EMT notes only block 2

• Acronyms
  • BSI
    • Body
    • Substance
    • Isolation
  • PPE
    • Personal
    • Protective
    • Equipment
  • PENMANN
    • Personal/Partner/Peeper Safety
    • Environmental Hazards
    • Number of victims/patients
    • Mechanism of Injury (MOI) or nature of illness (NOI)
    • Additional resources / ALS
    • Need for extrication
    • Need for c-spine
  • AVPU
    • Alert
      • The patient is awake
    • Verbal Response to verbal stimuli
    • Painful Responsive to painful stimuli
    • Unresponsive
  • ABC
    • Airway
      • Open, clear, and maintainable
    • Breathing
      • Rate, depth, and quality
    • Circulation
      • Capillary refill, obvious bleeding, pulse, skin signs (COPS)
  • PPPT
    • Person - what is your name?
    • Place - Do you know where you are right now?
    • Purpose (event) - what were you doing? Or, why we called here today?
    • time - DO you know approximately what time it is? What day of the week or what month
  • OPQRST
    • Onset - sudden or gradual
    • Provokes/Palliates - does anything make it better or worse?
    • Quality - can you describe the pain/discomfort? Heaviness, sharp, dull achy, stabbing, burning, tearing
    • region/radiation - where is the pain located and does it travel anywhere?
    • Severity - on scale 0-10, 10 being the worst pain in your life, what is it?
    • Time -how long ago did the pain/ discomfort start
  • Sample
    • Signs and symptoms - Any other complaints associated with C/C
    • Allergies - Do you have any allergies? Medications, insects, latex, food, etc
    • Medications - Are you currently prescribed any medications? Are you taking them as directed? When was the last time you took them?
    • Past pertinent medical history - are you seeing a doctor for any medical problems?
    • Last oral intake - when was the last you ate or drank anything?
    • Events leading up - what were you doing prior to symptoms starting?
  • IPA
    • Inspect
    • Palpate
    • Ausculate
  • DCAPBTLS
    • Deformities
      • Malformations or distortions of the body
    • Contusions
      • Injury to tissues with skin discoloration and without breakage of the skin, also called a bruise
    • Abrasions
      • Scrape caused by rubbing on a surface
    • Punctures or penetrations
      • Wound with an opening to the internal cavity usually by a sharp or fastmoving object
    • Burn
      • Burns are injuries to tissues caused by heat, friction, electricity, radiation, chemicals
    • Tenderness
      • Tender or sore to the touch
    • Lacerations
      • Torn or jagged wound
    • Swelling
      • Sign of inflammation can be blood or fluid leaving the capillary vessels entering the tissue
  • TIC
    • Tenderness
      • Pain on palpation
    • Instability
      • Excess movement on palpation
    • Creptius
      • Crackling or grating sound caused by bones rubbing against each other
  • PIG
    • P
      • Priapism
    • I
      • Incontinence
    • G
      • Genital bleeding
  • DRGERM
    • Distension
      • Seen or felt on palpation
    • Rigidity
      • Hardness felt on palpation
    • Guarding
      • Muscle contraction on palpation in response to pain
    • Evisceration
      • Abdominal organs protruding through the abdominal wall
    • Rebounding tenderness
      • Pain on release of palpation
    • Pulsating masses
      • Pulsates with heartbeat, felt on palpation, or sometimes seen
  • PMSC
    • Pulse
    • Motor
    • Sensory
    • Capillary refill
  • AMA
    • Against
    • Medical
    • Advice

Chapter 5

• Special word parts
  • Prefixes can indicate
    • Numbers
      • Some prefixes indicate that a term involves a number or two (or more) parts or sides
        • Examples: uni-, dipl-, null-, primi-, multi-, bi-
    • Colors
      • Several word roots describe color
        • Examples: cyan/o, leuk/o, erythr/o, cirrh/o, melan/o
    • Positions and directions
      • Prefixes can describe a position, direction, or location
        • Examples: ab-. Ad-, de-, circum-, peri-, trans-, epi-, supra-
• Common direction, movement, and position terms
  • Directional terms
    • Needed to discuss:
      • Where an injury is located
      • How pain radiates in the body
    • Some directional terms include
      • Right and left
      • Superior and inferior
        • Nearer to the head vs nearer to the feet
      • Lateral and medial
        • Farther from the midline vs closer to the midline
      • Proximal and distal
        • Closer to the trunk vs farther away from
      • Superficial and deep
        • Surface vs farther inside the body
      • Ventral and dorsal
        • Front and back
      • Palmar and plantar
        • Palm vs bottom of foot
      • Apex
        • tip(s) of a structure

Example: the apex of the heart is the bottom of the ventricles

• • • • Bilateral
        • Both sides of midline
      • Unilateral
        • One side of the midline
  • Movement terms
    • Flexion
      • Bending of a joint
    • Extension
      • Straightening of a joint
    • Adduction
      • Motion toward the midline
    • Abduction
      • Motion away from the midline
  • Anatomic positions
    • Prone
      • Lying face down
    • Supine
      • Lying face up
    • Fowler position
      • Semi-reclining with head elevated
    • Semi-fowler
      • Patient sits at a 45-degree angle
    • High-fowler
      • Patient sits at a 90-degree angle
• Breaking terms apart
  • Nephropathy
    • nephr/o/pathy
      • -pathy means disease
      • O (combining form)
      • Nephr means kidney
      • Overall means disease of the kidney
  • Dysuria
    • dys/ur/ia
      • -ia means condition of
      • Dys- means difficult, painful, or abnormal
      • Ur means urine
      • Dysuria = painful urination

Chapter 6

• Planes of the body
  • Three main areas
    • Coronal (frontal) plane
      • Divides the body front and back
    • Sagittal (lateral) plane
      • Divides the body left/right
      • Midsagittal (midline) plane
        • divides the body into equal left and right halves
    • transverse (axial) plane
      • Divides the body into top/bottom
  • Cells to systems
    • Cells
      • Foundation of the human body
    • Tissues
      • Cells that share a common function
    • Organs
      • Group of tissues that perform similar or interrelated jobs
    • Body systems
      • Organs with similar function working together
• The skeletal system
  • The skeleton gives us our recognizable human form
  • Composed of 206 bones
    • Axial skeleton
      • Foundation to which the arms and legs are attached
      • Includes
      • Skull
        • Cranium

Made up of 4 bones

• • • • Facial bones
        • Face

Made up of 14 bones

• • • • Thoracic cage
        • Formed by 12 thoracic vertebrae and 12 pairs of ribs
        • Thoracic cavity contains

Heart

Lungs

Esophagus

Great vessels

• • • • Vertebral column
        • Composed of 33 bones
        • Divided into 5 sections

Cervical

Thoracic

Lumbar

Sacrum coccyx

• • • Appendicular skeleton
      • Includes
        • Pelvis
        • Upper extremities

Upper extremity extends from pectoral girdle to fingertips

Composed of arms, forearms, hands, and fingers

• • • • • Joints
        • Lower extremities
• Joints
  • Occurs wherever bones come in contact
  • Consist of the ends of the bones and the connecting and supporting tissues
  • Two types of joints
    • Ball and socket joints
      • Allows rotation and bending
    • Hinge joint
      • Motion restricted to flexion and extension
• musculoskeletal system
  • Provides
    • Form
    • Upright posture
    • Movement
    • Protection of vital internal organs
  • Types of muscles
    • Skeletal
    • Smooth
    • Cardiac
  • Contraction and relaxation of system make it possible to move and manipulate the environment
    • A by-product of this movement is heat
  • Another function of the muscles is to protect the structures under them
• Respiratory system
  • Structures of the body that contribute to respiration
    • Nose
    • Mouth
    • Tongue
    • Jaw
    • Larynx
      • Divides upper and lower airway
    • Pharynx
      • Naso
      • Oro
      • Laryngo
    • Trachea
      • Epiglottis
• Lower airway
  • Thyroid cartilage
    • Adam’s apple
  • Cricoid cartilage
    • Immediately below the thyroid cartilage
      • Cricothyroid
  • Trachea
    • Ends at carina, dividing into right and left bronchi leading to bronchioles
• Lungs
  • Held in place by
    • Trachea
    • Arteries and veins
    • Pulmonary ligaments
  • Divided into two lobes
    • Right lung has
      • Upper
      • Middle
      • Lower
    • Left lung has
      • Upper
      • Lower
  • Within lobes are
    • Bronchi
    • Bronchioles
    • Alveoli
      • Allows for gas exchange
  • Pleaura
    • A layer of smooth, glistening tissue that covers each lung and lines the chest cavity
    • Between the two layers is a small amount of fluid that allows the tissues to glide smoothly
• Muscles of breathing
  • Diaphragm is the primary muscles of breathing
    • Also involved are
      • Neck
      • intercostal muscles
      • Abdominal muscles
      • Pectoral muscles
• Inhalation
  • Diaphragm and intercostal muscles contract
  • Pressure in the thoracic cavity decreases
  • Lungs fill with air
  • Active part of the respiratory system
• Exhalation
  • Diaphragm and intercostal muscles relax
  • Thoracic cavity returns to normal shape and volume
  • Passive portion of the respiratory system
• Respiratory system physiology
  • Function is to provide body with oxygen and eliminate carbon dioxide
  • Ventilation and respiration are two separate, interdependent functions of the respiratory system
  • Respiratory is the exchange of gases and carbon dioxide in thye alveoli and tissues
    • Provides oxygen to the cells and removes waste carbon dioxide
    • Diffusion
      • Passive process in which molecules move from an area of higher concentration to an area of lower concentration
  • Chemical control of breathing
    • Brainstem controls breathing by monitoring carbon dioxide in blood and spinal fluid primary reason for breathing is to lower carbon dioxide levels
    • Hypoxic drive
  • Nervous system control of breathing
    • The medulla initiates ventilation cycles
      • Stimulated by high carbon dioxide levels
    • The pons has two areas that help augment respirations during emotional or physical stress
  • Ventilation is simple air movement into and out of the lungs
    • Requires chest rise and fall
    • Tidal volume
      • Amount of air moved into or out of the lungs during a single breath
    • Residual volume
      • The gas that remains in the lungs to keep the lungs open
    • Dead space
      • The portion of the respiratory system that has no alveoli and where little or no exchange of gas between air and blood occurs
    • Respiratory rate x tidal volume = minute volume
• Characteristics of normal breathing
  • Normal rate and depth (tidal volume)
  • Regular rhythm or pattern of inhalation and exhalation
  • Clear, audible breath sounds on both sides of chest
  • Regular rise and fall movement on both sides of the chest
  • Movement of the abdomen
• Inadequate breathing patterns in adults
  • Labored breathing
  • Muscle retractions
  • Pale, cyanotic, cool, damp skin
  • Tripod position
  • Agonal gasps
• Circulatory system anatomy
  • Complex arrangement of connected tubes
    • Arteries
    • Arterioles
    • Capillaries
    • Venules
    • Veins
  • Two circuits
    • Systemic circulation
    • Pulmonary circulation
• The heart
  • Hollow muscular organ
  • Made of specialized cardiac muscle
  • Works as two paired pumps
  • Each side is divided into
    • Atrium (upper)
    • Ventricle (lower)
  • Circulation
    • The heart receives its blood from the aorta
    • Right side receives deoxygenated blood from the veins
    • Left side receives oxygenated blood from the lungs
  • Normal resting heart rate is 60-100 beats/min
  • Stroke volume
    • Amount of blood moved by one beat
  • Cardiac output
    • The amount of blood moved in 1 minute
    • HR x SV = CO
  • Electrical conduction system
    • Specialized tissue capable of initiating and conducting electrical current
    • Causes smooth, coordinated contractions
    • Contractions produce pumping action
• Arteries
  • Carry blood from the heart to all body tissues
  • Aorta branches into
    • Coronary
    • Carotid
    • Hepatic
    • Renal
    • Mesenteric
  • Pulmonary artery
    • Carries oxygen-poor blood to the lungs
  • Arteries branch into smaller arteries and then into arterioles
    • Arterioles branch into a series of increasingly smaller vessels until they connect to the capillaries
  • Pulse
    • Palpated most easily at the neck, wrist, or goin
    • Created by forceful pumping of blood out of the left ventricle and into the major arteries
• Capillaries
  • Connect arterioles to venules
  • Fine end divisions of arterial system
  • Allow contact between blood and cells
• Veins
  • Return oxygen-depleted blood to the heart
  • The superior vena cava carries blood returning from the head, neck, shoulders, and upper extremities
  • The inferior vena cava carries blood from the abdomen, pelvis, and lower extremities
  • Join at right atrium
• The spleen
  • Solid organ located under the rib cage
  • Filters blood
  • Particularly susceptible to injury from blunt trauma
• Blood compositions
  • Plasma
  • Red blood cells
  • White blood cells
  • Platelets
• The circulatory system
  • Blood pressure
    • Pressure that blood exerts against the walls of arteries
  • Systole
    • When the left ventricle of the heart contracts, it pumps blood from the ventricle into the aorta
  • Diastole
    • When the muscle of the ventricle relaxes, the ventricle fills with blood
  • Blood pressure reading
    • Systolic
      • High point of wave
    • Diastolic
      • Low point of wave
• Normal circulation in adults
  • Automatically adjusted and controlled
  • Perfusion
    • Circulation of blood in organ or tissue in adequate amounts to meet the needs of cells
    • Hypoperfusion
      • Inadequate blood supply to organs, tissues, and cells
• Inadequate circulation in adults
  • The system can adjust to small blood loss
    • Vessels constrict
    • The heart pumps more rapidly
  • With a large loss, adjustment fails, and the patient goes into shock
  • Mean arterial pressure can help detect shock
• Functions of blood
  • Fighting infection
  • Transporting oxygen
  • Transporting carbon dioxide
  • Controlling pH
  • Transporting wastes and nutrients
  • Clotting (coagulation)
• Nervous system control of cardiovascular system
  • Sympathetic nervous system is responsible for fight or flight response
    • Sends commands to adrenal glands
    • Epinephrine and norepinephrine are secreted to stimulate heart and blood vessels
  • Blood vessels have alpha-adrenergic receptors
  • The heart and lungs have beta-adrenergic receptors
  • Baroreceptors sense pressure in the blood vessels
  • The sympathetic and parasympathetic nervous system balance each other
• The nervous system anatomy and physiology
  • The most complex organ in the body
  • Divided into two main portions
    • central nervous system (CNS)
    • peripheral nervous system
  • Brain
    • Controlling organ of the body
    • Subdivisions
      • Cerebrum
      • Cerebellum
      • Brainstem
  • cerebrospinal fluid
    • Cushions and protects the brain and spinal cord
  • Circulation in the head
    • Oxygenated blood is supplied via carotid arteries
    • Deoxygenated blood is drained by the internal and external jugular veins
  • Spinal cord
    • Extension of the brainstem
    • Transmits messages between brain and body
• Peripheral nervous system
  • Divided into two main portions
    • Somatic nervous system
      • Transmits signals from brain to voluntary muscles
    • Autonomic nervous system
      • Involuntary actions
      • Split into two areas
        • Sympathetic nervous system (fight or flight)
        • parasympathetic nervous system (slows body)
  • Two types of nerves within peripheral nervous system
    • Sensory nerves carry information from body to cns
    • Motor nerves carry information from CNS to muscles
• Integumentary system anatomy
  • Two layers
  • Epidermis
  • Dermis
  • subcutaneous tissue under the skin
    • Fat that insulates and serves as energy reservoir
  • The skin is the largest single organ in the body
  • The major functions
    • Protects the body in the environment
    • Regulates body temperature
    • Transmits information from environment to brain
• digestive system
  • Gastrointestinal system
  • Abdomen :second major body cavity
  • Organized into 4 quadrants
    • Right upper
    • Left upper
    • Right lower
    • Left lower
  • Mouth
  • Lips
  • Cheeks
  • Gum
  • Teeth
  • Tongue
  • Salivary glands
  • Esophagus
  • Stomach
  • Pancreas
  • Liver
    • Bile ducts
  • Small intestine
  • Appendix
  • Rectum
  • Enzymes are added to food
    • By salivary glands, stomach, liver, pancreas, and small intestine
  • Food is converted into basic sugars, fatty acids, and amino acids
    • Further processed by liver
    • Circulated via blood throughout body
• Lymphatic system
  • Elements of the lymphatic system
    • Spleen
    • Lymph nodes
    • Lymph
    • Lymph vessels
    • Thymus gland
    • Other components
  • Supports the circulatory system and immune system
  • Lymph is a thin, straw-colored fluid that carries oxygen and nutrients to cells and waste products away
    • Helps to rid the body of toxins and other harmful materials
• Endocrine system
  • Complex message and control system
  • Integrates many body functions
  • Hormones are released directly into the bloodstream
    • Epinephrine, norepinephrine, insulin
  • The brain controls the release of hormones
  • Excess or deficiencies in hormones can cause disease
  • Controls the discharge of certain waste materials filtered from the blood by the kidneys
  • Controls fluid balance in the body
  • Filters and eliminates wastes
  • Controls pH balance
  • Kidneys
  • Ureter
  • Urinary bladder
• Genital system
  • Controls reproductive processes
  • Male system consists of
    • Testicles
    • Epididymis
    • Vasa deferentia
    • Prostate gland
    • Seminal vesicles
    • Penis
  • Female system consists of
    • Ovaries
    • Fallopian tubes
    • Uterus
    • Cervix
    • Vagina
• Life support chain
  • All cells in body require oxygen, nutrients, and removal of waste
  • The circulatory system is the carrier of these supplies and wastes
  • If interference occurs, cells become damaged and die
  • Cells use oxygen to turn nutrients into chemical energy through metabolism
  • Aerobic metabolism uses oxygen
  • Cells switch to anaerobic metabolism when oxygen is limited
  • Movement of oxygen, waste, and nutrients occurs by diffusion
  • pH is critical to diffusion
  • The body expends a large amount of energy to maintain normal pH
• Pathophysiology
  • The study of functional changes that occur when body reacts to disease
  • Respiratory compromise is the inability of the body to move gas effectively
    • Hypoxia
    • Hypercarbia
  • Factors that impair ventilation
    • Blocked airway
    • Impairment of the muscles of breathing
    • Airway obstructed physiologically (asthma)
    • Other factors
  • Factors that impair respiration
    • Change in atmosphere
    • High altitudes
    • Impaired movement of the gas across cell membranes
  • V/Q ratio
    • How much gas is being moved effectively through the lungs
    • How much blood is flowing around the alveoli where perfusion occurs
    • Mismatch occurs when one variable is abnormal
  • Effects of respiratory compromise on the body
    • Oxygen levels fall and carbon dioxide levels rise
    • Respiratory rate increases
    • Blood becomes more acidic
    • The brain sends commands to the body to breathe
    • Cells move from aerobic to anaerobic metabolism
• Shock
  • Occurs when organs and tissues do not receive enough oxygen
    • Impaired oxygen delivery causes cellular hypoxia
  • Categorized into several types depending on the cause
  • Effects of shock on the body
    • The level of oxygen supplied to the tissues falls
    • Cells engage in anaerobic metabolism
    • Severe metabolic acidosis ensues
    • Baroreceptors initiate the release of epinephrine and norepinephrine
    • The heart rate increases
    • The interstitial fluid moves into the capillaries
• Impairment of cellular metabolism
  • Results in the inability to properly use oxygen and glucose at the cellular level
  • Cells create energy through anaerobic metabolism
    • Can result in metabolic acidosis
  • Brain cells cannot use alternative fuels
  • Cellular injury may become irreversible

Chapter 7

• Neonates and infants
  • Neonates
    • Birth to 1 month
  • Infants
    • 1 month to 1 year
    • Develop at a starting rate
  • Weight
    • Neonate weights 6 to8 lb at birth
    • The heads accounts for 25% of body weight
    • Growth of about 1 oz per day
    • Weight triples by end of the first year
  • Cardiovascular system
    • At birth, neonate makes transition from fetal to independent circulation
  • Pulmonary system
    • Infants younger than 6 months are prone to nasal congestion
    • Infants have larger tongues and shooter, narrower airways, so airway obstruction is more common than in older children or adults
  • Nervous system
    • Evolution continues after birth
    • Moro reflex
      • Neonate opens arms wide, spread finders, and seems to grab at things
    • Palmar grasp
      • Occurs when an object is placed into the neonate's palm
    • Rooting reflex
      • Neonate instinctively turns head when something touches its cheek
    • Sucking reflex
    • Occurs when a neonate’s lips are stroked
  • Fontanelles
    • Spaces between bones that eventually fuse to form the skull
    • Posterior fontanelle fuses by 3 months
    • Anterior fontanelle fuses between age 9 and 18 months
  • Immune system
    • Maintains some of the mother’s immunities
    • Infants can also receive antibodies via breastfeeding
    • Psychosocial changes
      • Crying is the main method of communicating dishes
      • Infants develop relationships with their parents or caregivers at different rates
      • Bonding is based on a secure attachment
      • Anxious-avoidant attachment is found infants who are repeatedly rejected
      • Separation is anxiety is common is older infants
      • Trust and mistrust involves an infant’s needs being met
    • Toddlers and preschoolers
      • The cardiovascular system of toddler (1 to 3 years) or preschooler (4 to 6 years) is not dramatically different from an adult
      • Preschoolers (3 to 6 years)
        • Pulse 80 to 140 beats per minute
        • Respiratory rate: 20 to 25 breaths per minute
        • Systolic blood pressure: 80 to 100 mm Hg
        • Do not have well-developed lung musculature
        • Weight gain should level off
        • Passive immunity is lost
        • Neuromuscular growth also makes considerable progress at this age
        • Average age for completion of toilet training is 28 months
      • Psychosocial changes
        • Learn to speak and express themselves
        • Master basic language
        • Interact and play games with other children
        • Begin to understand cause and effect
        • Learn to recognize gender differences by observing role models
• School-age children
  • 6 to 12 years
  • Physical traits and functions continue to mature at a rapid rate
  • Growth of 4 lb and 2.5 inches each years
  • Permanent teeth comes in
  • Brain activity increases in both hemispheres
• Psychosocial changes
  • Preconventional reasoning
    • Children act to avoid punishment and get what they want
  • Conventional reasoning
    • Children look for approval from peers and society
  • Postconventional reasoning
    • Children make decisions guided by their conscience
  • Self concept and self esteem develop
• Adolescents
  • 12 to 18 years
  • Vital signs level off
    • pulse : 60 to 100 beats per minute
    • Respirations: 12 to 20 breaths per minute
    • Systolic blood pressure: 90 to 110 mm HG
  • 2 to 3 year growth spurt
    • Girls finish by 16 years; boys by 18 years
  • Reproductive system matures
    • Secondary sexual development takes place
    • Voices start to change
    • menstruation begins
    • Acne can occur
  • Psychological changes
    • Adolescents and their families often deal with conflict
    • Privacy becomes an issue
    • Self-consciousness increases
    • Adolescents may struggle to create their own identity
    • antisocial behavior and peer pressure peak at age 14 to 16 years
      • Smoking, illicit drug use, unprotected sex
      • Eat disorders
    • Code of ethics develops
    • High risk of suicide and depression
• Early adults
  • 19 to 40 years
  • Vital signs dont vary much from adolescents
  • From age 19 to 25, the body should be functioning at its optimal level
    • Lifelong habits are solidified
  • Psychosocial changes
    • Life centers on work, family, and stress
    • Settling down, marriage, and family
    • One of the more stable periods of life
• Middle adults
  • 41 to 60 years
  • Vital signs
    • Pule 60-100 beats per minute
    • Respiratory rate 12 to 20 breaths per minute
    • Systolic blood pressure 90 to 140 mm Hg
  • Vulnerable to vision and hearing loss
  • Cancer incidence increases
  • Menopause occurs in late 40s to early 50s
  • Diabetes, hypertension, and weight problems are common
  • Exercise and healthy diet can diminish the effects of aging
  • Psychosocial changes
    • Focus on achieving life goals
    • Readjust lifestyle as children leave home
    • Generally ave the physical, emotional, and spiritual reserves to handle life’s issues
    • Finances become a concern
    • May be caring for both children leaving for college and aging parents
• Older adults
  • 61 years and older
  • Life expectancy is constantly changing now
    • Almost 78 years
  • Cardiovascular system
    • Declines with age largely to due to atherosclerosis
    • Heart rate and cardiac output decrease
    • Vascular system becomes stiff
    • Ability to produce replacement blood cells declines, as does blood volume
  • Respiratory system
    • Size of airway increases
    • Surface area of alveoli decreases
    • Natural elasticity of the lungs decreases
      • Breathing becomes more labor intensive
    • Vital capacity decreases
    • Chest becomes more rigid and fragile
    • Cough and gag reflex diminish
    • Greater risk for aspiration and airway obstruction
    • More susceptible to lung infections
  • Endocrine system
    • Insulin production drops off
    • Metabolism decreases
    • The reproductive system changes to some extent
  • Digestive system
    • Taste sensations decrease
    • Saliva secretion decreases
    • Ability of the intestines to contract and move food diminishes
    • Gallstones become increasingly common
    • Anal sphincter changes can produce fecal incontinence
  • Renal system
    • Filtration function declines
    • Kidney mass decreases by 20%
    • Diminished blood flow to the kidneys
    • Decreased ability to clear wastes from the body and ability to conserve fluids when needed
  • nervous system
    • Motor and sensory neural networks become slower
    • Neurons are lost but there is no loss of knowledge or skill
    • Sleep pattens change
    • age-related shrinkage creates a void between the brain and the outermost layer of the meninges
    • peripheral nerve sensation is diminished
    • Increased reaction times cause longer delays between stimulation and motion
    • Slowdown in reflexes and decreased kinesthetic sense may contribute to falls and trauma
  • Sensory changes
    • Most older adults can see and hear well
    • May need glasses or hearing aids
    • Visual distortion are common
    • Hearing loss is four times more common than vision loss
  • Psychosocial changes
    • Until about 5 years before death, most people retain high brain function
    • Statistics indicate that 95% of the elderly live at home
    • Financial limits may restrict access to health care or medications

Chapter 10

• Scene size up
  • Your evaluation of the conditions in which you will be operating
  • Maintain situational awareness
  • Scene size-up combines
    • An understanding of the situation and conditions prior to responding
    • Dispatcher’s basic information
    • Observation of the scene
• Ensure scene safety
  • Issues can range from minor difficulties to major dangers
  • Do not enter until the scene is safe for your and your team
  • Typically, the way you enter an area is the way you will leave
  • Wear a high-visibility safety vest on roadways
  • Consider difficult terrain
  • Consider traffic safety issues
  • Consider environmental conditions
  • If appropriate, help protect bystanders from becoming patients
  • Hazards range from extreme weather conditions to the threat of physical violence
  • An emergency scene is a dynamically changing environment
• Determine mechanism of injury/nature of illness
  • Calls for assistance can be categorized as medical conditions, traumatic injuries, or both
  • Mechanism of injury (MOI)
    • Type or amount of force
    • How long it was applied
    • Where it was applied to the body
  • Blunt trauma
    • The force occurs over a broad area
    • Skin is usually not broken
    • Tissues and organs below the area of impact may be damaged
  • Penetrating trauma
    • The force of the injury occurs at a small point of contact between the skin and the object
    • open wound with high potential infection
    • For medical patients, determine with nature illness (NOI)
    • Similarities between MOI and NOI
    • Talk with the patient, family, or bystanders
    • Use your sense to check for clues
  • Be aware of scenes with more than one patient with similar signs or symptoms
    • Example: carbon monoxide poisoning
    • Could indicate an unsafe scene for the EMT
• Importance of MOI and NOI
  • Considering the MOI or NOI early can be of value in preparing to care for the patient
  • You may be tempted to categorize the patient immediately as either trauma or medical
  • Wear personal protective equipment
    • Should be adapted to the prehospital
• Consider additional/specialized resources
  • Some situations may require
    • More ambulances
    • Specialized resources
  • Specialized resources include
    • Advanced life support
    • Air medical support
    • Fire departments who may handle high-angle rescue, hazardous materials or water rescue
    • Law enforcement
  • To determine if you require additional resources, ask yourself
    • Does the scene pose a threat to me, my patients, or others?
    • How many patients are there?
    • Do we have the resources to respond to their conditions?
• Primary assessment
  • Begins when you greet your patient
  • The goal is to identify and initiate the treatment of immediate or potential life threats
  • Physically examine the patient and assess
    • LOC
    • ABCs
• Form a general impression
  • Formed to determine the priority of care
  • First part of primary assessment
  • Make a note of the person’s
    • Age, sex, and race
    • Level of distress
    • Overall appearance
  • Note the patient’s position
  • Avoid standing over the patient
  • Address the patient by name
  • Introduce yourself
  • Ask about the chief complaint
  • Address life-threats immediately
  • Determine if the patient’s condition is
    • Stable
    • Stable but potentially unstable
    • Unstable
• Scan for signs of uncontrolled bleeding
  • Uncontrolled external bleeding takes priority over other assessments
• Assess level of consciousness
  • The LOC can tell you a great deal about the patient’s neurologic and physiologic status
  • Assessment of an unconscious patient focuses on airway, breathing, and circulation
    • Sustained unconsciousness should warn you of a critical respiratory, circulatory, or central nervous system problem
  • Conscious with an altered LOC may be due to inadequate perfusion
  • Could also be caused by medications, drugs, alcohol, or poisoning
  • To assess for responsiveness, use the mnemonic AVPU
    • Awake and alert
    • Responsive to verbal stimuli
    • Responsive to pain
    • Unresponsive
  • Orientation tests mental status
  • Evaluates a patient’s ability to remember
    • Person
    • Place
    • Time
    • Event
  • Evaluates long-term memory, intermediate-term memory, and short-term memory
  • Altered mental status
    • Any deviation from alert and oriented to person, place, time, and event
    • Any deviations from the patients normal baseline
• Identify and treat life-threat
  • Conditions that cause sudden death
    • Airway obstruction
    • Respiratory failure
    • Respiratory arrest
    • Shock
    • Severe bleeding
    • Primary cardiac arrest
  • In most cases, begin with airway, followed by breathing and circulation
  • In some cases, it may be appropriate to address life threats to circulation first
• Assess the airway
  • Moving through the primary assessment, stay alert for signs of airways obstruction
  • Ensure the airway remains open (patent) adequate
  • Responsive patients
    • Patients who are talking or crying have an open airway
    • Watch and listen to how patients speak
    • If you identify an airway problem, stop the assessment and work to clear the patient’s airway
    • Unresponsive patients
      • Immediately assess the airway
      • Use the jaw-thrust technique when necessary
      • Use the head tilt-chin lift technique when necessary
      • Relaxation of the tongue muscles is a cause of airway obstruction
  • Signs of obstruction in an unconscious patient
    • Obvious trauma, blood, or obstructions
    • Nosy breathing
    • Extremely shallow or absent breathing
• Assess
  • Mental status
  • Pulse
    • The pulse is the pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries
    • Palpate (feel) the pulse
    • If you cannot palpate a pulse in an unresponsive patient, begin CPR
  • Skin condition
    • Evaluate the patient’s skin color, temperature, moisture, and capillary refill
    • A normally functioning circulatory system perfuses the skin with oxygenated blood
  • Skin color
    • Determined by the blood circulating through vessels and the amount and type of pigment present in the skin
    • Poor circulation will cause the skin to appear pale, white, ashen, or gray
    • When blood is not properly saturated with oxygen ,it appears blue
    • Changes in skin color may result from chronic illness
  • Skin temperature
    • Normal skin will be warm to the touch
    • Abnormal skin temperatures are hot, cold, and clammy
  • Skin moisture
    • Dry skin is a normal
    • Skin that is wet, moist, or excessively dry and hot suggest a problem
  • Capillary refill
    • Evaluate to assess the ability of the circulatory system to restore blood to the capillary system
    • Press on the patient’s fingernail
    • Remove the pressure
    • The nail bed should restore to its normal pink color
    • Should be restored to normal with 2 seconds
  • Assess and control external bleeding in trauma patients
    • Should occur before addressing airway or breathing concerns
    • Bleeding from a large vein is characterized by a steady flow of blood
    • Bleeding from an artery is characterized by a spurting flow of blood
  • Controlling external bleeding can be simple
    • Apply direct pressure
    • Apply a tourniquet if
      • Direct pressure is not quickly successful
      • Obvious arterial hemorrhage of an extremity
  • Identify injuries that must be managed or protected before the patient is transported
    • Take 60 to 90 seconds to perform
    • Not a systematic or focused physical examination
  • Primary assessment assists in determining transport priority
  • High-priority patients include thsoe with any of the following conditions
    • Unresponsive
    • Difficulty breathing
    • Uncontrolled bleeding
    • Altered level of consciousness
    • Severe chest pain
    • Pale skin or other signs of poor perfusion
    • Complicated childbirth
    • Severe pain in any area of the body
  • The golden hour is the time from injury to definitive care
    • Treatment of shock and traumatic injuries must occur
    • Immediate transport is one of the keys to survival of patients who need immediate care that the EMT cannot provide
  • Transport decisions should be made at this point, based on
    • Patients condition
    • Availability of advanced care
    • Distance of transport
    • Local protocols
• History taking
  • Provides detail about the chief complaint and the patients signs and symptoms
  • Includes demographic information
    • Date of the incident
    • Patients age, gender, race, past medical history, and current health status
  • Investigate the chief complaint
    • Make introductions, make the patient feel, obtain permission to treat
    • Ask a few simple and direct questions
    • Refer to patient as Mr. Ms, or Mrs, using the patients last name
    • Ask open-ended questions
  • If the patient is unresponsive, patient information and clues about the incident may be obtained from
    • Family members present
    • A person who may have witnessed the situation
    • Bystander
    • Medical alert jewelry
    • Other patient medical history documentation
  • Use the OPQRST mnemonic to assess symptoms
    • Onset
    • Provocation or palliation
    • Quality
    • region/radiation
    • Severity
    • Timing
  • Identify pertinent negatives
  • Use the mnemonic SAMPLE to the obtain with following information
    • Signs and symptoms
    • Allergies
    • Medications
    • Pertinent past medical history
    • Last oral intake
    • Events leading up to the injury/illness
• Taking history on sensitive topics
  • Alcohol and drugs
    • Signs may be confusing, hidden, or disguised
    • Patient may deny having any problems
    • History gathered may be unreliable
    • Do not judge the patient
    • Be professional in your approach
  • Physical abuse or violence
    • Report all physical abuse or domestic violence to the appropriate authorities
    • Fellow local protocols
    • Do not accuse; instead, immediately involve law enforcement
  • Sexual history
    • Consider all female patients of childbearing age who report lower abdominal pain to be pregnant
    • Ask about the patient’s last menstrual period
    • Inquire about urinary symptoms with male patients
    • When appropriate, ask all patients about the potential for sexually transmitted diseases

Chapter 11

• Anatomy of the respiratory system
  • The respiratory system consists of all the structures that make up the airway and help us breathe, or ventilate
  • The airway is divided into the upper and lower airways
• Anatomy of the upper airway
  • Nose
  • Mouth
  • Oral cavity
  • Pharynx
  • Larynx
  • The upper airway’s main function is to warm, falter, and humidify air as it enters the body
  • Pharynx
    • Muscular tube extending from nose and mouth to level of esophagus and trachea
    • composed , from top to bottom, of the nasopharynx, oropharynx, and laryngopharynx
  • Nasopharynx
    • Filters out dust and small particles
    • Warms and humidifies air as it enters the body
  • Oropharynx
    • Posterior portion of the oral cavity
    • The epiglottis is superior to the larynx
  • Larynx
    • Complex structure formed by many independent cartilaginous structures
    • Marks where the upper airway ends and the lower airway begins
    • Thyroid cartilage forms a V shape anteriorly
    • Cricoid cartilage is the first ring of the trachea
    • Glottis is the area between the vocal cords
• Anatomy of the lower airway
  • The lower airway’s function is to deliver oxygen to the alveoli
  • Includes
    • Trachea
      • Conduit for air entry into the lungs
      • Divides at the carina into two main stem bronchi, right and left
      • Bronchi are supported by cartilage
      • Bronchi distribute oxygen to the lungs
      • Bronchioles are made of smooth muscle
      • Smaller bronchioles connect to alveoli
      • Oxygen is transported back to the heart and distributed to the rest of the body
    • Bronchi
    • Lungs
  • The mediastinum contains
    • Heart
    • Great vessels
    • Esophagus
    • Trachea
    • Major bronchi
    • Many nerves
• Physiology of breathing
  • The respiratory and cardiovascular system works together
    • Ensure a constant supply of oxygen and nutrients is delivered to cells
    • Remove carbon dioxide and waste products
• Ventilation
  • Physical act of moving air into and out of the lungs
  • Inhalation
    • Active, muscular part of breathing
    • The diaphragm and intercostal muscles contract
    • This generates a negative pressure in the thorax, allow air to enter
    • The lungs require the movement of the chest and supporting structures to expand
    • Partial pressure: the amount of gas in the air or dissolved in fluid
    • Oxygen and carbon dioxide both diffuse until the partial pressures in the air and the blood are equal
    • Inspiration delivers oxygen to the alveoli
    • Tidal volume
    • Dead space
  • Exhalation
    • Does not normally require muscular effort
    • Passive process
    • Diaphragm and intercostal muscles relax
    • Smaller thorax compresses air into the lungs
  • Regulation of ventilation involves a complex series of receptors and feedback loops
    • Failure to meet the body’s need for oxygen may result in hypoxia
    • Based on pH changes in the blood and cerebrospinal fluid
  • Hypoxic drive
    • Typically seen in patients with end-stage COPD
• Oxygenation
  • Process of loading oxygen molecules onto hemoglobin molecules in blood stream
  • Required for internal respiration to take place
    • Does not guarantee that internal respiration is taking place
    • Ventilation without oxygenation can occur where oxygen levels have been depleted
• Respiration
  • Actual exchange of oxygen and carbon dioxide in the alveoli and tissues of the body
  • Cells take energy from nutrients and metabolism
  • External respiration
    • Bring fresh air into the respiratory system
    • Exchanges oxygen and carbon dioxide between alveoli and blood in pulmonary capillaries
  • Internal respiration
    • Exchange of oxygen and carbon dioxide between systemic circulatory system and cells
• Pathophysiology of respiration
  • Chemoreceptors monitor levels of
    • Oxygen
    • Carbon dioxide
    • Hydrogen ions
    • Ph of cerebrospinal fluid
  • Provide feedback to the respiratory centers
  • ventilation/perfusion ratio and mismatch
    • Air and blood flow must be directed to the same place at the same time
    • Ventilation and perfusion must be matched
    • Failure to match is the cause of abnormalities of oxygen and carbon dioxide exchange
  • ventilation/perfusion ratio and mismatch
    • Gas exchange does not take place
    • Lack of O2 in blood stream
    • CO2 is recirculated within bloodstream
    • Severe hypoxemia can occur
  • Factors affecting pulmonary ventilation
    • Intrinsic factors
      • Infections
      • Allergic reactions
      • Unresponsiveness
    • Extrinsic factors
    • Trauma
  • Factors affecting respiration
    • External factors
      • Atmospheric pressure
      • Partial pressure of O2
    • Internal factors
      • Pneumonia
      • Pulmonary edema
      • COPD/emphysema
  • Circulatory compromise
    • Trauma emergencies can obstruct blood flow to individuals cells and tissue
      • Simple or tension pneumothorax
      • Open pneumothorax
      • Hemothorax
      • Hemopneumothorax
    • Other causes
      • Blood loss
      • Anemia
      • Hypovolemic shock
      • Vasodilatory shock
• Patient assessment
  • Aerosol-generating procedures
    • CPR
    • Nebulizer treatment
    • Endotracheal intubation
    • Continuous positive airway pressure
  • Recognizing adequate breathing
    • Between 12 and 20 breaths/min
    • Regular pattern of inhalation and exhalation
    • Bilateral clear and equal lung sounds
    • Regular, equal chest rise and fall
    • Adequate depth (tidal volume)
  • Recognizing abnormal breathing
    • Fewer than 12 breaths/mins
    • More than 20 breaths/min
    • Irregular rhythm
    • Diminished, absent, or noisy auscultated breath sounds
    • Reduced flow of expired at nose and mouth
    • Unequal or inadequate chest expansion
    • Increased effort of breathing
    • Shallow depth
    • Skin that is pale, cyanotic, cool, or moist
    • Skin pulling in around ribs or above clavicles during inspiration
  • A patient may appear to breathing after the heart has stopped
    • Called agonal gasps
  • Cheyne-stokes respirations are often seen in patients with stroke or head injury
  • Ataxis respirations
    • Irregular or unidentifiable pattern
    • May follow serious head injuries
  • Kussmaul respirations
    • Deep, rapid respirations
    • Common in patients with metabolic acidosis
  • Patients with inadequate breathing need to be treated immediately
  • Assessment of respiration
    • Even though the patient may be ventilating appropriately, respiration may be compromised
    • Level of consciousness and skin color are excellent indicators of respiration
    • Also consider oxygenation
      • Pulse oximetry is considered a routine vital sign
      • Can be used as part of any patient assessment
• End-tidal CO2
  • Measurement of the maximal CO2 at the end of an exhaled breath
  • Low CO2 level
    • Hyperventilation
    • Decreased CO2 return to the lungs
    • Reduced CO2 production at the cellular level
  • High CO2 level
    • Ventilatory inadequacy
    • Apnea
  • Measured using capnometry and capnography devices
  • Normal range is 35-45 mm Hg
  • Can be used in spontaneously breathing patients with a special nasal cannula
• Opening the airway
  • Emergency medical care begins with ensuring an open airway
  • Rapidly assess whether an unconscious patient has an open airway and is breathing adequately
    • Position the patient correctly
    • Supine position is most effective
  • Unconscious patients should be moved as an unit
    • Most common airway obstruction is the tongue
• Head tilt-chin lift maneuver
  • Will open the airway in most patients
  • For patients who have not sustained or are not suspected of having sustained trauma
• Follow these steps
  • With the patient supine, position yourself besides the patient’s head
  • Place the heel of one hand on the forehead, and apply firm backward pressure with the palm
  • Place the fingertips of the other hand under the lower jaw
  • Lift the chin upward, with entire lower jaw
• Jaw-thrust Maneuver
  • If you suspect a cervical spine injury, use this maneuver
  • Follow these steps
    • Kneel above the patient’s head
    • Place your fingers behind the angles of the lower kaw
    • Move the jaw upward
    • Use your thumbs to help position the jaw
• Opening the mouth
  • Even if the airway is opened, the mouth many be closed
  • For the cross-finger technique
    • Place the tips of your index finger and thumb on the patient’s teeth
    • Push your thumb on the lower teeth
    • Push index finger on the upper teeth
    • The index finger and the thumb cross over each other
• Suctioning
  • You must keep the airway clear to ventilate properly
  • Portable, hand-operated, and fixed equipment is essential for resuscitation
  • A portable or fixed unit should have
    • Wide-bore, thick-walled, nonkinking tubing
    • Plastic, rigid pharyngeal suction tips
    • Nonrigid plastic catheters
    • A nonbreakable, disposable collection bottle
    • Water supply for rinsing the tips
• Techniques of suctioning
  • Inspect the equipment regularly
  • To operate the suction unit
    • To check the unit for proper assembly of its parts
    • Test the suctioning unit to ensure vacuum pressure of more than 300 mm Hg
    • Select and attach the appropriate suction catheter to the tubing
  • Never suction the mouth or nose for more than 15 seconds at one time for adult patients, 10 second for children, and 5 seconds for infants
    • Suctioning can result in hypoxia
  • When patients have secretions or vomitus that cannot be suctioned easily
    • Remove the catheter from patient’s mouth
    • Log roll the patient to the side
    • Clear the mouth carefully with a gloved finger
  • If the patient produces frothy secretions as quickly as you can suction them
    • Suction the airway for 15 seconds
    • Ventilate for 2 minutes
    • Continue this alternating pattern until all secretions have been cleared
• Basic airway adjuncts
  • Prevent obstruction by the tongue and allow for passage of air and oxygen to the lungs
  • Oropharyngeal airways
    • Keep the tongue from blocking the upper airway
    • Make it easier to suction the oropharynx
  • Indications
    • Unresponsive patients without a gag reflex
    • Apneic patients being ventilated with a bag-mask device
  • Contraindications
    • Conscious patients
    • Any patient who has intact gag reflex
  • Nasopharyngeal airways
    • Used in a patient who
      • Is unresponsive or has an altered LOC
      • Has an intact gag reflex
      • Is unable to maintain his or her own airway spontaneously
    • Indications
      • Semiconscious or unconscious patients with an intact gag reflex
      • Patients who will not tolerate an oropharyngeal airway
    • Contraindications
      • Severe head injury with blood in the nose
      • History of fractured nasal bone
• Nasal cannulas
  • Deliver oxygen through two small tube like prongs that fit into the nostrils
  • Can provide 24% to 44% inspired oxygen when the flowmeter is set at 1-6 L/min
  • Used in patients with mild hypoxemia
  • A patient who breathers through the mouth, or has a nasal obstruction, will not benefit
  • When you anticipate a long transport time, consider using humidifications
• Venturi masks
  • A number of settings can vary the percentage of oxygen while a constant flow is maintained
  • Delivers 24-40%
• Tracheostomy masks
  • Patients with tracheostomies do not breathe through their mouth and nose
  • Tracheostomy masks cover the tracheostomy hole and have a strap that goes around the neck
    • May not be available in an emergency setting
    • Improvise by using a face mask placed at the tracheostomy opening
• Assisted and artificial ventilation
  • Basic airway and ventilation techniques are extremely effective
    • Follow standard precautions as needed when managing a patient’s airway
  • Signs and symptoms of inadequate ventilation
    • Altered mental status
    • Inadequate minute volume
    • Excessive accessory muscle use and fatigue
  • When assisting with a bag-mask device
    • Explain the procedure to the patient
    • Place the mask over the nose and mouth’
    • Squeeze the bag each time the patient breathes
    • After the initial 5 to 10 breaths, deliver an appropriate tidal volume
    • Maintain an adequate minute volume
  • Artificial ventilation
    • Once a patient is not breathing, begin artificial ventilation immediately via
      • Mouth to mouth technique
      • One or two-person bag-mask device
  • Normal ventilation versus positive pressure ventilation
    • In normal breathing, the diaphragm contracts and negative pressure is generated in the chest cavity
    • Positive pressure ventilation is generated by a device that forces air into chest cavity
  • With positive pressure ventilation
    • Increased intrathoracic pressure required to have the same effects as normal breathing
    • Air is forced into the stomach, causing gastric distention
  • Mouth-to-mouth and mouth-to-mask ventilation
    • Barrier device is routinely used in mouth-to-ventilation
    • Mask with an oxygen inlet provides oxygen during mouth-to-mask ventilation
  • Bag-mask device
    • Provides less tidal volume than mouth-to-mask ventilation
      • An experienced EMT can provide adequate tidal volume
  • Gastric distention
    • Occurs when artificial ventilation fills the stomach with air
    • Most likely to occur when you ventilate the patient forcefully or too rapidly
    • May also occur when is obstructed
    • To prevent or alleviate distention
      • Ensure the patient’s airway is appropriately positioned
      • Ventilate at the appropriate rate
      • Ventilate with the appropriate volume
    • If the stomach appears distended, recheck and reposition at the head and perform rescue breathing
  • Passive ventilation
    • Expansion and contraction create a pump for air movement
    • Benefits patients who are receiving chest compressions
    • Can be enhanced using oropharyngeal airway and supplemental oxygen
  • Automatic transport resuscitator
    • Manually triggered device attached to a control box
    • Allows the variables of ventilation to be set
    • Lacks the sophisticated control of a hospital ventilator
    • Frees the EMT to preform other tasks
• Continuous Positive AIrway Pressure
  • Noninvasive ventilatory support for respiratory distress
    • Many people diagnosed with obstructive sleep apnea wear a CPAP unit at night
    • Becoming widely used at the EMT level
  • Mechanism
    • Increased pressure in the lungs opens collapsed alveoli
    • Opens collapsed alveoli
    • Pushes more oxygen across the alveolar membrane
    • Forces interstitial fluid back into the pulmonary circulation
    • Therapy is delivered through a face mask held to the head with a strapping system
    • Use caution with patients with potentially low blood pressure
  • Indications
    • Patient is alert and able to follow commands
    • Patient displays obvious signs of moderate to severe respiratory distress respiratory distress occurs after a submersion incident
    • Patient is breathing rapidly
    • Pulse oximetry reading is less than 90%
  • Contraindications
    • Patient in respiratory arrest
    • Patient is hyperventilating
    • Patient cannot speak
    • Patient is unresponsive or cannot follow verbal commands
    • Patient cannot protect his or her airway
    • Patient has hypotension
    • Signs and symptoms of a pneumothorax or chest trauma
    • Patient has a tracheostomy
    • Active gastrointestinal bleeding or vomiting
    • Patient has experienced facial trauma
    • Patient is in cardiogenic shock
    • Patient cannot sit upright
    • Patient cannot tolerate the mask
  • Application
    • Resistance create back pressure that pushes open smaller airway structures as the patient exhales
    • 7.0 to 10.0 cm HO is acceptable
  • Complications
    • Some patients may find CPAP claustrophobic
    • Risk of pneumothorax
    • Can lower the patient’s blood pressure
    • If the patient shows up signs of deterioration, remove CPAP and begin positive pressure ventilation using a bag-mask device
• Special Considerations
  • Stomas and tracheostomy lubes
    • Patients who have had a laryngectomy have a permanent tracheal stoma
    • Known as a tracheostomy
  • Stomas and tracheostomy tubes
    • Neither the head tilt-chin lift maneuver nor the jaw-thrust maneuver is required
    • If the patient has a tracheostomy tube, ventilate through the tube with a bag-mask device
    • If you cannot ventilate a patient with a stoma
      • Try suctioning the stoma
      • Seal the stoma while giving mouth-to-mouth
• Airway Obstruction
  • If an obstruction completely blocks the airway, it is a true emergency
    • Will result in death if not treated immediately
    • In an adult, usually occurs during a meal
    • In a child, can occur while eating, playing with small toys, or crawling
  • The tongue is the most common airway obstruction in an unconscious patient
  • Causes of airway obstruction that do not involve foreign bodies
    • Swelling, from infection, or acute allergic reaction
    • Trauma
  • Mild airway obstruction
    • Patients can still exchange air but will have respiratory distress
    • Noisy breathing,.wheezing, coughing
    • With good air exchange, do not interfere with the patient’s efforts to expel the object on his or her own
    • With poor air exchange, the patient may have increased difficulty breathing stridor, cyanosis
    • Treat immediately
  • Severe airway obstruction
    • Patients cannot breathe, talk or cough
• Emergency Medical care for foreign body airway obstruction
  • Perform a head tilt-chin lift maneuver to clear a tongue obstruction
  • Large obstructions should be swept forward out of the mouth with your gloved index finger
  • Abdominal thrusts are the most effective method of dislodging and forcing out an object

Chapter 12

• How medications work
  • Pharmacology is the science of drugs
  • A medication is a substance used to
    • Prevent or treat disease
    • Relieve pain
  • Pharmacodynamics is a process by which medication works on the body
  • Agonist
    • Causes stimulation of receptors
  • Antagonist
    • Binds to a receptor and blocks other medications or chemicals
  • Dose
    • Amount of medication given
  • Action
    • The therapeutic effect that a medication is expected to have on the body
  • Pharmacokinetics
    • Actions of the body upon the medication or chemical
      • Onset of action
      • Duration
      • Elimination
      • Peak
    • Factors affecting how a medication works
      • Route of administration
      • Shock states
    • Indications
      • Reasons or conditions
    • Contraindications
      • Harmful effects
      • Absolute
      • Relative
    • Adverse effects
      • Unintended effects
      • Untoward effects
• Medication names
  • Generic name
    • Example: ibuprofen
  • Trade name
    • Example: tylenol
• Routes of administration
  • Enteral medications enter the body through the digestive system
  • Parenteral medications enter the body by some other means
  • Absorption is the process by which medications travel through body tissues to the blood stream
  • Common routes of administration
    • Per rectum (PR)
    • Oral or per os (PO)
  • Intravenous (IV)
    • Into the vein
  • Intraosseous (IO)
    • Into the bone
  • Subcutaneous (SC)
    • Beneath the skin
  • Intramuscular (IM)
    • Into the muscle
  • Inhalation
    • Inhaled into the lungs
  • Sublingual (SL)
    • Under the tongue
  • Transcutaneous
    • Through the skin
  • Intranasal (IN)
    • Into the nostril via a mucosal atomizer device
• Medication forms
  • Tablets and capsules
    • Capsules are gelatin shells filled with powdered or liquid medication
    • Tablets often contain other materials that are mixed with the medication and compressed
  • Solutions and suspensions
    • A solution is a liquid mixture of substances
      • Will not separate by filtering or letting it stand
      • Can be given as an IV, IM, or SC injection
    • Suspension is substance that does not dissolve well in liquids
      • Will separate if it stands or is filtered
  • Metered-dose inhalers
    • Liquids or solids broken into small enough droplets or particles may be inhaled
    • A metered dose inhaler (MDI) directs such substances through mouth into lungs
    • Delivers the same amount each time
  • Topical medications
    • Include lotions, creams, and ointments
    • Applied to skin surface and affect only that area
    • Examples:
      • Lotion
      • Cream
      • Ointment
  • Transcutaneous medications
    • Designer to be absorbed through the skin
    • Also referred to as transdermal
    • May have systemic effects
    • If you touch the medications with your skin, you will absorb it just like the patient
  • Gels
    • Semiliquid
    • Administered in capsules or through plastic tubes
    • Example:
      • Oral glucose for patients with diabetes
• General steps in administering medication
  • Medications should be administered only under the authorization of medical control
  • Follow the “rights” of medication administration
  • Medication errors almost always result from failure to follow these rights
• Medication administration and the EMT
  • Circumstances in which medications may be administered
    • Peer-assisted administration
    • Patient-assisted administration
    • EMT-administered medications
  • Determined by
    • State and local protocols
    • Medical control
• Oral medications
  • Confirm that the patient has a patent airway and is able to swallow and then instruct the patient to swallow or chew the medication
  • Oral glucose
    • A sugar that cells use for energy
    • Treats hypoglycemia
    • EMTs give it only by mouth
    • Do not give it to an unconscious patient or one who cannot protect the airway
  • Aspirin
    • Reduces fever, pain, and inflammation
    • Inhibits platelet aggregation
      • Useful during hear attack
    • Contraindications
      • Hypersensitivity to aspirin
      • Liver damage, bleeding disorder, asthma
      • Should not be given to children
• Sublingual medications
  • Advantages
    • Easy to advise patients
    • Quick absorption
  • Disadvantages
    • Constant evaluation of the airway
    • Possible choking
    • Not for uncooperative or unconscious patients
  • Nitroglycerin
    • Relives angina pain
    • Increases blood flow
    • Relaxes veins
    • Before administering
      • Check blood pressure
      • Obtain order to administer
    • Possibility of MI, if no relief
    • Should not be used with erectile dysfunction medications
    • May cause mild headache
    • Administration by tablet
      • Sublingually under the tongue
      • Slight tingling or burning
      • Storage is important
    • Administration by metered-dose spray
      • On or under tongue
      • One spray = one tablet
    • Administration considerations for both tablet and spray
      • Wait 5 minutes before repeating dose
      • Monitor vital signs
      • Wear gloves
      • Know local protocols
    • Advantages
      • quick , easy access without using vein
      • Stable blood flow to muscles
    • Disadvantages
      • Use of a needle
      • Patients may fear pain or injury
    • Epinephrine
      • Controls fight-or-flight response
      • Primary medications for delivery IM
      • Also called adrenaline, released inside the body under stress
      • Sympathomimetic
      • Increases heart rate and constricts blood vessels
      • Do not give to patients with hypertension, hypothermia, MI, or wheezing
      • May be delivered with an auto-injector to treat life-threatening anaphylaxis
        
      • Naloxone
        • Use to reverse the effects of an opioid overdose
        • Important considerations

Consult medical direction

Effects may not last as long as opioids; repeated doses may be necessary

Can cause severe withdrawal symptoms

Consider your safety

• • • • • The most common technique for naloxone administration is via the intranasal route
      • Oxygen
        • All cells need it to survive
        • Generally administered via

nonrebreathing mask

Nasal cannula

• • • • Moi and nebulizers
        • Liquid turned into mist or spray
        • Medication breathed in and delivered to alveoli
        • Fast absorption rate
        • Easy route to access
        • Portable
      • Use a spacer to avoid spray misdirection
        • Fits over the inhaler like a sleeve
        • Patient sprays the prescribed dose into the chamber
        • And then breathes in and out of the mouthpiece
        • Especially useful with young children
      • Small-volume nebulizers
        • Easier to use than MDIs
        • Take longer to deliver medications
        • Require an external air or oxygen source
        • More effective in patients with moderate to severe respiratory distress
        • Can be used while a patient is on CPAP and during bag-mask ventilation
• Patient medications
  • Patient assessment includes finding out which medications the patient is taking
    • Provides vital clues to the patients conditions
    • Guides treatment
    • Will be useful to the emergency department
  • Do not underestimate the importance of obtaining a thorough medication history
  • Medications are often not taken as prescribed
  • Medications may alter the clinical presentation
• Medications errors
  • Inappropriate use of a medication that could lead to patient harm
  • May be possible to minimize errors if circumstances are understood
  • Ensure the environment does not contribute to errors
  • If a medication error occurs
    • Provide appropriate patient care
    • Notify medical control
    • Follow protocols
    • Document thoroughly,accurately, and honestly
    • Talk with your partner, supervisor, or

Chapter 13

• Pathophysiology
  • Diffusion is a passive process in which molecules move from an area with a higher concentration of molecules to an area of lower concentration
    • Oxygen and carbon dioxide move across the walls of the alveoli
  • In cases of poor perfusion
    • Transportation of carbon dioxide out of tissues is impaired
    • Results in a dangerous buildup of waste products, which may cause cellular damage
  • Shock is a state of collapse and failure of the cardiovascular system that leads to inadequate circulation
    • Early recognition can save lives
    • Requires immediate recognition and rapid treatment
  • cardiovascular system consists of three parts
    • Pump (heart)
    • Set of pipes (blood vessels or arteries)
    • Contents (the blood)
  • Perfusion triangle
    • When a patient is in shock, one or more of the three parts is not working properly
  • Blood pressure is the pressure of blood within the vessels at any moment in time
    • Systolic
      • Peak arterial pressure
    • Diastolic
      • Pressure in the arteries while the heart rests between heartbeats
  • Pulse pressure is the difference between the systolic an diastolic pressure
    • It signifies the amount of force the heart generates with each contraction
    • A pulse pressure less than 25 mm Hg may be seen in patients in shock
  • Blood flow through the capillary beds is regulated by the capillary sphincters
    • Under the control of the autonomic nervous system
    • Regulation of blood flow is determined by cellular needs
  • Perfusion also requires adequate
    • Oxygen exchange in the lungs nutrients in the form of glucose in the blood
    • Waste removal, primarily through the lungs
  • Mechanisms are in place to help support the respiratory and cardiovascular systems when the need for perfusion of vital organs is increased
    • Includes the autonomic nervous system and hormones
  • Hormones are triggered when the body sense pressure falling
    • Cause an increase in
      • Heart rate
      • Strength of cardiac contractions
      • Peripheral vasoconstriction
  • This response causes all the signs and symptoms of shock
• Causes of shock
  • Many different shocks result from three basic causes’
    • Pump failure
    • Poor vessel function
    • Low fluid volume
• Cardiogenic shock
  • Caused by inadequate function of the heart
  • A major effect is the backup of blood into the pulmonary vessels
  • Resulting buildup of pulmonary fluid is called pulmonary edema
  • Develops when the heart cannot maintain sufficient output to meet the demands of the body
  • Cardiac output depends on adequate
    • Contractility of the heart muscle
    • Amount of blood to pump
    • Resistance to flow in the peripheral circulation
• Obstructive shock
  • Caused by a mechanical obstruction that prevents an adequate volume of blood from filling the heart chambers
  • Three of the most common examples
    • Cardiac tamponade
      • Collection of fluid between the pericardial sac and the myocardium becomes large enough to prevent ventricles from filling with blood
      • Signs and symptoms are referred to as beck triad
    • Tension pneumothorax
      • Caused by damage to lung tissue
      • Air normally held within the lung escapes into the chest cavity
      • The lung collapses, and air applies pressure to the organs, including the heart and great vessels
    • Pulmonary embolism
      • A blood clot that blocks the flow of blood through pulmonary vessels
      • If massive
        • Can result in complete backup of blood in the right ventricle
        • Leads to catastrophic obstructive shock and complete failure
• Distributive Shock
  • Results from widespread dilation of small arterioles, small venules, or both
  • The circulating blood volume pools in the expanded vascular beds
  • Tissue perfusion decreases
  • Septic shock
    • Occurs as a result of severe infections in which toxins are generated by bacteria or by infected body tissues
    • Toxins damage vessel walls, causing increased cellular permeability
    • Vessel walls leak and are unable to contract well
    • Widespread dilation of vessels, in combination with plasma loss through the vessel walls, results in shock
  • Neurogenic shock
    • Usually the result of high spinal cord injury
    • Nerve impulses to blood vessels below the level of the injury are blocked
    • All vessels cut off from the nerve impulses will dilate, causing the blood to pool
  • Anaphylactic shock
    • Occurs when a person reacts violently to a substance to which he or she has been sensitized
    • Sensitization means becoming sensitive to a substance that did not initially cause a reaction
    • Each subsequent exposure tends to produce a more severe reaction
  • Psychogenic shock
    • Caused by a sudden reaction of the nervous system
    • Produces temporary, generalized vascular dilation
    • Results in fainting
    • Life-threatening causes include irregular heartbeat and brain aneurysm
    • Non-life threatening events include receipt of bad news or experiencing fear or unpleasant sights
  • Hypovolemic shock
    • Result of an inadequate amount of fluid or volume in the circulatory system
    • Hemorrhagic causes and nonhemorrhagic
    • Occurs with severe thermal burns
• The progression of shock
  • Stages in the progression of shock
    • Compensated shock
      • Early stage when the body can still compensate for blood loss
    • Decompensated shock
      • Late stage when blood pressure is falling
    • No way to assess when effects irreversible
    • Must recognize and treat shock early
  • Blood pressure may be the last measurable factor to change in shock
    • When a drop in blood pressure is evident, shock is well developed
    • Particularly true in infants and children
    • When blood pressure drops in infants and children in shock, they are close to death
  • Also expect shock if a patient has any one of the following conditions
    • Multiple severe fractures
    • Abdominal or chest injury
    • A severe infection
    • A major heart attack
    • Anaphylaxis
• Scene size-up
  • Be alert to potential hazards to your safety
  • Use gloves and eye protection for trauma scenes or if bleeding is suspected
  • Mechanism of injury/nature of illness
• Primary assessment
  • Perform a rapid exam
  • Determine the level of consciousness
  • Identify and manage life-threatening concerns
  • Determine priority of the patient and transport
  • Provide high-flow O2 to assist in perfusion
  • For hypoperfusion, treat aggressively and provide rapid transport
  • Request advanced life support (ALS) as necessary
  • Form a general impression
  • Assess the airway to ensure it is patient
  • Assess breathing
  • An increased respiratory rate is often an early sign of impending shock
  • Assess patient’s circulatory status
  • A rapid pulse suggests compensated shock
  • In rapid shock for compensated shock, the skin may be col, clammy, or ashen
  • Assess for and identify any life-threatening bleed and treat it at once
  • Determine if patient is high priority, if ALS is needed, and which facility to transport to
  • Trauma patients with shock or a suspicious MOI generally should go to a trauma center
• History taking
  • Determine the chief complaint
  • Obtain a SAMPLE history
• Secondary Assessment
  • Repeat the primary assessment, followed by focused assessment
  • If a life-threatening problem is found, treat it immediately
  • Obtain a complete set of baseline vital signs
  • Use monitoring devices
• Reassessment
  • Reassess the patient’s
    • Vital signs
    • Interventions
    • Chief complaint
    • ABCs
    • Mental status
    • Determine what interventions are needed
    • Focus on supporting the cardiovascular system
    • Treat for shock early and aggressively by
      • Providing oxygen
      • Keeping the patient warm
• Emergency medical care for shock
  • As soon as you recognize shock, begin treatment
    • Follow standard precautions
    • Control all obvious bleeding
    • Make sue the patient has an open airway
    • Maintain manual in-line stabilization if necessary, and check breathing and pulse
    • Comfort, calm, and reassure the patient
    • Never allow patient to eat or drink anything prior to being evaluated by a physician
    • If spinal immobilization is indicated, splint the patient on a backboard
    • Provide oxygen and monitor patient’s breathing
    • Place blankets under and over the patient
    • Consider the need for ALS
    • Accurately record the patient the patient’s vital signs and approximately every 5 minutes
• Treating cardiogenic shock
  • If patient cannot generate the necessary contraction to pump blood throughout the circulatory system
  • Patient may present with chest pain
  • Patients in cardiogenic shock should not receive nitroglycerin; they are hypotensive
  • Patients usually have
    • Low blood pressure
    • Weak, irregular pulse
    • Cyanosis about lips/underneath fingernails
    • Anxiety
    • Nausea
  • Place the patient in a position that eases breathing as you give high-flow oxygen
  • Assist ventilations as necessary
  • Provide prompt transport
  • Consider meeting ALS en route to hospital
• Treating obstructive shock
  • Increasing cardiac output is the priority
  • Apply high-flow oxygen
  • Surgery is the only definitive treatment
  • For tension pneumothorax
    • Apply-flow oxygen to prevent hypoxia
    • Chest decompression is required
    • Ask for ALS early in call if available, but do not delay transport
• Treating septic shock
  • Hospital management is required
  • Use standard precautions and transport
  • Administer high-flow oxygen
  • Ventilatory support may be necessary
  • Use blankets to conserve body heat
  • Notify “sepsis team” if available
• Treating neurogenic shock
  • Emergency treatment
    • Obtain and maintain a proper airway
    • Provide spinal immobilization
    • Assist to inadequate breathing
    • Conserve body heat
    • Ensure the most effective circulation
  • Transport promptly
• Treating anaphylactic shock
  • Administer epinephrine
  • Promptly transport the patient
  • Provide high-flow oxygen and ventilatory assistance en route
  • A mild reaction may worsen suddenly
  • Consider requesting ALS backup, if available
• Treating psychogenic shock
  • In an uncomplicated case of fainting, once the patient collapses, circulation to the brain is restored
  • Psychogenic shock can worsen other types of shock
  • If the patient falls, check for injuries
  • If the patient reports being unable to walk after a fall, suspect another problem
  • Transport the patient promptly
• Treating hypovolemic shock
  • Control all obvious external bleeding
  • Keep the patient warm
  • Recognize internal bleeding and provide aggressive support
  • Secure and maintain an airway, and provide respiratory support
  • Transport as rapidly as possible
• Treating shock in older patients
  • Older patients have more serious complications than younger ones
  • Illness is not just part of aging
  • Many older patients take medications that mask or mimic signs of shock

Chapter 14

• Elements of BLS
  • Noninvasive emergency life-saving care
  • Used to treat medical conditions including
    • Airway obstruction
    • Respiratory arrest
    • Cardiac arrest
  • Focus is on the ABCs
    • Airway (obstruction)
    • Breathing (respiratory arrest)
    • Circulation
  • Ideally, only seconds should pass between the time you recognize a patient needs BLS and the start of treatment
    • Permanent brain damage is possible if the brain is without oxygen for 4 to 6 minutes
  • Cardiopulmonary resuscitation
    • Reestablishes circulation and artificial ventilation in a patient who is not breathing and has no pulse
  • CPR steps
    • Restore circulation
    • Open the airway
    • Restore breathing
  • BLS differs from advanced life support
  • ALS involves
    • Cardiac monitoring
    • Intravenous fluids and medications
    • Advanced airway adjuncts
• System components of CPR
  • AHA chan of survival
    • Recognition and activation of the emergency response system
    • Immediate, high quality CPR
    • Rapid defibrillation
    • Basic and advanced emergency medical services
    • ALS and post-arrest care
    • Recovery
• Assessing the need for BLS
  • Always begin by surveying the scene
  • Complete primary assessment as soon as possible
    • Evaluate ABCs
  • Determine unresponsiveness
    • Should take less than 10 seconds
  • Basic principles of BLS are same for infants, children, and adults
  • Although cardiac arrests in adults usually occurs before respiratory arrest, the reverse is true for infants and children
• Automated External Defibrillation
  • Vital link in the chain of survival
  • Should be applied to cardiac arrest patients as soon as available
  • If you witness cardiac arrest, begin CPR and appl;y the AED as soon as it is available
  • Children
    • Apply after first five cycles of CPR
    • Use pediatric-sized pads and dose-attenuating system
      • If neither is available, then use AED with adult-sized pads with anterior-posterior placement
  • Special situations
    • Pacemakers and implanted defibrillators
    • Wet patients
    • Transdermal medication patches
• Positioning the patient
  • For CPR to be effective, patient must supine on firm, flat surface
  • Must be enough space for two rescuers to perform CPR
  • Log roll patient onto long backboard
• Check for breathing and a pulse
  • Quickly check for breathing and a pulse
    • Visualize the chest for signs of breathing
    • Palpate for a carotid pulse
  • Provide external chest compression
    • Apply rhythmic pressure and relaxation to lower half of sternum
    • Compressions squeeze heart, acting as a pump to circulate blood
    • Avoid leaning on the chest in between compressions
  • Administer chest compressions
    • Allow the chest to completely recoil between compressions
    • Proper hand positioning is crucial
    • Injuries can be minimized by proper technique and hand placement
• Opening the airway and providing artificial ventilation
  • If the patient is adequately breathing, and there are no signs injury to the head, spine, hip, or pelvis, place the patient in the recovery position
    • Maintains clear airway
    • Allows vomitus to drain from mouth
    • Roll the patient as a unit
  • The combination of lack of oxygen and too much carbon dioxide in the blood is lethal
  • If the patient is not breathing, ventilations can be given by one or two EMS providers
  • Use a barrier device
  • For a patient with a stoma, place a bag-mask device or pocket mask device directly over the stoma
  • Artificial ventilation may result in gastric distention
  • Have a suction unit available in case patient vomits
• One-rescuer Adult CPR
  • Single rescuer gives both chest compressions and artificial ventilations
  • Ratio of compressions to ventilation is 30:2
• Two-rescuer Adult CPR
  • Always preferable to one-rescuer CPR
    • Less tiring
    • Facilitates effective chest compressions
  • Switching rescuers during CPR is critical to maintain high-quality compressions
    • Recommended to switch positions every 2 minutes
• Devices and techniques to assist circulation
  • Active compression-decompression CPR
    • Involves compressing the chest and then actively pulling it back up to its neutral position
  • Impedance threshold device
    • Limits air entering lungs during recoil phase between chest compressions
  • Mechanical piston device
    • Allows rescuer to configure the depth and rate of compression
  • Load-distributing band CPR or vest CPR
    • A circumferential chest compression device composed of constricting band and backboard
  • Manual chest compression remain the standard of care
• Infant and Child CPR
  • Cardiac arrests in infants and children follows respiratory arrest
    • Airway and breathing are the focus of pediatric BLS
  • Causes of child respiratory problems
    • Injury
    • Infections
    • Foreign body
    • Submersion
    • Electrocution
    • poisoning/overdose
    • SIDS
  • Determine the unresponsiveness
    • Gently tap on the shoulder and speak loudly
  • Check for breathing and a pulse
    • Assessment occurs simultaneously
    • Should take no longer than 10 seconds
  • Foreign body obstructions in children is common
    • If child is unresponsive, place into recovery position
  • Techniques for opening the airway are modified for pediatric patients
  • Place a wedge under the upper chest
  • Provide rescue breathing
  • Not breathing and has a pulse
    • 1 breath every 2 to 3 seconds
  • Not breathing and no pulse
    • 2 breaths after every 30 compressions
• Interrupting CPR
  • CPR is a crucial, life-saving procedure
  • If no ALS is available at scene
    • Provide transport per local protocols
    • Consider requesting ALS rendezvous en route to hospital
  • Try not to interrupt CPR for more than a few seconds
  • Chest compression fraction
    • The total percentage of time during a resuscitation attempt in which chest compressions are being performed
    • Should be at least 80%
• When Not to Start CPR
  • If the scene is not safe
  • If the patient has obvious signs of death
    • Rigor mortis
    • Dependent lividity
    • Putrefaction or decomposition
    • Evidence of nonsurvivable injury
  • If the patient and physician have previously agreed on do not resuscitate orders
    • When in doubt begin CPR
• When to stop CPR
  • Once you begin CPR, continue until
    • S
      • Patient starts breathing and has a pulse
    • T
      • Patient is transferred to another provider of equal or higher-level training
    • O
      • You are out of strength
    • P
      • Physician directs to discontinue
• Foreign Body Airway Obstructions in adults
  • Airway obstruction may be caused by
    • Relaxation of throat muscles
    • Vomited or regurgitated stomach contents
    • Blood
    • Damaged tissue
    • Dentures
    • Foreign bodies
  • In adults, usually occurs during a meal
  • In children, usually during a meal or at play
  • Patient with mild airway obstruction is able to exchange air but with signs of respiratory distress
  • sudden , severe obstruction is usually easy to recognize in responsive patients
  • In unresponsive patients, suspect obstruction if maneuvers to open airway and ventilate are ineffective
  • Abdominal-thrust maneuver (heimlich) is recommended in responsive adults and children older than 1 year
  • Instead of abdominal-thrust maneuver, use chest thrusts for the following responsive patients
    • Women in advanced stages of pregnancy
    • Obese patients
  • Unresponsive patients
    • Determine unresponsiveness
    • Check for breathing and a pulse
    • If pulse is present and breathing is absent, attempt ventilation
    • If two attempts do not produce visible chest rise, perform 30 compressions, open airway, and look in mouth
      • Attempt to carefully remove any visible object
• Foreign body airway obstruction in infants and children
  • Common problem
  • If there are sign and symptoms of airway obstruction, do not waste time trying to dislodge a foreign body
  • On responsive, standing or sitting child, perform heimlich maneuver
  • On unresponsive child older than 1 year, manage in the same manner as an adult
  • Responsive infants
    • Do not use abdominal thrusts
    • Perform back slaps and chest thrusts
  • In unresponsive infants, begin CPR, beginning with chest compressions
  • Do not check for a pulse before starting compressions
  • Open the airway and look in the mouth
    • Remove the object if seen
    • Resume chest compressions if no object is seen
• Special Resuscitation Circumstances
  • Opioid Overdose
    • Standard resuscitation measures take priority over naloxone administration
  • Cardiac arrest in pregnancy
    • Priorities are to provide high-quality CPR and relieve pressure off the aorta and vena cava
• Grief support for family members and loved ones
  • Family members may experience a psychologic crisis that turns into a medical crisis
  • Family members and loved ones will remember this event in detail for the rest of their lives
  • Keep the family informed throughout the resuscitation process
  • After resuscitation has stopped, helpful measures include
    • Take the family to a quiet, private place
    • Use clear language and speak in a warm, sensitive, caring manner
    • Exhibit calm, reassuring authority
    • Use the patient’s name
    • Use eye contact and appropriate touch
    • Expect emotion
    • Be supportive but do not hover
    • Ask if a friend or family member can be called
  • Ensure that children are not ignored
• Education and training for the EMT
  • CPR skills can deteriorate over time
    • Practice often using manikin-based training
    • CPR self-instruction through a video and/or computer-based modules with hand-on practice
• Education and training for the public
  • You are a patient advocate
  • You must do your part to facilitate the training of laypeople in the critical skills of CPR and AED operation

Chapter 15

• Types of Medical Emergencies
  • Respiratory emergencies
    • Patients have trouble breathing or the amount of oxygen supplied to the tissues is inadequate
  • Cardiovascular emergencies
    • Caused by conditions by affecting the circulatory system
  • Neurologic emergencies
    • Involve the brain
  • Gastrointestinal conditions
    • Appendicitis
    • Diverticulitis
    • Pancreatitis
  • Urologic emergency
    • Kidney stones
  • Endocrine emergencies
    • Most commonly caused by complications of diabetes mellitus
  • Hematologic emergencies
    • May be the result of sickle cell disease or blood-clotting disorders
  • Immunologic emergencies
    • Involve the body’s response to foreign substances
  • Toxicologic emergencies
    • Include poisoning and substance abuse
  • Some medical emergencies are caused by psychological or behavioral problems
  • Gynecologic emergencies
    • Involve female reproductive organs
• Patient Assessment
  • Similar to the assessment of the trauma patient, but with a different focus
  • Focused on
    • Nature of illness (NOI)
    • Symptoms
    • Chief complaint
  • Establish an accurate medical history
  • Use dispatch information to guide initial response
  • Do not get locked into preconceived idea of the patient’s condition
  • Assessment may be difficult with uncooperative or hostile patients
    • Maintain a professional, calm, nonjudgemental demeanor
    • Refrain from labeling patients
    • A frequent caller may have a different complaint this time
• Scene size-up
  • Make certain the scene is safe
  • Use standard precautions
  • Determine the number of patients and whether you need additional help
• Nature of illness (NOI)
  • Index of suspicion
    • Your awareness of potentially serious underlying injuries or illness
• Primary assessment
  • Develop a general impression
    • Perform a rapid examination of the patient
    • Quickly determine the patient’s level of consciousness
  • Airway and breathing
    • Unconscious patients, ensure the airway is open and they are breathing adequately
    • Check respiratory rate, depth, and quality
    • Consider applying oxygen if breathing has been affected
    • For unconscious patients, make sure to open the airway usin the proper technique
  • Apply oxygen to patients
    • In shock
    • With difficulty breathing
    • When low oxygen saturations are measured
  • Unconscious patients may need airway adjuncts and ventilatory assistance with a bag-mask device
  • Circulation
    • In a conscious patient by checking the radial pulse and observe the patient’s skin color, temperature, and condition
    • For unconscious patients, assess circulation at the carotid artery
  • Transport decision
    • Patients in need of rapid transport
      • Unconscious or have an altered mental status
      • Airway or breathing problems
      • Obvious circulation problems such as severe bleeding or sign of shock
• History taking
  • Determine what the problem is or what may be causing the problem
  • Gather a thorough history
  • For an unconscious patient, survey the scene for medication containers or medical devices
  • Obtain sample history and use the OPQRST mnemonic
  • Record any allergies, medical conditions, and medications
  • Some patients take numerous medications; take the medications with you to to hospital
• Secondary assessment
  • May occur on scene or en route to the ED
    • In some cases you may not have time
  • Physical examination
    • All conscious patients should undergo a limited or detailed physical examination
    • For unconscious patients, always perform a secondary assessment of the entire body or head-toe-examination
    • Examine the head, scalp, and face
    • Examine the neck closely
    • Assess the chest and abdomen
    • Palpate the legs and arms
    • Examine the patient’s back
  • Vital signs
    • Assess the pulse for rate, quality, and regularity
    • Identify the rate, qualify, and regularity of the respirations
    • Obtain an initial blood pressure
    • Consider obtaining a blood glucose level and a pulse oximetry reading
• Reassessment
  • Performed once the assessment and treatment have been completed
  • Begins and continues throughout transport
    • Consider the need for ALS backup
  • Reassess interventions
  • Document any developed changes
• Management transport and destination
  • Most medical emergencies require a level of treatment beyond that available in the prehospital setting
    • May require advanced testing available in a hospital
    • May be beyond the scope of the EMT to administer medications to patient
    • EMTs can use the AED
  • Scene time
    • May be longer for medical patients than for trauma patients
    • Gather as much information as possible to transmit to the ED
    • Critical patients always need rapid transport
  • Type of transport
    • Life threatening conditions: light and siren
    • Non life threatening condition: consider nonemergency transport
  • Modes of transport
    • Air
      • Air transport EMS units are generally staffed by critical care transport professionals and paramedics
    • Ground
      • Ground transport EMS units are generally staffed by EMTs and paramedics
  • Destination selection
    • Generally, the closest hospital should be your destination
    • Sometimes the patients will benefit from going to another hospital capable of handling her or her particular condition
• Infectious Disease
  • General assessment principles
    • Approach like any other medical patient
    • Perform scene size-up, take standard precautions, and complete primary assessment
    • Gather patient history using OPQRST to elaborate on the patient’s chief complaint
    • Obtain a sample history and a set of baseline vital signs
    • Ask whether the patient has recently traveled or has come in contact with someone that has
    • Focus on any life-threatening conditions identified in the primary assessment
    • Be empathetic
    • Place the patient in the position of comfort on the stretcher and keep them warm
    • Use standard precautions
• Epidemic and pandemic considerations
  • Epidemic
    • New cases of disease in a human population substantially exceed what is expected
  • Pandemic
    • A disease outbreak that occurs on a global scale
• Influenza
  • Those with chronic medical conditions, compromised immune systems and the very young and the very old are most susceptible to complications of influenza
  • Transmitted by direct contact with nasal secretions and aerosolized droplets from coughing and sneezing by infected people
  • For diseases that can be passed by respiratory route
    • Always wear PPE
    • Place a surgical mask on patients with suspected or confirmed respiratory disease
  • Annual influenza immunization is important for EMS personnel to protect and providers and patients
• Herpes Simplex
  • Common virus strain carried by humans
  • Symptomatic infections cause vesicles that appear on the lips or genitals
  • Can cause more serious illnesses in susceptible patients
  • Primary mode of infection is through close personal contact
• HIV infection
  • EMTs face a risk of exposure
  • No vaccine yet exists
  • AIDS can still be fatal, but with treatment, patients can expect near-normal lifespan
  • Not easily transmitted in the work setting
    • Your risk of infection is limited to exposure to an infected patient’s blood or body fluids
  • Many patients with HIV show no symptoms
    • Always wear the proper types of gloves
    • Take great care in handling and disposing of needles
    • Cover any open wounds
  • If you think a patient’s blood or secretions may have entered your system, seek medical advice and notify your infectious disease officer
• Hepatitis
  • Inflammation of the liver
  • Can be caused by viruses and toxins
  • There is no sure way to tell which hepatitis patients are contagious
  • Vaccination with Hep V vaccine is highly recommended for EMTs
• Meningitis
  • Inflammation of the meningeal coverings of the brain and spinal cord
  • Most forms of meningitis are not contagious
  • Take standard precautions
  • Can be treated at the ED with antibiotics
  • After treating a meningitis patient, contact your employer representative
• Tuberculosis
  • Most infected patients are well most of the time
  • Chronic mycobacterial disease that usually strikes the lung
  • Patients who pose the highest risk almost always have a cough
    • N95 or HEPA mask is required to stop droplet nuclei
  • Absolute protection from the tubercle bacillus does not exist
    • One third of the world’s population is infected with tuberculosis
  • Have tuberculin skin tests regularly
    • Preventive therapy is almost 100% effective
• Whooping cough
  • Also pertussis
  • Mostly affects children younger than 6 years
  • Symptoms include fever and a “whoop” sound that occurs when inhaling after a coughing attack
  • The best way to prevent exposure is to be vaccinated
    • Place a mask on the patient and yourself
• MRSA
  • A bacterium that causes infection
  • Resistant to many antibiotics
  • In health care settings, MRSa is transmitted from patient to patient by health care providers’ unwashed hands
  • Factors that increase the risk of MRSA
    • Antibiotic therapy
    • Prolonged hospital stays
    • A stay in an intensive care or burn unit
    • Exposure to an infected patient
  • MRSA results in soft-tissue infections
• Global Health Issues
  • Covid-19
    • Originated in Wuhan, Hubei Province, China
    • Quickly spread, infecting millions, killing hundreds of thousands
    • Controlling the virus: social distancing
    • Symptoms include fever, cough, shortness of breath that appears 2-14 days after exposure
    • CDC website
  • MERS-CoV
    • First human case discovered in 2012 Saudi Arabia
    • No cure or vaccines for this virus at present
    • Place a surgical mask on the patient if MERS-CoV is suspected
  • Ebola
    • 2014 outbreak of the Ebola virus in West Africa
    • Incubation period
      • 6-12 days after exposure
      • Symptoms may not appear for as long as 21 days after infection
      • Fatality rate can be as high as 70% if treatment in an ICU is not initiated promptly
• Travel Medicine
  • Beware of travel-acquired infections when assessing a patient who was recently outside of the United States
  • Patients can present with a variety of symptoms
  • When you encounter an ill patient with a recent travel history, place a mask on the patient and gather as much information as possible
• Important questions to ask include
  • Where did you recently travel?
  • Did you receive any vaccinations before your trip?
  • Were you exposed to any infectious diseases?
  • Is there anyone else in your travel party who is sick?
  • What types of foods did you eat?
  • What was your source of drinking water?
• Conclusion
  • Assessment and treatment of medical patients can be challenging and interesting because of the nature of medical conditions
    • The condition of a medical patient may not be as apparent as in trauma patient and treatment may be as straightforward
    • Patients sometimes have more than one isolated problem

Chapter 16

• Anatomy of the Respiratory System
  • Respiratory system includes all the structures that contribute to breathing
    • Diaphragm
    • Chest wall muscles
    • Accessory muscles of breathing
    • Nerves to the muscles
  • Upper airway consists of structures above the vocal cords
    • Nose and mouth
    • Jaw
    • Oral cavity
    • Pharynx
  • Principal function of lungs is respiration
    • Exchange of oxygen and carbon dioxide
  • Air travels through trachea into lungs to:
    • Bronchi (larger airways)
    • Bronchioles (smaller airways)
    • Alveoli (where actual exchange takes place)
• Physiology of respiration
  • Respiration process
    • Inspiration
    • Expiration
  • Oxygen is provided to the blood
  • Carbon dioxide is removed
  • Takes place rapidly at level of alveoli
  • In the alveoli
    • Oxygen passes into capillaries
    • carbon dioxide returns to lungs
  • Brainstem senses blood’s carbon dioxide levels
    • Regulates breathing rate and depth
• Pathophysiology
  • Oxygen exchange can be hindered by
    • Conditions in the anatomy of the airway
    • Disease processes
    • Traumatic conditions
    • Abnormalities in pulmonary vessels
  • Recognize the signs and symptoms of inadequate breathing and know what to do about it
  • Some patients have chronic carbon dioxide
    • Low levels of oxygen control breathing
    • Use caution when administering oxygen
• Causes of Dyspnea
  • Patients often have dyspnea or hypoxia with
    • Pulmonary edema
    • Hay fever
    • Pleural effusion
    • Obstruction of the airway
    • Hyperventilation syndrome
    • environmental/industrial exposure
    • Drug overdose
  • Dyspneic patients may have
    • Gas exchange obstructed
    • Damaged alveoli
    • Obstructed air passages
    • Obstructed blood flow to the lungs
    • Excess fluid in pleural space
  • Patients may also complain of chest tightness or air hunger
  • Common with cardiopulmonary diseases
  • Pain can cause rapid, shallow breathing
• Upper or lower airway infection
  • Infectious diseases may affect all parts of the airway
  • Some forms of obstruction cause dyspnea
    • Mucus and secretions obstructing airflow in major passages
    • Swelling of soft tissues in upper airways
    • Impaired exchange of gases in the alveoli
• Croup
  • Inflammation and swelling of pharynx, larynx, and trachea
  • Stridor and seal-bark cough
  • Responds well to humidified oxygen
• Epiglottis
  • Bacterial infection causing inflammation of epiglottis
  • Children are often found in tripod position and drooling
  • Position comfortable and provide oxygen
• Respiratory Syncytial Virus (RSV)
  • Common cause of Illness in young children
  • Causes infection in the lungs and passages
  • Look for signs of dehydration
  • Treat airway and breathing problems
  • Humidified oxygen is helpful
• Bronchiolitis
  • Viral illness often caused by RSV
  • Usually affects newborns and toddlers
  • Bronchioles become inflamed, swell, and fill with mucus
  • Provide oxygen therapy and frequently reassess
• Pneumonia
  • Bacterial pneumonia will come on quickly and result in high fever
  • Viral pneumonia presents will more gradually and is less severe
  • Especially affects people who are chronically ill
  • Assess temperature and provide airway support and supplemental oxygen
• Pertussis
  • Airborne bacterial infection that mostly affects children younger than 6 years
  • Patients will be feverish and exhibit a “whoop” sound on inspiration after a coughing attack
  • Watch for dehydration and suction as needed
• Influenza type A
  • Became pandemic in 2009
  • Symptoms include fever, cough, sore throat, muscles aches, headache, and fatigue
  • May lead to pneumonia or dehydration
• COVID-19
  • Similar to the virus that causes the common cold
  • Preferentially affects the elderly, those living in close quarters with one another, and those with weakened immune systems
  • Transmitted by aerosol droplets and airborne particles
  • Respiratory deterioration may occur rapidly
• Tuberculosis (TB)
  • Bacterial infection that most often affects the lungs
  • Can remain inactive for years
  • Patients often complain of fever, coughing, night sweats, and weight loss
  • Wear gloves, eye protection, and an N-95 respiratory
• Acute Pulmonary Edema
  • Heart muscle cannot circulate blood properly
  • Fluid build up within alveoli and in lung
    • Usually result of congestive heart failure
    • Most patients have a long-standing history of chronic congestive heart failure
    • In severe cases, a frothy pink sputum forms at the nose and mouth
• Chronic Obstructive Pulmonary Disease (COPD)
  • Slow process of dilation and disruption of airways and alveoli
  • Caused by chronic bronchial obstruction
  • tobacco smoke can create chronic bronchitis
  • Emphysema is the most common type of COPD
    • Loss of elastic material in the lungs
    • Causes included inflamed airways, smoking
  • Most patients with COPD have elements of both chronic bronchitis and emphysema
  • Patients with pulmonary edema will have wet lungs
  • patients with COPD will have dry lung sounds
  • Can be easily confused with congestive heart failure
  • Treat the patient, not the lung sounds
• Asthma, Hay Fever, and Anaphylaxis
  • Result of allergic reaction to inhaled, ingested, or injected substance
    • In some cases, allergen cannot be identified
  • In some cases, there is no identifiable allergen
  • Asthma is acute spasm of smaller air passes (bronchioles), associated with excessive mucus production and swelling of the mucus membranes
  • Asthma affects all ages
    • Most prevalent in children 5-17 years
  • Produces characteristic wheezing
  • Asthma attack may be caused by allergic reaction to foods or allergens or severe emotional distress, exercise, and respiratory infections
  • Hay fever causes cold-like symptoms
    • Allergens include pollen, dust mites, pet dander
  • Anaphylactic reaction can produce severe airway swelling
    • Total obstruction is possible
    • Treat with epinephrine, oxygen, and antihistamines
• Spontaneous Pneumothorax
  • Pneumothorax is accumulation of air in pleural space
  • Most often caused by trauma
  • May be caused by medical conditions
    • Spontaneous pneumothorax
  • Occurs with lung infections in weak lungs
  • Patient becomes dyspneic
  • Breath sounds may be absent on affected side
• Pleural Effusion
  • Collection of fluid outside the lung
  • Compresses lung and causes dyspnea
  • Can stem from irritation, infection, congestive heart failure, or cancer
  • Upright position eases pain
• Obstruction of the airway
  • Patient with dyspnea may have mechanical obstruction
  • In unconscious patients, obstruction may be caused by aspiration of vomitus or tongue blocking the airway
  • If patient was eating just before dyspnea, always consider foreign body obstruction
• Pulmonary Embolism
  • A blood clot that circulates through the venous system
    • Circulation cut off partially or completely
    • Significantly decreases blood flow
    • If large enough, can cause sudden death
  • Signs and symptoms include
    • Dyspnea
    • Tachycardia
    • Tachypnea
    • Varying degrees of hypoxia
    • Cyanosis
    • Acute chest pain
    • Hemoptysis
• Hyperventilation
  • Overbreathing to the point that arterial carbon dioxide falls below normal
  • May be indicator of life-threatening illness
  • Body may be trying to compensate for acidosis
    • Buildup of excess acid in blood or body tissues
  • Can result in alkalosis
    • Buildup of excess base in body fluids
  • Can cause symptoms of panic attack
    • anxiety
    • Dizziness
    • Numbness
    • Tingling or painful spasms of the hands/feet
• Environmental/industrial exposure
  • Pesticides, cleaning solutions, chemicals, chlorine, and other gases can be released
  • Carbon monoxide
    • Odorless
    • Highly poisonous
    • Produced by fuel-burning appliances and smoke
  • Do not yourself at risk
• Scene size-up
  • Scene safety
    • Use standard precautions and PPE
    • Consider possibility of infectious disease or toxic substance
  • Mechanism of injury/ NOI
    • If in question, ask why 9-1-1 was activated
    • Question the patient, family, and/or bystanders to determine NOI
• Primary Assessment
  • Identify immediate life threats
  • Form a general impression
    • Note age and position of patient
    • Use AVPU scale
    • Ask patient about chief complaint
  • Airway and breathing
    • Make sure airway is patent and adequate
    • Assess rate, rhythm, and quality
    • Ask the following questions
      • Is the air going?
      • Does the chest rise and fall with each breath
      • Is the rate adequate for the victim’s age
    • Assess breath sounds
      • Check breath sounds on the right and left sides of the chest
      • Abnormal sounds include wheezing, rates, rhonchi, and stridor
    • Circulation
      • Assess pulse rate, rhythm, and quality
      • Evaluate for shock and bleeding
      • Assess perfusion by evaluating skin color, temperature, and condition
    • Transport decision
      • If condition is unstable and there is possible life threat
        • Address the life threat
        • Proceed with rapid transport
• History Taking
  • Investigate chief complaint
  • Find out what the patient has done for the breathing problem
  • SAMPLE history
  • OPQRST assessment
    • Onset, provocation/palliation, quality, radiation/region, severity
  • PASTE assessment
    • Specific for patients with dyspnea
    • Progression, associated chest pain, sputum, talking tiredness, exercise tolerance
• Secondary Assessment
  • More in-depth assessment of body systems
  • Proceed only after addressing life-threats
  • Use monitoring devices if you have them
  • Look for signs of COPD
    • Patient older than 50 years of age
    • History of lung problems
    • Active or former cigarette smoker
    • Tightness in chest
    • Constant fatigue
    • Barrel-like appearance to chest
    • Use of accessory muscles
    • Abnormal breath sounds
• Reassessment
  • Repeat the primary assessment
    • Assess for changes in condition
• Interventions may include
  • Oxygen via nonrebreathing mask at 15 L/min
  • Positive pressure ventilations
  • Airway management techniques
  • Positioning in high fowler position or position of choice
  • Assisting with respiratory medications
• Emergency Medical Care
  • Administer supplemental oxygen
  • Some patients may need CPAP or bag-mask device
  • Patient may have metered-dose inhaler or small-volume nebulizer
  • Consult medical control and make sure medication is indicated
  • Ensure there are no contraindications
  • Most medications are used to relax the muscles that surround the air passages in the lungs
  • Common side effects of inhalers
    • Increased pulse rate
    • Nervousness
    • Muscle tremors
• Treatment of Specific Conditions
  • Upper or lower airway infection
    • Administer humidified oxygen
    • Do not attempt to suction the airway or place an oropharyngeal airway
    • Position comfortable
    • Transport promptly
  • Acute pulmonary edema
    • Provide 100% oxygen
    • Suction if necessary
    • Position comfortable
    • Provide CPAP if indicated and allowed by protocol
    • Transport promptly
  • Chronic obstructive pulmonary disease
    • Assist with prescribed inhaler
      • Watch for side effects from overuse
    • Position comfortably
    • Transport promptly
  • Asthma
    • Be prepared to suction
      • Assist asthma patient with prescribed inhaler
      • Provide aggressive airway management, oxygen, and prompt transport
  • Hay fever
    • Unlikely to need emergency treatment
  • Anaphylaxis
    • Remove the offending agent
    • Maintain the airway
    • Transport rapidly
    • Administer epinephrine
  • Spontaneous pneumothorax
    • Provide supplemental oxygen
    • Transport promptly
    • Monitor carefully
  • Pleural effusion
    • Fluid removal must be done in hospital
    • Provide oxygen
    • Transport promptly
  • Obstruction of airway
    • Partial obstruction
      • Provide supplemental oxygen and transport
    • Complete obstruction
      • Clear obstruction and administer oxygen
    • Transport rapidly to emergency department
  • Pulmonary embolism
    • Supplemental oxygen is mandatory
    • Position comfortably
    • If hemoptysis is present, clear airway immediately
    • Transport promptly
  • Hyperventilation
    • Complete primary assessment and gather history
    • Do not have patient breathe into paper bag
    • Reassure the patient and provide supplemental oxygen
    • Transport promptly
  • environmental/industrial exposure
    • Ensure patients are decontaminated
    • Treat with oxygen, adjuncts, and suction based on presentation
  • Foreign body aspiration
    • Clear the airway
    • Provide oxygen and transport
  • Tracheostomy dysfunction
    • Position comfortably
    • Suction to clear the obstruction
    • Provide oxygen
  • Asthma
    • Provide blow-by oxygen
    • Use MDIs
  • cystic fibrosis
    • Genetic disorder that affects the lungs and digestive system
    • Suction and oxygenate as needed

Chapter 17

• Anatomy & physiology
  • Heart’s job is to pump blood to supply oxygen-enriched blood cells to tissues
  • Divided into left and right sides
  • Upper chambers (atria) receive incoming blood
  • Lower chambers pump outgoing blood
  • One-way valves keep blood flowing in the proper direction
  • The aorta, the body’s main artery, receives blood ejected from left ventricle
  • Heart’s electrical system controls heart rate and coordinates atria and ventricles
  • electrical impulses start at the SA node
    • Passes from the atria to the ventricles
  • Automaticity allows spontaneous contraction without a stimulus from a nerve source
  • Automatic nervous system controls involuntary activities
  • The ANS has two parts
    • sympathetic nervous system
    • Parasympathetic nervous system
  • The myocardium must have a continuous supply of oxygen and nutrients to pump blood
  • Cardiac output is increased by increasing the heart rate or stroke volume
  • In the normal heart, increased blood is delivered to the myocardium by dilating the coronary arteries
  • Coronary arteries are blood vessels that supply blood to the heart muscle
  • Coronary arteries start at the first part of the aorta
    • Right coronary artery
    • Left coronary artery
  • Arteries supply oxygen to different parts of the body
    • Right and left carotid
    • Right and left subclavian
    • Brachial
    • Radial and ulnar
    • Right and left iliac
    • Right and left femoral
    • Anterior and posterior tibial and peroneal
  • Arterioles and capillaries are smaller vessels
    • Capillaries connect arterioles to venules
  • Venules are the smallest branches of the veins
  • Blood consists of
    • Red blood cells, which carry oxygen
    • White blood cells. Which fight infection
    • Platelets, which help blood to clot
    • Plasma, which is the fluid cells float in
  • Blood pressure is the force of circulating blood against artery walls
    • Systolic blood pressure
      • The maximum pressure generated by left ventricle
    • Diastolic blood pressure
      • The pressure against artery walls while the left ventricle is at rest
    • A pulse is felt when blood passes through an artery during systole
      • Peripheral pulses felt in the extremities
      • Central pulse felt near the body’s trunk
  • Cardiac output is the volume of blood that passes through the heart in 1 minute
  • Perfusion is the constant flow of oxygenated blood to tissues
  • If perfusion fails, cellular and eventually patient death occur
• Pathophysiology
  • Chest pain usually stems from ischemia, which is decreased blood flow
  • Ischemic heart disease involves a decreased blood flow to one or more portions of the heart
  • If the blood flow is not restored, the tissue dies
  • Atherosclerosis is the buildup of calcium and cholesterol in the arteries
  • A thromboembolism is a blood clot floating through blood vessels
  • If a clot lodges in a coronary artery, acute myocardial infarction results
  • Coronary artery disease is the leading cause of death in the united states
  • Controllable AMI risk factors
    • Cigarette smoking, high blood pressure, high cholesterol, diabetes, lack of exercise, and obesity
  • Uncontrollable AMI risks factors
    • Older age, family history, atherosclerotic coronary artery disease, race, ethnicity, and being male
  • Acute coronary syndrome is caused by myocardial ischemia
    • Amgoma pectoris
    • Acute myocardial infarction
  • Angina pectoris occurs when the heart’s need for oxygen exceeds supply
    • Crushing or squeezing pain
    • Does not usually lead to death or permanent heart damage
    • Should not be taken as a serious warning sign
  • Unstable angina
    • Occurs in the absence of a significant increase in oxygen demand on the heart muscle
  • Treat angina patients like AMI patients
  • AMI pain signals actual death of cells in heart muscle
    • Once dead, cells cannot be revived
    • Clot-busting drugs or angioplasty within the first few hours prevents damage
    • Immediate transport is essential
  • Signs and symptoms of AMI
    • Weakness, nausea, sweating
    • Chest pain, discomfort, or pressure
    • Low jaw, arm, back, abdomen, or neck pain
    • irregular heartbeat and syncope
    • shortness of breath
    • nausea/vomiting
    • Pink, frothy, sputum
    • Sudden death
  • AMI pain differs from angina pain
    • Not always due to exertion
    • Lasts 30 minutes to several hours
    • Not always relieved by rest or nitroglycerin
  • AMI patients may not realize they are experiencing a heart attack
  • AMI and cardiac compromise physical findings
    • Fear, nausea, poor circulation
    • Faster, irregular, or bradycardic pulse
    • Decreased, normal, or elevated blood pressure
    • Normal or rapid and labored respirations
    • Patients express feelings of impending doom
  • Three serious consequences of AMI
    • Sudden death
    • Cardiogenic shock
    • Congestive heart failure
  • Dysrhythmia: heart rhythm abnormalities
    • Premature ventricular contractions
    • Tachycardia
    • Bradycardia
    • Ventricular tachycardia
    • Ventricular fibrillation
  • Defibrillation restores cardiac rhythms.
    • Can save lives
    • Initiate CPR until a defibrillator is available.
  • Asystole
    • Absence of all heart electrical activity
    • Reflects a long period of ischemia
    • Nearly all patients will die.
  • Cardiogenic shock
    • Often caused by heart attack
    • Heart lacks power to force enough blood through circulatory system.
    • Inadequate oxygen to body tissues causes organs to malfunction.
    • Recognize shock in its early stages.
  • Congestive heart failure
    • Often occurs a few days following heart attack
    • Increased heart rate and enlargement of left ventricle no longer make up for decreased heart function
    • Lungs become congested with fluid.
    • May cause dependent edema.
  • Hypertensive emergencies
    • Systolic pressure greater than 180 mm Hg
    • Common symptoms
      • Sudden, severe headache
      • Strong, bounding pulse
      • Ringing in the ears
  • Hypertensive emergencies (cont’d)
    • Common symptoms
      • Nausea and vomiting
      • Dizziness
      • Warm skin (dry or moist)
      • Nosebleed
      • Altered mental status
      • Sudden pulmonary edema
  • Hypertensive emergencies (cont’d)
    • If untreated, can lead to stroke or dissecting aortic aneurysm.
    • Transport patients quickly and safely.
    • Consider ALS assistance.
  • Aortic aneurysm is weakness in the wall of the aorta.
    • Susceptible to rupture
    • Dissecting aneurysm occurs when inner layers of aorta become separated.
    • Primary cause: uncontrolled hypertension
  • Aortic aneurysm (cont’d)
    • Signs and symptoms
      • Very sudden chest pain
      • Comes on full force
      • Different blood pressures
    • May be difficult to tell the difference between a dissecting aneurysm and AMI
    • Transport patients quickly and safely.
• Scene Size-up
  • Scene safety
    • Ensure the scene is safe.
    • Follow standard precautions.
  • Nature of illness (NOI)
    • Obtain clues from dispatch, the scene, patient, family members, bystanders.
• Form a general impression.
  • If unresponsive and not breathing, begin CPR and call for AED.
• Airway and breathing
  • Oxygen saturation less than 95%: apply oxygen via nasal cannula at 4 L/min
  • Not breathing or inadequate breathing: 100% oxygen with bag-mask device
  • Pulmonary edema: bag-mask device or CPAP
• Circulation
  • Check pulse, skin, capillary refill.
  • Consider treatment for cardiogenic shock.
• Transport decision
  • Decision based on ability to stabilize life threats during primary assessment
  • Transport in a stress-relieving manner.
• Emergency medical care for chest pain or discomfort
  • Ensure a proper position of comfort.
  • Give oxygen if indicated.
  • Depending on protocol, prepare to administer low-dose aspirin and assist with prescribed nitroglycerin.
  • Aspirin
    • Prevents blood clots from forming or getting bigger
    • 81 mg chewable tablets
    • Recommended dose: 162 mg (two tablets) to 324 mg (four tablets)
  • Nitroglycerin
    • Available forms
      • Sublingual pill
      • Sublingual spray
      • Skin patch applied to chest
    • Mechanism of action:
      • Relaxes blood vessel walls
      • Increases blood flow and oxygen supply to heart
      • Decreases workload of heart
      • Dilates blood vessels
    • Side effects:
      • Decreased blood pressure
      • Severe headache
    • Contraindications:
      • Systolic blood pressure <100 mm Hg
      • Head injury
      • Use of erectile dysfunction drugs within 24 hours
      • Maximum prescribed dose has been given.
• Cardiac Monitoring
  • For an ECG to be reliable and useful, electrodes must be placed in consistent positions.
  • Basic principles should be followed to minimize artifact in the signal.
  • Guiding principles:
    • May need to shave body hair
    • Rub electrode site with alcohol swab before application.
    • Attach electrodes to ECG cables before placement.
    • Confirm electrode placement.
  • Once electrodes are in place, switch on the monitor.
    • Print a sample rhythm strip.
    • If strip shows artifact, confirm electrodes are firmly applied and cable is plugged in.
  • Heart surgeries and Cardiac Assistive Devices
    • Many open-heart operations have been performed in the last 40 years.
    • Coronary artery bypass graft
      • Chest or leg blood vessel is sewn from the aorta to a coronary artery beyond the point of obstruction.
    • Percutaneous transluminal coronary angioplasty
      • A tiny balloon is inflated inside a narrowed coronary artery.
  • Patients who have had open-heart procedures may or may not have long chest scars.
  • Treat chest pain in a patient who has had any of these procedures the same as a patient who has never had heart surgery.
  • Some patients have implanted cardiac pacemakers to maintain a regular cardiac rhythm and rate.
  • Cardiac pacemakers (cont’d)
    • This technology is very reliable.
    • Pacemaker malfunction can cause syncope, dizziness, or weakness due to an excessively slow heart rate.
      • Transport patients promptly.
  • Automatic implantable cardiac defibrillators
    • Used by some patients who have survived cardiac arrest due to ventricular fibrillation
    • Monitor heart rhythm and shock as needed.
    • Treat chest pain patients with these devices like other patients having an AMI.
    • Electricity is low so it will not affect rescuers.
  • External defibrillator vest
    • A vest with built-in monitoring electrodes and defibrillation pads worn by the patient
    • Attached to a monitor
    • Uses high-energy shocks
      • Do not touch the patient if devices warns it is about to deliver a shock.
    • Vest should remain in place while CPR is being performed unless it interferes with compressions.
  • Left ventricular assist devices (LVADs)
    • Used to enhance the pumping of the left ventricle
    • Most common ones have an internal pump and external battery pack.
    • Most patient will not have a palpable pulse.
    • Transport all supplies and battery packs with the patient.
  • The complete cessation of cardiac activity
  • Absence of a carotid pulse
  • Was terminal before CPR and external defibrillation were developed in the 1960s
  • High-quality CPR, early defibrillation, and access to advanced care can improve outcomes.
  • Analyzes electrical signals from heart
    • Identifies ventricular fibrillation
    • Administers shock to heart when needed
  • AED models:
    • All require some operator interaction.
    • Most have a computer voice synthesizer advising steps to take.
    • Most are semiautomated.
  • Advantages of AED use:
    • Quick delivery of shock
    • Easy to operate
    • ALS providers do not need to be on scene.
    • Remote, adhesive pads safe to use
    • Larger pad area = more efficient shocks
  • Other considerations
    • Not all patients in cardiac arrest require shock.
    • All patients in cardiac arrest should be analyzed with an AED.
    • Asystole indicates no electrical activity.
    • Pulseless electrical activity usually refers to a state of cardiac arrest that exists despite an organized electrical complex.
  • Early defibrillation
    • Few cardiac arrest patients survive outside a hospital without a rapid sequence of events.
    • Chain of survival:
      • Early recognition and activation of EMS
      • Immediate bystander CPR
      • Rapid defibrillation
      • Basic and advanced EMS
      • ALS and postarrest care
      • Recovery
  • Early defibrillation (cont’d)
    • CPR prolongs period during which defibrillation can be effective.
    • Has resuscitated patients with cardiac arrest from ventricular fibrillation
    • Nontraditional first responders are being trained in AED use.
  • ALS and postarrest care
    • Continue ventilation.
    • Maintain oxygen saturation.
    • Assure blood pressure >90 mm Hg.
    • Targeted temperature management upon arrival to the hospital
    • Advanced assessment techniques and interventions
  • Recovery
    • May take a year or longer
  • Integrating the AED and CPR
    • Work the AED and CPR in sequence.
    • Do not touch the patient during analysis and defibrillation.
    • CPR must stop while AED performs its job.
  • AED maintenance
    • Maintain as manufacturer recommends.
    • Read the operator’s manual.
    • Document AED failure.
    • Check equipment daily at beginning of shift.
    • Ask manufacturer for maintenance checklist.
    • Report AED failures to manufacturer and US Food and Drug Administration (FDA).
  • Medical direction should approve written protocol for AED use.
  • Continuing education with skill competency review is generally required for EMS providers.
• Emergency medical care for cardiac arrest
  • Preparation
    • Make sure the electricity injures no one.
    • Do not defibrillate patients in pooled water.
    • Do not defibrillate patients touching metal.
  • Preparation (cont’d)
    • Carefully remove nitroglycerin patch and wipe with dry towel before shocking.
    • Shave hairy chest to increase conductivity.
    • Determine the NOI and/or MOI.
  • Call for ALS assistance in a tiered system.
  • Begin chest compressions and attach AED as soon as available with witnessed cardiac arrests.
  • Follow local protocol for patient care after AED use.
    • After AED protocol is completed, one of the following is likely:
      • Pulse regained
      • No pulse regained and no shock advised
      • No pulse regained and shock advised
  • Wait for ALS and continue shocks and CPR on scene.
  • If ALS is not responding and protocols agree, begin transport when:
    • The patient regains a pulse.
    • 6 to 9 shocks are delivered.
    • AED gives three consecutive messages (every 2 min of CPR) advising no shock.
  • Cardiac arrest during transport:
    • Stop the vehicle.
    • Begin CPR if AED is not immediately available
    • Call for ALS support.
    • Analyze rhythm.
    • Deliver shock, if indicated, and resume CPR.
    • Continue resuscitation per local protocol.
  • Coordination with ALS personnel
    • If AED available, do not wait for ALS.
    • Notify ALS of cardiac arrest.
    • Do not delay defibrillation.
    • Follow local protocols for coordination.
• Management of return of spontaneous circulation
  • Monitor for respirations.
  • Provide oxygen via bag-mask device at 10 breaths/min.
  • Maintain SpO₂ between 95% and 99%.
  • Assess blood pressure.
  • See if patient can follow simple commands.
  • Immediately begin transport if ALS is not en route per local protocol.
  • Monitor for respirations.
  • Provide oxygen via bag-mask device at 10 breaths/min.
  • Maintain SpO₂ between 95% and 99%.
  • Assess blood pressure.
  • See if patient can follow simple commands.
  • Immediately begin transport if ALS is not en route per local protocol.