Medical / ObGyn

Sign and Symptom

Sign: objective finding

Symptom: subjective finding patient feels

how often assess vitals?

Assess vitals every 5 mins for unstable, 15 for normal

Transport:

• never appropriate to transport kids in parents arms

• can use law enforcement

Sphygmomanometer

wraps around arm 1-1.5 times, 2/3 length armpit to elbow crease

To measure response to painful stimuli:

• pinch earlobe 

• pressing on bone above eye 

• pinching neck muscles

quadrants of body

• The left upper quadrant: contains the stomach, spleen, and a portion of the pancreas. 

• The right upper quadrant: contains the liver, gallbladder, duodenum of the small intestine, and a portion of the pancreas. 

• The left lower quadrant: contains the large and small intestines. Of the large intestines, the left lower quadrant contains the descending and left half of the transverse colon. 

• The right lower quadrant: contains the large and small intestines. Of the large intestines, the right lower quadrant contains the ascending colon, the right half of the transverse colon, and the appendix.

The left upper quadrant

contains

• stomach

• spleen

• portion of pancreas.

The right upper quadrant

contains

• liver

• gallbladder

• duodenum of small intestine

• portion of the pancreas.

The left lower quadrant

contains the large and small intestines.

Of the large intestines, left lower quadrant contains descending (colon) and left half of the transverse colon.

The right lower quadrant

contains the large and small intestines. Of the large intestines, the right lower quadrant contains the ascending colon, the right half of the transverse colon, and the appendix.

Internal bleeding

Cullen sign:

• bruising around umbilicus

• is a potential sign of internal bleeding, particularly in the abdomen. )is a potential sign of internal bleeding, particularly in the abdomen( intraperitoneal hemorrhage)

Grey Turner sign:

• bruising along sides of the abdomen (flank ecchymosis)

• retroperitoneal hemorrhage

Murphy’s sign:

• just below costal margin on inspiration with palpation (Cholecystitis)

• retroperitoneal hemorrhage

• a physical exam maneuver used to assess for acute cholecystitis (inflammation of the gallbladder).

Kehr’s sign:

• pain in tip of shoulder due to blood/irritants in peritoneal cavity when person is lying down

• in left shoulder = ruptured spleen

Cullen sign

bruising around umbilicus is a potential sign of internal bleeding, particularly in the abdomen)

(intraperitoneal hemorrhage)

Grey Turner sign

bruising along sides of the abdomen (flank ecchymosis)
retroperitoneal hemorrhage

Murphy’s sign

just below costal margin on inspiration with palpation (Cholecystitis)
retroperitoneal hemorrhage
a physical exam maneuver used to assess for acute cholecystitis (inflammation of the gallbladder).

Kehr’s sign

pain in tip of shoulder due to blood/irritants in peritoneal cavity when person is lying down
in left shoulder = ruptured spleen

GI Internal Bleeding

• dark tarry stools (melena)

• Coffee grounds in vomit

• bloody vomit (hematemesis)

Upper GI Bleeding

Mallory-Weiss syndrome: a condition characterized by a tear or laceration of the mucous membrane lining the lower esophagus or upper stomach.

Boerhaave syndrome: rupture of the esophagus, typically caused by forceful vomiting or straining

Lower GI bleeding:

• Ulcerative colitis: inflammation of the colon

Gallstones

aka cholelithiasis; right upper quadrant pain, may radiate to right upper back, shoulder, flank

Cholecystitis

inflammation of gallbladder; vomiting, right upper quadrant pain, referred pain to right shoulder, nausea, vomiting, fever, jaundice, light loose bowel

Appendicitis

 lower right quadrant pain, nausea, vomiting, fever, chills, rebound tenderness

Pancreatitis

upper L and R pain, radiates to back and worsens after eating; nausea, vomiting, abdominal distension, tenderness (can be caused by gallstones)

Hepatitis

right upper quadrant pain, jaundice

Internal bleeding lacerated liver: referred pain to right shoulder

Pneumonia

cough, fever, dyspnea, occasionally pain that radiates to upper abdomen

Kidney

hematuria (red blood cells in the urine), flank pain, costovertebral angle tenderness/guarding

Renal calculi

flank or lower back pain, solid mineral deposits that form inside the kidneys.

Urinary tract injury (kidney, ureter, bladder):

bloody urine (hematuria)

Dialysis side effects

muscle cramps, hypotension, electrolyte imbalance

Respiratory alkalosis:

hyperventilation, fever, aspirin overdose
Respiratory alkalosis is a when your blood pH is above 7.45 due to an issue with your breathing.

Opiates/Narcotics (morphine, heroin, methadone, oxy, fentanyl)

• pinpoint pupils

• hypoventilation/respiratory arrest

• Hypotension

• Sedation

• coma 

• Unconscious

•  Bradypnea

• Cyanosis

• pinpoint pupils = respiratory and cardiac arrest 

• respiratory acidosis 

• Naloxone: IV, IM, or INasally

Everything slows down

Sympathomimetics (cocaine, meth, epi, albuterol MDMA, PCP) 

• stimulants that mimic SNS 

• Hypertension

• Tachycardia

• dilated pupils

• Agitation

• Seizures

• hyperthermia

Anticholinergic (diphenhydramine, atropine, chlorpheniramine, doxylamine)

• Tachycardia

• Hypertension

• Hyperthermia

• dilated pupils

• dry skin/mucous membranes

• decreased bowel sounds

• and sedation/coma. 

• Hyperthermia

• warm red skin; hot as a hare

• mad as a hatter, dry as a bone,

•  red as a beet; 

• mad as a hatter

a substance that blocks acetylcholine, a chemical messenger that transmits signals in the nervous system. By blocking these signals, these agents stop involuntary muscle movements and reduce secretions in the body.

Cholinergic poisoning

• Diarrhea

• excessive tears

• Drooling

• mucus secretion

• abnormal heart rate

more nervous system secretion

Sedative-hypnotic

• Hypoventilation

•  Hypotension

• slurred speech

• sedation/coma 

• sedative-hypnotics generally do not affect pupil diameter.

(diazepam, secobarbital, flunitrazepam, midazolam, Xanax, valium, ket)

Beta Blockers:

• treat hypertension, interfere with SNS 

• Bradycardia

• Hypotension

• possibly coma 

• hypoglycemia with pediatric

Localized allergy:

• sudden pain, swelling, localized heat, urticaria, redness, dry cough 

• Leukotrienes: immune system chemicals that cause inflammation, tighten airway muscles, and produce excess mucus

• histamine a natural chemical messenger made by your immune system. It helps protect your body from germs, controls stomach acid, and wakes up your brain.

anaphylaxis

serious system allergic reaction -bronchospasm, tachycardia, wheezing, chest tightness, coughing, dyspnea, hypotension, anxiety, GI issues

Bee Sting:

• gently scrape skin with stiff rigid object (credit card) 

• don’t use tweezers or forceps, may inject more venom into wound

Diphenhydramine:

• used for allergies 

• blocks histamine effects 

• Side effects: drowsiness, increased eye fluid pressure

Epinephrine:

• sympathomimetic for allergy 

• medical direction required 

• patient doesn’t need to be in severe respiratory distress/arrest 

• needs to be prescribed to patient 

• side effects: tachycardia, hypertension, restlessness

Albuterol:

• Bronchodilator

• relaxes smooth muscle 

• does not affect blood flow, lung compliance, or mucus production

Activated Charcoal

 1-2 g per kg body weight; 1 kg = 2.2lb  (not appropriate for acid, alkali, petroleum )

Heat Exhaustion

dizziness, syncope, altered mental, nausea, vomiting, headaches, muscle cramping

Heat stroke

flushed skin, hot dry skin, elevated body temperature (104), body stops sweating

To estimate patient’s core body temperature

place back of a non gloved hand against skin of patient’s abdomen

Dehydration:

in infants (dry gums/lips, sunken eyes, loose skin without elasticity, sunken fontanelle, lethargy, irritability, refusal of bottles)

Seizures:

Preeclampsia

Eclampsia

Postictal state

Preeclampsia

possible complication during 2nd half of pregnancy

severe hypertension, headaches, visual abnormalities, edema, anxiety (typically affects primigravida patients) protein in urine, swelling hands and feet, blurred vision placed on bed rest to prevent eclampsia

Eclampsia

onset of seizures due to hypertension

Postictal state

Lethargy, drowsiness, confusion, nausea, hypertension, headache, disoriented

Lactic acidosis breathing fast and deep to reduce CO2 lvls altered mental muscles relax/floppy

anticonvulsants

carbamazepine (Tegretol), clonazepam (klonopin)

Febrile seizures: 

• children under 6 years

• occur with sudden spike in body temperature

clonic seizure 

combines a tonic phase (muscle stiffening and loss of consciousness) and a clonic phase (rhythmic jerking), typically lasting 1 to 3 minutes.

Common seizure causes in adults:

• epilepsy, tumors, infection, poisoning, drug overdose, fever, stroke 

in active seizure

• don’t place anything in their mouth, maintain airway

•  only life threatening conditions should be treated 

• general tonic clonic, not longer than 15 mins, short or absent postictal phase 

• ABCs, cool with damp towels, transport 

• blow by blow oxygen if refuse oxygen

Bleeding during pregnancy:

• Ectopic pregnancy

• Spontaneous abortion

• Abruptio Placentae

• Placenta Previa

Ectopic pregnancy

embryo develops outside uterus, sudden lower abdominal pain

Spontaneous abortion

miscarriage

Abruptio Placentae

separation of placenta prematurely from uterine wall
caused by hypertension or trauma
may result in shock if severe blood loss
severe pain

Placenta Previa

placenta develops over the cervical opening, bleeding but no pain

Supine Hypotensive Syndrome

• pregnant patient lies supine and the pregnant uterus compresses the inferior vena cava

• blood return to the heart is decreased, resulting in subsequent hypotension

• any patient in the third trimester of pregnancy should be positioned on the left side during transport

• pallor, tachycardia, sweating, nausea, and dizziness

Maternal Physiological changes:

• 30-50% increase in blood volume, CO

• faster blood clotting time

• increased heart rate

• increased respiratory rate

Birth

• normal gestation is 40 wks

• 2nd trimester: rapid uterine growth

Labor

• onset of labor starts with uterine contractions, rupture amniotic sac/blood streaked mucus (bloody show)

• three stages

First stage

(12-18 hrs) uterine contractions, cervix dilation, cervix fully dilated

Second Stage:

• baby enters birth canal, baby delivered 

• after baby head delivered it rotates to side 

• guide head down to help upper shoulder deliver 

• support head and upper body as shoulders deliver 

• upward guidance of head to deliver lower shoulder

Third Stage

• delivery of placenta 

• massage uterus in firm circular kneading motion to slow bleeding after placenta delivery

cutting cord

prior to cutting cord, assess baby for resp distress; clamp 2-3 inches apart and cut between; placental delivery follows in 30 min

just born breathing

baby should breathe spontaneously in 15-30 seconds after birth

Delivery on scene if

crowning, transport delay, multigravida (shorter labor) -unlikely if no urge to push, water just broke, had a bloody show

Meconium staining:

• Fetal stool appears as green fluid during rupture of amniotic sac

• higher risk in post-term deliveries

• aspirated by fetus, can result in respiratory distress, obstruction, fetal death

• suction nose and mouth

• Sign of stress on infant

Nuchal cord:

• wrapped around baby’s neck

• the first step is to attempt to gently slip the cord over the baby's head if it's loose enough. If the cord is tight or cannot be easily released, the EMT should clamp the cord in two places and cut it between the clamps to facilitate delivery.

Prolapsed cord:

• cord presents through vagina prior to fetus; dangerous because fetal head may compress cord and cut off oxygen and circulation

• do not attempt to push cord back

• occurs early in labor, usually time to transport

• place patient in supine with foot of cot raised 6-12 inches higher than head, hips elevated on pillow OR knew chest position kneeling and bent forward while face down (keep weight off fetus and cord), wrap cord in sterile towel moistened with saline

• If the umbilical cord precedes the baby's head or body during delivery, the cord can be compressed by the baby's weight, cutting off the baby's oxygen supply. In this case, an EMT needs to insert a gloved hand into the vagina, raise the presenting part (baby's head or body) to relieve pressure on the cord, and ensure the baby's survival.

Cephalic (Head First)

The most common and ideal presentation, with the head entering the birth canal first.

Breech (Bottom or Feet First)

The buttocks or feet are the first part to enter the birth canal.

Shoulder or limb presentation

a shoulder, arm, or leg enters the birth canal first, cannot be delivered in field, requires surgical intervention

after birth

dry infant and place on mother abdomen to begin skin to skin contact 

sterile gauze to wipe mouth/nose

APGAR checks at 1 and 5 mins after birth

APGAR

Appearance (skin color)

Pulse (heart rate)

Grimace (reflex irritability)

Activity (tone)

Respiration

Appearance

Pulse

Grimace

Activity

Respiration

Neonates: 

• under 2.5 pounds at risk for complications 

• prematurity (before 30 weeks) is most common cause of respiratory distress

At risk for SIDS:

• maternal smoking

• maternal age less than 20 yrs old

• low birthweight

Diabetes

• Normal Glucose: 80-120 mg/dL 

• oral glucose contraindicated for unresponsive/unconscious or without gag reflex

• Can cause polyuria, polydipsia, polyphagia, fatigue, weight loss 

• Insulin use

Gestational diabetes

• a condition where a woman without a previous history of diabetes develops high blood sugar levels during pregnancy.

• typically emerges around the 24th week of pregnancy.

• increased thirst. needing to pee more often than usual. a dry mouth. tiredness. blurred eyesight.

Hypoglycemia

• hypotension, weak, rapid pulse, altered mental 

• cool clammy pale skin, altered mental 

• tremors, palpitations

• anxiety/arousal, sweating

• hunger, paresthesias

•  cognitive impairment, behavioral changes, psychomotor abnormalities

• seizures and coma at lower plasma glucose concentrations. 

• slow shallow respirations 

• treat with oral glucose 

• rapid onset

Hyperglycemia:

• vomiting, nausea, abdominal pain 

• Hypotension

• weak, rapid pulse, 

• altered mental 

• increased urine glucose, osmotic diuresis, increased urine frequency, polyuria, polydipsia, dehydration -

• intense thirst/hunger

• -sweet, fruity breath 

• Kussmaul respirations (rapid, deep) 

• rapid weak/thready pulse 

• restlessness 

• abnormal/slurred speech 

• unsteady gait 

• gradual onset

Diabetic ketoacidosis DKA (type 1)

• ketoacidosis, hyperglycemia 

• fruity smelling breath 

• Kussmaul respirations (breathe rapidly to compensate for acidemia) 

• may be hypotensive and tachycardic 

• can develop in 24 hours 

• abdominal pain, body aches, nausea, vomiting, altered mental 

• infection + discontinuation of insulin, pancreatitis, MI, drugs, cerebrovascular accident