EMT Exam #1

What is the goal of EMS research?

Improving patient outcomes

Cranium

Top, back, and sides of skull

On-Line Medical Control

Type of medical direction given through orders by phone or radio

Off-Line Medical Control

Type of medical direction given through standing orders and protocols

Head to Toe Exam

Used for: • Significant MOI • Unresponsive, AMS • Multiple injuries • Multiple body systems

1973

Year of National Emergency Medical Service Systems Act (NEMSSA)

1970

Year of the Founding of National Registry of EMTs (NREMT)

1966

Year that the Department of Transportation was charged with developing EMS standards

draw-sheet method

a method of transferring a patient from bed to stretcher by grasping and pulling the loosened bottom sheet of the bed

Medical Director

a physician that has ultimate responsibility for patient care aspects of EMS system • All patient care performed under their direction • Oversees training • Develops treatment protocols

Immune System Exam

*note: pt conditions can change dramatically with allergic reactions* • History - History of allergies * Exposure to known allergens *What are typical reactions like? - History of asthma - Symptoms of tightness in chest or throat - GI distress, itchiness, or rash - Medications for allergic reaction • Physical Exam - Inspect point of contact with allergen. - Inspect patient's skin for rash or hives. - Inspect the face, lips, and mouth for swelling. - Listen to the patient speak. - Listen to lungs to ensure adequate breathing.

Accessing EMS System

-911 telephone access Available in most but not all areas -Enhanced 911 Provides caller number and location for landline phones -Cell phones Newer models may provide location in some areas

Types of Emergency Moves

-Clothes Drag -One Rescuer Assist -Two Rescuer Assist -Stair Drag -Firefighter Drag -Firefighter's Carry

Long backboard

-a rigid device, usually made of plastic or a composite material, that is used to stabilize a patient with a suspected spine injury (also called a long spine board) --patients are log rolled on -comes with various straps

Inserting NPA

1. Lubricate outside of tube with water-based lubricant before insertion 2. Push tip of nose upward; keep head in neutral position 3. Insert into nostril; advance until flange rests firmly against nostril

Performing Jaw-Thrust Maneuver

1. Place one hand on each side of patient's lower jaw at angles of jaw below ears 2. Using your index fingers, push angles of patient's lower jaw forward 3. Do not tilt or rotate patient's head

Performing Head-Tilt Chin-Lift Maneuver

1. Place one hand on forehead and fingertips of other hand under patient's lower jaw 2. Tilt head 3. Lift chin 4. Do not allow mouth to close

Acquiring Blood Glucose Measurement

1. Prepare device, test strip, and lancet 2. Cleanse patient's finger with alcohol 3. Perform finger stick with lancet 4. Wipe away first drop of blood 5. Apply blood to test strip 6. Use glucose meter to analyze sample and provide reading

No Chest Rise During BVM Ventilation

1. Reposition head 2. Check for escape of air around mask; reposition fingers and mask 3. Check for airway obstruction or obstruction in BVM system 4. Use alternative method

binder lift

A harness with handles to lift patient

Stair Chair

A lightweight folding device that is used to carry a conscious, seated patient up or down stairs.

Extremity Lift

A method of lifting and carrying a patient during which one rescuer slips hands under the patient's armpits and grasps the wrists, while another rescuer grasps the patient's knees.

basket stretcher

A rigid stretcher commonly used over rough terrain, in technical and water rescues that surrounds and supports the patient yet allows water to drain through holes in the bottom. Also called a Stokes Stretcher

recovery position (lateral recumbent position)

A side-lying position used to maintain a clear airway in unconscious patients without injuries who are breathing adequately.

wheeled ambulance stretcher

A specially designed stretcher that can be rolled along the ground. A collapsible undercarriage allows it to be loaded into the ambulance. Also called the stretcher or an ambulance stretcher.

Flexible Stretcher

A stretcher that is a rigid carrying device when secured around a patient but can be folded or rolled when not in use. Made of canvas or rubberized or other flexible material, often with wooden slats sewn into pockets and three carrying handles on each side. can be useful in restricted areas or narrow hallways

Scoop Stretcher

A stretcher that is designed to be split into two or four sections that can be fitted around a patient who is lying on the ground or other relatively flat surface; also called an orthopedic stretcher.

Bariatric ambulance

Ambulance for the obese

Implied consent

Assumed consent

Levels of EMS training

Basic Life Support -Emergency Medical Responder (EMR) -Emergency Medical Tech (EMT) Advanced Life Support -Advanced Medical Tech (AEMT) -Paramedic

Power Stretcher

Battery powered hydrolic system, will lift a patient from the ground level to the loading position or lower a patient from the raised position. 1. Lifts patients for 20 consecutive runs 2. Can lift up to 700 pounds.

Physical Examination: Palpation

Feel for • Abnormalities in shape • Temperature • Texture • Sensation

Cartoid Pulse

Felt along large carotid artery on either side of the neck

Femoral Pulse

Felt along the inner thigh, at the area of the pelvis

Face

Front of the skull

Physical Examination: Auscultation

Listen for • Decreased or absent breath sounds

Trauma Physical Examination: Inspection

Look for • Abnormalities in symmetry • Color • Shape • Movement

Scene Safety Considerations: Within Sight of Scene

Look for: -Clues to escaped hazardous materials -Collision Victims on or near road -Smoke not seen at a distance -Broken utility poles and downed wires - Be alert for persons walking along side of road toward collision scene - watch for signals of police officers and other EMS personel

Scene Safety Considerations: Upon Approaching Scene

Look/listen for other emergency units approaching look for signs of a collision-related power outage Observe trafic flow Look for smoke in direction of collision scene

Urgent Move: Rapid Extraction

Move patient from sitting to supine position on long backboard while always maintaining stabilization and support of the head/neck, torso, and pelvis

Expressed consent

Must be informed

Assessment Comparison

No Significant MOI, CAO • Assessment focused on areas patient notes are painful or that MOI indicates • Chief complaint (why patient called EMS) • History of present illness (HPI)—information on how injury occurred Significant MOI, AMS • Full Head to Toe Rapid Assessment

Components of the EMS System: Emergency Department Staff

Patient care transferred to someone with higher or equal level of care

Chain of Human Resources in EMS System

Patient→ A citizen calls 911→ 911 dispatcher→first responders→EMTs→Emergency department staff→allied health staff

Short Spine Board

Primarily for removing patients from vehicles when a neck or spine injury is suspected. A vest type can be used instead if necessary.

Quality Improvement (QI)

Process of continuous self-review with the purpose of identifying & correcting aspects of the system • Ways you can be a part of QI: • Carefully written documentation • Obtain feedback • Maintain equipment • Continue your education

Finding History of Present Illness & Past Medical History (unresponsive)

Question bystanders • What is patient's name? • What happened? • Did you see anything else? • Did patient complain before this happened? • Does patient have any illnesses or problems? • Is patient taking medications?

The Assessment Process

Scene Size-Up Initial/Primary Assessment Secondary Assessment -Detailed Assessment Reassessment

The Medical Pathway

The Rapid Medical Exam • Unresponsive or AMS • Unknown Issue(s) Focused Exam • No significant DIstress • Responsive • Alert and Oriented

The Trauma Pathway

The Rapid Trauma Exam • Un-Responsive or AMS • Significant MOI • Multiple injuries • Multiple body systems involved Focused Exam • No Significant MOI • Responsive • Single Injury • Alert and Oriented

Mechanism of Injury (MOI)

The event or forces that caused the patient's injury

Alveolar ventilation

air actually reaching alveoli

Dead space air

air moved in ventilation not reaching alveoli

Tidal volume

amount of air moved in one breath

Vacuum Mattress

conform to body contours to immobilize geriatric patients with pelvic fractures

Patient Characteristics

determine the form of assessment

External respiration

diffusion of oxygen and carbon dioxide (exchange of gases) between alveoli and circulating blood. <-Also called alveolar respiration

shock position

elevation of the feet of a supine patient 6 to 12 inches; recommended for shock that is not caused by injury

Internal (cellular) respiration

exchange of gases between blood and cells

Power Grip

gripping with as much hand surface as possible in contact with the object being lifted, all fingers bent at the same angle, and hands at least 10 inches apart

Diffusion

movement of gases from high concentration to low concentration

fowler/semi-fowler position

sitting up

Bariatric Stretcher

stretcher that can support up to 1600 pounds. For very large patients

Body Mechanics

the proper use of the body to facilitate lifting and moving and prevent injury

Freedom House

• 1968-1975 • Only ambulance service that would respond to impoverished sections of the city • Among the first to treat cardiac arrest -Chest compressions -Rescue breathing -Prehospital Intubation

Dr. Ron Stewart

• 1978 - became the Medical Director of the City of Pittsburgh Department of Public Safety Bureau of EMS • Founder of the Center for Emergency Medicine • Countless awards and achievements

Stages of Stress

• 1st Alarm reaction -fight or flight • 2nd Resistance - coping • 3rd Exhaustion - loss of ability to resist or adapt to the stressor

Verbal

• A patient that is only responsive to verbal stimuli may appear lethargic when you approach the scene • As you speak loudly to the patient, they are able to respond.

Medical Resources

• ALS Backup • Supervisor Response • Additional Units • Bariatric Unit

Secondary Assessment of Medical Patients

• AMS/Unresponsive - Rapid Medical Exam - Patient environment • Alert & Oriented, Specific Complaint - Chief Complaint - Physical Exam

Physical Traits of a Good EMT

• Ability to lift and carry equipment and patients • Good eyesight (distance and reading) and color vision • Good communication skills (oral and written)

Inhalation

• Active process • Muscles contract, size of chest increases • Negative pressure pulls air into lungs

Types of Stress Reactions

• Acute Stress Reaction • Delayed Stress Reaction • Cumulative Stress Reaction

Airway Assessment

• Addressed immediately during patient assessment • Two questions must be answered • Is airway open? • Will airway stay open?

Lymphoid organs

• Adenoids • Tonsils • Spleen • Thymus • Nodes

Perfusion

• Adequate circulation of blood and exchange of oxygen and waste products • Hypoperfusion (shock) • When flow becomes inadequate

Consent for Mentally Incompetent Adults

• Adult patients incapable of informed decisions about care • State and local laws and protocols permit transport of such patients under implied consent

Severe Fall

• Adult: more than 20 feet • Child: more than 10 feet (2-3 times child's height) • Important factors • Height from which patient fell • Surface patient fell onto • Part of patient that hit ground • Anything that interrupted fall

Common Pulse Locations

• Central • Carotid • Femoral • Peripheral • Radial • Brachial

Respiratory Anatomy

• Air enters body through the mouth and nose. • It moves through the oropharynx and the nasopharynx .• The pharynx includes both areas. • Air moves toward the lungs • Epiglottis • Closes over glottis • Larynx • Voice box containing vocal cords • Cricord cartilage forms lower portion. • Trachea • Lungs • Bronchi • Alveoli • Diaphragm

Airway Adjuncts

• Airway position and maneuvers are short-term solutions • Airway adjunct provides longer term air channel • Two most common airway adjuncts: • Oropharyngeal airway (OPA) - Oral Airway • Nasopharyngeal airway (NPA) - Nasal Airway (Trumpet)

Assess Mental Status: AVPU

• Alert - Document orientation: person, place, time, and event • Verbal response • Painful (tactile) response • Unresponsive

Safe Haven Laws

• Allow person to drop an infant or child at any fire, police, or EMS station • States have different guidelines for ages of children included • Protect children who may otherwise be abandoned or harmed by parents unwilling or unable to care for them

Ryan White CARE Act

• Allows EMS providers to seek to determine if exposure to infectious disease has occurred • Agency's Infection Control Officer gathers facts about exposures • Officer notifies EMS provider of exposure • Agency refers EMS provider to health care professional for evaluation and follow-up

Rigid Pharyngeal Suction Tip

• Also called "YankauerTip" or "Hard" cath • Larger bore than flexible catheters • Suction only as far as you can see • Do not lose sight of distal end • Careful insertion helps prevent gag reflex or vagal stimulation

Flow-Restricted Oxygen-Powered Ventilation Device

• Also called a manually triggered ventilation device • Adults only • High pressure port on regulator • Follow same procedures for mask seal as for BVM • Trigger device until chest rises• Repeat every 5 seconds

Findings that may indicate critical patient:

• Altered mental status • Anxiety • Pale, sweaty skin • Obvious trauma to head, chest, abdomen, pelvis • Specific positions indicating distress • Patients appearing lifeless - Resuscitate by beginning CPR compressions - Prepare AED as soon as possible

Stretcher Rules

• Always have two providers holding the stretcher • Do not move around at "load" height • The person in the front steers • The person in the rear pushes

Other Additional Resources

• Any call with one more than one patient needs the additional resource of another ambulance • What other situations may require specialized resources? - Fire - Technical rescue - Hazardous materials response - Bariatric patient

Circulation

• Assess pulse • Assess skin • Assess bleeding • Signs/Symptoms of shock

General Impression

• Assesses environment, patient's chief complaint, and appearance • Helps determine patient severity • Helps set priorities for care and transport • "Look Test": feeling from environmental observations as well as first look at patient

Evaluating Respiration

• Assesses how well cardiopulmonary system is accomplishing oxygenation and carbon dioxide removal • Brain and body cells need a steady supply of oxygen • Hypoxia: low oxygen level in cells • Carbon dioxide must be continuously removed • Hypercapnea: high carbon dioxide level • Hypocapnea: low co2 level

Circulation: Skin

• Assessing skin• - "Normal" circulation: warm, pink, dry skin - Shock: pale, clammy (cool and moist) skin

Alert

• Awake, answering questions • Determine orientation - Person• Place - Time - Event • The patient who is alert and completely oriented is documented as CAOx4

Scene Size-Up

• BSI -------------------------------------------------- • Scene Safety • Nature of Illness (NOI)Mechanism of Injury (MOI) • Number of patients • Additional Resources --------------------------------------------------- • (C-spine Consideration)

Categories of Vital Signs

• Baseline vital signs: first vital signs obtained • Repeat vital signs: gain further information by establishing trends

Lower Airway

• Begins at glottic opening • Epiglottis • Trachea • Carina • Bronchial passages • Mainstem Bronchi • Bronchioles

Upper Airway

• Begins at mouth and nose • Air is warmed and humidified in nasal turbinates • Pharynx • Oropharynx, nasopharynx, and laryngopharynx • Ends at glottic opening

Nasal Cannula (NC)

• Best choice for a patient who refuses to wear an oxygen face mask or for titration • Provides oxygen concentrations of 24%-44% • Should deliver no more than 4-6 liters per minute

Skin Color

• Best places to assess skin color: • Nail beds • Inside of cheek • Inside of lower eyelids • Normal Findings: • Pink • Abnormal Findings: • Pale • Cyanotic (blue-gray) • Flushed (red) • Jaundiced (yellow) • Mottled (blotchy)

Pupils

• Black center of eye• Assess size, equality, and reactivity • Cover one eye and shine a light into other eye, repeat with other eye

Respiratory Distress

• Body compensating for a respiratory challenge and meeting metabolic needs

Skull

• Bony structure of the head • Function to enclose, protect brain

Respiratory System

• Brings in oxygen via inhalation • Excretes carbon dioxide via exhalation

Blood Pressure Monitor

• Cardiac monitor • Available on ALS ambulances • Blood pressure capabilities • Do not rely solely on automatic blood pressures

Standard of Care

• Care expected from EMT with similar training for patient in a similar situation • Meeting standard of care reduces risk of legal action • Scope of practice: what you can do • Standard of care: how you should do it

Things that make assessing pupils difficult:

• Cataracts • Color Contacts • Different Color

Nervous System

• Central nervous system • Brain • Spinal cord • Peripheral nervous system • Sensory nerves • Motor nerves • Autonomic nervous system • Involuntary motor functions

What Reassessment Identifies

• Changes (subtle and profound) • Trends - Deterioration - Improvement •all of above guide priorities!

Head Assessment (Trauma)

• Check Head • Check Face • Check Neck - Step Off - JVD - Tracheal Deviation

Trauma Extremities

• Check each extremity for DCAP BTLS - Legs - Arms • When you reach the distal portion of each extremity check: - Circulation, Sensation, and Motor function (CSM) also known as PMS (Pulse, Motor Sensation)

Circulation: Bleeding

• Check for signs of major bleeding • Gross blood sweep

Repeat Assessments

• Chief complaint may change, especially with regard to severity • Ask about changes in symptoms, especially ones anticipated because of treatments administered • Repeat physical exam to identify changes from baseline • Check any interventions

Mandatory Reporting Guidelines

• Child, elderly, or domestic abuse • Sexual assault • Stab/gunshot wounds • Animal attacks • Check local laws and protocols

Upper extremities

• Clavicle• Scapula • Acromion process • Acromioclavicular joint • Humerus • Radius • Ulna • Wrist • Carpals • Hand • Metacarpals • Phalanges are finger bones.

Oxygen Cylinders

• Come in various sizes • D—about 350 L of O2 • E—about 625 L of O2 • M—about 3,000 L of O2 • G—about 5,300 L of O2 • H—about 6,900 L of O2

Reassessment: Reassess Vital Signs

• Compare results with baseline measurements • Re-evaluate oxygen • Re-evaluate any interventions performed or in place • Document findings to record and identify trends

Pelvis Assessment (Trauma)

• Compression • Flexion Genitals • As needed based on situation and injury • Also check for Priapism

Humidifier

• Connected to flowmeter • Provides moisture to dry oxygen from supply cylinder

Is the Airway Open?

• Conscious patient • Alert • Actively talking • Crying • Unconscious patient • Look • Listen • Feel

Skeleton

• Consists of skull and spine, ribs and sternum, shoulders and upper extremities, and pelvis and lower extremities

Digestive System

• Consists of: • Stomach • Small intestine • Larges intestine • Accessory organs • Liver • Gallbladder • Pancreas • Spleen • Appendix

Thorax

• Contains the heart, lungs, and major blood vessels • The thorax protects the heart, lungs, and major blood vessels

Assessing Pulse Rate

• Count pulsations for 30 seconds and multiply by 2 • If rate, rhythm, or force is not normal, continue with count for full 60 seconds

Law Enforcement Resources

• Crime Scene • Crowd/Disorderly bystanders • Violent patient

Negative Side Effects of Positive Pressure Ventilation

• Decreasing cardiac output/dropping blood pressure • Gastric distention • Hyperventilation

Trauma Physical Examination: DCAP-BTLS

• Deformities • Contusions (brusing) • Abrasions (scrapes) • Punctures/Penetrations • Burns • Tenderness • Lacerations (open wounds) • Swelling

Venturi Mask

• Delivers specific concentrations of oxygen by mixing oxygen with inhaled air • Some have set percentage and flow rate; others have adjustable Venturi port

Flexible Suction Catheter

• Designed to be used when a rigid tip cannot be used • Come in various sizes identified by a number "French" • Larger the number, larger the catheter • Not typically large enough to suction vomitus or thick secretions • May kink • Can be passed through a tube such as the endotracheal tube • Can be used for suctioning the nasopharynx

Nature of the Call

• Determining why EMS has been called • Mechanism of injury • Nature of illness

Oropharyngeal Airway (OPA)

• Device used to move tongue forward as it curves back to pharynx • Sizes: infant to large adult

Types of Advanced Airway Devices

• Devices requiring direct visualization • ET - Endotracheal Intubation • Devices inserted "blindly" • iGel • King • LMA

Pediatric Note: Blood Pressure

• Difficult to obtain on infants and children younger than 3 years • You gain much more useful information from observations such as sick appearance, shortness of breath, or unconsciousness. • Use age/size-appropriate cuff

If in Doubt About Refusal

• Discuss decision with patient • Ensure patient understands risks • Consult medical direction • Ask to contact family member • Contact law enforcement • Listen to patient to determine why refusing care

Bronchoconstriction

• Disorder of lower airway • Smooth muscle constricts internal diameter of airway • Affects the ability to move air

Key Concerns with PPV

• Do not ventilate patient who is vomiting or has vomitus in airway—PPV will force vomitus into patient's lungs • Watch chest rise and fall with each ventilation • Ensure rate of ventilation is sufficient

Doctors of Freedom House

• Dr. Nancy Caroline • First medical director of freedom house • Dr. Peter Safar • "Father of CPR" • Trained lay people to become medics

Specific Diseases of Concern

• Ebola - Infections in 2014 in US - Hemorrhagic fever - High rates of death and lack of definitive treatment • Severe Acute Respiratory Syndrome (SARS)• - Spread through respiratory droplets • Middle Eastern Respiratory Syndrome (MERS) - Found primarily on the Arabian Peninsula • Avian flu - Found in poultry; can affect humans - Not easily transmissible from human to human • Influenza - Around for hundreds of years - 1918 pandemic killed between 30 and 50 million people around the world

Check Interventions

• Ensure adequacy of oxygen delivery and artificial ventilation • Ensure management of bleeding • Ensure adequacy of other interventions

Before Lifting

• Estimate the patient's weight • Then add the weight of the equipment • Know your own limitations • Plan and communicate with partner

Establish Danger Zone

• Evaluate hazard and restrict area based on threat level • Different hazards require different-sized danger zones

Capillary Refill

• Evaluate in patients six or younger • Press on nail bed and observe how long it takes normal pink color to return • Normal Finding: • less than 2 seconds • Abnormal Finding: • Longer than 2 seconds

When to Reassess

• Every 15 minutes for stable patient (Q15) • Every 5 minutes for unstable or potentially unstable patient (Q5) • If you believe there may have been a change in patient's condition, repeat at least primary assessment

Ventilating a Breathing Patient

• Explain procedure to patient • After sealing mask on patient's face, squeeze bag with patient's inhalation

Performing Detailed Physical Exam

• Expose patient • Work around immobilization equipment • Components similar to rapid trauma exam • More detail and focus

Skin Temperature

• Feel patient's skin with back of hand • Normal Findings: • Warm • Abnormal Findings: • Hot • Cool • Cold

Skin Condition

• Feel patient's skin with back of hand• Normal Findings: • Dry • Abnormal Findings: • Diaphoretic/Moist • Clammy

Reproductive System

• Female reproductive system- Ovaries- Uterus- Vagina • Male reproductive system- Testes- Penis

Lower extremities

• Femur • Patella • Tibia • Fibula • Ankle • Lateral malleolus • Medial malleolus

Evaluate for threat of violence

• Fighting or loud voices • Weapons visible or in use • Signs of alcohol or other drug use • Unusual silence • Knowledge of prior violence

Fire Resources

• Fire • Rescue Situations • Hazmat • Rope Rescue

Oxygen Pressure Regulator

• Flowmeter • High Pressure Port • Pressure Gauge • Nipple

Approach to the Primary Assessment

• Focus on life threats - Airway (A), breathing (B), circulation (C) - A-B-C if patient has signs of life - C-A-B if patient appears lifeless, no pulse - Immediate interventions may be needed • May vary depending on - Patient's condition - On the scene resources

The EMS Approach to Diagnosis

• Follows same steps as emergency physician - Most are abbreviated or limited. • Considers most serious conditions associated with patient - Rules them in or out • Creates a diagnosis

Blood Pressure (in terms of heart)

• Force blood exerts against the walls of blood vessels • Systolic (upper reading) • Arterial pressure when left ventricle contracts• Diastolic (lower reading) • Pressure when left ventricle refills

Mechanism of Injury

• Forces that caused the injury • Understanding forces can predict injury patterns • Can be very useful in predicting injuries associated with certain types of motor vehicle crashes

Positive Pressure Ventilation (PPV)

• Forcing air or oxygen into lungs when a patient has stopped breathing or has inadequate breathing • Uses force exactly opposite of how the body normally draws air into the lungs

Signs of Inadequate Airway

• Foreign bodies in airway • No air felt or heard (air exchange below normal) • Absent or minimal chest movements • Abnormal breathing sounds

Joints

• Formed when bones connect to other bones 2 Types: Ball and Socket, Hinge

Primary Assessment Steps

• Forming a general impression - C-Spine Decision • Assessing mental status (AVPU) • Assessing airway • Assessing breathing • Assessing circulation • Determining patient priority

Anatomy of the Heart

• Four chambers • Two atria (upper areas) • Two ventricles (lower areas) • Pathway of blood through heart • Right atrium • Right ventricle • Left atrium • Left ventricle

Integumentary System

• Functions • Protection • Water balance • Temperature regulation • Excretion • Shock (impact) absorption • Layers • Epidermis • Dermis • Subcutaneous

Steps of Primary Assessment

• General impression - C-Spine Decision • Mental status • ABCs • Priority for transport

Three main functions of the Musculoskeletal System

• Gives the body shape • Protects vital internal organs • Provides for body movement

Good Samaritan Laws

• Grant immunity from liability if person acts in good faith within level of training • Rarely applies to on-duty personnel • May not cover EMTs in some situations • Does not protect persons from gross negligence or violations of law

HIV/AIDS

• HIV • Attacks immune system, leaving patient unable to fight off infection • AIDS • Set of conditions that results when the immune system has been attacked by HIV • Lower risk for health care workers than hepatitis or TB • Contact with blood is the usual route of infection

Bag-Valve Mask (BVM)

• Handheld ventilation device • Used to ventilate patient in respiratory failure or respiratory arrest.

Things to Consider During Refusal

• Have witnesses to refusal • Inform patient that if changes mind, can call back • If possible, have friend or relative remain with patient • Document, document, document

Pediatric Trauma Exam

• Head - Do not apply pressure to fontanelles - Collisions can produce head injuries • Nose and ears - Look for blood and clear fluids - Mucus or blood clot obstructions can disrupt breathing • Neck - Proportionately larger heads increase chance of spinal cord injury - Can have spinal cord injury without spinal bone fractures • Airway - Keep infant's head in neutral position - Keep child's head in neutral-plus or sniffing position • Chest - Check for even breath sounds - Check for symmetry, bruising, paradoxical movement, and retraction • Abdomen - Note rigid or tender areas and distention - Injury that impedes movement of diaphragm can compromise breathing • Pelvis - Check stability of pelvic girdle • Extremities - Capillary refill and distal pulse - Check for painful, swollen, and deformed injury sites

Up and Over Injury Pattern

• Head on Collision • Head hits windshield • Starring/Spidering • Chest/abdomen strike steering wheel

Down and Under Injury Pattern

• Head on collision • Knees strike dashboard • Concern for major bleeding

Cardiovascular System

• Heart • Blood • Blood vessels

Nervous System Exam

• History - Determine patient's mental status. - Determine patient's normal state of mental functioning. - Obtain history of neurologic conditions. - Note patient's speech. • Physical Exam - Perform a stroke scale. - Check peripheral sensation and movement. - Gently palpate the spine. - Check extremity strength. - Check patient's pupils for equality and reactivity. - Examine the patient's gait. - Get a blood glucose level

Endocrine System Exam

• History - Diabetes mellitus or thyroid disease history - Current medications and whether being taken properly - Whether patient has eaten or exerted energy at an unusual level - Whether patient is sick - Whether patient has taken blood glucose or uses insulin pump • Physical Exam - Evaluate patient's mental status. - Observe the patient's skin. - Obtain a blood glucose level. - Look for an insulin pump. - Look for medical jewelry.

Cardiovascular System Exam

• History - Existing cardiac conditions and medications - Signs and symptoms of episode - Description of chest pain using OPQRST - Determine specific characteristics of discomfort • Physical Exam - Look for signs condition may be severe. - Obtain pulse. - Obtain blood pressure. - Note pulse pressure. - Look for jugular vein distention (JVD). - Palpate the chest. - Observe posture and breathing.

Respiratory System Exam

• History - Obtain history of existing respiratory conditions and medications taken for each. - Determine if medications have been taken as prescribed. - Determine if signs and symptoms of this episode match previous episodes. • Physical Exam - Mental status - Level of respiratory distress - Chest wall motion - Auscultate lung sounds - Use pulse oximetry - Observe edema - Fever

Gastrointestinal System Exam

• History - Pain or discomfort - Oral intake - History of gastrointestinal issues - Vomiting - Bowel movements • Physical Exam - Observe patient's position. - Assess the abdomen. - Inspect other parts of the gastrointestinal system. - Inspect vomitus or feces if available.

Musculoskeletal System Exam

• History - Prior injuries - Whether patient takes blood-thinning medication - Underlying diseases or conditions that make fractures more common - History to determine if a medical problem caused the traumatic injury • Physical Exam - Inspect for signs of injury, such as deformity. - Palpate areas with suspected injury. - Compare sides for symmetry. - Be alert for crepitation. - Assess patient head-to-toe if there are multiple injuries or if the patient is unresponsive.

Responsive Medical Patient

• History of present illness (HPI) OPQRST • Past medical history (PMH) SAMPLE • Focused physical exam • Baseline vital signs

Number of Patients

• How many patients present? • Are there sufficient resources on hand to care for all patients?

Moving Patients With Suspected Spinal Injury

• If a patient has the potential for a spinal injury we want to keep their spine in a straight line. • Immobilize head, neck, and spine before move, if possible

Unresponsive

• If the patient does not respond to any of the previous stimuli, they are unresponsive

Circulation: Shock

• If the patient is believed to be shock it is important to treat: - Shock position - Keep the patient warm - Deliver oxygen

Maneuvers for Opening Airways

• If the patient's airway is not open, OPEN IT!!! • Head-tilt, chin-lift maneuver • jaw-thrust maneuver

Pelvis

• Ilium • Ischium • Pubis • Hip joint • Acetabulum • Ball at proximal end of femur

Components of the EMS System: Allied Health Staff

• Imaging • Respiratory Therapists • Physical Therapy • Etc.

General Principles Trauma

• In all areas look for DCAP-BTLS or other abnormal findings • Communicate with patient • Assume spinal injury (apply collar) • Stop or alter assessment process to provide care (life-threatening)

Unresponsive Medical Patient

• Inability to communicate shifts initial focus from chief complaint and history taking • Begin with physical exam and baseline vital signs • Gather history from bystanders or family members • Do rapid assessment of entire body

Findings Indicating Airway Problems

• Inability to speak • Unusual raspy quality to voice • Stridor • Snoring • Gurgling

Pediatric Note: Opening the Airway

• Infants and small children often have larger occipital regions of their heads • Lying flat may cause hyperflexion of neck and airway occlusion • Evaluate need to pad behind patient's shoulders to achieve neutral airway position

Hepatitis B and C

• Infection that causes inflammation of the liver • Can live on surfaces in dried blood for several days (30+ days) • Hepatitis B (HBV) is deadly; killed hundreds of health care workers each year before vaccine was available • Hepatitis C (no vaccine yet) poses same risk.

Four risk types for EMTs:

• Inhalation • Ingestion • Absorption • Injection

Respiratory Physiology

• Inhalation (active process) • Diaphragm and intercostal muscles contract; diaphragm moves downward, and ribs move upward and outward. • Negative pressure pulls air into lungs. • Exhalation (passive process) • Diaphragm and intercostal muscles relax. • Positive pressure pushes air out of lungs. • Ventilation • Movement of gases to and from alveoli • Respiration • Exchange of gases between cells and bloodstream

Need for Priority Transport

• Initiate priority transport if a life-threatening problem cannot be controlled or threatens to recur • Continue assessment and care en-route

Blunt-Force Trauma

• Injury caused by a blow that strikes body but does not penetrate skin or other body tissues • Signs are often subtle and easily overlooked • Maintain index of suspicion based on mechanism of injury

Breathing

• Is the patient breathing? • Is the breathing adequate? • Is the patient hypoxic? • Are there any injuries affecting breathing?

Reaching

• Keep back in locked-in position • Avoid twisting while reaching • Avoid reaching more than 15-20 inches in front of body • Avoid prolonged reaching when strenuous effort is required

Dental Appliances

• Leave in place during airway procedures when possible • Partial dentures may become dislodged during an emergency • Be prepared to remove if airway endangered

Advance Directives

• Legal document expressing patient's wishes if patient unable to speak for self - Do not resuscitate order (DNR) --POLST - Living will - Health Care Proxy -- Power of Attorney (POA) • These do not prevent the EMT from providing comfort measures

Power Lift

• Lift from a squatted position • Feet flat and shoulder width • Back straight and locked • Keep weight as close to your body as possible

Crime Scenes

• Location where crime was committed or anywhere evidence may be found • Once police have made scene safe, EMT's priority is patient care • Know what evidence is • Take steps to preserve evidence

Forming a General Impression

• Look - Patient's age, sex, and position • Listen - Moaning, snoring, or gurgling respirations • Smell - Fumes, urine, feces, vomitus, or decay

Penetrating Trauma

• Low-velocity (knife) injuries - Damage limited to area penetrated - May be multiple wounds • Medium-velocity (handgun/shotgun) and high-velocity (rifle) injuries may be anywhere in the body - Damage from the bullet itself - Damage from cavitation

Airway Management

• Make it • Open the airway using the appropriate maneuver • Check it • Check for any sign of obstruction • Keep it • How do we keep it?

Airway

• Make it, check it, keep it

Obstructions

• Many suction units are not adequate for removing solid objects • Objects may have to be removed with manual techniques: abdominal thrusts, chest thrusts, finger sweeps

Pulse Equality

• Many times it is beneficial to check a central and peripheral pulse simultaneously • This can give us important information about the patient's perfusion status • Normal Finding: • central and peripheral finding equal • Abnormal Finding: • Pulse Deficit - central pulse is greater than distal pulse

Assisting with Intubation

• Maximize oxygenation prior to procedure • Position patient in sniffing position • Cricoid pressure • Confirmation • Securing tube in place

Capnography

• Measures amount of carbon dioxide exhaled• End-tidal carbon dioxide, or ETCO2 • Normal level 35 to 45 mmHg • Indirectly indicates how well tissues are using oxygen and performing other physiological functions • Methods • Patient breathing spontaneously has special nasal cannula applied. • In the ventilated patient, a plastic "collar" fits between the bag-valve and the mask (or advanced airway).

Blood Glucose Level

• Measures quantity of glucose in the bloodstream • Measured by glucometer • Normal Finding: • 60-140 mg/dL • Abnormal Findings • Below 60 mg/dL • Above 140 mg/dL • Permission from medical direction or by local protocol is required to perform blood glucose monitoring • Monitors must be calibrated and stored according to manufacturer's recommendations

Types of Ventilation/Respiratory Problems

• Mechanics of breathing disrupted • Gas exchange interrupted • Circulation problems

Foot

• Metatarsals • Calcaneus • Heel • Phalanges • Toe bones

Consent for Children

• Minors not permitted to provide consent for treatment • Obtain from parent or legal guardian • Possible exceptions: - In loco parentis - Emancipated minors - Life-threatening illness or injury

Ethics

• Morals or standards governing actions • Not always required by law • "Golden Rule" standard • Very important in EMS • Good ethical behavior—what you do when no one is looking

Nature of the Illness

• More commonly used for medical calls • Reason patient called EMS • Essentially evaluates the chief complaint • Information may be obtained from many sources - Patient - Family and bystanders - Scene

Pulse Rhythm

• Reflects regularity • Regular when intervals between beats are constant • Irregular when intervals are not constant

Additional HPI Questions (Trauma)

• Nature of force involved • Direction and strength of force • Protective equipment used by patient • Actions taken to prevent or minimize injury • Areas of pain and injuries resulting from incident

Important Physical Findings (unresponsive)

• Neck: JVD, medical identification devices • Chest: breath sounds • Abdomen: distention, firmness or rigidity • Pelvis: incontinence of urine or feces • Extremities: pulse, motor function, sensation, oxygen saturation, medical identification devices

Focused Physical Exam (trauma)

• No significant MOI • Patient alert and oriented • Specific complaint • Areas assessed depend on injuries and chief complaint • Mechanism of injury may point to potential injuries • Three techniques: inspection, palpation, auscultation - Exposure

Pupil Equality

• Normal Findings: • Pupils are of equal size • Abnormal Findings: • Pupils are unequal

Pupil Reactivity

• Normal Findings: • Reactive to light • Constrict with light • Dilate when light is removed • Abnormal Findings: • Fixed/Non-reactive • Sluggish

Pupil Size

• Normal Findings: • Midpoint • Abnormal Findings: • Dilated • Constricted • "Blown"

Respiratory Quality

• Normal Findings: • Normal • Non-labored • Abnormal Findings: • Shallow • Labored • Noisy

Pulse Rate

• Number of beats of heart per minute • Normal Findings: Adults 60-100 beats per minute • Abnormal Findings: • Tachycardia - Too Fast • Bradycardia - Too Slow

Duty to Act

• Obligation to provide care • While on duty, EMT obligated to provide care if no threat to safety • Follow local laws and protocols • Follow own conscience

Airway Obstructions

• Obstruction may result from poor muscle tone caused by altered mental status • Foreign bodies: food, small toys • Liquids: blood, vomit • Swelling: infection, burns, allergic reaction

Suctioning

• Obvious liquids (blood, secretions, vomit) must be removed from airway to prevent aspiration into lungs • Use vacuum device to remove liquids from airway

Respiratory Failure

• Occurs when challenge overcomes compensation or compensatory steps can no longer continue • Also known as inadequate breathing • Exceptionally important to recognize; often a precursor to respiratory arrest

Tuberculosis (TB)

• Often infects lungs • Can be highly contagious • Can be spread through air • Consider precautions with any patient having productive cough

Acute Stress Reaction

• Often linked to catastrophe, Signs and symptoms develop quickly • Occurs in EMTs and patients • Normal reactions to extraordinary situation • May require immediate intervention from physician or mental health professional

Respiratory Failure: When to Intervene

• Often respiratory failure patients will be breathing and conscious • Identify signs of inadequate breathing :• Signs/Symptoms of respiratory Failure • If breathing is inadequate, immediate intervention is necessary

Abandonment

• Once care initiated, may not be discontinued until transferred to medical personnel of equal or greater training • Failure to do so may constitute abandonment

C-Spine Decision

• Once you've formed your general impression you should make a C-Spine Decision • If there is any possibility of a cervical spine injury direct another provider to hold manual c-spine

OPQRST

• Onset • Provocation • Quality • Region; Radiation • Severity • Time

Inserting OPA

• Open mouth with crossed-finger technique • Position airway with tip pointing toward roof of mouth 1. Insert until you meet resistance 2. Gently rotate airway 180°so tip is pointing down into pharynx 3. Check that flange of airway is against lips 4. Monitor patient closely

Assessing the Abdomen (trauma)

• Palpate all four quadrants • Distention • Rigidity • Tendernessr

Staging

• Parking away from the scene, until it is secure • Certain calls you will be advised to "Stage" • You can always make that decision for yourself/your crew

Exhalation

• Passive process • Muscles relax; size of chest decreases • Positive pressure created; air pushed out

Components of Secondary Assessment (Trauma)

• Patient History - Past Medical History (PMH) - History of Present Illness (HPI) • Physical Exam • Vital Signs

Components of Secondary Assessment (not trauma)

• Patient History - Past Medical History (PMH) - History of Present Illness (HPI) • Physical Exam • Vital Signs

Involuntary Transportation

• Patient considered threat to self or others • Court order • Usually requires decision by mental health professional or police officer • If patient restrained, must not risk legal liability

Refusal of Care

• Patient may refuse care or transport - Legally able to consent - Mentally competent and oriented - Fully informed of risks - Sign release form • Despite all precautions, EMT may still be held liable

Non-Urgent Move

• Patient stable • No immediate life threat • Patient can be assessed, treated, and moved in normal way • Take all required precautions not to aggravate existing conditions

Chief Complaint

• Patient's description of why EMS was called - May be specific—"abdominal pain" - May be vague—"not feeling good"

Oxygen Benefits

• Patients that are sick and injured can benefit from a higher percentage of inhaled oxygen • Can be beneficial in many situations: • Respiratory or cardiac arrest • Shock • Respiratory distress and lung diseases • Head injuries • Other serious injuries

Physical Examination Techniques

• Performed before, during, or after patient history • Three primary techniques - Observe: Look at the patient for an overall sense of patient condition - Auscultate: Listen for sounds of an abnormal condition - Palpate: Feel an area for deformities or other abnormal findings

Mouth to Mask Ventilation

• Performed using a pocket face mask 1. Open airway 2. Connect oxygen and run at 15 Lpm 3. Position mask on patient's face• Apex over bridge of nose • Base between lower lip and prominence of chin 4. Hold mask firmly in place; maintain head tilt 5. Exhale into mask port 6. Allow passive exhalation

Organ Donor

• Person with completed legal document allowing donation of organs and tissues in event of death • May be identified by family members, donor card, driver's license • Receiving hospital and/or medical direction should be advised per protocol

Tracheostomy Mask

• Placed over stoma or tracheostomy tube to provide supplemental oxygen • Connected to 8-10 Lpm

Composition of the Blood

• Plasma • More than half the volume of the blood • Red blood cells • R B Cs, erythrocytes, red corpuscles • White blood cells • W B Cs, leukocytes, white corpuscles • Platelets • Help with clotting

Good Personal Traits of an EMT

• Pleasant • Sincere • Cooperative • Resourceful • Self-starter • Emotionally stable • Able to lead • Neat and clean

Rules for Lifting

• Position feet properly • Use legs • Never turn or twist • Do not compensate when lifting with one hand

Temperature

• Possible locations: Temporal (forehead), Rectal, Oral, Tympanic (Ear), Axilla (armpit) • Normal findings: • 98.6 F or 37 C • Factors: • Time of day • Activity level • Age • Where measured

Delayed Stress Reaction

• Post-traumatic stress disorder (PTSD) • Signs and symptoms not evident until long after incident • Delay makes dealing with reaction much harder—patient may not recognize what is causing problem • Requires intervention by mental health professional

Pulse Quality

• Pressure of pulse wave as it expands artery • Normal Findings: Strong • Abnormal Findings: • Thready—when pulse feels weak and thin • Bounding - when the pulse feels abnormally strong

Pulse (in terms of Heart)

• Pressure wave of blood flowing down an artery when the left ventricle contracts • Can be felt by compressing an artery over a bone

Confidentiality

• Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) • Information on patient's history, condition, treatment considered confidential • Can be shared with other health care personnel as part of patient's continuing care • Otherwise must be obtained through subpoena

Ventilation

• Process of moving air into and out of chest

Endocrine System

• Produces hormones that regulate many body activities and functions • Pancreas • Adrenal glands- Secrete epinephrine

Assisting with a Trauma Intubation

• Provide manual in-line stabilization throughout procedure • Position hands to hold stabilization, but allow for movement of jaw

Automatic Transport Ventilator (ATV)

• Provides automated ventilations • Can adjust ventilation rate and volume • Provider must assure appropriate respiratory rate and volume for patient's size and condition

What are the Vital Signs?

• Pulse (HR) • Respiration (RR) • Skin color, temperature, and condition • Capillary refill (in infants and children) • Pupils • Blood pressure • Oxygen Saturation (Not very accurate)

PEARL

• Pupils are Equal And Reactive to Light

Pushing or Pulling

• Push, don't pull • Back locked in • Line of pull through center of body • Weight close to body • When weight is below waist, use kneeling position • Avoid pushing or pulling overhead • Elbows bent, arms close to sides

The Emergency Medicine Approach to Treatment

• Quickly rule out or treat immediate life threats. • Gather information from patient, family, friends. • Perform physical exam. • Focus on ruling out worst-case scenario. • Red flags suggest serious problem. • May be responsible for multiple patients • Must be very efficient -Be available for another call as soon as possible. • Work in uncontrolled environment • Limited tools and skill set • Narrow educational focus

Pulse Reporting

• Rate • Quality • Regularity • Equality

Reassessment: Repeat Primary Assessment

• Recheck for life-threatening problems • Reassess mental status • Maintain open airway • Monitor breathing (rate and quality) • Reassess pulse (rate and quality) • Monitor skin color and temperature • Re-establish patient priorities

Respiratory Rhythm

• Reflects regularity • Normal Findings: • Regular when intervals between beats are constant • Abnormal Findings • Irregular when intervals are not constant

Scope of Practice

• Regulations and ethical considerations that define extent or limits of job duties • May include skills and procedures • Determined by national, state, local laws, statutes, and protocols

Signs of Respiratory Distress

• Relatively normal mental status • Relatively normal oxygen saturation and end tidal carbon dioxide • Relatively normal skin color • Shortness of breath • Increased respiratory rate and heart rate • Accessory muscle use and position changes

Reassessment: Observing Trends

• Repeat reassessment steps frequently. • Notice and document trends. • Trending - Changes in a patient's condition over time • Trends may indicate new treatments or adjustments to ongoing treatments.

Urgent Move

• Required treatment can be performed only if patient is moved • Patient's condition rapidly deteriorating • Performed with precautions for spinal injury

Situations calling for breathing assistance:

• Respiratory arrest • Not alert, inadequate breathing • Some alertness, inadequate breathing • Adequate breathing, but signs suggesting respiratory distress or hypoxia

Cumulative Stress Reaction

• Results from years of sustained low-level stressors • Early signs: vague anxiety, emotional exhaustion • Progresses to physical complaints, loss of emotional control, depression • May present as severe withdrawal or suicidal thoughts requiring long-term psychological intervention

Pediatric Airway Assessment

• Retractions • Nasal flaring • Anatomical Differences • Smaller mouth and nose • Larger tongue • Narrow, flexible trachea

Additional Questions

• SAMPLE(R) - Risk Factors • OPQRST - AS/PN - Associated Signs - Pertinent Negatives

Auscultation

• Select and position cuff • Palpate brachial artery at crease of elbow • Position stethoscope over brachial pulse • Close the bulb valve and squeeze the bulb to inflate the cuff • Listen and inflate until gauge reads 30 mm higher than the point the pulse sound disappeared • Slowly release air from cuff• When you hear the first sounds, note the reading on gauge, that is the systolic pressure• Continue to deflate cuff • When sounds turn to dull, muffled thuds, and stops the reading on the gauge is diastolic pressure

Signs of hypoxia or hypercapnea

• Shortness of breath (symptom) • Increased respiratory rate and depth • Increased heart rate • Changes in level of consciousness • Restlessness • Cyanosis (bluish color on lips and nailbeds) • Chest pain

SAMPLE

• Signs and symptoms • Allergies • Medications • Pertinent past history • Last oral intake • Events leading to the injury or illness

Signs of Respiratory Failure

• Signs of respiratory distress with evidence that compensation is no longer effective • Signs of poor oxygenation and/or poor removal of CO2 • Signs of decompensation • No or poor air movement • Diminished or absent breath sounds • Breathing rate too rapid, too slow, or irregular • Patient unable to speak • Unusual noises (wheezing, crowing, stridor, snoring, gurgling, gasping)

Medical Patient Rapid Physical Exam

• Similar to physical exam for trauma patient • Assess head, neck, chest, abdomen, pelvis, extremities, and posterior • Consider ALS backup

Nasopharyngeal Airway (NPA)

• Soft, flexible tube inserted through nostril and into hypopharynx • Moves tongue and soft tissue forward to provide a channel for air • Can be used in patients with intact gag reflex or clenched jaw • Come in various sizes • Typical adult sizes: 34, 32, 30, and 28 French

Negligence

• Something was not done, or was done incorrectly • Must prove: - EMT had duty to act - Breach of duty—EMT failed to provide standard of care expected or failed to act - Proximate causation—patient suffered harm because of EMT action or inaction • Negligent EMT may be required to pay damages • Res ipsa loquitur (the thing speaks for itself): legal concept important in negligence cases - the occurrence of an accident implies negligence.

Determining Patient Priority

• Stable - No threats to ABCs found - General impression not concerning • Potentially unstable - Potential for deterioration can indicate potentially unstable category • Unstable - Threat to ABC's

Chest (Upper Torso) Assessment (Trauma)

• Start at clavicle • Check sternum • Apply C-collar • Complete sternum • Check High and Wet • Check for Paradoxical motion • Crepitation

Two-Rescuer BVM Ventilation

• Strongly recommended by American Heart Association (AHA) • Most difficult part of BVM ventilation is obtaining adequate mask seal, hard to maintain seal while squeezing bag • One rescuer squeezes bag; other rescuer maintains seal • Can be used with head-tilt chin-lift. • If trauma is suspected, change hand placement to bring jaw upward toward mask, without tilting head or neck

Pathophysiology

• Study of how disease processes affect function of body

Suctioning Techniques

• Suction no longer than 10 seconds at a time • Prolonged suctioning can cause hypoxia and bradycardia • If patient vomits for longer than 10 seconds, continue to suction • In the event of copious, thick secretions consider removing tip or catheter and using large bore, rigid suction tubing • Place tip or catheter where you want to begin suctioning • Suction only on the way out • Move catheter from side to side

Suction Device Requirements

• Suction units must be tested at the start of each shift • Must generate vacuum of no less than 300 mmHg when collecting tube is clamped

Artificial Ventilation of a Stoma Breather

• Surgical opening in the neck • Clear mucus plugs or secretions common • Leave head and neck in neutral position • Use pediatric-sized mask to establish seal around stoma • If unable to artificially ventilate through stoma, seal stoma and attempt artificial ventilation through mouth and nose

Respiratory Compensation

• The body goes through three specific stages when respiratory compensation is needed: • Respiratory Distress • Respiratory Failure •Respiratory Arrest

Blood Pressure

• The force against the walls of the blood vessels • Systolic: the pressure when the heart is contracting • Diastolic: the pressure when the heart is relaxed • Change is more significant than one measurement (trending) Normal Findings: • Systolic no greater than 120 mmHg • Diastolic no greater than 80 mmHg Abnormal Findings: • Hypertension: high blood pressure • Hypotension: low blood pressure

Oxygen Saturation (SpO2)

• The ratio of the amount of oxygen present in the blood to the amount that could be carried • Measured using a pulse oximeter • Normal Finding • 94%-100% • Accuracy of reading can be affected by: • Decreased circulation to the finger • Carbon monoxide • Excessive movement • Nail polish • Anemia

Spinal column

• Thirty-three vertebrae • Essential for movement, sensation, and vital functions

Circulation: Pulse

• Three results of assessing pulse - Within normal limits - Unusually slow - Unusually fast- - Not at all

Emergency Move

• Three situations may require the use of an emergency move: • Hazardous scene • Care of life-threatening conditions that require repositioning • The necessity to reach other patients .• Should only be used only when absolutely necessary • Try to move the patient in line with the long axis of the spine

Alveoli

• Tiny sacs in grapelike bunches at the end of the airway • Surrounded by pulmonary capillaries • Oxygen and carbon dioxide diffuse through pulmonary capillary membranes

Components of the EMS System: Specialized Care Facilities

• Trauma centers • Burn centers • Stroke centers • Cardiac centers • Labor and delivery • Pediatrics

Immediate Intervention ABC

• Treat any life-threatening ABC problem as soon as discovered!

Detailed Physical Exam

• Typically completed en route to hospital • Gathers additional information • Complements primary and secondary assessments • Performed after all critical interventions completed • Primary assessment re-evaluated again before initiating

Renal System

• Urinary system • Helps the body regulate fluid levels, filter chemicals, and adjust body pH • Kidneys- Principal organs • Bladder- Fluid reservoir for urine • Ureters- Transport urine to bladder from kidneys • Urethra- Excretes urine from the bladder to external environment

Rules for Using Airway Adjuncts

• Use OPA only on patients not exhibiting gag reflex • Open patient's airway manually before using adjunct device • When inserting airway, take care not to push patient's tongue into pharynx • Have suction ready • Do not continue inserting airway if patient gags • Maintain head position after adjunct insertion • Patient may regain consciousness • Be prepared to remove adjunct and have suction ready • Use infection control practices while maintaining airway

Ventilating with a BVM

• Use an E-C Clamp on the face mask • Supply of 15 Lpm O2 attached and enters reservoir • Squeeze the bag until chest rise• When released, passive exhalation by patient occurs

Oxygen Safety

• Use pressure gauges, regulators, and tubing intended for use with oxygen • Use non-sparking wrenches • Replace disposable gaskets each time a cylinder is changed • Properly secure oxygen cylinders in a cool, ventilated space • Never drop cylinder or move by dragging • Never leave cylinder in upright position without being secured • Never allow smoking around oxygen or use oxygen equipment around open flame • Never use grease or adhesive tape on a cylinder • Test cylinders hydrostatically every 5 years

Pediatric Note: Inserting OPA

• Use tongue depressor or rigid suction tip and insert OPA directly • Do not rotate into place

Urgent Move: Onto Long Spine Board

• Used if immediate threat to life and suspicion of spine injury • Place spine board next to body; log-roll onto board • Lift onto stretcher • Secure to stretcher; load into ambulance

Palpation

• Used in noisy environments • When palpating a blood pressure you will only receive a reading for the systolic blood pressure • 120/P • Position cuff and find radial pulse • Inflate until gauge reads 30 mm higher than the point the pulse disappeared • Slowly deflate cuff • Note reading when radial pulse returns (systolic pressure)

Radial Pulse

• Used in patients older than 1 year • Found by placing first two fingers on thumb side of patient's wrist just above the crease

Brachial Pulse

• Used in patients younger than 1 year • Found by placing three fingers on patient's anterior upper arm (between bicep and triceps muscle) just distal to armpit

Painful

• Uses tactile stimuli • This patient may have a response such as withdrawing or localizing the pain

Assessing Breathing

• Ventilation: the process of inhaling and exhaling • Respiration: the exchange of gases • Between the alveoli and blood • Between the blood and the cells

Ventilating the Intubated Patient

• Very little movement can displace an endotracheal tube • Compliance • Pay attention to resistance to ventilations; report changes

Partial Rebreather Mask

• Very similar to nonrebreather mask • No one-way valve in opening to reservoir bag • Delivers 40%-60% oxygen at 9-10 Lpm • Also called a "simple mask"

Muscles

• Voluntary (skeletal)• Involuntary (smooth) • Cardiac • Automaticity • Heart has ability to generate and conduct own electrical impulses

Respiratory Arrest

• When breathing completely stops.

Respiration

• With regard to vital signs, respiration means the act of breathing in and out • Measurement includes rate, rhythm, and quality

Placement of Blood Pressure Cuff

• Wrap cuff around patient's upper arm • Cuff should cover two thirds of upper arm • Lower edge of cuff placed about 1 inch above crease of elbow

Critical Incident Stress Management (CISM)

• a comprehensive system that includes education and resources to both prevent stress and to deal with stress appropriately when it occurs • CISD: Critical Incident Stress Debriefing

Diagnosis

• label for condition • Based on history, physical examination, vital signs • Involves both physical and intellectual activity *EMTs cannot actually diagnose*

Respiratory Rate

• number of breaths the patient takes in 1 minute • Count number of breaths taken over 30 seconds and multiply by 2 • Normal Findings: (adult at rest) 12-20 breaths per minute • Rates above 24 breaths per minute (rapid) or below 8 breaths per minute (slow) are potentially serious findings • Age, sex, size, physical conditioning, and emotional state influence breathing rates

Nonrebreather Mask

•Best way to deliver high concentrations of oxygen to a breathing patient • Provides oxygen concentrations of 80%-100% • Minimum flow rate 8 Lpm • "Normal" flow rate 12-15 Lpm

Lymphatic System Functions

•Capture fluid •Maintain balance of fluid

The Patient History

•History of the present illness (HPI) - Information gathered regarding the symptoms and nature of the patient's current concern - Obtained using OPQRST • Past medical history (PMH) - Information gathered regarding the patient's health problems in the past - Obtained using SAMPLE