle is the most muscular and strongest part of the heart.
Cardiac Conduction System: The contraction, or beating, of the heart is an automatic, involuntary process.). Regulation of rate, rhythm, and force of heartbeat comes, in part, from the cardiac control centers of the brain. Nerve impulses from these centers are sent to the pacemaker and conduction system of the heart. These nerve impulses and chemicals (epinephrine, for example) released into the blood control the hearts rate and strength of contractions.
The Conduction System Sinoatrial node Site of impulse formation Internodal tracts provide impulse transmission across both atria and also to the AV node Intrinsic rate 60100 bpm Atrioventricular node Temporarily slows impulse before it reaches the ventricles Intrinsic rate 4060 bpm Bundle of His Connects the AV node to the bundle branches Intrinsic rate 2040 bpm Right and left bundle branches Transmit the impulse from the AV node to each of the two ventricles Alexanuia Bamilton SmaitReview Purkinje fibers Terminal portion of the conduction system that provides the electrical impulse to the contractile cells of the ventricles This allows organized contraction of the ventricles. Intrinsic rate less than 20 bpm
Coronary Arteries branch off from the aorta and supply the heart muscle with blood. Although the heart has blood constantly moving through it, it receives its own blood supply from the coronary arteries. Damage or blockage to these arteries usually results in chest pain. Important to note are the coronary arteries, which are the first arteries to arise from the aorta, and provide perfusion to the myocardium. Partial or full occlusion of these arteries is what precipitates cardiovascular compromise in patients. When the heart does not receive a constant supply of oxygenated blood, cells begin to malfunction or cease to function.
Vessels of Circulation: Blood vessels are described by their function, location, and whether they carry blood away from or to the heart. Artery: vessel that carries blood away from the heart o Arteries begin with large vessels, like the aorta. They gradually branch to smaller and smaller vessels. ! The smallest branch of an artery is called an arteriole. Capillaries are tiny blood vessels found throughout the body o where gases, nutrients, and waste products are exchanged between the bodys cells and the bloodstream. From the capillaries the blood begins its return journey to the heart by entering the smallest veins. ! these small veins are called a venule. Vein: vessel that carries the blood from the capillaries back to the heart is called o . From the venules, the veins get gradually larger, eventually reaching the venae cava.
Cardiac Compromise : is a blanket term that refers to any kind of problem with the heart.
Atherosclerosis is a build-up of fatty deposits on the inner walls of arteries. This build-up causes a narrowing of the inner vessel diameter, restricting the flow of blood. Alexanuia Bamilton SmaitReview o Fats and other particles combine to form this deposit, known as plaque. As time passes, calcium can be deposited at the site of the plaque, causing the area to harden. Arteriosclerosis is a stiffening or hardening of the artery wall resulting from calcium deposits. Often called hardening of the arteries, this condition causes the vessel to lose its elasticity, changing blood flow and increasing blood pressure. Aneurysm: from weakened sections in the arterial walls. Each weak spot that begins to dilate (balloon) o weakened section of an artery bursts, there can be rapid, life- threatening internal bleeding. o Tissues beyond the rupture can be damaged because the oxygenated blood they need is escaping and not reaching them. o If a major artery ruptures, death from shock can occur very quickly. When an artery in the brain ruptures, a severe form of stroke occurs. The severity is dependent on the site of the stroke and the amount of blood loss.
Causes of Cardiac Compromise Electrical Malfunctions of the Heart: generally result in a dysrhythmia, an irregular, or absent heart rhythm o Bradycardia : Less than 60 beats per minute o Tachycardia : Greater than 100 beats per minute o No pulse :Cardiac arrest Mechanical Malfunctions of the Heart o can lead to cardiac arrest, shock, pulmonary edema or congestive heart failure. o A lack of oxygen has caused the death of a portion of the myocardium. The dead area can no longer contract and pump. If a large enough area of the heart dies, the pumping action of the whole heart will be affected. Angina pectoris means, literally, a pain in the chest. o narrowed the arteries that supply the heart. During times of exertion or stress, the heart works harder. The portion of the myocardium supplied by the narrowed artery becomes starved for oxygen. When the myocardium is deprived of oxygen, chest painangina pectorisis the most frequent result. This pain is sometimes called an angina attack. acute myocardial infarction (AMI): portion of the myocardium (heart muscle) dies as a result of oxygen starvation o AMI is brought on by the narrowing or occlusion of the coronary artery that supplies the region with blood. Rarely, the interruption of blood flow to the myocardium may be due to the rupturing of a coronary artery (aneurysm). Alexanuia Bamilton SmaitReview 2#.3%$),4% 5%6*) 76,"0*%8 left ventiicle cannot effectively pump o The signs anu symptoms: ! Naikeu oi seveie uyspnea (shoitness of bieath) ! Tachycaiuia (iapiu heait iate gieatei than 1uu bpm) ! Bifficulty bieathing when supine (oithopnea) ! Suuuenly waking at night with uyspnea (paioxysmal noctuinal uyspnea) ! Fatigue on any type of exeition ! Anxiety ! Tachypnea (iapiu iespiiatoiy iate) ! Biaphoiesis (sweating) ! 0piight position with legs, feet, aims, anu hanus uangling ! Cool, clammy, pale skin ! Chest uiscomfoit ! Cyanosis ! Agitation anu iestlessness uue to the hypoxia ! Euema (swelling) to the ankles, feet, anu hanus ! Ciackles anu possibly wheezes on auscultation ! Becieaseu Sp02 ieauing ! Signs anu symptoms of pulmonaiy euema ! Bloou piessuie may be noimal, elevateu, oi low ! Bistenueu neck veinsjugulai venous uistension (}vB) (late) ! Bistenueu anu soft, spongy abuomen
Alexanuia Bamilton SmaitReview
Signs and Symptoms of Cardiac Compromise Difficulty breathing (dyspnea) Nausea, vomiting Anxiety/feeling of impending doom The elderly, diabetics, and female patients may not experience chest pain or discomfort in cardiac compromise. Weakness and difficulty breathing are more common symptoms. Cool, pale skin Dizziness Sweating Abnormal heart rates Tachycardiafaster than 100 bpm Bradycardiaslower than 60 bpm Abnormal blood pressures
Automated External Defibrillation # only if theyre pulseless Many EMS systems have resuscitated patients with AEDS (automated external defibrillators) The highest survival rates occur in systems with strong links in the chain of survival Extremely accurate
Types of AEDs: Semi automatic/shock advisory o Computer in AED analyzes rhythm and advises EMT to deliver shock Fully automatic o EMT turns on power and attached to patient; shock delivered automatically if needed Monophasic: o sends single shock (energy current) from one pad to the other Biphasic: o sends shock in both directions, measures resistance and adjusts energy o Causes less damage to heart muscle
Inappropriate Shock Very rarely does the AED computer make a mistake Alexanuia Bamilton SmaitReview AED related errors are almost always human error due to o Touching the patient during analysis o Not stopping the ambulance to analyze rhythm
Shockable Rhythm AEDs will shock two rhythms o Ventricular fibrillation ! Up to 50% of cardiac arrest patients o Ventricular tachycardia
Shock or Compression First? When the response time is greater than 4 to 5 minutes, it is appropriate to do 2 minutes of CPR (about 5 cycles) prior to analyzing and administering the first shock. It is appropriate to re-prime the pump by doing CPR for 2 minutes. If you come on the scene and a citizen or other provider is already doing high-quality compressions, you can count that effort toward the first 2 minutes and proceed with applying the AED.
Witnessed arrest Do not delay defibrillation to perform CPR. Defibrillation is the top priority! Unwitnessed arrest Do not delay CPR to perform defibrillation. CPR is the top priority!
Call ALS because paramedics can do a better job by inserting IVs, getting medication.etc.
Additional Safety Consideration Water o Dry patients chest. Remove from wet environment Metal o Ensure no one is touching any metal that the patient is in contact with Medication patch o If patch is visible on chest, remove it with gloved hands before delivering shock
Alexanuia Bamilton SmaitReview Diabetic Emergencies & Altered Mental Status
Diabetes Mellitus: The condition brought about by decreased insulin production, or the inability of the body cells to use insulin properly (which prevents the bodys cells from taking the simple sugar called glucose from the bloodstream) Insulin allows sugar to pass from the bloodstream to the bodys cells o Glucose, a form of sugar, is the bodys basic source of energy. The sugars that a person eats are converted into glucose, which is then absorbed into the bloodstream. o To enter the cells, insulin, a hormone produced by the pancreas, must be present. Without insulin, the cells can be surrounded by glucose but still starve for this sugar.
Noimal ulucose Regulation
Biabetes is tieateu with injections oi oial meuication
9-1% : &,6;%)%$: also iefeiieu to as insulin-uepenuent uiabetes mellitus (IBBN), since these patients aie iequiieu to inject insulin to iegulate theii bloou glucose levels. patient's pancieas usually uoes not seciete any insulin. o most commonly unuei the age of 4u o The patients aie typically lean fiom weight loss. Theii bloou glucose levels aie extiemely high if untieateu.
Alexanuia Bamilton SmaitReview 9-1% :: &,6;%)%$: also iefeiieu to as non-insulin-uepenuent uiabetes mellitus (NIBBN) patients usually uo not have to inject insulin. iegulate theii uiet anu exeicise anu take oial uiugs to help the pancieas seciete moie insulin oi to make the insulin that is secieteu moie effective in facilitating movement of glucose into the cells.
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Hypoglycemia: (low blood sugar) a life-threatening emergency for people with diabetes. Causes: o After taking too much insulin o Vomiting # no food going in o After unusual amount of exercise o Reduced sugar intake caused by not eating Signs and Symptoms: o Rapid onset o Intoxicated appearance, staggering, slurred speech, unconsciousness o Cold, clammy skin o Rapid heart rate o Seizures (severe cases) o Unusual or bizarre behavior o Anxiety o Refusal to cooperate or combativeness
Hyperglycemia : (high blood sugar) is a slow-onset condition from decreased insulin levels in people with diabetes. Causes: o Forgotten or insufficient insulin dose o Infection o Stress o Increased dietary intake Signs and Symptoms o Slow onset o Nausea/vomiting o Acetone odor on breath o Increased urination/hunger/thirst
Distinguishing the Difference Hypoglycemia: o Rapid onset o Skin is cold, pale, moist, or clammy. o No breath odors Hyperglycemia: o Slow onset o Skin is warm, red, or dry. Alexanuia Bamilton SmaitReview o Acetone odor on breath o Increased urination/hunger/ thirst o Abdominal cramps
Assessing Diabetic Emergencies Perform initial assessment o ABCs ! Maintain airway. ! Administer oxygen. Perform focused history and physical exam. o When and how did it start? o How long did it last? o Complaints of other symptoms? o Any trauma involved? o Any medical alert tags? o Has the patient seized? o Fever? o Interruptions in episode? Get SAMPLE history. o Note any medical alert tags. If the patient has a history of diabetes: o When did patient last eat? o Any medications? Last taken? o Any other illnesses? o Can the patient swallow? Take baseline vital signs. Give oral glucose if all of these conditions are met: o History of diabetes o Altered mental status o Patient can swallow If patient becomes unconscious, stop glucose administration immediately and secure the airway! If no improvement, consult medical direction. If patient is not awake enough to swallow: o Secure airway. o Administer oxygen. o Position appropriately. o Request ALS and transport.
Blood Glucose Meters 80120 mg/dl Normal 6080 mg/dl Moderate hypoglycemia Below 50 mg/dl Severe hypoglycemia Above 120 mg/dl Hyperglycemia Question results that are inconsistent with patients condition. Alexanuia Bamilton SmaitReview
Using Blood Glucose Meter and Test Strip Prepare the device including a test strip and lancet. Use an alcohol prep to cleanse the patients finger. After allowing the alcohol to dry, use the lancet to perform a finger stick on the patient. Wipe away the first drop of blood that appears. Apply the blood to the test strip. The blood glucose meter analyzes the sample and provides a readingusually in less than a minute.
Causes of Inaccurate Readings: Meter not calibrated Low batteries in meter Improperly stored or expired test strip Insufficient blood on test strip
Administration of Oral Glucose Squeeze glucose onto tongue depressor Insert Tongue Depressor between the Patients Cheek and Gum
Indications: Altered mental status Ability to swallow
Contraindications: Unconsciousness Diabetic who has not taken insulin for days Inability to swallow
Dosage: one tube Actions: Increases blood sugar Side effects: None when given properly May be aspirated if given to patient without gag reflex
Reassessment strategies: If patient seizes or loses consciousness, remove tongue depressor and secure airway.
Altered Mental Status
Causes: Hypoglycemia Poisoning (including alcohol and drugs) Alexanuia Bamilton SmaitReview Infection Head trauma Hypoxia
Emergency Care: Secure airway. Ventilate and suction as needed. Transport. Evaluate potential causes.
Seizures Sudden change in sensation, behavior, or movement caused by irregular electrical activity of the brain
Causes: Toxin: Drug or alcohol use, abuse, or withdrawal Brain tumor Congenital brain defects Trauma: Head injuries can cause seizures, as can scars formed at the site of previous brain injuries. Infection/fever: Swelling or inflammation of the brain caused by an infection can cause seizures. o (#1 cause in pediatric patients 6 months to 3 years old) Metabolic: Seizures can be caused by irregularities in the patients body chemistry (metabolism). Epilepsy Stroke Hypoglycemia Eclampsia (complication of pregnancy) Hypoxia: lack of oxygen Heat stroke
Information to Obtain What was the patient doing before the seizure? What movements were exhibited? Loss of bladder or bowel control? What did the patient do after the seizure? Length of episode?
Emergency Care: Place patient on floor. Position patient on side. Loosen restrictive clothing. Remove harmful objects. Alexanuia Bamilton SmaitReview Protect patient from injury; do not hold patient still or place anything in mouth.
After seizure subsides: o Protect airway with positioning and suction. o If cyanotic, ventilate with oxygen. o Treat injuries. o Transport.
Simple Partial Seizure: there is tingling, stiffening, or jerking in just one part of the body.
Complex Partial Seizure: also called psychomotor or temporal lobe, characterized by abnormal behavior that varies widely from person to person.
Generalized Seizure: In a tonic-clonic (also called grand mal) seizure, there is often no aura or other warning. This type of seizure is characterized by unconsciousness and major motor activity. Convulsion usually lasts only a few minutes and has three distinct phases: Tonic phase. The body becomes rigid, stiffening for no more than 30 seconds. Breathing may stop, the patient may bite his tongue (rare), and bowel and bladder control could be lost. Clonic phase. The body jerks about violently, usually for no more than 1 or 2 minutes (some can last 5 minutes). The patient may foam at the mouth and drool. His face and lips often become cyanotic. Postictal phase. This begins when convulsions stop. The patient may regain consciousness immediately and enter a state of drowsiness and confusion, or he may remain unconscious for several hours. Headache is common.
Absence Seizures: brief(usually only 1 to 10 seconds) There is no dramatic motor activity and the person usually does not slump or fall. Instead there is a temporary loss of concentration or awareness. A child may suffer several hundred absence seizures a day, severely interfering with his ability to pay attention and do well in school
Status Epilepticus: A life-threatening condition in which the patient has two or more convulsive seizures without regaining consciousness or lasting more than 5 minutes Emergency Care: o Secure the airway. o Ventilate with 100% oxygen. o Request ALS. o Transport immediately.
Stoke Death or injury of brain tissue that is deprived of oxygen Alexanuia Bamilton SmaitReview Caused by a blockage (ischemic) or bleeding (hemorrhagic) of a blood vessel in the brain ischemic stroke : caused by blockage of an artery that supplies blood to part of the brain or bleeding from a ruptured blood vessel in the brain. It can occur when a clot or embolism occludes an artery or as the result of atherosclerosis. hemorrhagic stoke: caused by bleeding into the brain is called. result of longstanding high blood pressure (hypertension). It also can occur when a weak area of an artery (an aneurysm) bulges out and eventually ruptures, forcing the brain into a smaller than usual space within the skull. Signs and Symptoms Intoxicated appearance, slurred speech, unconsciousness Severe headache, vision changes One-sided weakness on body Confusion Loss of bladder/bowel control Unequal pupils High blood pressure
Transient Ischemic Attack (ITA): Mini-stroke Signs and symptoms of a stroke Often resolved before EMS arrival Symptoms resolve without treatment in less than 24 hours Significant risk of having a full stroke
Treatment: Prompt transport is critical. Identify potential stroke patients and notify the hospital. Maintain airway; administer oxygen.
Cincinnati Prehospital Stroke Scale: 1. Have patient attempt to smile. 2. Have patient attempt to hold arms straight in front of her for 10 seconds. o A normal response is for the patient to move both arms at the same time. o An abnormal response is for one arm to drift down or not move at all. 3. Evaluate patients speech. o like slurred speech, the wrong words, or no speech at all.
Presence of any one sign indicated 72% probability of stroke Presence of all three signs indicates an 85% probability of stoke
Dizziness and Syncope Alexanuia Bamilton SmaitReview Syncope is a brief loss of consciousness. It can occur at any age; more common in elderly. It may be an indicator of a serious medical problem.
Causes: Hypovolemia: or low fluid/blood volume, can cause dizziness or syncope when the patient attempts to sit up or stand. o Trauma o Dehydration Metabolic: something is wrong w/ the brain or the structures near it o Hypoglycemia o Stroke o Seizure Environmental/toxicological: imbalances can lead to alterations in consciousness. o Alcohol/drugs o Carbon monoxide o Panic/anxiety Cardiovascular o Fast or slow heart rates ! A dysrhythmia that results in the heart beating extremely fast (a tachycardia) can lead to either dizziness or syncope. o Electrical system disturbance o Vagus nerve stimulation
Assessment Obtain a SAMPLE history. Ask about onset time, activities. Length of episode? Any previous episodes?
Treatments Any medications for this condition? Any nausea/vomiting/bowel changes? Administer high-concentration oxygen. Loosen restrictive clothing. Lay patient flat and elevate legs (if no suspected spinal injury). Treat any associated injuries. Request ALS and transport.
Allergic Reactions
Identifications Alexanuia Bamilton SmaitReview Identification of an allergic reaction Mild allergic reaction versus anaphylaxis Treatment of an allergic reaction Identification of candidates for epinephrine auto-injection Documentation of findings and treatment
Allergic Reaction: An exaggerated reaction of the human bodys immune system to any foreign substance
Allergen: Something that causes an allergic reaction
Anaphylaxis: A life-threatening allergic reaction that causes shock (hypoperfusion) and airway swelling Referred to as anaphylactic shock
Auto-Injection: Epinephrine carried by individuals who are subject to severe allergic reactions Spring-loaded needle and syringe with a single dose of epinephrine Automatically releases and injects the medication through the skin when the device is pressed firmly against the body
Epinephrine: A hormone produced by the body that constricts blood vessels and dilates respiratory passages
Causes of Allergic Reactions: insect stings, plants, medications, foods, etc.
Signs and Symptoms: Skin: o Itching o Hives o Flushing o Swelling o Warm Respiratory: o Tightness in throat o Rapid breathing o Cough o Labored breathing o Hoarseness o Stridor
Generalized Findings: Cardiac o Increased heart rate o Decreased heart rate Alexanuia Bamilton SmaitReview Itchy, watery eyes Headache Runny nose Sense of impending doom
Signs and Symptoms of Shock Altered mental status Flushed, dry, clammy, or pale skin Nausea or vomiting Changes in vital signs (pulse, respirations, blood pressure)
Mild allergic reaction or Anaphylaxis Perform initial assessment. Perform focused history and physical exam. Look for itching, hives, respiratory distress, or signs of hypoperfusion. Assess baseline vitals and get SAMPLE history.
Treatment Manage airway and breathing. High-concentration oxygen by Nonrebreather Positive pressure ventilations Consider assisting with epinephrine auto-injector IF: Signs and symptoms of shock are present. Patient is prescribed auto-injectorconsult medical direction. No auto-injector availablerapid transport or call for ALS intercept.
Epinephrine Auto Injection (Epi pen) Self-administered Epinephrine :prescribed by physician. Authorization: administer or help patient
When to Administer: Respiratory distress Signs and symptoms of shock (hypoperfusion) Signs of allergic reaction Physician has prescribed epinephrine to patient Medical direction authorizes epinephrine
Dosage: Adult: one auto-injector Child: one pediatric auto-injector
What to look for: Injector prescribed for THIS patient? Expiration date Alexanuia Bamilton SmaitReview Liquid cloudy or discolored? Give epinephrine ONLY to patients that have been prescribed auto-injectors
Procedure: Check liquid to make sure it is clear. Remove cap. Press injector firmly against patients thigh o (outside of thigh, midway between waist and knee). Not necessary to remove clothing prior to administration Follow your local protocols.
Action of Epinephrine: Dilates bronchioles: Constricts blood vessels.
Protocol Has to be a severe allergic reactions, either respiratory distress or shock Medication is prescribed for the patient by a physician Medical direction authorizes use for this patient
Side Effects: Increased heart rate Pallor and dizziness Chest pain Headache, excitability, and anxiety Nausea and vomiting
Reassessment Strategies: If patients condition WORSENS: o Consult medical direction. o Treat for shock. o Be prepared to use CPR/AED. If patients condition IMPROVES: o Continue oxygen. o Treat for shock (hypoperfusion).
Alexanuia Bamilton SmaitReview OBGYN Care of the mother before delivery
Anatomy: Fetus-developing baby Uterus-a muscular organ also called the womb Cervix- the neck of the uterus Vagina- canal Placenta- attached to the wall of the uterus and is composed of maternal and fetal tissues
Blood from the fetus is sent through blood vessels in the umbilical cord to the placenta where the blood picks up nourishment from the mother, then returns through the umbilical cord to the fetus body. The fetus is enclosed and protected within a thin, membranous bag of waters known as the amniotic sac. Amniotic fluid serves as a cushion. As the child develops, child ingests some amniotic fluid.
Stages of Pregnancy 1st trimester (1st3rd months) o Fetus is being formed 2nd trimester (5th month) o Uterus grows rapidly, reaching the umbilicus 3rd trimester (7th month) o Uterus now reaches the epigastrium
Types of Presentation Cephalic # normal, head first birth Breech # buttocks or both feet deliver first Alexanuia Bamilton SmaitReview
Stages of Labor
The first stage of labor is also called the dilation period. Picture the uterus as a long- neck bottle. In order to expel the contents, the neck of the bottle must be stretched to the size of a wide-mouth jar. Before the cervix can fully dilate, the long neck of the cervix must be shortened and thinned (this process is called effacement) to the wide-mouth-jar shape.
A and B) beginning of contractions to full cervical dilation. Cervix expands until head can pass through c)baby enters birth canal and is born d) delivery of the placenta
Labor Pains: Ache in lower backs Pain in lower abdomen, with increased intensity Regular intervals o Lasting from 30 seconds to 1 minute o Occurring at 2-3 minute intervals
Pre-delivery Evaluation Name, age, due date? First pregnancy? Contractions or pain? Onset? Bleeding or discharge? o meconium staining: Fluid that is greenish or brownish-yellow in color may be an indication of maternal or fetal distress during labor Crowning? (do you see the babys head?)
Evaluation of Labor Pains Contraction time, or durationthe time from the beginning of contraction to when the uterus relaxes (from start to end). Contraction interval, or frequencythe time from the start of one contraction to the beginning of the next (from start to start). Alexanuia Bamilton SmaitReview o When contractions last 30 seconds to 1 minute and are 2 to 3 minutes apart, delivery of the baby may be imminent. Feel the urge to move bowels Feel the need to push Rock hard abdomen
Transport Decision Based on assessment o Birth imminent if contractions less than 2 minutes apart o crowning Numbers of prior births Distance to hospital Note: make sure shes on her left side with pillows o Baby and mother must be in same ambulance
Supine hypotensive syndrome Dizziness and drop in blood pressure Referred to as vena cava compression syndrome Decreased blood return leads to drop in blood pressure and shock
Treatment of hypotension Transport on left side: counteract or avoid the possible drop in blood pressure, all third-trimester patients should be transported on their left side Pillow or rolled blanket behind back should be placed behind the back to maintain proper positioning.
Preparing for Delivery Patient privacy Standard Precautions Position mother on bed, floor, or ambulance stretcher Remove clothing Position your assistant Position equipment near patient (OB kit # If you are not in a private room and transfer to the ambulance is not practical (crowning is present), ask bystanders to leave There is a high probability of splashing blood and other body fluids during delivery. Have the mother lie with knees drawn up and spread apart
Delivering the Baby Alexanuia Bamilton SmaitReview Encourage her to relax between contractions. Continue to time her contractions from the beginning of one contraction to the beginning of the next. Keep someone at the mothers head to provide support, and monitor vital signs, and be alert for vomiting. If no one is on hand to help, be alert for vomiting and check vital signs between contractions.
Normal Delivery: Position your gloved hands at the mothers vaginal opening when the babys head starts to appear. Do not touch the area around vagina except to assist with delivery. Place one hand below the babys head as it delivers. o Spread your fingers evenly, remembering that the skull contains soft spots, or fontanelles. If the amniotic sac has not broken by the time the babys head is delivered, use your finger to puncture the membrane. Do not pull on baby
Checking for Umbilical Cord Once the head delivers, check to see if the umbilical cord is wrapped around the babys neck. Tell the mother not to push while you check. Then gently loosen the cord if necessary. If the cord is wrapped around the babys neck, try to place two fingers under the cord at the back of the babys neck. Bring the cord forward, over the babys upper shoulder and head. o If you cannot loosen or slip the cord over the babys head, the baby cannot be delivered. So immediately clamp the cord in two places using the clamps provided in the obstetric kit. Gently unwrap the ends of the cord from around the babys neck, and then proceed with the delivery.
Delivery Steps: babys coming out Check airway. Most babies are born face down and then rotate to the right or left. Support the babys head. Continue to support the head with one hand and, with the other hand, wipe the mouth and nose with sterile gauze pads. Use the rubber bulb syringe to suction the babys mouth, then the nose. Compress the syringe BEFORE placing it in the babys mouth. The upper shoulder (usually with some delay) will deliver next, followed quickly by the lower shoulder. (assist with upper shoulders) Support the trunk Support the torso and legs Note: Remember that newborns are very slippery. Once the feet are delivered, lay the baby on his side with his head slightly lower than his body
Alexanuia Bamilton SmaitReview Delivery Steps: Once the feet are delivered, lay the baby on his side with his head slightly lower than his body. Wipe blood and mucus from nose and mouth Suction again Warmth is critical (can rub the back) Wrap baby in warm towel, head lower than trunk
Post Delivery Try to keep the baby on the same level as mother Wait for umbilical cord to stop pulsating Clamp and cut umbilical cord Note exact time of birth
Cutting the Umbilical Cord Infant warm Sterile clamps or umbilical tape 1st clamp 3 inches from mother 2nd clamp 7 inches from baby Cut between clamps
Care of the newly born
-within the first 30 seconds the baby you start to cry -babies may appear cyanotic at first but will pink up within 30 seconds if not, follow blow by blow enriched oxygen if not, then bag mask ventilation if not working, Chest compressions
Alexanuia Bamilton SmaitReview
Assessmentnewly born Breathing, heart rate, crying, movement, skin color Pulse greater than 100 bpm o If less than 60, begin CPR Vigorous crying Moving extremities Blue coloration hands and feet ONLY Reassess after 5 minutes: these signs should still be apparent, with breathing becoming more relaxed. The blue coloration may or may not disappear, but it should not spread to other parts of the body
Resuscitation-Newly Born Warmth and clear airway Suction (using bulb syringe) Establish breathing Assess heart rate, respirations and color
Respirations Newborn should begin breathing within 30 seconds Provide only small puffs of air if using mouth to mask Rate of 40 to 60 breaths per minute Adequate respirations and a pulse rate greater than 100 per minute Supplemental oxygen
Heart Rate Heart rate less than 100 beats per minute o Ventilate at a rate of 40 to 60 per minute o 1 every 3 seconds Heart rate is less than 60 beats per minute o Initiate chest compressions Rate of 120 compressions per minute 3:1 ratio of compressions to respirations 90 compressions and 30 ventilations per minute
Stimulation Gentle but vigorous rubbing of the babys back It is not uncommon for this blue color to remain for the first few minutes
Cultural considerations Be sensitive to various ethnic, cultural, and religious groups regarding child birth If possible, allow time for family to respond to birth
Care of the Mother After Delivery Alexanuia Bamilton SmaitReview
Delivery of the Placenta: The third stage of labor is the delivery of the placenta with its umbilical cord section, membranes of the amniotic sac, and some of the tissues lining the uterus. Labor pains Lengthening of cord, which indicates the placenta, has separated from the uterus. Process may take longer than 30 minutes Transport can be delayed Observe for delivery of placenta When placenta delivers, place in plastic bag for transport to hospital o Place in a container and label In most cases, the placenta will be expelled within a few minutes after the baby is
Control Vaginal Bleeding Place sanitary napkin over vagina. (Do not place anything in the vagina) Position mothers legs lowered and together. Elevate her feet. Massage the uterus o Feel the mothers abdomen until you note a grapefruit-sized object. This is her uterus. Rub this area lightly with a circular motion. It should contract and become firm, and bleeding should diminish. The mother may want to nurse the baby. Treat torn perineum as a wound.
Breech Presentation: Most common abnormal delivery Buttocks first or both legs first Increased risk of prolapsed cord Possible meconium staining
Patient Care: Transport rapidly. Never attempt to pull legs. Provide high-flow oxygen. Position mother in head-down position. If body delivers, support it. Alexanuia Bamilton SmaitReview Provide care for baby, cord, mother, and placenta.
Prolapsed Cord: After the amniotic sac ruptures, the umbilical cord, rather than the head, may be the first part presenting at the vaginal opening. Position mother head down and buttocks raised using, gravity to lessen pressure on the birth canal. Provide high-concentration oxygen. Check for pulses and wrap cord. (keep it warm) Insert several fingers into vagina to push up on babys head. Transport.
Limb Presentation Limb protrudes from vagina Commonly a foot or arm Cannot be delivered in prehospital Rapid transport essential for survival
Assessment look for crowning arm or leg or both shoulder and arm
Patient Care Keep baby off cord Transport mother Mother in head down position High flow oxygen For a limb presentation, do not try to pull on the limb or replace the limb into the vagina. Do not place your gloved hand into the vagina, unless there is a prolapsed cord.
Multiple Births More than one baby born during single delivery Twins not considered complication Alexanuia Bamilton SmaitReview Call for assistance: you should have enough personnel and equipment to be prepared for multiple resuscitations.
Assessment Mother should be aware. Abdomen appears unusually large. Multiple contractions
Patient Care Clamp of tie cord of 1 st baby before the 2 nd baby is born 2 nd baby either before of after placenta provide care
Premature Birth Infant weights less than 5-1/2 lbs. (2.5 kgs) Born before 37th week Assessment o Full term vs. premature o Head is larger
Patient Care Keep baby warm: Premature infants are at great risk of developing hypothermia. Once breathing, the baby should be dried and wrapped snugly in a warm blanket. Keep airway clear Provide ventilations, as needed Watch for umbilical cord bleeding o Examine the cut end of the cord carefully. If there is any sign of bleeding, even the slightest, apply another clamp or tie closer to the babys body. Provide oxygen Avoid contamination Transport in warm ambulance
Meconium: earliest stools of an infant. Problem if child is covered in it. Results from fetus defecating Sign of fetal or maternal distress Assessment Amniotic fluid greenish or brownish-yellow Risk for respiratory problems
Patient Care Reduce risk of aspiration. o (do not stimulate the infant before suctioning the oropharynx) Suction mouth then nose. Alexanuia Bamilton SmaitReview Maintain open airway. Provide ventilations and/or chest compressions. Transport.
Emergencies in Pregnancy Pre birth bleeding Ectopic pregnancy Seizures Miscarriage and abortion Trauma stillbirths
Placenta previa Placenta in abnormal position Tearing of placenta May occur in 3 rd trimester Life threatening to mother and baby
Abruptio Placentae Placenta separates from uterine wall Partial or complete Life threatening May occur in 3 rd trimester This is extremely painful o Complaint of abdominal pain
Ruptured Uterus As the uterus enlarges throughout pregnancy, the uterine wall becomes extremely thin and is prone to spontaneous or traumatic rupture
Signs and Symptoms Main sign-profuse bleeding Associated abdominal pain Shock Rapid heartbeat may indicate significant blood loss.
Patient CareExcessive Bleeding Signs of shock high concentration of oxygen Sanitary napkin over vagina Save tissue.
Ectopic Pregnancy Normal pregnancyegg divides in the oviduct (fallopian tube) Ectopic pregnancyegg implanted outside the uterus Alexanuia Bamilton SmaitReview o May be on the outside of fallopian tube or abdominal cavity Acute abdominal pain Vaginal bleeding Rapid and weak pulse (later sign) Low blood pressure (a very late sign)
Patient Care consider the need for immediate transport position the patient for shock care for shock nothing by mouth
Alexanuia Bamilton SmaitReview Infants and Children
Developmental Characteristics Newborns # birth-1 year Toddlers # 1-3 years Preschool # 2-6 years School aged # 6-12 years Adolescents # 12-18 years
Behavioral Traits
Newborns and Infants birth # 1 year Tolerate parental separation poorly Exhibit minimal anxiety over presence of strangers Accept undressing but want to feel warm Can track movement visually (follows movement with eyes) Do not tolerate oxygen masks Have a parent hold the infant during the physical exam Keep hands and tools warm Observe breathing from a distance Examine the head last Listen to lungs (before child is upset)
1-3 years Do not tolerate parental separation Do not like to be touched May perceive illness as punishment Sensitive about modesty. Easily frightened (i.e., by needles) Have a parent hold the child during the physical exam. Explain that the child was not bad. If clothing is removed, replace it. Try to examine the head last. Explain what you do in advancebut use a childs terms.
Preschool (3-6 years) Do not tolerate parental separation Do not like to be touched Sensitive about modesty (do not like their bodies exposed) May perceive illness as punishment Tend to fear blood, pain, and permanent injury or disfigurement. Have a parent hold the child during the physical exam. If clothing is removed, replace it. Alexanuia Bamilton SmaitReview Be calm, reassuring, and respectful. Explain what you do in advance. Allow the child to give the history.
School age (6-12 years) Cooperative, but expect to have opinions heard Sensitive about modesty (do not like their bodies exposed) Tend to fear blood, pain, and permanent injury or disfigurement Allow the child to give the history. Explain as you examine. Be calm, reassuring, and respectful. Respect the childs modesty.
Adolescent (12-18 years) Expect to be treated as adults Generally act as though indestructible May fear lasting disfigurement Variable emotional and physical development may produce some insecurity about self-image Try to respect the emerging adult, yet reassure the remaining child. Explain as you examine. Be calm, reassuring, and respectful. Respect the young adults modesty and need for privacy.
Anatomical Differences
Airway Differences Small airways are more easily blocked. Child's tongue is larger. Infants are nose-breathers. o Suctioning nasopharynx improves breathing significantly. The trachea (windpipe) is softer and more flexible in infants and children. The trachea is narrower and is easily obstructed by swelling or foreign objects. The chest wall is softer, and infants and children tend to depend more on their diaphragms for breathing Put childs head in neutral position, not hyperextended. Children can compensate (breathe faster/harder) for a while, then get worse rapidly. Alexanuia Bamilton SmaitReview
Head Bigger, softer: A childs head is proportionately larger and heavier than an adults until about the age of 4 Infants and small children have disproportionately larger heads (until about age 4). Note the effect of padding. Fontanelles (soft spots) exist until about 1218 months old. o Sunken fontanelles may indicate dehydration. o Bulging fontanelles may indicate crying or head injury
Chest and Abdomen Increased elasticity of chest Primarily abdominal breathers (infants primarily nose-breathers) Less protection than adults for internal organs
Body Surface Larger in proportion to body mass making child more prone to heat loss Increased risk of hypothermia Burn injuries calculated differently
Blood Volume: the blood volume of a pediatric patient is less than the blood volume of an adult. A newborn does not have enough blood to fill a 12-ounce soda can, and an 8- year-old has only about 2 liters of blood. Therefore, a blood loss that might be considered moderate in an adult can be life threatening for a child. Alexanuia Bamilton SmaitReview
Assessment Two methods: Pediatric Assessment Triangle (PAT) OR Step-by-Step Assessment
Pediatric Assessment Triangle is a method of pediatric assessment from two viewpoints. from the doorway. o Observe appearance: ! Mental status ! Body position/muscle tone o Observe breathing effort. o Observe circulation (skin color). hands on - Provide interventions and assess for any further concerns. o Appearance o Breathing o Circulation
Step by Step Assessment
General impression Observe: o Quality of cry or speech o Emotional state o Response to your presence o Tone and body position o Mental status o Effort of breathing o Skin color Observe interaction with environment and parents: o Normal behavior for age? o Playing or moving around? Alexanuia Bamilton SmaitReview o Attentive? o Eye contact? o Recognize and respond to parents?
Initial Assessment Airway # open? Adequate? Any steps needed to ensure it remains open? Breathing o Chest expansion and symmetry o Effort of breathing o Nasal flaring o Retractions o Rate Respirations o Look for crowing or noisy respirations, wheezing, stridor or grunting, and equal expansion o Rate
Approach to Evaluation Assess circulation: Pulse o For assessment, check the radial pulse in a child, the brachial pulse in an infant. For basic life support, check the carotid pulse in a child, the brachial or femoral pulse in an infant In infants and children 5 years old or younger Capillary refill Skin color, temperature, condition
Opening the Airway: Use Head-Tilt, Chin-Lift Without Hyperextension
Suctioning: Ensure small enough catheter. Do not insert too deeply. Suction as briefly as possible.
Sings of Partial Airway Obstruction Stridor, crowing or noisy respirations Retractions on inspiration Pink mucous membranes and nail beds Alert
Treating Partial Airway obstruction Place in position of comfort Administer high conc oxygen Transport without agitating
Complete Airway Obstruction No crying or speech Initial difficulty breathing that worsens Cough becomes week and ineffective Altered mental status, unconsciousness
Clearing foreign body objects Infants # back blows and chest thrusts Children# abdominal thrusts
Oral Airways Use correct size Use tongue depressor to hold tongue down Insert right side up
Nasal Airways Use proper size Do not use if facial or head trauma exists Insertion technique same as for adult
Oxygen Therapy Alexanuia Bamilton SmaitReview Nonrebeather Blow by technique # hold tubing 2 inches from face or insert tubing into paper cup o Not Styrofoam Artificial Ventilation o Use proper size mask and bag o If trauma involved, use jaw thrust o If unable to maintain mask seal with one hand, use two Mouth to mouth ventilations Bag valve mask o Squeeze bag slowly/evenly until chest rises o If under 8 years old, ventilate 20 times a minute o If over 8 years old, ventilate 10-12 times a minute
Shock (hypoperfusion) Causes: o Diarrhea, vomiting, dehydration o Trauma and blood loss o Infection o Abdominal injuries Uncommon causes o Allergic reactions o Poisoning o Cardiac problems Signs o Rapid breathing o Pale cool clammy skin o Weak/absent peripheral pulses o Delayed capillary refill o Decreased urine output o Changes in mental status o Lack of tears when crying
Treating Shock Maintain airway & administer high-concentration oxygen. Ventilate as needed. Control bleeding. Alexanuia Bamilton SmaitReview Elevate legs. Keep warm. Transport.
Common Medical Problems
Respirator Emergencies Upper airway obstruction : Stridor on inspiration Lower airway disease: Wheezing and respiratory effort on exhalation OR rapid breathing without stridor
Early Respiratory Distress Nasal flaring Stridor, wheezing Retractions o Between ribs (intercostal) o Above clavicles (supraclavicular) o Below ribs (subcostal) Respiratory rate >60 Altered mental status Cyanosis Decreased muscle tone Excessive use of accessory muscles
Respiratory Arrest Little or no muscle tone Unconsciousness Slow/absent pulse
Respiratory Emergencies High-concentration oxygen Ventilate if respiratory distress severe: o Altered mental status o Cyanosis not improving with oxygen o Poor muscle tone o Respiratory arrest
Croup Viral inflammation of trachea and larynx Usually affects ages 6 months to 4 years Onset typically at night Seal-like barking cough Signs of respiratory distress
Treatment of Croup Alexanuia Bamilton SmaitReview Place in position of comfort. Administer high-concentration oxygen. Cool air may provide relief. Transport.
Epiglottis A life-threatening emergency! Bacterial inflammation of epiglottis Usually affects ages 3 to 7 Sudden onset of high fever Tripod positioning Painful swallowing and respiratory distress
Treatment of Epiglottis Place in position of comfort. Administer high-concentration oxygen. Transport immediately. Do not increase childs anxiety. Do not place anything in patients mouth.
Fever Variety of causes Goal is to cool without causing hypothermia. Be prepared for seizures.
Emergency Care of fever Remove clothing. Avoid hypothermia. Transport. If protocols allow: o Cover with soaked towels. o Allow small sips of water
Seizures Should be considered life-threatening in children May be brief or prolonged May cause injuries Causes: o Fever o Infection o Poisoning o Hypoglycemia o Trauma o Hypoxia o Idiopathic (unknown cause) Alexanuia Bamilton SmaitReview
Assessing seizures: Has child had seizures before? If yes, was this a typical seizure? Anti-seizure medication taken? Any fever?
Treatment of Seizures Establish airway. Position on left side if no spinal trauma. Have suction ready. Administer oxygen. Ventilate if needed. Transport.
Altered Mental Status Causes: Hypoglycemia Poisoning Post-seizure Infection Head trauma Hypoxia Shock
Emergency Care of altered mental status Establish airway. Administer high-concentration oxygen. Ventilate and suction as needed. Consider spinal precautions. Transport.
Poisoning: Emergency Care
Conscious patient Contact medical direction. Give activated charcoal as directed. Administer oxygen. Transport and monitor patient.
Unconscious patient Rule out trauma. Establish airway. Administer oxygen; ventilate as needed. Transport. Alexanuia Bamilton SmaitReview Contact medical direction.
Drowning: means that a patient has been submerged in water and has suffered either a cardiac or a respiratory arrest. If heart and respiratory function are not restored, it is a drowning. However, if the patient has a return of pulse and/or breathing, even temporarily, it is a near-drowning. Patients who have been submerged in cold water have been revived 30 minutes or more after submersion Ventilation is top priority. Consider possibilities of trauma, hypothermia, and drug ingestion. Transport.
Sudden Infant Death Syndrome Sudden death without identifiable cause in infant <1 year old. Cause is not well understood. Most common time of discovery is early morning.
Emergency Care: Try to resuscitate unless rigor mortis is present. Avoid comments that blame parents. Expect parents to feel remorse and guilt.
Trauma
Blunt trauma Motor vehicle crashes: o Unrestrained passenger (neck and head injuries) o Restrained passenger (abdominal and lower spine injuries) Motor vehicle impacts o Struck while riding bicycle (head, abdominal, spinal injuries) o Pedestrian struck by vehicle (head, abdominal and femurs injuries) Falls from height : neck and head injuries Diving into shallow water : head and neck injuries Sports injuries Child abuse
Specific types of injuries: Head (common injury area) o Airway maintenance critical o Can result in respiratory arrest o Nausea and vomiting very common Chest o Childrens ribs less rigid and more pliable o Result in injury to internal organs without external wounds Abdomen Alexanuia Bamilton SmaitReview o More common injured in children than adults o May be subtle and difficult to detect o Air in stomach may cause gastric distention or impede breathing Extremities o Managed the same as for adults
Trauma: other considerations Pneumatic anti shock garment o Use only if: ! Child fits garment ! Trauma with hypoperfushion and pelvic instability ! Do not inflate abdominal compartment Burns o Cover with sterile dressing o Follow local protocol with regard to transport to burn center
Child abuse and neglect Abuse: improper or excessive action so as to injure or cause arm Child abuse can take several different forms, often occurring in combination. These forms include: o Psychological (emotional) abuse o Neglect: Giving insufficient attention or respect to someone who has a claim to that attention o Physical abuse o Sexual abuse
Signs of abuse Physical abuse and sexual abuse are the forms of child abuse EMT is most likely to suspect. EMT must be aware of condition in order to recognize it. Multiple bruises in different stages of healing o Slap marks, bruises, abrasions, lacerations, and incisions of all sizes and with shapes matching the item used. Injury not consistent with mechanism described Injury matches item used to cause it Fresh burns Parents seem not to care as much as they should Conflicting stories Child afraid to describe how injury occurred
Signs of neglect Lack of adult supervision Child appears malnourished Unsafe living environment Untreated chronic illness Alexanuia Bamilton SmaitReview
Handling abuse and neglect Head injuries are most lethal. o Shaken baby syndrome: Closed head injuries occur to many infants and small children who have been severely shaken. ! Indications: bulging fontanelle due to increased intracranial pressure from the bleeding of torn blood vessels in the brain, unconsciousness, Abdominal injuries include ruptured spleens, livers and lungs lacerated by broken ribs, internal bleeding from blunt trauma and punching, and lacerated and avulsed genitalia. Bite marks may be present showing the teeth size and pattern of the adult mouth. Burn marks that are small and round from cigarettes; glove or stocking burn marks from dipping in hot water; burns on buttocks and legs (creases behind the knees and at the thighs are protected when flexed); and demarcation burns in the shape of an iron, stove burner, or other hot utensil are frequently found. Do not accuse anyone in the field. Required reporting: follow state laws and protocol and document objective information
Infants and Children with Special Needs
Children with special needs Premature infants with lung disease Infants and children with heart disease Infants and children with neurological disease Children with chronic disease or altered function from birth
Technologically Dependent Children (High tech kids) Tracheostomy tube: tubes that have been placed into the childs trachea to create an open airway o Complications: Obstruction, Bleeding, Air leak, Dislodged tube, Infection o Managing Tracheostomy Tube ! Maintain open airway. ! Suction. ! Maintain a position of comfort. ! Transport. Central intravenous lines o IVs that are very long ! Tip in vein near heart o Complications: ! Cracked line ! Infection Alexanuia Bamilton SmaitReview ! Clotting off ! Bleeding o Care: If bleeding is present, apply pressure. Transport. Gastrostomy tubes: Tube placed directly into stomach for child who usually cannot be fed by mouth Shunts: Tube running from brain to abdomen to drain excess cerebrospinal fluid o Should the shunt malfunction, pressure inside the skull will rise, causing an altered mental status. o An altered mental status may also be caused by an infection. These patients are prone to respiratory arrest.
Provider Response
EMTs frequently feel anxiety about treating children because they: Lack experience Fear failure Identify with their own children
To reduce anxiety about treating children: Remember that most adult care is similar for children. Practice with children playing the patient and use proper-sized equipment on them.
Patients Age 65+ Neatly half have bone/joint disorders A third have high blood pressure and heart disease ! are hearing impaired 1/10 have diabetes and/or visual impairments most take multiple medications more than half of patients age over 85 live alone or with a spouse this number is even greater in the 65 to 74 range o only 5% live in nursing homes 1 out of every 8 people is over age 65
Communication with Geriatric Patients May have vision deterioration Possible hearing loss Difficult speech pattern o Dentures o Previous medical problems Dont assume o Confusion is normal for any patient o Aging does not mean impaired thinking ability
Assessing Geriatric patients Physical hazards that could produce injuries? Environment well ordered? Are meds organized and current? Food half eaten? Surroundings sanitary? Temp of home?
General Impression Level of distress? Body position Medical equipment: oxygen tank, hospital bed? Mental status: normal baseline?
Focused and Sample History May have long medical history or none at all May have multiple medications or none at all May have little knowledge of their condition or know it very well
Assess ABCs Airward and breathing may be affected by o Stiffness in neck o Dentures (can cause blockage) Alexanuia Bamilton SmaitReview Arthritis/circulation may be affected by irregular heart rate
Use Special Consideration Be gentle, esp. if skin appears thin and fragile Listen patiently Protect patients modesty Take extra time to pad or cushion unusual body curves.
Common complaints of elderly patients
Pharmacology: Elderly use far more medication than other age groups May lose track if they have taken them Expensive; may not take regularly Drug patient interactions Drug-drug interactions o may act differently on each patients o may interact with each other
Shortness of Breath May or may not have chest pain o Asthma, emphysema, heart failure, myocardial infarction Chest pain May or may not have shortness of breath o Angina, myocardial infarction, aortic aneurysm, pneumonia(4 th leading cause of death in the elderly)
Other complaints Abdominal pain: may be aneurysm or bowel obstruction Weakness/malaise: may be sign of underlying problem Depression/suicidal behavior: elderly males most successful of all age groups
Additional Concerns 25% of hospital admissions for falls result in death o impact on lifestyle can be devastating o circumstances of falls are often linked to serious disorders many elderly fear hospitalization o loss of control over own circumstances o separation from loved ones o high costs can wipe out resources o consider the possibility that an elderly patient might understate medical complaints.
Hazardous material: common Any substance (gas, liquid, or solid) capable of creating harm to people, property and the environment
DOT: DOT utilizes 8 hazardous classes, some which contain subcategories called classifications, and a 9 th covering other regulated materials. DOT includes in its regulations hazardous substances and wastes as an ORM- E both of which are regulated by the EPA. Class 1: explosives (blasting agents_ Flammable gas (compressed gas) Flammable liquid (combustible liquid) Flammable solids (w/wet) Oxidizer (organic peroxide) Poison/toxic inhalation
Risk Assessment The danger of injury, damage or loss will occur Somebody or something likely to cause injury, damage or loss The statistical chance of danger from something, especially from the failure if an engineered system,
Safety Precautions Park upwind, uphill Keep a safe distance. keep people away from the area Avoid contact with material Do not enter hazmat scene Removal of non ambulatory patients done by trained personnel
HAZMAT zones: Cold zone: o The area contains the command post and such other support functions as are deemed necessary to control the incident. Clean zone or support zone Buffer zone/warm zone o The area where personnel and equipment for decontamination and hot zone takes place. It includes control points for the access corridor and thus assists in reducing the spread of contamination o Also referred to as decontamination-contamination reduction corridor or limited access zone o Decontamination involves volumes and volumes of water Hot zone: Alexanuia Bamilton SmaitReview o Area immediately surrounding a hazardous materials incident. It should extend far enough to prevent adverse effects from the hazardous materials released. This zone is also referred to as the Exclusion Zone
Levels of Protection Level A: highest level of respiratory, skin , eye and mucous membrane protection. Fully encapsulated, vapor-tight, chemical resistant suit, boots, inner outer gloves, coveralls, hardhat and SCBA Level B: highest level of respiratory but with a lesser degree of skin, eye and mucous membrane protection. Primarily a splash hazard Level C: airborne contaminates are known, APR can be used and where skin, eye , mucous membrane contact is unlikely Splash protection Level D: work uniforms, shoes, no respiratory protection required
Treat/Transport Contaminated Patients All patients/emergency personnel operating in the hot/warm zones are considered contaminated All patients/emergency personnel undergo decontamination prior to entering the ambulance The hospital may decide to decontaminate the patients a second time
Hazardous Materials A placard and an orange panel Reference Book NFPA 704 Diamond System: fixed facilities o Blue: health hazard o Red: fire hazard o Yellow: reactivity o White: protective equipment
Emergency Response Guide Book The Yellow sections list hazardous materials in numerical order by placard number. It can be used to find the appropriate GUIDE NUMBER Blue sections list hazardous materials in alphabetical order. It can be used to find the appropriate GUIDE number Alexanuia Bamilton SmaitReview o Products highlighted in Green have special isolation/evacuation information Orange section consists of numbered guides that lists the materials potential hazards: health, fire/explosion, public safety, and emergency response.
HAZMAT Scene Size up: Dispatch information Scene survey Incident command report/briefing Confirm the nature of the call/emergency Operational time frame Manpower and emergency Additional resources needed Start TRIAGE Initial assessment Priority
Avoiding the Product EMS operates in the cold zone Deals with non contaminated patients or patients that have been put through the decontamination process Keep the vehicle in a ready condition
Response to HAZMAT releases This plan is for emergency response operations for releases of, or substantial threats of releases of hazardous substances. EMS defines hazardous substances as: flammable liquids/solids, explosives, gases, and oxidizers. Recognition/Anticipation: hazardous materials can be found in every household (chemical storage areas, paint and hardware stores, pool supply businesses, agricultural/gardening facilities, sewage treatment and waste disposal centers, power companies, radiation treatment centers, fuel/oil storage areas) In addition to labels, placards, warning signs or the presence of suspicious containers, EMS teams must also include the presence of certain patient complaints as possible indicators. This may include but not limited to complaints such as nausea, vomiting, dyspnea, headache, dizziness, syncope, profuse diaphoresis, burns, altered mental status.
INCIDENT COMMAND A management system designed to provide a structured process of coordinating emergency response resources at situations involving Fires Hazardous materials Alexanuia Bamilton SmaitReview Multiple casualty incidents Rescue operations
Unified Command: used to coordinate resources of multiple types of services in a given jurisdiction Fire Ems Police Government agencies Commonly implemented for more incident responses
Singular Command: used to coordinate resources of a single type of service in a given jurisdiction Ems response with limited or no other services involvement Example: multiple victims of food poisoning at a wedding reception
Incident Command System: When is the ICS implemented? When more than two ambulances are needed at a scene When multiple emergency services are needed at a scene All HAZMAT responses All mass casualty incidents
Role of the EMS Incident Commander: Location: incident command post Radio ID: EMS command Reports to: Incident Commander in Unified Command model Duties: manages overall EMS response to incident o Administrative function (does not provide hands-on care)
EMS Incident Commander Establishes and functions in the EMS sector of the Incident Command Post Coordinates actions of all EMS personnel Serves as liaison to Fire/police/rescue agencies Assesses incident to determine manpower/equipment/supply needs Determines the number of causalities
Designate EMS Operations Officers Triage officer: o Location: incident site o Radio ID: triage o Reports to: EMS command o Duties: initiates triage ! Determines accurate number of victims Alexanuia Bamilton SmaitReview ! Establishes a triage/treatment area with the following considerations: sheltered, access to ambulance transportation, establish access control, personnel ! Two states of triage: field triage and second triage in treatment area Staging officer Treatment officer Transportation officer Communications officer Safety officer EMS command assistant
Triage Categories Priority One (P-1 Tx, red tag) o Treatable life threatening injuries: airway, breathing, severe bleeding, altered mental status, severe burns, shock, severe medical conditions o RED tag Priority Two (P-2 Tx, Yellow Tag) o Serious, but not life threatening ! Burns without airway involvement ! Major or multiple musculoskeletal injuries ! Back injuries without spinal cord damage Priority Three (P-3 Tx, Green Tag) o Walking wounded ! Minor musculoskeletal injuries ! Minor soft tissue injuries
Field Triage: START (Simple Triage and Rapid Treatment Is victim walking? Yes # green tag No # check respiratory status Respirations Present? No: position airway o Respirations adequate? Less than 10/min ! Yes # red ! No # black Yes o > 30/min # red tag o >10/min and <30/min # assess hemodynamic status Hemodynamic status adequate? Carotid pulse? No # black tag Yes o Radial pulse absent. Capillary refill > 2 seconds. Skin-cool and moist ! # red tag o Radial pulse present. Capillary refill < 2 seconds. Skin is warm dry and pink Alexanuia Bamilton SmaitReview ! # assess mental status Mental Status Adequate? No: unresponsive, disoriented, fails to follow simple commands # red Yes (alert and oriented, follows simple commands) # Green tag
Role of Staging Officer Ensures that all vehicles re properly positioned to allow for immediate egress Ensures that all vehicle drives remain with vehicle Directs vehicle slow as requested by transportation officer Maintains documentation of victims
Communications Officer: Establishes communicated area at the command post Contact area receiving hospitals and determine bed availability, forward this info to transportation officer
Transfer of Command Must be done each time a new individual assumes Incident Command position A verbal report must be given by the outgoing commander to the incoming commander Transfer of command is completed with a radio message to all units indicating a transfer of command o EMS command to all units ! Command has been transferred from MLSS M9 to County EMS 1
Putting it all together First In unit responsibilities o Scene size up ! Scene safety and hazards ! Number of victims ! Perform START o Do not treat patients during the size up o Determine need to implement incident command system (paramedic) ! Rule of thumb " >2 ambulances needed at scene 6 green tag patients 4 yellow tag 2 red tag o Assume position of EMS command until ambulance service officer arrives at scene, at which time command is transferred from the EMT to the officer. o Upon arrival of subsequent EMS units, EMS command appoints officers
Pitfalls of ICS Alexanuia Bamilton SmaitReview Communications: unnecessary chatter and freq overload Mobile ICS officers: too many cooks Lack of personnel: need for rehab, knowing ones limitations Free lancing
Phases of the Ambulance Call Preparation for the call Dispatch and responding Transferring patient to the ambulance Transporting the patient Terminating the call
Preparation for the Call Check equipment o Mechanical/fluids o Walk-around o Communication o Treatment supplies o Safety equipment o Other supplies
Mechanical/Fluids: Follow your agencys checklist through a careful mechanical inspection o Under hoot check o Starts o Streers o Stops o Stays running Walk around: Start the engine. Turn on the lighting equipment. o New body damage o Fluid leaks o Tire wear o Warning equipment Communications: radio equipment and your warning equipment are vital to your patients safety o Dispatch o Handheld o Medical direction Treatment supplies o Suction o Oxygen/resuscitation o Carrying devices o Defibrillation Safety Equipment o Standard precautions equipment o Binoculars o Scene wear Other Supplies Alexanuia Bamilton SmaitReview o Carry-in kits o Maps/GPS o Personal gear Ensure cleanliness o Carry in gear o Ambulance interior and exterior
Dispatch and Response Central access (911) 24 hour availability trained personnel (EMDs)
Information o Nature of call o Name, location, callback number o Location of patient o Number of patients and severity o Special problems Procedures: notify dispatch when responding Personnel available for response: o At least one EMT in patient compartment (minimum staffing) o Two EMTs preferred
En Route to Call Driving the ambulance: emergency vehicle operations course recommended. o course mandated in some areas. o Good operators and tolerate other drivers o Mentally and physically fit o Emotions under control and able to perform under stress o Wear safety belts (both driver and passengers) o Be familiar with vehicle o Be alert to road and weather conditions o Do not operate under the influence or when fatigued o Use caution when using emergency lights/siren o Select appropriate route o Maintain safe following distance
Driving Hazards: o Intersections # most common accident type o Use caution with escorts and multiple-vehicle responses ! Motorists dont expect second emergency vehicle Other Procedures o Obtain additional info from dispatch o Assign personnel specific duties o Assess equipment needs
Alexanuia Bamilton SmaitReview Arrival at the Scene Parking the ambulance o Park uphill from leaking hazards o Park 100 feet from wreckage o Set parking brake and utilize warning lights o Avoid parking were exit will be hampered. Procedures o Notify dispatch o Size up the scene: safety, body substance isolation and the # of patients.
On Scene Actions o Stay organized o Move rapidly and efficiently toward goal of transportation
Transferring Patient to Ambulance Procedures o Prepare patient for transport o Complete critical interventions o Check dressings and splints o Select proper moving device and secure patient
Transporting Patient Notify dispatch Continue ongoing assessment Notify receiving facility Reassure patient Prepare for any changes
At Receiving Facility o Notify uispatch o 0se caution backing into facility ! 0se a "spottei" whenevei possible Patient Tiansfei at Facility o Pioviue veibal anu wiitten iepoits to staff o Ensuie tiansfei of caie to hospital peisonnel
9%*+,.6),.3 )5% 26"" Notify uispatch Piepaie foi the next call Restock equipment Refuel unit Complete anu file iepoit Complete cleaning anu uisinfection Alexanuia Bamilton SmaitReview
Belicoptei Lanuing Zone Requiies 1uu' x 1uu' aiea Less than 8 uegiee slope Fiee of wiies, tiees, people anu loose objects Nevei shine light at pilot
Bangei Aiea: Ciouch while appioaching to stay well below moving iotois. Appioach fiom uownhill siue
Appioach to Belicoptei: Follow uiiections of ciew Ciew will uiiect patient loauing Stay cleai of tail iotoi No smoking, tiaffic, vehicles within 1uu' of helicoptei