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EMT Review

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PCR
patient care report
Purpose of a PCR
medical record, legal document, billing, training and research
Patient refusals
Should use patients words to describe refusal, signed by family as witnesses, write what specific outcomes that you warned,
Refusals with medication
if you give a medication and then the patient refuses care, remind them that it will most likely wear off
Closed injuries
injuries that don't penetrate the skin
Open injuries
surface of the skin or mucus membrane is broken, revealing underlying deeper tissue
Types of Burn Injuries
thermal, chemical, electrical, radiation burns
Considerations with burns
rapid fluid loss
increased heat loss --> hypothermia
sepsis
Superficial Burn
red skin, painful (first degree, sunburn)
Partial Thickness Burn
blister formation, very painful
Full Thickness (3rd degree) Burn
Nerve endings are burned (painless), black or waxy look
Full Thickness (4th degree) burn
involves bone destruction
Rule of Burn Classification
when in doubt, call it the next worse degree
Rule of 9s
determine how much of a body is burned
Rule of 9's Pediatrics
for each year over 1 year old, subtract 1% from head and equally to leg
Burn Severity Factors
depth, classification, surface area burned, preexisting medical conditions, associated trauma
Circumferential burn
burn that goes all the way around a body part
Potential hazards with circumferential burns
restricted ventilation (if occurs on chest), burns in joint areas can cause disability because of scar formation
compartment syndrome
A painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues.
Minor Burn
<10% burn in adults
<5% burn in pediatric or geriatric
<2% full thickness burn
Moderate Burn
10-20% burn in adult
5-10% burn in pediatric or geriatric
2-5% full thickness burn
Circumferential burn
Medical condition that predisposes patient to infection
Major Burn
>20% burn in adult
>10% burn in pediatric or geriatric
>5% full thickness burn
high voltage burn
significant burn involving the face, eyes, ears, hands, feet, genitalia, joints
significant associated injuries
Burn Treatment
Remove to safe area
Extinguish Fire
Remove Clothing
Cool adherent substances
DO NOT rupture blisters
Cover with sterile dressings
Cover with burn sheet
Dressings for Burn Wounds
Moist: limit to small areas <10%
Dry: for larger areas due to concern for hypothermia
Acid burns
immediate coagulation type necrosis
Alkali Burns
liquefactive necrosis with continued penetration into deeper tissue resulting in extensive injury
Chemical Burn Management
get the chemical off
flush for 20-30 minutes
Liquid Chemical Removal
wash off with fluid, remove contact lenses
Dry Chemical Removal
brush away chemicals, wash off with water
Pepper Spray and Tear Gas
mucous membrane and respiratory tract irritant, skin sensitizer
Pepper Spray and Tear Gas Management
treat respiratory distress, continue irrigation and decontamination
(effects will wear off after about 20 minutes)
Electrical Burns
skin burns where current enters and leaves
Alpha Particle Radiation
large, travel short distance, minimal penetrating ability, can harm internal organs if inhaled, ingested or absorbed
Beta particle radiation
small, lots of energy, better penetrating ability, usually enter through damaged skin, ingestion or inhalation
Gamma and X Ray
most dangerous penetrating radiation, may produce localized skin burns and extensive internal damage
Dislocations
Displacement of a bone from its normal position in a joint. Characterized by marked deformity, swelling, pain aggravated by movement, loss of normal motion, numbness, impair circulation to limb
Assessing CSMT Function With Possible Dislocations
if joint is dislocated, assess distal nerve and vascular function by checking CSMT. If a limb has lost circulation, motor or sensory function, attempt to reposition the dislocated joint then reassess CSMTs and not any changes. Discontinue repositioning if the patient experiences increased pain
Dressings
used primarily to stop bleeding
Bandages
placed over the dressings in order to secure them and prevent further bleeding
Occlusive Dressings
cover open wounds such as an abdominal evisceration or an open chest wound. They provide an airtight seal and prevent air or moisture from entering or leaving the chest cavity.
Overall management priorities
life threatening injuries, limb threatening injuries, manage all other conditions
Fracture
when a bone or set of bones are broken
Strain
an injury to a muscle or muscle and tendon where it has become overextended or stretched
Sprain
an injury to a joint, where there is possible damage to or possible tearing of ligaments
Critical Musculoskeletal Injuries
clavicle and rib fractures, femur fractures, pelvic fractures, spinal injuries
Clavicle and Rib Fractures
worried about the structures in the proximal area
Femur fractures
worried about the amount of potential blood loss and the amount of force it would require to fracture
Pelvic Fractures
worried about the amount of blood loss and the structures within the cavity
Treatment of Musculoskeletal Injuries
apply cold to the injury to reduce swelling, elevate extremity, transport
Flail Chest
loss of stability of the thoracic cage following multiple fractures of the ribs with or without accompanying fracture of the sternum
S&S of Flail Chest
unequal chest rise/fall, similar signs to those which occur with inadequate breathing
Treatment of Flail Chest
Manual stabilization, bulky dressing
Rigid Splints
commercially made splints
Pressure Splints
splints that utilize air pressure to achieve immobilization
Traction Splints
commercially made splints that provide for a counter-pull against spastic muscles to achieve immobilization of femur fractures
Contraindications for Traction Splints
injury is within 2 inches of the knee, knee is injured, hip is injured, pelvis is injured, partial amputation
Sling and Swathe
used to immobilize the shoulder and upper extremity injuries.
Tips for Immobilization
pad shoulders to keep neutral position in children, don't take football players helmet off, child safety seats may be used to secure infants, but the child must be removed first and roll a towel for a pad for the head
Scalp and facial injuries
very vascular and may bleed more than expected, can produce partial or complete airway obstruction
With Skull Injuries keep an eye out for
bruising around eyes, bruising behind ears, CSF in blood from eyes, nose or ears, head trauma with unequal pupils
Lacerations
deep cut or tear in skin or flesh
Contusions
region of injured tissue or skin in which blood capillaries have been ruptured (bruise)
hematoma
localized collection of blood outside the blood vessels, usually in liquid from within the tissue.
S&S of head injury
AMS, change in consciousness, nausea, vomiting, loss of euro function, seizures, unequal pupils
Indications for leaving a helmet in place
helmet does not interfere with assessment and monitoring of airway/breathing, no current or impending airway/breathing problems, patient can be adequately immobilized with the helmet in place, patients head rests snugly in the helmet ensuring there is no movement of the head after the helmet is secured on the board
Poisoning
accidental and has adverse effects from plants, foods, chemical or pharmaceutical agents on the body
Overdose
Intentional, excessive doses of medications
Peak Age Groups for Poisoning/OD
toddler to preschool children, young adult age group
Routes of Absorption
ingestion, absorption, injection, inhalation
Poisoning and Overdose Specific Questions
Substance, when were they exposed, amount, time period, interventions, estimated weight
Contraindications of Activated Charcoal
ingestions of bleach, ammonia, or ethyl alcohol
Common causes of behavioral changes
low blood sugar, lack of O2, inadequate blood flow to brain, head trauma, mind altering substances, excessive heat or cold
Methods for calming patients
introduce yourself and your role, speak slowly and clearly, show you are listening by rephrasing back parts of what individual is saying, use positive body language, don't be judgmental, acknowledge their feelings, give them space
Cerebrovascular Accident (CVA)
sudden interruption of blood flow to the brain that results in neurological deficit.
Risk Factors for CVAs
hypertension, diabetes, arteriosclerosis, hyperlipidemia, polycythemia, cardiac disease
S&S of CVA's
weakness, altered LOC, dizzy, visual disturbances, facial numbness, headache, convulsions, incontinence, dysarthria (slurred speech), aphasia (loss of speech), hemiparesis or hemiplegia on opposite side of affected area of the brain
Common Causes of CVA's
cerebral thrombosis
Adult Pulse Rate
60-100 bpm
bradycardia
<60 bpm
tachycardia
>100bpm
Adult Respiration Rate
12-20 bpm
Cheynes-Stokes Respirations
progressively deeper and sometimes faster breathing, followed by gradual decrease that results in temporary apnea
Central Neurogenic Hyperventilation
characterized by deep and rapid breaths at a rate of at least 25 breaths per minute. (Sign the patient might enter a coma) Related to head trauma
Kussmaul Respirations
deep and rapid respirations (associated with diabetes)
Ataxic Respiration
characterized by complete irregularly it breathing, with irregular pauses and increasing periods of apnea
Normal BP
systolic= 100+age (up to 140, not less than 80)
diastolic= not > 90
Orthostatic Hypotension
blood pressure defined as a systolic pressure decrease of at least 20 or diastolic bp decrease of at least 10 within 3 minutes of standing. (may be associated with an increase in patients pulse rate)
Pale/white, gray skin color
can indicate shock
Flushed
CO poisoning, B/P elevation, fever, etc
Blue
hypoxia
Jaundice
liver injury/failure, hepatitis, cirrhosis
normal pulse ox
93-99%
hypoxia
SPO2 <93%
Why would we do Blood Glucose Monitoring
ALOC, Dizziness, history of diabetes, syncope, diaphoresis
Normal Blood Glucose Value
60-150
Low Blood Glucose Value
<60
High blood glucose value
>150
Diabetic Ketoacidosis blod glucose value
250-500
Respiratory Distress
difficulty breathing, patient may be pale/cyanotic, have general malaise
When a pt complains of shortness of breath, you should immediately
adminsister oxygen
Severe respiratory distress indicates that you should
start positive pressure ventilation!
Respiratory failure
respiratory effort is lessening, LOC decreasing, CNS depression/decomp.
Respiratory Arrest
patient is not breathing!
Respiratory Cycle
ventilation, gas exchange, perfusion
ventilation
inhalation/expiration
gas exchange
alveolar/capillary exchange
perfusion
blood stream/tissue organ exchange
dyspnea
abnormal breathing
apnea
without breathing
hypoxia
low oxygen perfusion
bronchospasm
narrowing of the bronchi and bronchioles due to swelling and irritation; results in wheezing
crowing
in upper airway, related to obstruction
stridor
high pitched, breath sound. caused by a blockage in the throat or larynx.
Tracheal Deviation
when trachea shifts to one side or the other
Jugular Venous Distention
throbbing veins in neck
ventilation for adults
12 times per minute
ventilation for children/infants
20 times per minute
types of COPD
chronic bronchitis, emphysema
people with COPD are more prone to...
spontaneous pneumothorax
Sign of spontaneous pneumothorax
decreased or absent sounds on the side of the affected area
Chronic Bronchitis
productive cough, inflammation and excessive mucus production, restricted air movement, gas exchange compromised
Emphysema
loss of elasticity of the alveolar walls, distention of the sacs causing air trapping, patient retains carbon dioxide, non productive cough, prolonged exhalation, wheezing
Asthma
reversible narrowing of the lower airways, mucus traps air in the alveoli, exhalation becomes difficult and patients must force air out past constricted airways
Pneumonia
viral/bacterial disease infecting the lower respiratory tract, causes lung inflammation, poor gas exchange
Pneumonia S&S
fever, chills, cough, dyspnea, localized chest pain, sharp, worse with breathing, rhonchi/crackles
Pulmonary Embolus
sudden blockage of blood flow through a pulmonary artery or branches, due to blood clot, air bubble, foreign body, fat particle. decreases gas exchange, results in hypoxia
When should we expect pulmonary embolus
if there is a sudden onset of unexplained dyspnea, hypoxia, tachypnea, and stabbing chest pain. Will have normal breath sounds and adequate volume.
Acute Pulmonary Edema
excessive amount of fluid between alveoli and capillary space, disturbs gas exchange, causes hypoxia.
Acute Pulmonary Edema S&S
dyspnea worse with exertion, dyspnea with increases when lying down, tachycardia, pale, moist skin, swollen lower extremities
Upper Airway Issues
stridor and crowing indicate upper airway obstruction, usually due to edema or foreign body obstruction
low airway issues
wheezing is a sign of lower airway problems
Where can you place a pulse ox?
finger, toe, earlobe, bridge of nose
Metered Dose Inhaler Administration
have patient, exhale fully, wrap lips around opening, inhale slowly as you depress canister (5 sec), hold breathe for 10 seconds, exhale slowly
MDI side effects
tachycardia, arrhythmia, anxiety
Inadequate Breathing requires...
positive pressure ventilation and high flow oxygen
Airway Suctioning for adults
rigid catheter (15 seconds)
Pediatric Airway Suctioning
french catheter, bulb syringe (5 seconds)
PPV but no airway insertion...
indicated in situations where a patient is able to maintain airway but is not breathing adequately
Angina Pectoris
chest pain, no permanent damage, S&S include dyspnea, nausea, sweating, weakness, squeezing
Acute Myocardial Infarction
oxygen can't reach the heart, injury and death of heart muscle, S&S radiating pain, dyspnea, indigestion, weakness or fatigue
Congestive Heart Failure
Left sided heart failure. failure to pump blood effectively, results in systemic edema and pulmonary edema,
CHF S&S
difficulty breathing while supine, racing heart, feel weak, dizzy, swelling in legs, ankles, feet, could have JVD
CHF treatment
place patient upright unless they are not comfortable in this position
Rales
clicking, rattling, crackling noises heard on auscultation of the lung caused by the "popping open" of small airways and alveoli
Cor Pulmonate
right sided heart failure, clear lungs
Traumatic Chest Pain
often affects chest wall, but can affect the heart. If associated with blunt force trauma, may result in failure of chest cavity to fully expand.
Pulseless Adult Patient
CPR with AED
Pulseless Peds. Patient
pulse rate <60 in an infant indicates CPR
Shockable Rhythms
ventricular fibrillation and ventricular tachycardia
CPR rates
30:2
CVA
sudden interruption of blood flow to the brain that results in neurological deficit
CVA or Stroke transport
true emergency, rapid transport!! 3 hour window from onset of symptoms for the best outcome
Risk Factors for CVA's
hypertension, diabetes, arteriosclerosis, hyperlipidemia, polycythemia, cardiac disease
S&S of CVA's
weakness, altered LOC, dizziness, visual disturbances, facial numbness, headache, convulsions, dysarthria, dysphasia, aphasia, hemiparesis
Common Causes of CVAs
cerebral thrombosis (clot in brain), cerebral embolus (foreign body in brain), cerebral hemorrhage (blood vessel bursts in brain)
Most common type of CVA
cerebral thrombosis, commonly occurs at night and patient awakens with ALOC, loss of speech, sensory or motor function, headache is not common with this type of CVA
Most common types of Embolus
clotted blood, air bubbles, tumor fragments, fat particles
Cerebral Embolus
symptoms occur when patients is awake and active, headache is common with this type of CVA
Cerebral Hemorrhage
commonly occur during stress or exertion, presentation is often abrupt
S&S of cerebral hemorrhage
signs of bushings reflex, hypertension, bradycardia, cheyne-stokes respirations
Transient Ischemic Attack
"mini strokes" symptoms last 24-72 hours then resolve without deficit, precursor to a CVA
Cincinnati Preshospital Stroke Screening (F.A.S.T)
check for facial droop (have pt. smile, frown, show teeth)
check for arm drift
have pt repeat back phrase
when was the pt. last known to be normal
Type 1 Diabetes
Child onset, pancreas cannot produce insulin, patient always uses insulin, prone to DKA
Type 2 Diabetes
adult onset, pancreas cannot produce enough insulin or resists its actions, patient may control with diet, exercise, pills or in extreme cases insulin.
Gestational Diabetes
onset of diabetes with pregnancy
Low Blood Sugar
<60
Normal Blood Sugar
60-150
Hyperglycemic Levels
>150
Diabetic Ketoacidosis blood sugar levels
250-500
Hypoglycemia
pale, diaphoretic, altered mental status, may vomit
Treatment for Hypoglycemia
oral glucose if patient can swallow, otherwise protect airway
Signs of DKA
frequent urinating, hungry, thirsty, dehydration, vomiting, loss of weight, kussmaul respirations, acetone smell
Hypoglycemic Levels
blood glucose <60
DKA
the body in an attempt to compensate for hyperglycemia developed an acidotic state
seizure
sudden and temporary alteration in brain function caused by massive electrical discharge in a group of nerve cells in brain
Generalized Seizure
(both hemispheres) grand mal or petite mal
Partial Seizure
(1 hemisphere) simple or complex
Primary Seizure
caused by disease process (like epilepsy) or unknown etiology
Secondary Seizures
caused by some other process (trauma, poisoning, etc)
Tonic Clonic (Grand Mal)
tonic phase the muscles stiffen, clonic phase the muscles start to jerk (seizure usually lasts about 2-3 minutes)
Petit Mal Seizure
usually causes a few seconds lapse of awareness, may be accompanied by eyelids or eyes rolling back into head, may look like daydreaming or staring off into space, can occur 50-100 times a day
Simple Partial Seizure
twitching/jerking of leg/arm, inappropriate sensation or emotion, lasts about 30 seconds
Complex partial Seizure
mumbling, wandering, picking at clothes, repeating actions, smacking lips, person is usually confused after seizure
Epilepsy
chronic brain disorder characterized by recurrent seizures
Status Epilepticus
seizures last more than 5 minutes in duration of seizures that occur consecutively without a period of consciousness
Common causes of seizures
fever, infection, poisoning, hypoglycemia, hyperglycemia, head injury, epilepsy, hypoxia, stroke, drug and alcohol withdrawal, dysrhythmias, ecclampsia
Febrile Seizures
seizure caused by high fever, usually occur in children ages 6 months to 5 years, range in duration from seconds to 15 minutes, temp. usually greater than 102. Not about the temperature, its about how fast they get to that temperature
Treatment for Seizure Patients
bsi, scene safety, assess responsiveness, C spine, open airway and suction, breathing, protect patient from harming themselves, transport
Poisoning
accidental, adverse effects of plants, foods, chemicals or pharmaceutical agents on the body
overdose
intentional, poisoning by excessive doses of medications
2 peak age groups for OD/poisoning
toddler/preschool, young adult group
Activated Charcoal
should be administered within 1 hour for the greatest effect and should NOT be used for ingestions of bleach, ammonia, or ethyl alcohol
movement of drugs in the body
absorption, distribution, metabolism, excretion
Routes of administration
intravenous, sublingual, intramuscular, subcutaneous, oral, inhalation, transdermal, intraosseous
5 Rights of Medications
right...
patient
route
dose
time
drug
Drugs to know
aspirin, epinephrine, oral glucose, nitro, inhaler, activated charcoal, oxygen
Aspirin Indication
chest pain consistent with cardiac etiology
How does aspirin work?
prevents existing clots from worsening and future clots from forming
Contraindications for Aspirin
allergy, bleeding disorder, bleeding ulcer, signs of CVA, children/adolescents
Oral Glucose
simple sugar supplement that raises blood sugar levels
Oral Glucose Dose
15 grams
Indications for Oral Glucose
altered mental status, possible diabetic emergency
Contraindications for Oral Glucose
unresponsive, no gag reflex
EPI indications
emergency treatment of anaphylaxis
EPI side effects
tachycardia, anxiety, hypertension, headache, pallor, sweating, dizzy, weakness, tremor, nausea, vomit
EPI dose
adult .3mg auto injector, pediatric .15mg auto injector for 66 lbs or less
Oxygen indications
hypoxia, potential hypoxia, pain, compensation, hypo perfusion or potential for it
Nitro
dilates blood vessels, reducing blood pressure and lessening workload on heart and increasing oxygenation of the heart
Nitro Indications
cardiac chest pain
Nitro Contraindications
BP less than 100 systolic, not patients meds, signs of CVA, erectile dysfunction meds
Inhalers
reverse bronchospasm and open up lower airway
Inhalers contraindications
not patients med, unresponsive, unable to assist, tachycardia
how does activated charcoal work?
binds contents of stomach and prevents absorption of contents into bloodstream
indications for Activated charcoal
oral overdose of certain meds/pills
contraindications for activated charcoal
unresponsive patient, absent gag reflex, certain meds, intake greater than 1 hour prior to administration
AVPU
alert, verbal, painful, unresponsive
OPQRST
onset, provokes, quality, region/radiation, severity, time
3 stages of labor
1. effacement/dilation 2. expulsion 3. placental delivery
Labor Stage 1
begins with the first uterine contraction and ends with complete dilation of cervix
Labor Stage 2
begins with complete dilation of the cervix and ends with delivery of the infant
Labor Stage 3
begins with delivery of infant and ends with delivery of placenta
Miscarriage
spontaneous abortion
Ecclampsia
seizure during pregnancy (transport patient on left side)
Vaginal Bleeding
late pregnancy vaginal bleeding can present with or without pain
Questions to ask during OBGYN emergencies
are you pregnant?
how long have you been pregnant?
are there contractions or pain?
any bleeding/discharge?
is crowning occurring during contractions?
frequency and duration of contractions?
does mother feel as if she is having a BM with increasing pressure in vaginal area?
dose she feel the need to push?
rock hard abdomen?
What NOT TO DO during OBGYN emergencies
never touch vaginal areas except during delivery and when partner is present, do not let the mother go to the bathroom, do not hold mothers legs together
Prepping for baby delivery
apply gloves, mask, gown, eye protection. Have mother lie with knees drawn up and spread apart. elevate butt with blankets/pillows, create a sterile field around vaginal opening with sterile towels or paper barriers
baby delivery
when infants head appears during crowning, place fingers on bony part of skull, exert gentle pressure to prevent explosive delivery. If amniotic sac does not break, use a clamp to puncture and push it away from infants head and mouth
after baby is delivered
support head, suction mouth/nostrils two or three times, wrap in warm blanket
umbilical cutting
place clamp on cord 8-10 inches from baby, place second clamp approx. 4 fingers from baby, after pulsations cease, cut between the clamps
placenta care
wrap in towel and put in plastic bag and transport it with mother to hospital
Care for mother after delivery
place sterile pads over the opening of vagina, lower mothers legs and help her hold them together
Regular blood loss after delivery
500cc, a nursing newborn will assist with bleeding control in a pregnant patient who has just delivered
if there is excessive bleeding after delivery...
massage uterus,
APGAR
appearance, pulse, grimace, activity, respiratory (done 1 min. after delivery and 5 min. after delivery)
APGAR 0 points
absent heart rate, absent respiratory effort, flaccid muscle tone, no irritability response, blue/pale color
APGAR 1 point
HR <100, slow/irregular respiratory effort, some muscle tone, some irritability, blue/pink
APGAR 2 points
>100 HR, strong cry, active motion, vigorous, fully pink
Newborn Breathing Effort
if it is shallow, slow or absent; provide artificial ventilations
Newborn HR <100 beats
provide artificial ventilation
newborn HR <80 beats and not responding to ventilations
begin chest compressions
Newborn, if central cyanosis is present with spontaneous breathing and an adequate HR...
administer free flow oxygen (10-15 LPM) using oxygen tubing held as close to the newborns face as possible
Prolapsed Cord
condition where cord presents through the birth canal before delivery of the head; presents a serious medical emergency which endangers unborn fetus
Prolapsed Cord Care
position the mother with head down, butt raised using gravity to lessen pressure on birth canal, place moist dressing on cord to keep it moist
Breech Birth Presentation
occurs when butt or lower extremity are low in uterus and will be the first art of the fetus delivered
risks of breech birth
newborn at risk for delivery trauma and prolapsed cord
Breech birth management
place mother in head down position with pelvis elevated, place arm under the infant supporting its body and place hand into vagina using gainers to provide an airway for the the infants lodged head
Limb Presentation
occurs when a limb of the infant protrudes from the birth canal (usually a foot)
limb presentation management
transport rapidly with mother in head down/pelvis elevated position
Multiple Births
call for additional resources, be prepared for more than 1 resuscitation
Meconium Staining
amniotic fluid that is greenish or brownish yellow rather than clear, sign of possible fetal distress during labor
Premature Delivery
always at risk for hypothermia, usually requires resuscitation
fowlers position
prone position
lateral recumbent
Mass casualty incident
any event that places excessive demands on personnel on hands or equipment on hand
Manageable span of control
Ideally no more than 5!! number of personnel under any individuals direct control.
START Triage System
Always approach helicopter from...
downhill side
Recovery Position
helps keep airway open, allows fluid to drain from mouth, prevents aspiration
Recovery Position for Unresponsive Breathing Infant
hold infant facedown over your arm with head slightly lower than body, support head and neck with you hand and keep nose and mouth clear
To carry patient down steps...
two rescuer extremity carry
General Impression
formed to determine priority of care and is based on the EMT immediate assessment of the environment and the patients chief complaint
Priority Patients
poor general impression, unresponsive patients, responsive but not following commands, difficulty breathing, shock, complicated childbirth, chest pain with BP<100systolic, uncontrolled bleeding, severe pain anywhere
Situation where hospital staff have requested that you transport patients who carry equipment or medication that you cannot
advise them that you are not permitted to do so
Standard of Care
expected care, skill and judgement under similar circumstances by a similarly trained, reasonable EMT
Elements required to prove negligence
duty to act, breach of duty, actual damage/harm, proximate cause (most difficult to prove in negligence cases)
Informed Consent
occurs when the patient agrees to treatment after being advised of the possible risks/benefits
Expressed Consent
consent given by adults who are of legal age and mentally competent to make a rational decision in regard to their medical well being. Should be able to answer
person, place, time and event
implied consent
for an unconscious patient.
the consent is presumed a patient or patients parent or guardian would give if they could, such a for an unconscious patient or a parent who cannot be contacted when care is needed. Until patient become conscious and can make rational decisions on their own.
Involuntary Consent
Consent granted by the court. Common for patients who are held for mental health evaluation, or patients by law enforcement who are in protective custody. Also, used on patient who have disease which treatens a community at large.
DNR
do not resuscitate. a legal document usually signed by the patient and his physician which states that the patient has a terminal illness and does not with to prolong life through resuscitative efforts
Even when an alert and orient patient is refusing transport....
always call medical control!
Neonate
child from birth to 1 month of age
Neonate Vital Signs
RR 40-60 per minute, Pulse 140-160bpm, systolic BP 70
1 Year Old Vital Signs
RR 20-30 breaths per minute, pulse 120 bpm, systolic BP 90
Pulmonary System Differences in Infants
airway is shorter, narrower, less stable and more easily obstructed, primarily nose breathers until 4 weeks of age, lung tissue is fragile and prone to trauma, accessory muscles are immature and chest wall is rigid
Fontanelle
soft spots on the skull that allow the head to compress in the birth canal during delivery and to allow for the growth of the brain during infancy. Fontanelles will be depressed if child is dehydrated
toddler
1-3 years of age
preschooler
3-6 years of age
school aged children
6-12 years of age
school aged children vital signs
pulse rate 70-110bpm, RR 20-30 bpm, systolic BP between 80-120
adolescence
between 12 and 18 yoa
adolescence vital signs
pulse rate 55-150bpm, RR 12-20 bpm, systolic BP 100-120
early adulthood
20-40 yoa
early adulthood vital signs
HR 70bpm, RR 16-20 bpm, BP 120/80
middle adulthood
more susceptible to chronic illness and disease, cardiovascular health becomes a concern, cardiac output decreases, cholesterol levels increase
late adulthood
61 and older
AEIOU TIPS
pneumonic for causes of Altered Level of Consciousness
what does AEIOU TIPS stand for?
alcohol, acidosis, anoxia, epilepsy, environment, insulin, overdose, uremia, undergoes, trauma, toxins, tumors, infection, psychiatric disorders, stroke
Glasgow Coma Scale
assesses neurological status, assess level of consciousness
Speciality Facilities
trauma centers, burn centers, pediatric centers, pediatric centers, poison center
Hypo perfusion
inadequate tissue perfusion, inadequate delivery of O2 and nutrients to the body tissues, inadequate elimination of metabolic waste
Stages of Shock
compensated, decompensated, irreversible
Compensated Shock
body is able to compensate and maintain tissue perfusion
Decompensated Shock
body begins to lose ability to compensate, inadequate perfusion begins
Irreversible Shock
cell and tissue damage result in multi-system organ failure leading to death
Types of Shock
hypovolemic, obstructive, cardiogenic, distributive
Hypovolemic Shock
blood loss, dehydration, etc.
Obstructive Shock
Tension Pneumo, Cardiac Tamponade
Cardiogenic Shock
CHF, Heart Disease, AMI
Distributive Shock
neurogenic or vasodilation, anaphylactic, septic
Liver and Spleen Injury
lose blood pretty quick
S&S of Distributive Shock
skin becomes warm pink and dry, mottling in some areas, pallor and cyanosis in upper surfaces. Pulse highly variable. Slow, shallow and abnormal respirations. Hypothermia
Anaphylactic Shock S&S
hives, itching, flushing, pallor, cyanosis, abrupt fall in cardiac output, rapid shallow respirations, stridor, wheezing, crackles, leads to respiratory arrest, selling of mucous membranes, pulmonary edema
Septic Shock S&S
flushed pink, pale, or cyanotic skin, purple blotches, peeling skin, BP increases but later decreases, dyspnea with altered lung sounds, high fever (except in some elderly and very young patients), late sign: pulmonary edema
How does age affect environmental emergencies?
infants have poor thermoregulation and are unable to shiver, children may not think to wear layers, older adults lose subcutaneous tissues and have poor circulation
Temp. for Hypothermia
most hypothermia occurs at temps. between 30-50 degrees F
Temp for heatstroke
most heatstroke occurs when the temp is 80 degrees F and the humidity is 80%
5 ways the body can lose heat
conduction, convection, radiation, evaporation, respiration
Hypothermia
lowering core body temp. below 95. Body loses ability to regulate its temperature and generate body heat. Eventually key organs begin to slow down. Care is most critical within the first 30 minutes.
Mild Hypothermia
95-90 degrees. Mild to moderate shivering, rapid respirations and pulse, numbness in fingers and toes
When body is 90 degrees..
confusion sets in and patient may start to stumble.
Moderate Hypothermia
90-85 degrees. Lethargy, sleepy, slow pulse. Loss of dexterity, may not be able to ambulate. pale or blue extremities. May no longer shiver.
Severe Hypothermia
80 degrees or below. coma, irrational, slow respirations, cardiac arrhythmia,
when body is below 78 degrees...
clinical death occurs, unconscious, apneic, pulseless
Considerations for Local Cold Injuries
duration of exposure, temperature the part was exposed to, wind velocity during exposure
S&S of Frosting and Immersion Foot
pale, cold to the touch skin. normal color does not return after palpation of skin. Skin of the foot may be wrinkled but can also remain soft. Patient reports loss of feeling/sensation in injured area
Frostbite
most serious local cold injury because the tissues are actually frozen
S&S of frostbite
heard and waxy look, feels firm, blisters and swelling, skin may appear red with purple and white, or mottled and cyanotic
Superficial Frostbite
only skin is frozen
Deep Frostbite
deeper tissues are frozen
General Management of Cold Emergencies
move patient from environment, do not allow pt to walk, remove any wet clothing, place dry blankets under and over pt, give pt warm, humidified oxygen, do not massage extremities, do not allow patient to eat.
Management for Mild Hypothermia
apply heat packs to groin, armpit and cervical regions, rewarm patient slowly, give warm fluids by mouth
Management for Moderate or Severe Hypothermia
never try to actively rewarm patient! Goal is to prevent further heat loss, remove wet clothing, cover with a blanket and transport. Consider blisters as protection, don't break them!
Normal Body Temperature
98.6
Hyperthermia
core temp. of 101 or higher
3 levels of heat injury
heat cramps, heat exhaustion, heat stroke
Heat Cramps
electrolyte deficiency
heat exhaustion
body spending most of its compensatory mechanisms
heat stroke
body compensation overwhelmed and shuts down
heat stroke S&S
hot, dry, flushed skin. early on skin may be moist/wet. Quickly rising body temperature. Falling LOC. Change in behavior. Unresponsiveness, seizures. Strong, rapid pulse at first, becoming weaker with falling blood pressure, increasing RR, lack of perspiration.
Management for Heat cramps and exhaustion
replace fluids by mouth, cool the patient with water spray or mist
Management for Heat Stroke
actively cool pt with cold packs in pulse points, passively cool with A/C, stripping pt.
Drowning
process of experiencing respiratory impairment from submersion/immersion in liquid
With Submersion incidents always consider...
spinal injuries
Descent Emergencies
caused by the sudden increase in pressure as the person dives deeper into the water
Decompression Sickness
nitrogen bubbles form in the muscle tissues, causing extreme pain. May occur from about 12 hours after the dive to up to 72 hours after the dive
Air Gas Embolism
same concept as decompression sickness, but more severe to include CNS depression, stroke like S&S, will occur sooner than DCS, about 15 minutes post-dive
Acute Mtn. Sickness
higher than 8000 feet. Caused by ascending too high too fast or not being acclimatized to high altitudes
High Altitude Pulmonary Edema
10,000 feet or higher
10,000 feet or higher, fluid collects in lungs, hindering passage of O2 in bloodstream
S&S of High Altitude Pulmonary Edema
shortness of breath, cough pink sputum, cyanosis, rapid pulse
High Altitude Pulmonary Edema 12,000 feet or higher S&S
severe constant throbbing headache, ataxia, extreme fatigue, vomiting, LOC
Lightning
respiratory or cardiac arrest is the most common cause of lighting related deaths
kinematics of trauma; when weight is doubled
energy is also doubled
kinematics of trauma; when speed is doubled
energy is quadrupled
Types of Car Crashes
head on, rear impact, side impact, rotational impact, rollover
Types of Motorcycle Crashes
head on, angular impact, ejection, laying down on bike
Where to put flares in MVA
500 feet in each direction from collision scene
Blast Injuries; primary blast
pressure wave, gas containing organs rupture
Blast Injuries; Secondary Blast
flying debris
Blast Injuries; tertiary blast
thrown victim impacts
Closed Injuries
injuries that do not penetrate skin
Open Injuries
open soft tissue injury is an injury where the surface of skin or the mucous membrane is broken, exposing underlying, deeper tissue
Potential Complications of Burn Injuries
hypo/hyper thermia, infection
Burn Depth Classifications
superficial, partical thickness, full thickness, full thickness 4th degree
Rule of Nines
Rules of Nines Pediatrics
for each year over 1 yoa subtract 1% from head and add equally to legs
Patient Age considerations for Burns
less than 2 or greater than 55 yoa have increased incidence of complications
circumferential burns
deep full thickness burns of an extremity or around the chest/abdomen
Minor Burn Criteria
3 degree: <2% BSA
2 degree: <15% BSA
1 degree: <20% BSA
Moderate Burn Criteria
3 degree: 2-10%
2 degree: 12-30% or 10-20 pediatric
excluding hands, face, feet, genitalia, without complicating factors
Critical Burn Criteria
3 degree: >10%
2 degree: > 30% or >20% pediatric
burns with respiratory injury
hands, face, feet, genitalia
circumferential burns
burns complicated by other trauma
underlying health problems
electrical and deep chemical burns
When auscultating over lungs you would hope to hear
vesicular breath sounds
Diabetic Shock
severe hypoglycemia
S&S of diabetic shock
dizzy, irritable, moody, hungry, shaky, sweaty, rapid pulse, confusion, headache, poor coordination, fainting, seizures, coma. Can occur when you are sleeping; crying out at night, nightmares, damp PJs from perspiration, waking tired, irritable or confused.
respiratory alkalosis
disturbance in acid and base balance due to alveolar hyperventilation. leads to decreased partial pressure of arterial carbon dioxide.
paradoxical motion
motion of the flail segment that occurs due to pressure changes associated with respiration that the rib cage normally resists.
How much oxygen does a BVM deliver with no supplemental O2 attached?
21% produced
cells that die during a stroke
infarcted cells
fight/flight response
peripheral nervous system
croup
difficulty breathing, fast breathing, noisy breathing, shortness of breath, wheezing
treatment of croup
nasal cannula at 4lpm
emphysema
air pockets in lungs. people with emphysema have difficulty breathing from a limitation in blowing air out. Smoking is the most common cause.
pneumothorax S&S
sudden sharp chest pain, may feel tight in chest, shortness of breath, rapid heart rate, rapid breathing, cough, fatigue, cyanosis
open pneumothorax treatment
seal with occlusive dressing
hemothorax
similar to pneumothorax except that blood, not air, is collecting in pleural space.
Cardiac Tamponade
compression of heart caused by fluid collecting in the sac surrounding heart (pericardial sac)
S&S Cardiac Tamponade
low BP, shortness of breath, lightheadedness, pain in chest, fast pulse, sensation of abnormal HR, fast breathing, faint heart sounds, swelling in extremities
Treating Cardiac Tamponade
high concentration O2, ensure patient is kept warm, rapid transport
flail chest
when several ribs are broken and detached, causing a flailing portion of chest. Can apply bulky dressing if protocol allows.
Patient saturation level low or normal but has mild respiratory difficulty
nasal canal with O2 flowing between 2-6 LPM
Patient working hard to breathe
nonrebreather mask at 12-15LPM
diaphoretic
sweating heavily
alcohol
pupils dilate
hemorrhagic stroke
caused by ruptured blood vessels that cause brain bleeding
Intracerebral Hemorrhage S&S
present immediately after stroke occurs, may include total or limited loss of consciousness, nausea, vomit, sudden and severe headache, weakness or numb feeling in face, leg or arm on one side of the body.
Subarachnoid Hemorrhage S&S
sudden onset of symptoms. Severe headache, stiff neck, nausea, vomit, inability to tolerate light, LOC
Ischemic Stroke
stroke caused by blood clots
peptic ulcer
sore that develops on lining of esophagus, stomach or small intestine.
S&S of stomach ulcer
upper abdominal pain, radiating pain to shoulder, can be burning or dull pain, indigestion, nausea, passing excessive gas, vomiting, fatigue, abdominal discomfort
esophageal varices
abnormal veins in lower part of the tube running form throat to stomach
S&S of esophageal varices
vomiting blood, tar like stool, bloating, difficulty swallowing, enlarged veins around belly button
peritonitis
inflammation of the membrane lining the abdominal wall and covering the abdominal organs
peritonitis S&S
pain, tenderness, rigid abdominal muscles, fever, nausea, vomit, bloating, chills, fever, loss of appetite
ectopic pregnancy
pregnancy in which the fertilized egg implants outside the uterus
ectopic pregnancy S&S
pelvic pain, vaginal bleeding, pain in abdomen, bloating, nausea, vomit, cramping
Treatment Ectopic Pregnancy
...
pancreatitis
...
placenta previa
condition that occurs when the placenta partially or totally obstructs the cervix
common risk factors for placenta previa
treatments for infertility, prior caesarean section, advanced maternal age
S&S placenta previa
painless bleeding during third trimester, assess color and amount of blood
placenta abruption
occurs when the placenta or a portion of it tears away from the inner lining of uterus
S&S of placenta abruption
significant bleeding that can be concealed or vaginal bleeding, abdominal pain, rapid transport!
spontaneous abortion
fetal death prior to 20 weeks gestation. If patient has passed fetal tissue, collect all parts for examination by a physician.
gallbladder attack
components in bile crystallize and harden in gallbladder, leading to gallstones.
S&S of gallbladder attack
fever, jaundice, nausea, vomit, clay colored stools
acute coronary syndrome
condition brought on by sudden reduction or blockage of blood flow to the heart
S&S acute coronary syndrome
heart attack like chest pressure, chest pressure while resting or doing light activity, pain in chest, arm, jaw, shortness of breath, sweating,
red tag
immediate;
respirations greater than 30/min
no radial pulse/ cap refill >2 sec
unable to follow simple commands
veins vs. arteries
arteries carry blood away
veins carry blood too heart
right sided heart failure
distended neck veins, chronic pedal edema
helminth
classification of large parasitic worm that is often found in the g.i tract
Nalaxone
administer based on respiratory status. If pt is hyperventilating or in resp. arrest, you should administer. Commonly packed as .4mg/mL that are 5ml of solution for a total dose of 2mg. Administer enough to get a return of spontaneous adequate respirations.
yellow tag
observation required, stable condition, not immediately in danger of death
green tags
walking wounded
white tags
dismiss, no doctors car required
black tags
deceased or not able to survive
APGAR
abdominal organs