Emergency Medical Procedures and Assessment: Scene Size-Up to Medical Legal Aspects

Scene Size-Up

First step: BSI, scene safety, MOI/NOI, number of patients, additional resources needed.

Primary Survey (ABCDE)

Airway, Breathing, Circulation, Disability (neuro), Expose/Environment — find and fix life threats.

Secondary Survey

Head-to-toe physical exam + SAMPLE history after life threats addressed.

SAMPLE

Signs/Symptoms, Allergies, Medications, Pertinent past history, Last oral intake, Events leading up to.

OPQRST

Onset, Provocation/Palliation, Quality, Radiation/Region, Severity, Time — pain assessment tool.

GCS (Glasgow Coma Scale)

Eyes (4) + Verbal (5) + Motor (6) = max 15. Less than 8 = severe TBI, consider airway.

AVPU

Alert, Verbal response, Painful response, Unresponsive — quick LOC assessment.

LOC

Level of Consciousness — baseline mental status indicator.

MOI

Mechanism of Injury — how force was applied (e.g., MVC, fall).

NOI

Nature of Illness — the medical complaint (e.g., chest pain, dyspnea).

Perfusion

Delivery of oxygenated blood to tissues.

Diaphoresis

Excessive sweating; often a sign of shock, MI, or hypoglycemia.

Skin Signs (CTC)

Color, Temperature, Condition — assess perfusion and systemic status.

Capillary Refill

Normal less than 2 sec. Greater than 2 sec = poor perfusion (less reliable in adults).

Pulse Oximetry (SpO2)

Normal 94-100%. Not reliable in shock, CO poisoning, or poor perfusion.

Trending

Tracking changes in vitals over time to identify improvement or deterioration.

Baseline Vitals

Initial set of vitals to compare all future readings against.

Reassessment

Repeat primary survey + vitals every 5 min (unstable) or 15 min (stable).

Airway Patency

Airway is open and clear; no obstruction.

Sniffing Position

Neutral/slight extension of the neck — optimal airway alignment in adults.

Head-Tilt Chin-Lift

Basic airway maneuver; do NOT use if spinal injury suspected.

Jaw Thrust

Airway maneuver of choice with suspected c-spine injury.

Oropharyngeal Airway (OPA)

Rigid airway adjunct for unconscious patients with no gag reflex.

Nasopharyngeal Airway (NPA)

Soft airway adjunct; can use if patient has gag reflex. Contraindicated with suspected basilar skull fracture.

BVM (Bag-Valve-Mask)

Manual ventilation device. 1 breath every 5-6 sec (adult); maintain visible chest rise.

Tidal Volume

Amount of air per breath; ~500 mL in adults. Just enough for visible chest rise.

Minute Volume

Tidal volume x respiratory rate = total air moved per minute.

Adequate Breathing

Adult: 12-20/min, adequate depth, equal bilateral breath sounds, no accessory muscle use.

Agonal Respirations

Ineffective gasps; seen just before death. Requires immediate BVM.

Kussmaul Respirations

Deep, labored, rapid breathing; seen in DKA (metabolic acidosis).

Cheyne-Stokes Respirations

Crescendo-decrescendo breathing with apneic periods; severe brain injury or impending death.

Biot's Respirations

Irregular rate and depth with sudden apnea; brainstem injury.

Stridor

High-pitched inspiratory sound = partial upper airway obstruction.

Wheezing

High-pitched expiratory sound = lower airway obstruction (asthma, COPD).

Crackles (Rales)

Wet, bubbly sounds = fluid in alveoli (CHF, pneumonia).

Rhonchi

Low-pitched gurgling in large airways; mucus/secretions.

Grunting

Expiratory sound in children = significant respiratory distress.

Nasal Flaring

Flaring nostrils on inspiration = increased work of breathing (especially in peds).

Retractions

Skin pulling inward between ribs/clavicles = significant respiratory distress.

Tripod Position

Patient leaning forward on hands to maximize breathing effort.

Hypoxia

Insufficient O2 at tissue level. SpO2 less than 94%. Tx: O2 therapy.

Hypoxemia

Low O2 in the blood specifically.

Hypercarbia (Hypercapnia)

Elevated CO2; result of hypoventilation.

Hypocapnia

Low CO2; result of hyperventilation.

Yankauer Suction

Used to clear oropharynx. Suction no longer than 15 sec at a time.

CPAP

Continuous Positive Airway Pressure. Used for CHF/pulmonary edema and COPD exacerbations.

Cardiac Output (CO)

Heart rate x stroke volume. Normal ~5 L/min.

Stroke Volume

Amount of blood ejected per heartbeat (~70 mL).

Preload

Volume of blood in the ventricle before contraction (filling pressure).

Afterload

Resistance the heart must overcome to eject blood.

ACS (Acute Coronary Syndrome)

Umbrella term: unstable angina, NSTEMI, STEMI.

AMI (Acute MI)

Myocardial infarction — coronary artery blocked, muscle dying. Tx: O2, ASA, nitro, transport.

Angina

Chest pain from temporary myocardial ischemia; relieved by rest or nitro.

Stable Angina

Predictable, exertion-related, relieved by nitro/rest.

Unstable Angina

Occurs at rest, increasing severity — medical emergency.

STEMI

ST-elevation MI — full coronary occlusion. Needs cath lab ASAP.

Ischemia

Decreased blood flow causing O2 deprivation but no tissue death yet.

Infarction

Tissue death from prolonged ischemia.

V-Fib

Chaotic, ineffective quivering — no pulse. Tx: immediate defibrillation.

Pulseless V-Tach

Organized but ineffective rhythm. Tx: defibrillate same as V-fib.

V-Tach with Pulse

Has output but unstable. Tx: follow ACLS, may cardiovert.

Asystole

Flatline. No electrical activity. Tx: CPR + epinephrine; NOT defibrillated.

PEA (Pulseless Electrical Activity)

Rhythm on monitor but no pulse. Tx: CPR, treat H's and T's.

H's and T's

Reversible cardiac arrest causes: Hypovolemia, Hypoxia, H+ acidosis, Hypo/hyperkalemia, Hypothermia | Tension PTX, Tamponade, Toxins, Thrombosis.

AED

Analyzes rhythm and delivers shock if shockable. Use ASAP in pulseless arrest.

CPR Compression Rate

100-120/min. Depth: at least 2 inches adults, ~2 inches children, ~1.5 inches infants.

Compression:Ventilation Ratio

30:2 adults/children. Infants: 30:2 (1 rescuer), 15:2 (2 healthcare providers).

CHF (Congestive Heart Failure)

Heart can't pump effectively; fluid backs up. Left: pulmonary edema. Right: peripheral edema, JVD.

Pulmonary Edema

Fluid in lungs from left-heart failure. Crackles, pink frothy sputum, severe dyspnea.

JVD (Jugular Vein Distension)

Sign of right heart failure, tension PTX, or cardiac tamponade.

Cardiogenic Shock

Heart failure causing inadequate CO. Hypotension + pulmonary edema. Do NOT give large fluid bolus.

Syncope

Transient loss of consciousness from decreased cerebral perfusion.

Dyspnea

Subjective difficulty breathing.

Orthopnea

Dyspnea that worsens when lying flat; relieved by sitting up (CHF sign).

Asthma

Lower airway bronchospasm. Wheezing, prolonged expiration. Tx: albuterol, O2.

Status Asthmaticus

Severe asthma unresponsive to bronchodilators — life threat.

COPD

Chronic Obstructive Pulmonary Disease — emphysema and chronic bronchitis.

Emphysema

Alveolar destruction causing air trapping, barrel chest, pursed-lip breathing.

Chronic Bronchitis

Chronic airway inflammation + excess mucus. 'Blue bloater.'

Hypoxic Drive

COPD patients may depend on low O2 to breathe. Give O2 but monitor; don't withhold.

Pulmonary Embolism (PE)

Clot in pulmonary artery. Sudden dyspnea, pleuritic chest pain, tachycardia. Risk: DVT, immobility.

Pneumothorax

Air in pleural space causing lung collapse. Decreased breath sounds on affected side.

Tension Pneumothorax

Air trapped under pressure. Tracheal deviation AWAY from affected side, absent breath sounds, JVD, hypotension. Tx: needle decompression.

Open Pneumothorax

Sucking chest wound. Tx: 3-sided occlusive dressing.

Hemothorax

Blood in pleural space. Decreased breath sounds, dullness to percussion.

Flail Chest

3 or more consecutive ribs broken in 2 or more places causing paradoxical movement. Tx: BVM, PPV.

Pneumonia

Lung infection. Fever, productive cough, localized crackles.

Hemorrhagic Shock Class I

Less than 750 mL lost (less than 15%). Minimal symptoms.

Hemorrhagic Shock Class II

750-1500 mL lost (15-30%). Tachycardia, anxiety, decreased pulse pressure.

Hemorrhagic Shock Class III

1500-2000 mL lost (30-40%). Hypotension, altered mental status, marked tachycardia.

Hemorrhagic Shock Class IV

Greater than 2000 mL lost (greater than 40%). Severe hypotension, lethargy, life-threatening.

Tourniquet Application

2-3 inches above wound. Tighten until bleeding stops. Note time. Don't remove.

Cavitation

Temporary cavity created by bullet's kinetic energy transfer to tissue.

Coup-Contrecoup

Brain injury at site of impact AND opposite side from brain rebounding.

Epidural Hematoma

Arterial bleed between dura and skull. Lucid interval then rapid deterioration.

Subdural Hematoma

Venous bleed under dura. Slower onset, chronic or acute.

Subarachnoid Hemorrhage

Bleed in subarachnoid space. 'Worst headache of my life.'

Battle's Sign

Bruising behind ears (mastoid) — basilar skull fracture. Delayed sign.

Raccoon Eyes

Periorbital ecchymosis — basilar skull fracture. Delayed sign.

CSF Rhinorrhea/Otorrhea

CSF leaking from nose or ears — basilar skull fracture.