Comprehensive Emergency Medical Technician (EMT) Practice Guide and Study Notes

Airway, Ventilation, and Oxygenation (Chapter 10)

• Definitions of Gas Exchange and Air Movement:

  • Ventilation: This is defined as the mechanical movement of air specifically into and out of the lungs.
  • Respiration: This refers to the actual exchange of oxygen and carbon dioxide at the cellular or alveolar level.

• Intervention Protocols for Respiratory Conditions:

  • Chronic Obstructive Pulmonary Disease (COPD) Presentation: Patients exhibiting stable but elevated respiratory rates (e.g., $30\,breaths/min$), pale skin, and $SpO_{2}$ of $91\%$ who are speaking in $3$- to $4$-word sentences and have bilateral wheezing should receive high-concentration oxygen via a nonrebreather mask (NRB) while assessments continue.
  • Immediate Positive-Pressure Ventilation (PPV): This is required when a patient exhibits signs of inadequate breathing or respiratory failure. Examples include an unresponsive patient following an opioid overdose with a respiratory rate of $4\,breaths/min$ and shallow respirations, or a patient with a rate of $8\,breaths/min$, shallow respirations, and decreasing responsiveness.
  • Primary Purpose of PPV: To force air into the lungs when the patient's spontaneous breathing is either inadequate or completely absent.

• Differentiating Respiratory Distress from Respiratory Failure:

  • Respiratory Distress: Characterized by audible wheezing, tachypnea (e.g., $22\,breaths/min$), and the ability to speak in full sentences while maintaining normal mental status.
  • Respiratory Failure: Indicated by deteriorating mental status (drowsiness, confusion), shallow respirations, cyanosis of the lips, and the inability to maintain adequate gas exchange. A patient with severe distress who suddenly becomes quiet and stops wheezing is most likely progressing into failure due to minimal air movement.

• Pediatric Respiratory Assessment:

  • Significant distress in infants is indicated by nasal flaring, intercostal retractions, and a respiratory rate of $62\,breaths/min$.
  • A child in respiratory distress who suddenly becomes quiet, lethargic, and experiences a decrease in respiratory rate from $42\,breaths/min$ down to $10\,breaths/min$ is entering respiratory failure.

• Capnography and Gas Exchange:

  • Inadequate Ventilation: A capnography reading of $58\,mmHg$ combined with shallow respirations and deteriorating mental status indicates carbon dioxide retention.
  • Shock and Perfusion: A low capnography reading (e.g., $18\,mmHg$) after significant blood loss suggests poor perfusion caused by shock rather than hyperventilation.

• Airway Adjuncts and Maneuvers:

  • Repositioning: If the chest does not rise during BVM ventilation of an unconscious patient despite a good seal, the EMT must first reposition the airway using the head tilt–chin lift or jaw-thrust maneuver.
  • Airway Choice: An oropharyngeal airway (OPA) is most appropriate for unresponsive patients without a gag reflex.
  • Effective Ventilation Markers: The most reliable indicator that BVM ventilations are effective is visible chest rise with each delivered breath.
  • Complications of Excessive Ventilation: Forceful or rapid ventilation can cause gastric distention (noticeable abdominal expansion), increasing the risk of vomiting and aspiration, and potentially decreasing cardiac output.

• Oxygen Delivery Devices:

  • Nonrebreather Mask: Provides the highest concentration of oxygen to a patient who is breathing adequately.
  • Nasal Cannula: Appropriate for patients with mild shortness of breath and an $SpO_{2}$ of approximately $94\%$.

Scene Size-Up and Operations (Chapter 16 - Part 1)

• Prioritization of Scene Safety:

  • At a vehicle collision with fuel leaks or deployed airbags, Ensuring scene safety is the absolute first priority before approaching patients.
  • Hazardous Materials: If several workers are unconscious in a warehouse with a chemical odor, EMTs must stay outside the hazard zone and request a HazMat team.
  • Violence: If people are actively fighting at a residence, EMTs must retreat to a safe location and request law enforcement assistance.
  • Electrical Hazards: If damaged electrical wires are lying across a crashed vehicle, EMTs must stay away and request the power company.
  • Changing Scene Conditions: If smoke emerges from a vehicle during patient care, the crew and patient must move to a safe location immediately.

• Mechanism of Injury (MOI) and Trauma Suspicion:

  • Internal Injuries: Significant internal injuries may exist despite a lack of external symptoms or bleeding. This is particularly true in high-speed head-on collisions or falls from significant heights (e.g., $25\,feet$ onto concrete).
  • Trauma Classification: A gunshot wound to the abdomen is classified as penetrating trauma, whereas a motorcycle collision or a fall are generally blunt trauma (unless specific penetration occurs).
  • Ejection: A patient ejected (e.g., $40\,feet$) during a rollover crash has a greatly increased likelihood of severe multisystem trauma.

• Resource Management:

  • Multiple-Patient Incident: In a scene with multiple vehicles and patients, ensure scene safety, request additional EMS resources, and begin triage.
  • Extrication: Request fire/rescue as early as possible if a patient is trapped and expects a prolonged extrication.
  • Air Medical Transport: Highly supported for patients with multisystem trauma who are a significant distance (e.g., $45\,minutes$) from the nearest trauma center.
  • Incident Command System (ICS): The primary purpose of ICS is to coordinate resources, communication, and operations under one organized structure.

Patient Assessment and Physiological Indicators (Chapters 12, 13, 14, 15)

• Primary Assessment Priorities:

  • Purpose: To identify and immediately treat life-threatening problems in the Airway, Breathing, Circulation, Disability, and Exposure (ABCDE).
  • Immediate Life Threats: Severe bleeding from an extremity (e.g., the thigh) must be controlled with direct pressure or a tourniquet before continuing the assessment.
  • Unresponsive Patients: If a patient becomes unresponsive during assessment, the priority is to reassess the airway, breathing, and circulation immediately.
  • Transport Priority: High priority is given to patients with altered mental status, signs of shock, or severe respiratory distress.

• Mental Status (AVPU and GCS):

  • AVPU: A patient who opens eyes when spoken to and follows commands is "Alert."
  • Glasgow Coma Scale (GCS): A patient who opens eyes to speech ($3$), is confused ($4$), and obeys commands ($6$) has a score of $13$.

• Secondary Assessment and Specific Findings:

  • DCAP-BTLS: Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling.
  • Basilar Skull Fracture: Indicated by "raccoon eyes" (periorbital ecchymosis) and Battle's sign (bruising behind the ears).
  • Flail Chest: Identified by a segment of the chest moving inward during inspiration and outward during expiration (paradoxical motion).
  • Abdominal Assessment: Rigidity and guarding suggest internal bleeding or organ injury.
  • Neurovascular Assessment: Always check distal pulse, motor function, and sensation (PMS) before and after splinting an extremity.
  • Jugular Vein Distention (JVD): Suggests increased intrathoracic pressure, such as tension pneumothorax or cardiac tamponade.

• History Taking (SAMPLE and OPQRST):

  • SAMPLE: Signs/Symptoms, Allergies, Medications (prescriptions, OTC, supplements), Past Medical History, Last oral intake, Events leading up.
  • OPQRST: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity ($0-10$ scale), Time.
  • Unconscious Patients: Search for medical alert jewelry, medication bottles, and interview family/bystanders.

• Vital Signs and Trending:

  • Normal Ranges for Adults: Blood pressure $120/80\,mmHg$; pulse oximetry above $94\%$.
  • Normal Infant Respiratory Rate: $30-60\,breaths/min$.
  • Adult Capnography: $35-45\,mmHg$.
  • Shock Indicators: Tachycardia, weak pulses, pale/cool/clammy skin, delayed capillary refill (greater than $2\,seconds$ in children), and decreasing blood pressure (e.g., $88/54\,mmHg$).
  • Orthostatic Hypotension: A drop in blood pressure and increase in heart rate when moving from lying to standing (e.g., $124/78$ to $98/64\,mmHg$ with heart rate increasing from $82$ to $110\,beats/min$).
  • Pulse Oximetry Limitations: Inaccuracies result from poor peripheral perfusion, cold extremities, or excessive patient movement.
  • Reassessment Frequency: Reassess stable patients every $15\,minutes$ and unstable patients every $5\,minutes$.

Documentation and Communication (Chapters 16 - Part 2, 17)

• Accurate Documentation (PCR):

  • Objective vs. Subjective: Objective information is observable and measurable (e.g., "Skin pale, BP $88/54$," "Slurred speech, smelled of alcohol"). Subjective info is what the patient says (e.g., "I feel dizzy").
  • Error Correction: On paper, draw a single line through the error, write the correct info, and initial it. Never erase or use correction fluid.
  • Legal and HIPAA: Documentation supports continuity of care and serves as a legal record. Discussing patient data with uninvolved friends is a HIPAA violation.
  • Refusal of Care: Must document the assessment, care provided, risks explained (informed refusal), the patient's decision, and obtain signatures.

• Effective Communication:

  • Closed-Loop Communication: Repeating an order back to a team member to confirm understanding (e.g., repeating the dose of aspirin before administering).
  • Radio Reports: Should include age, sex, chief complaint, vitals, treatments, and ETA.
  • Special Populations:
    • Hearing Impaired: Face them, speak clearly at a normal volume, reduce background noise, and ensure hearing aids are functional.
    • Pediatric: Kneel to eye level, use simple language, and explain steps before doing them.
    • Language Barrier: Use professional interpreter services or simple gestures; do not rely on children to translate.

Emergency Pharmacology (Chapter 18)

• The Six Rights of Medication Administration:

  1. Right Patient
  2. Right Medication
  3. Right Dose
  4. Right Route
  5. Right Time
  6. Right Documentation

• Specific Medications and Protocols:

  • Aspirin (ASA): Used for crushing chest pain; standard dose often $324\,mg$ (chewable). Contraindicated if there is an allergy or active bleeding.
  • Nitroglycerin (NTG): Administered sublingually. Contraindicated if systolic blood pressure is too low (standard threshold often below $90-100\,mmHg$; e.g., withhold if BP is $82/54\,mmHg$).
  • Albuterol: Used for bronchospasm/wheezing in asthma. Administered via Metered-Dose Inhaler (MDI) or nebulizer.
  • Epinephrine: Used for anaphylaxis (hives, swelling, wheezing, respiratory distress). Assist with prescribed auto-injector even if recently expired if symptoms are severe, following medical direction.
  • Oral Glucose: Indicated for conscious diabetic patients who can swallow and follow commands ($BGL < 60\,mg/dL$). Never give to unconscious patients.
  • Naloxone (Narcan): Used for suspected opioid overdose with respiratory depression. EMT priority is opening the airway and BVM ventilation prior to/alongside administration. Monitoring is essential as respiratory depression can return when naloxone wears off.