RC health services final exam

Understand how epinephrine can affect the nervous system

During the fight-or-flight response the sympathetic nervous system sends commands to the adrenal glands to secrete epinephrine and norepinephrine. Epinephrine improves the ability of the heart to cope with stress

Anatomical position Fowler Supine Prone Recovery

Fowler: sitting position Supine: laying flat on back Prone: laying flat on stomach Recovery: laying on the side

Generic name: Epinephrine Trade name: Epipen

Action: stimulates nervous system, causing bronchodilation Indications: Anaphylactic reaction Contraindications: chest pain of cardiac origin, hyperthermia, hypertension Routes: IM Side effects: hypertension, tachycardia, anxiety, restlessness Interactions: increases effects of other nervous system stimulants Adult dose: 0.5 mg for adults; 0.15 mg for children Administration concerns: medications will last approximately 5 minutes; do not repeat dose; ensure ALS is en-route for continuing treatment

Chapter 22: Understand how to assess and manage psychiatric emergencies: Acute psychosis, Suicidal patients, Agitated delirium

Acute psychosis: a state of delusion in which the person is out of touch with reality. Affected people live in their own reality of ideas and feelings. To the person experiencing a psychotic episode the line between reality and fantasy is blurred. That reality may make patients belligerent and angry towards others. Patients may become silent and withdrawn as they give all their attention to the voices and feelings within. Psychotic episodes occur for many reasons; the use of mind-altering substances is one of the most common causes, and that experience may be limited to the duration of the substance within the body. Other causes include intense stress, delusional disorders, and more commonly, schizophrenia. Some psychotic episodes last for brief periods; other last a lifetime. Dealing with a psychotic patient is difficult. The usual methods of reasoning with a patient are unlikely to be effective because the psychotic person has his or her own rules of logic that may be quite different from nonpsychotic thinking. Follow these guidelines in dealing with a psychotic patient: -Determine if the situation is a danger to yourself or others. -Clearly identify yourself. ("I'm Gloria. I'm and EMT with the ambulance service, and this my partner, Stan. We've come to see if we can help. Can you tell us what is happening?") -Be calm, direct, and straightforward. Your composure and confidence can do a great deal toward calming the patient. -Maintain an emotional distance. Do not touch the patient, and do not patronize the patient or be effusively reassuring. -Do not argue. Do not challenge patients regarding the reality of their beliefs or the validity of their perceptions. DO not go along with their delusions simply to humor them, and not make an issue of the delusions. Talk about real things. -Explain what you would like to do. ("Let's walk downstairs to the ambulance.") -Involve people the patient trusts, such as family or friends, to gain the patient's cooperation Excited Delirium: also known as agitated delirium or exhaustive mania. Delirium is a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions. Agitation is a behavior characterized by restless and irregular physical activity. Although patients experiencing delirium are generally not dangerous, if they exhibit agitated behavior they may strike out irrationally. One of the most important factors to consider in these cases is your personal safety. -The symptoms of agitated delirium may include hyperactive irrational behavior with possible vivid hallucinations, which can create the potential for violent behavior. Common physical symptoms include hypertension, tachycardia, diaphoresis, and dilated pupils. Because hallucinations are erroneous perceptions of reality, the patient may perceive you as a threat. Agitation is recognized as a biologic attempt to release nervous tension and can produce sudden, unpredictable physical actions in your patient. -If you think you can safely approach the patient, be very calm, supportive, and empathetic. Be an active listener by nodding, indicating understanding, and by limiting your interruptions of the patient's comments. It is extremely important to approach the patient slowly and purposefully and to respect the patient's personal space. Limit physical contact with the patient as much as possible. It is also imperative that you do not leave the patient unattended, unless the situation becomes unsafe for you or your partner. -Use careful interviewing to assess the patient's cognitive functioning. Try to indirectly determine the patient's orientation, memory, concentration, and judgement by asking simple questions such as "When did you first begin to notice these feelings?" Through interviewing, try to determine what the patient is thinking. Are the patient's thoughts disorganized? For example, does the patient begin to answer your question and then drift off only to begin discussing a childhood friend? Is the patient experiencing delusions or hallucinations? Does the patient have an unusual worries or fears? For example, does the patient express anxiety if you go to close to a pile of old newspapers? -Pay particular attention to the patient's ability to communicate clearly, and make notes on the patient's apparent mood. Is the patient anxious, depressed, elated (extremely happy or joyful), or agitated? Pat attention to the patient's appearance, dress, and personal hygiene. -If the patient appears to be experiencing a drug overdose, take all medication bottles or illegal substances with you to the medical facility. The patient should be transported to a hospital with psychiatric facilities capable of handling the condition. Whenever possible, refrain from using lights and sirens, because bright lights and loud sounds may aggravate the patient's condition. -If the patient's agitation continues, request ALS assistance so chemical restraint can be considered. Uncontrolled or poorly controlled patient agitation and and physical violence can place the patient at risk for sudden cardiopulmonary arrest. Physical agitation can lead to sudden death, thought to result from metabolic acidosis. Physical control measures (including TASERs) can contribute to sudden death in the patient's. Also, this condition can be worsened by stimulant drugs (eg, cocaine) or alcohol withdrawal. Finally, positional asphyxia occurs when a patient's physical position restricts chest wall movements or causes airway obstruction. It can also cause sudden death. Suicide: the most significant risk factor that contributes to suicide is depression. Anytime you encounter an emotionally depressed patient, you must consider the possibility of suicide. The risk factors for suicide are: -Depression at any age, feeling trapped or purposeless -Previous suicide attempt (about 80% of successful suicides were preceded by at least one prior attempt) -Current expression of wanting to commit suicide or sense of hopelessness. -Specific plan for suicide -Family history of suicide -People older than 40 years, particularly if single, widowed, divorced, alcoholic, or depressed (Men who are older than 55 have an especially high risk and are very often successful if they if they make an attempt.) -Recent loss of spouse, significant other, family member, or support system -Chronic debilitating illness or recent diagnosis of serious illness -Feeling anxious, agitated, angry, reckless, or aggressive; also dramatic mood changes such as from depression to agitation. -Financial setback, loss of job, police arrest, imprisonment, or some sort of social embarrassment -Alcohol and substance abuse, particularly wit increasing use. -Children of an alcoholic or abusive parent -Withdrawal from family and friends or a lack of social support, resulting in isolation -Significant anniversaries of sentinel events -Unusual collection of acquisition of things that can cause death, such as a gun, a large volume of pills -It is a common misconception that people who threaten suicide never commit it. Suicide is a cry for help. Threatening suicide is an indication that someone is in a crisis that he or she cannot handle alone. Immediate intervention is necessary. - Whether the patient has any of these risk factors, you must be alert to follow the warning signs: -Does the patient have an air of tearfulness, sadness, deep despair, or hopelessness that suggests depression? -Does the patient avoid eye contact, speak slowly or haltingly, and project a sense of vacancy, as if he or she really is not there -Does the patient seem unable to talk about the future? Ask the patient whether he or she has any vacation plans. Suicidal consider the future so uninteresting that they do not think about it; people who are seriously depressed consider the future so distant that they may not be able to think about it at all. -Is there any suggestion of suicide? Even vague suggestions should not be taken lightly, even if presented as a joke. If you think that suicide is a possibility, do not hesitate to bring up the subject. You will not give the patient ideas if you ask directly, "Are you considering suicide?" -Does the patient have any specific plans related to death? Has the patient recently prepared a will? Has the patient given away significant possessions or told close friends what he or she would like done with them? Arranged for a funeral service? These are critical warning signs. -Consider also, the following additional risk factors for suicide: -Are there any unsafe objects in the patient's hands or nearby (a sharp knife, glass, poisons, or a gun)? -Is the environment unsafe (an open window in a high-rise building, a patient standing on a bridge or precipice)? -Is there evidence if self-destructive behavior (partially cut wrists, excessive alcohol or drug use)? -Is there an imminent threat to the patient or others? -Is there an underlying medical problem? -Are there cultural, religious, or social beliefs promoting suicide? -Has there been trauma? -On the basis of your observations and conversations with the patient, you may need to determine in interventions such as restraints are needed. Remember, a suicidal patient may be homicidal as well. Do not jeopardize your life or the lives of your partners. If you have reason to believe that you are in danger, you must obtain police intervention. In the meantime, try not to frighten the patient or make him or her suspicious. Remember, the most important service you can provide for a suicidal patient is compassionate transportation to a medical facility where the patient can receive proper treatment.

Understand the difference between a living will and a healthcare directive

An advanced directive is also known as a living will or healthcare directive

Understand how and AED works and when to use it

An automated external defibrillator (AED) is a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation and pulseless ventricular tachycardia,, used in cases of cardiac arrhythmias which lead to sudden cardiac arrest

Understand the pathophysiology, assessment and management of the various chest injuries.

Chest injuries -Pneumothorax: -Pneumothorax is the accumulation of air in the pleural space. This can compress lung space, prevent gas exchange, and lead to hypoxia. -Can be due to trauma or nontraumatic injury to lung tissue -Lung sounds may be diminished or absent over injured areas -Tension Pneumothorax -A tension pneumothorax causes a progressive collapsing of lung tissue -The entire lung and great vessels can be compressed to the other side of the chest. Lung sounds will be absent over the affected area. -The patient will develop severe respiratory distress and eventually respiratory failure. Compression of the great vessels can restrict blood flow, leading to shock and death. -Tracheal deviation toward the unaffected side is a late and ominous sign -Sucking chest wound (open pneumothorax) -If an open chest injury penetrates the pleural space, it can draw air during inhalation -Penetrating thoracic injuries should be covered with a three-sided occlusive dressing to prevent air from entering the chest cavity. -Hemothorax: bleeding into the pleural space. Watch for signs and symptoms of shock. Surgery is frequently required to control bleeding -Cardiac tamponade (pericardial tamponade) -Occurs when blood or other fluid accumulates in the pericardial sac and compresses the heart. -Cardiac function can be severely compromised, leading to circulatory collapse -Beck's triad (indicative of cardiac tamponade) -JVD -Muffled heart sounds -Narrowing pulse pressure (difference between systolic and diastolic pressures) -Clavicle and rib fractures -Clavicle and rib fractures can be associated with pneumothorax -Clavicle and rib fractures are common and should not be dismissed -A fracture to one of the first several ribs indicates a serious mechanism of injury. Additional injuries should be suspected -Patient may present with subcutaneous emphysema. Subcutaneous emphysema is a "crackling" sensation upon palpation due to air escaping into the fatty tissue. -Flail chest -Occurs when a portion of the thorax becomes separated from the rest of the thorax -Caused by the fracture of at least two consecutive ribs in two or more places. It can also occur if the sternum becomes separated from the rib cage. -The patient may exhibit paradoxical motion of the separated chest wall. Paradoxical motion occurs when a potion of the chest wall appears to move in the opposite direction of the rest of the thoracic cage. -Patients with a suspected flail chest and inadequate breathing should be ventilated with a BVM and high-flow oxygen. Ensuring adequate ventilation is a higher priority than applying a bulky dressing to the thorax. Assessment: During the primary assessment, you must quickly identify and treat potential life threats and determine priority of patient care and transport. Life-threatening hemorrhage, when present, should be addressed immediately, even before airway concerns. -Note the patient's LOC. Responsive patient's may be able to tell you their chief complaint. Note not only what they say, but also how they say it. Difficulty speaking may indicate several problems, and chest injury is an important one. Perform a rapid physical examination of the patient. Look for obvious injuries, the appearance of blood, and difficulty breathing. Look for cyanosis, irregular breathing, and chest rise and fall on only one side. Observe the neck, looking for accessory muscle use while breathing; also look for extended or engorged jugular veins. If no obvious problems are seen, begin looking for them by focusing on the ABCs. The initial general impression will help you develop an index of suspicion for serious injuries and determine your sense of urgency for medical intervention. History taking: Once you have identified and treated life threats, you can move on to gathering a history from the patient. If you have not yet done so, determine an investigate the patient's chief complaint and further investigate the MOI. Identify any associated sign and symptoms and pertinent negatives. If the patient was assaulted with a blunt object such as a bat, further evaluate the spinal region for injury, because the force may have been transferred through the body from the point of impact. Secondary Assessment: In a patient who has and isolated injury to the chest, such as in a stabbing, you should focus your assessment on the isolated injury the patients chief complaint, and the body region affected. Ensure that wounds are identified and bleeding is controlled. Note the location and extent of the injury. Assess all underlying systems. Examine the anterior and posterior aspects of the chest wall, and be alert to changes in the patient's ability to maintain adequate respirations. -It is important in patients with a chest injury not to focus only on a chest wound. With significant trauma, you should quickly assess the entire patient from head to toe. Reassessment: This identifies how your patient's condition is changing. It should focus on repeating the primary assessment, reassessing the chief complaint, and reassessing intervention performed. Reevaluate the patient's airway, breathing, pulse, perfusion, and bleeding. Other interventions should be assessed to determine if they are effective. Reassess vital signs and compare them to vital signs taken earlier. Vital signs must be reassessed frequently to be able to trend the patient's status and determine if they are compensating versus decompensating. -Provide appropriate spinal immobilization of any patient who as blunt trauma with suspected spinal injuries. Maintain and open airway, be prepared to suction the patient, and consider an oropharyngeal or nasopharyngeal airway. If significant bleeding is visible, you must control the bleeding. Whenever you suspect significant bleeding, provide high-flow oxygen. If needed, provide assisted ventilation using a BVM with high-flow oxygen.

Understand situation awareness

Practice situational awareness. Situational awareness is the ability to understand and react to the threats around you. Remember, that scenes are dynamic, and be alert for changing situations. Consider weather and environmental conditions, and always be aware of traffic, patient's, and bystanders.

Understand signs, symptoms, adventitious breath sounds associated with specific respiratory diseases Wheezes Rhonchi Crackles Stridor Decreased or absent breath sounds

Seen in picture listed (Table 15-5 in book)

Chapter 9: Scene size up, Understand situational awareness and how to protect your own safety

Situational awareness is paying attention to the conditions and people around you and knowing the dangers that these conditions or people may cause. Situational awareness is necessary throughout the entire call to maintain safety. Make sure the path to the patients is free of and compromising obstacles, such as mud, water, or vehicles. Wear a high visibility vest to ensure safety on the roadway. Place yourself between the patient and any possible weapons they may use to harm you.

Understand the common signs of acute radiation toxicity.

Signs and symptoms of acute radiation sickness include nausea, vomiting, diarrhea, fever, headache, and sick lesions.

Understand signs and symptoms

Signs are objective conditions that you can observe or measure. Symptoms are subjective and are experienced by the patient

Understand the pathophysiology and progression of shock

In the early stages of shock, the body will try to compensate and maintain homeostasis. However, as shock progresses, blood flow eventually slows and ceases. This inadequate state of oxygen and nutrient delivery to the cells of the body causes organs and then organ systems to fail. If not treated promptly, shock can be fatal. the body relies on the circulatory system for adequate perfusion of blood. A number of cases can cause hypoperfusion or shock

Routes of Administration: Inhalation

Inhaling or breathing in parenteral:rapid Aerosols, fine powders, sprays

Intraosseous (IO)

Into bone Parenteral:immediate Requires drilling a needle into the outer layer of the bone. (Most often used in children)

Intranasal

Into the nose Parenteral:rapid Liquid medication pushed through a specialized device called mucosal atomizer device (MAD) administered into a nostril

Intravenous (IV)

Into vein parenteral:immediate Injected directly into vein

Chapter 1: Level of government responsible for EMS regulation regarding EMT requirements and violations

Licensure of EMTs is a state function subject to the laws and regulations of the state in which the EMT practices. At the federal level, NHTSA brings in experts to create the National scope of practice model.

Chapter 26: Understand pathophysiology, assessment and management of wounds, burns and crush syndrome

There are three types of soft tissue injuries. Any one of these conditions can cause serious illness and even death. Soft tissues are often injured because they are exposed to the environment. -Closed injuries: in which soft-tissue damage occurs beneath the skin or mucous membrane but the surface of the skin or mucous membrane remains intact. -Types of closed injuries include: -Contusion -Hematoma: a collection of blood beneath the skin -Crush injury: may be open or closed; can cause compartment syndrome -Management of closed soft tissue injuries: RICES -Rest: keep the patient as quiet and comfortable as possible -Ice: use ice or cold packs to slow bleeding by causing blood vessels to constrict and also to reduce pain -Compression: apply pressure over the injury site to slow bleeding by compressing the blood vessels -Elevation: raise the injured part just above the level of the patient's heart to decrease swelling -Splinting: immobilize a soft-tissue injury or an injured extremity to decrease bleeding and reduce pain. -Open injuries: in which there is a break in the surface of the skin or mucous membrane, exposing deeper tissues to potential contamination. -Types of open injuries include: -Abrasion: a scrape to the skin due to surface friction -Laceration: a jagged cut -Penetrating wound: puncture wound -Incision: a sharp, clean cut -Avulsion: injury caused by a flap of skin being torn partially or completely loose -Crush injury: may be open or closed -Amputation: when part of the body is severed completely from the rest -Management of an open soft tissue injury. Treatment is the same as for external bleeding. -Apply direct pressure and elevate the injured area -Apply a dressing and bandage -Continue to elevate as needed -Apply a tourniquet for uncontrolled hemorrhage -The primary assessment for a patient with a closed or open injury should focus on identifying and managing life-threatening concerns and identifying transport priority. -Check for responsiveness. If the patient is alert, ask about the chief complaint to help direct you to any apparent life threats. If the patient is not alert, determine if he/she responds to verbal or painful stimuli or if he/she is unresponsive. An unresponsive patient may indicate a life-threatening condition. Administer high-flow oxygen via a nonrebreathing mask t patients whose LOC is less than alert and oriented, treat for potential shock, and provide immediate transport to the ED. Providing high-flow oxygen may help reduce the effects of shock and assist in perfusion of damaged tissues, particularly in crush injuries. If the patient has signs of hypoperfusion, treat aggressively for shock. -Ensure the patient has a clear and patent airway. If the airway is not patent, take the necessary steps to make it clear and patent. Protect the patient from further spinal injury as you manage the airway by preventing the head and torso from moving. If the patient in unresponsive or has a significantly altered LOC, consider inserting an OPA or NPA and suction as needed. -You must quickly assess the patient for adequate breathing. Inspect and palpate the chest wall for DCAP-BTLS. If a soft-tissue injury is discovered on the chest wall or abdomen, auscultate for clear and symmetric breath sounds, and look at the structure of the chest wall to ensure equal expansion and rise an fall of the chest. Then provide high-flow oxygen, or provide assisted ventilations using a bag-valve mask (BVM) as needed, depending on the LOC and if the patient is breathing inadequately. -Open soft-tissue injuries of the face and neck have a potential to interfere with the effectiveness of the airway and breathing. Evaluate the patient's voice and ability to speak to identify throat injuries. If an open injury is found on the chest, evaluate for air movement through the wound in the form of bubbling or sucking sounds, which indicate a deep penetrating injury. Assess the patient's back for injuries that might need treatment as well. Quickly place an occlusive dressing over the wound. Provide high-flow oxygen or assisted ventilations with a BVM as needed, depending on the patient's LOC and on the adequacy of the patient's breathing. Monitor the patient for signs of increasing respiratory distress that may require you to relieve pressure built up under the dressing (caused by a pneumothorax). -Quickly assess the patient's pulse rate, rhythm, and quality; determine the skin condition, color, and temperature; and check the capillary refill time. These assessments will help you determine the presence of circulatory problems or shock. Closed soft-tissue injuries may not always have visible signs of bleeding because most of the bleeding is occurring inside the body. Your assessment of the pulse and skin will indicate how aggressively you need to treat your patient for shock. -Determine whether your patient needs immediate transport or stabilization on scene. If the patient you are treating has an airway or breathing problem or signs and symptoms of shock or internal bleeding, you must consider rapid transport to the hospital for treatment or request ALS support. Also if you identify conditions that have the potential to become unstable, such as a distended abdomen or femur fractures, the patient requires rapid and immediate transport. -You should also consider whether transport to the closest hospital is appropriate or whether the patient would be better served by transport to a trauma center that might be further away. In some situations it may be appropriate to request aeromedical transport to expedite transfer to a trauma or specialty center. Each consideration requires that you clearly and completely understand your local resources and protocols -Burns: in which the soft-tissue damage occurs as a result of thermal heat, frictional heat, toxic chemicals, electricity, or nuclear radiation. The severity of burns ranges from severe to minor (discussed in next question). -Thermal burns: caused by heat, such as from water, steam or fire. Management of thermal burns include: - Stop the burning process with a moist sterile burn sheet until skin is no longer hot to the surface. -Replace moist burn sheets with dry sterile burn sheets to reduce risk of hypothermia and infection. -Remove clothing that may be trapping heat -Remove jewelry since massive swelling is likely -Treat for shock as needed -Things to remember when managing electrical burn patients include: -Assess scene safety first. Do not attempt to remove patient from an electrical source without proper training. -Significant unseen injury may have occurred between entrance and exit points on the body. -Electrical burn patients are at high risk of respiratory and cardiac arrest. -All electrical injury patients require transport and evaluation by a physician. -Management for chemical burns include: -Eyes and respiratory system are at high risk for chemical burn injury. -Assess scene safety first. Do not risk exposure without proper training and personal protective equipment. -If safe to do so: -remove contaminated clothing, jewelry, etc. -brush off any dry chemical on skin. -irrigate patient with large amounts of water. -avoid contaminating unaffected areas with runoff. -Treat as thermal burn -The primary assessment includes a rapid exam of the patient to identify and manage life-threatening concerns and to assist with transport decisions. The primary assessment begins when you approach the patient and form a general impression. -Check for responsiveness using the AVPU scale. Assess a patient's mental status by asking the patient about his or her chief complaint. If the patient is alert, this should help direct you to any apparent life threat. If the patient is not alert, determine if he or she responds to verbal or painful stimuli or if he or she is unresponsive. An unresponsive patient may indicate a life-threatening condition. In all patients whose LOC is less than alert and oriented, you should administer high-flow oxygen via a nonrebreathing mask and provide immediate transport to the ED. -Ensure the patient has a clear and patent airway. if the patient is unresponsive or has a significantly altered LOC, consider inserting a properly sized OPA or NPA. B alert to signs that the patient has inhaled hot gases or vapors, such as singed facial hair or soot present in or around the airway. Heavy amounts of secretions and frequent coughing may also indicate a respiratory burn. -Quickly assess for adequate breathing. Inspect and palpate the chest wall for DCAP-BTLS. Check for clear and symmetrical breath sounds and provide high-flow oxygen or provide assisted ventilations using a BVM as needed, depending on the LOC and breathing rate/quality of your patient. Burn patients are trauma patients. Evaluate and treat them for spinal injuries and airway problems concurrently. How you open the airway depends on whether a neck injury is suspected. -Quickly asses the pulse rate and quality and determine perfusion based on the patient's skin condition, color, temperature, and capillary refill time. If you see significant bleeding, take the necessary steps to control it. Significant bleeding is an immediate life threat. If the patient has obvious life-threatening external hemorrhage, control the bleeding firs (before airway and breathing); then treat the patient for shock as quickly as possible. Shock frequently develops in burn patients. Treat the shock by preventing heat loss. This is very important because the damaged skin has only a limited ability to regulate body temperature. Cover the patient with a blanket to prevent heat loss. -If the patient you are treating has an airway or breathing problem, significant burn injuries, significant external bleeding, or signs and symptoms of internal bleeding, consider rapid transport to the nearest hospital, trauma center, or burn center for treatment. Consulting with ALS providers may be appropriate for burn patients with moderate or severe burns and buns of the airway or inhalation injury. ALS providers can treat these patients with endotracheal intubation and intravenous fluids to support airway, breathing, and circulation (shock) difficulties. These can progress so rapidly that immediate ALS assistance can make the difference between life and death.

Understand trauma scoring, rapid transport and destination issues.

Trauma scoring: calculates a number from 1 to 16, with 16 being the best possible score. It takes into account the Glasgow Coma Scale (GCS) score, respiratory rate, respiratory expansion, systolic blood pressure, and capillary refill. The GCS is an evaluation tool used to determine LOC. It evaluates and assigns point values (scores) for eye opening, verbal response, and motor response; the scores are then totaled and help to effectively predict patient outcomes. The lower the score, the more severe the extent of brain injury. The trauma score relates to the likelihood of patient survival. However, this scoring system does not accurately predict survivability in patients with severe head injuries, because motor and verbal deficits make those criteria difficult to assess; in its place, the Revised Trauma Score (RTS) is used. GCS: table 24-3 in book. -Revised Trauma Score (RTS): the numeric scoring of trauma patients for determining the severity of their injury is common practice in the health care profession. When the various scoring systems were created, it was thought that the implementation of the scoring system would assist in rapidly identifying the severity of the patient's injuries. There are several different trauma scoring systems. The RTS is most commonly used for patients with head trauma because it is weighted to compensate for major head injury without multisystem injury or major physiologic changes. -The RTS is a physiologic scoring system that is also used to assess the severity of a trauma patient's injuries. Objective data used to calculate the RTS include the GCS score, systolic blood pressure (SBP), and respiratory rate (RR). In addition to assessing injury severity, the RTS has also demonstrated reliability in predicting survival in patients with severe injuries. The highest RTS a patient can receive is 12; the lowest is 0. RTS: table 24-4 in book Rapid transport: Scene time for critically injured patients should be less than 10 minutes. Call for ALS and helicopter assistance early, possibly even before you arrive on scene, to avoid delays in treatment and transport. If the patient is critically injured use the guidelines below on deciding if air or ground transportation is more appropriate: -There is an extended period required to access or extricate a remote (injured hiker, snowmobiler, or boater) or trapped patient (in a crashed car) which depletes the window to get the patient to the trauma center. -Distance to the trauma center is greater than 20 to 25 miles. -The patient needs medical care and stabilization at the ALS level, and there is no ALS-level ground ambulance service available within a reasonable time frame. -Traffic conditions or hospital availability make it unlikely that the patient will get to a trauma center via ground ambulance within the ideal time frame for best clinical outcome. -There are multiple patients who will overwhelm resources at the trauma center(s) reachable by ground within the time window. -EMS systems require bringing a patient to the nearest hospital for initial evaluation and stabilization, rather than bypassing those facilities and going directly to a trauma center. This may add delay to definitive surgical care and necessitate air transport to mitigate the impact of that delay. -There is a mass-casualty incident. Destination issues: There are different levels of trauma centers and some centers do not have the resources needed to treat the patients. -Level I: regional resource center and generally serves large cities or heavily populated areas. Level I must be capable of providing every aspect of trauma care from prevention through rehabilitation; therefore the facility must have adequate personnel and resources available. -Level II: typically located in less populated areas. They are expected to provide initial definitive care, regardless of injury severity. Because of its location and resources, a level II trauma center may not be able to provide the same comprehensive care as a level I facility. -Level III: serves communities that don't have access to a level I or II facility. level III provides resuscitation, care, and stabilization. A level III facility must have transfer agreements with a level I or II trauma center and must have protocols in place to transfer patients whose needs exceed the resources of the facility. -Level IV: typically found in remote outlying areas where no higher level of care is available. They provide advanced trauma life support prior to transfer to a higher level trauma center. Such a facility may be a clinic urgent care facility, with or without a physician.

Dysphagia

Difficulty eating or swallowing

Understand the various types of chemical/nerve/biologic agents

Chemical agents: are liquids or gases that are dispersed to kill or injure. -Vesicants (blister agents): -Cause pain, burns, and blisters to exposed skin, eyes, and respiratory tract. -Depending on the vesicant agent, the onset of signs and symptoms could be delayed several hours. -Affected areas should be irrigated with copious amounts of water as soon as possible. -Respiratory/Pulmonary agents (choking agents): -Cause lung injury -Signs and symptoms include dyspnea, cough, wheezing, runny nose, and sore throat. -Manage the airway, administer oxygen, and support ventilation as needed. -Metabolic agents (cyanides): -Cyanide interferes with the body's ability to deliver oxygen to the cells, leading to severe hypoxia and death. -Cyanide is also known as a "blood agent" -Signs and symptoms include dizziness, weakness, anxiety, nausea, tachypnea, seizures, and respiratory arrest. -Management: -Administer high-flow oxygen -Support positive-pressure ventilation as needed -There are antidotes for cyanide poisoning, but they must be administered quickly by ALS personnel. Nerve agents: among the most deadly chemical developed. They are classified as WMDs. Nerve agents are not readily available to the general public and are extremely toxic and rapidly fatal with any route of exposure. Designed to kill a large number of people with small quantities, nerve agents can cause cardiac arrest within seconds to minutes of exposure. G-agents came from the early nerve agents. There are three G-series agents, which are all designed with the same basic chemical structure with slight variations to produce different properties. The two variations of these agents are lethality and volatility. The following G-agents are listed from high volatility to low volatility: -Sarin (GB): highly volatile colorless and odorless liquid. Turns from liquid to gas within seconds to minutes at room temperature. Highly lethal, with an LD50 of about 1 drop. The LD50 is the standard measurement that represents the amount that will 50% of a population exposed to this level. Sarin is primarily a vapor hazard, with the respiratory tract as the main route of entry. This agent is especially dangerous to enclosed environments such as office buildings, shopping malls, and subway cars. When this agent comes into contact with the skin, it is quickly absorbed and evaporates. When sarin is on clothing, it has the effect of off-gassing, which means that the vapors are continuously released over a period of time (like perfume). -Soman (GD): twice as persistent, five times as lethal. It has a fruity odor as a result of the type of alcohol used in the agent and generally has no color. This agent is a contact and inhalation hazard that can enter the body through skin absorption and through the respiratory tract. A unique additive in GD causes it to bind to the cells that it attacks faster than any other agent. This irreversible binding is called aging, which makes it more difficult to treat patients who have been exposed. -Tabun (GA): approximately half as lethal as sarin and 36 times more persistent. Under the proper conditions it will remain present for several days. It has a fruity smell and an appearance similar to sarin. These components used to manufacture GA are easy to acquire, and the agent is easy to manufacture, which makes it unique. GA is a contact and inhalation hazard that can enter the body through skin absorption and through the respiratory tract. -V agent (VX): clear oily agent that has no odor and looks like baby oil. V agent was developed by the British after WWII and has chemical properties similar to the G-series agents. The difference is that VX is more than 100 times as lethal as sarin and extremely persistent. In fact, VX is so persistent that given the proper conditions, it will remain relatively unchanged for weeks to months. These properties make VX primarily a contact hazard because it lets off very little vapor. It is easily absorbed into the skin, and the oily residue that remains on the skin's surface is extremely difficult to decontaminate. Nerve agents all produce similar symptoms but have varying routes of entry. Nerve agents differ in lethal concentrations or dose and also differ in their volatility. Some agents are designed to quickly become a gas (non-persistent or highly volatile) whereas others remain a liquid for a period of time (persistent or nonvolatile). Signs and symptoms of the nerve agent exposure (SLUDGEM): -Salivation, seizures -Lacrimation (excessive tearing) -Urination -Defecation -Gastric upset -Emesis -Miosis (pupillary constriction) Management: -Aggressive airway management, including suction, and ventilatory support may be needed. -The patient will likely need specific medications to counteract the nerve agent. Get the patient to ALS providers as soon as possible. Biologic agents: -Biologic agents are used to cause disease. -Even small quantities of certain biological agents can cause disease in large numbers of people. -Signs and symptoms include fever, weakness, respiratory distress, and flu-like symptoms. -Management is based on providing supportive care for the patient's symptoms.

Understand the differences between oxygen demand and supply

-Myocardial oxygen demand: is the amount of oxygen that the heart requires to maintain optimal function. -Myocardial oxygen supply: is the amount of oxygen provided to the heart by the blood which is controlled by the coronary arteries.

Focused vs. Rapid assessment

A focused assessment is usually performed on patients who are responsive or a have a non-significant MOI. It is based on the chief complaint and what system or body part it affects. The Rapid assessment is usually less focused and performed while forming the general impression

Per os (PO)

By mouth Enteral:slow Enters blood stream through digestive tract

Chapter 5: Medical terminology Common root words Cardi Hepat Nephr Neur Psych Thorac

Cardi — heart — tachycardia — Fast heart rate Hepat — liver — hepatomegaly — enlargement of the liver Nephr — kidney — nephropathy — disease of the kidney Neur — nerves — neurologist — physician who specializes in diseases of the nervous system Psych — mind — psychology — study of the mind Thorac — chest — thoracic — pertaining to the chest or thorax

Chapter 32: Understand pathophysiology, assessment and management of environmental emergencies

Cold emergencies: - Two important systemic effects of cold on the body are vasoconstriction (to conserve heat) and an eventual slowing of metabolic rate -The body loses heat in 5 basic ways -Conduction: direct transfer of eat through contact with a colder structure. Example: bare feet on a cold floor -Convection: loss of eat to passing air. Example: standing in a cold breeze -Evaporation: loss of heat through evaporation of water from the skin. Example: getting out of the pool or shower -Respiration: in a cold environment, exhaled air has been warmed within the body. That heat is lost on exhalation -Radiation: transfer of radiant heat. Example: entering a walk-in freezer -Hypothermia -Hypothermia is a systemic cold emergency. It affects the entire body, not just an isolated area -It develops when the body's core temperature falls below that needed to maintain homeostasis. -Signs and symptoms -Note that the signs and symptoms of hypothermia get progressively more severe as the core body temperature fall. -Skin -Hypothermic patients will develop cold skin even at their core. Assess by feeling the torso, not the extremities or forehead. -Pale and/or cyanosis -Shivering -Shivering occurs early and helps increase body heat -It ceases with extreme hypothermia -Loss of coordination -Muscles begin to stiffen -Patient has difficulty speaking -Altered LOC -LOC can range from confused to coma in severe hypothermia -As mentation falters, patients may lose survival instincts and leave shelter or remove clothing -Vitals -Bradycardia, Bradypnea, and hypotension -Vitals can be so depressed, the patient appears to be in cardiac arrest even when they are not -Severe untreated hypothermia will eventually lead to coma -Management of hypothermia -Manage life-threatening conditions -Pulse check should be extended to determine if patient is in cardiac arrest or severely bradycardic -Consult local protocol regarding use of AED for hypothermic patients -Remove patient from cold environment -Remove wet clothing; prevent further heat loss -Prehospital warming is often limited to passive rewarming measures only (such as blankets). Consult local protocol and medical direction -Rewarming too rapidly can cause ventricular fibrillation -Local cold emergencies -Those parts of the body exposed to the environment, such as hands, feet, nose, and ears, are at most risk for local cold emergencies -Frostnip -Frostnip (also called chilblains) develops when body parts get very cold but are not yet frozen -Signs and symptoms include pale and cold skin, and loss of sensation in affected areas -Trench foot: also called immersion foot, trench foot can develop when the feet have prolonged exposure to cold and water -Frostbite -Frostbite is the most dangerous local cold emergency -The tissue is frozen, which frequently leads to permanent damage -Frostbite can lead to gangrene (tissue death), which can lead to systemic infection and death if untreated -Signs and symptoms -Hard, frozen tissue -Possible blistering -Possible mottling -Management of cold emergencies -Remove patient from cold environment -Remove wet clothing -Protect affected areas from further injury -Remove any jewelry -Bandage, splint affected areas -Keep patient immobile -Do not rub affected areas -Do not apply direct heat unless authorized by medical direction Heat emergencies -Two important systemic effects of heat on the body are vasodilation (to shed excess heat) and an increase in metabolic rate -Heat cramps -Heat cramps are a local heat emergency -Heat cramps typically occur during prolonged exertion and are likely caused by an electrolyte imbalance -Management of heat cramps includes rest, rehydration, and restoration of electrolytes -Heat exhaustion -Heat exhaustion is a systemic heat emergency and occurs frequently -Heat exhaustion is caused by a combination of heat exposure and hypovolemia -Signs and symptoms of heat exhaustion -History of exertion in a warm environment -Dizziness, weakness -Nausea, vomiting -Headache -Possible muscle and abdominal cramps -Thirst -Tachycardia -Possible positive changes in orthostatic vitals -Heatstroke -Heatstroke is an uncommon, extremely dangerous systemic heat emergency -The body loses the ability to regulate body heat. Body temperature rise rapidly and will lead to death if untreated -Heatstroke can develop due to exertion, or from passive exposure to a hot environment (for example, a home without air conditioning during a heat spell or a child left in a hot car) -Signs and symptoms of heatstroke -Similar to those of heat exhaustion -Altered or decreased LOC -Skin may be hot and dry or wet -Seizures -Management of systemic heat emergencies -Move patient to a cooler environment -If a patient is completely alert, water can be administered -If heatstroke is suspected, cooling measures must be rapid and aggressive -Expose patient to improve dissipation of heat -Cool patient with water, wet towels, cold packs, etc.. -Cold packs are best applied to groin, neck, armpits -Rapid transport in indicated -Prepare for vomiting and/or seizures Miscellaneous environmental emergencies -Scene safety is the top priority during all environmental emergencies -Drowning and diving injuries -Drowning patient's are at risk for aspiration, cardiac arrest, trauma, cervical-spine (c-spine) injury, and hypothermia -Do not attempt water rescue without proper training -Consider possible c-spine if unsure how patient entered the water -Consult medical direction regarding possible transport to decompression (diving) chamber -Lightning Injuries -Treat as a trauma patient -Victims in cardiac arrest due to lightning strikes may be savable with rapid ventilatory support, CPR, and defibrillation with and AED -Manage respiratory arrest and cardiac arrest aggressively. Apply AED rapidly -Bites and stings -Monitor the patients airway, breathing, circulatory status, and LOC -Clean the wound -Consider applying a cold pack -If the patient demonstrates any systemic complications, transport rapidly ***Always take a history during the assessment and management. ***Reassess vital signs every 5 minutes or an unstable patient and every 15 minutes for a stable patient ***Always manage life-threatening first ***Check the ABCs and reassess them to see any changes

Understand how t control shock

Control any bleeding, keep the patient in a supine position. Supply the patient with oxygen. Prevent the loss of body heat with a blanket, Transport the patient and reassess vital signs every 5 minutes.

Different roles and responsibilities and how it compares to the role of others in EMS

EMT: trained in basic life support; AED, use of airway adjuncts, and assisting with certain medications EMR: has very basic training and provides care before the ambulance AEMT: has training in specific aspects in ALS, such as IV therapy and the administration of certain medications Paramedic: has extensive training in ALS, including endotracheal intubation, emergency pharmacology, cardiac monitoring, and other advanced assessment and treatment skills

Chapter 3: Understand the difference between expressed consent, implied consent, and involuntary consent

Expressed consent: when a patient verbally or otherwise EMS acknowledges that he or she wants you to provide care Implied consent: applies when the patient is unconscious or otherwise incapable of making a rational, informed decision about care. the law assumes that the patient would give consent if able to Involuntary consent: applies to patients who are incapable of making rational decisions about care due to injury or mental illness. This type of consent usually comes from the legal guardian of the person

Chapter 19: Understand the anatomy, physiology, pathophysiology, assessment, and management of acute diabetic emergencies, sickle cell crisis and clotting disorders

Hematology is the study of blood-related diseases. There are three disorders that can create a prehospital emergency. -Sickle cell disease (hemoglobin S disease) -Hemophilia A (classic hemophilia or factor VIII deficiency) -Thrombophilia Anatomy and physiology -Blood is made up of four components -Erythrocytes (red blood cells) -Red blood cells (RBCs) make up 42% to 47% of a person's total blood volume. RBCs contain an important protein, hemoglobin, which carries 97% of the oxygen in the blood and some of the carbon dioxide. -Leukocytes (white blood cells) -White blood cells (WBCs) make up 0.1% to 0.2% of a person's blood cell volume. In a healthy person, WBCs collect dead cells and provide for their correct disposal. In times of health, WBC levels are low. When an infection develops, WBCs and all of their complementary defense systems are activated and their numbers grow. -Platelets -Platelets make up 4% to 7% of a person's blood cell volume and are essential for clot formation. When damage occurs to your skin or to a blood vessel, platelets are sent to the site of the injury to assist in forming a blood clot to stop the bleeding. Without this protective response, bleeding from a simple cut could be uncontrollable. -Plasma -Plasma serves as the transportation media for all of the blood components as well as proteins and minerals. -Each of the components of the blood serves a purpose in maintaining a person's homeostatic balance. Each of the body's other systems provides for and utilizes the blood in a very specific way. In turn, the blood transports oxygen and carbon dioxide into and out of tissues to sustain the function of the organ system and tissues. Pathophysiology -Sickle Cell disease: also called hemoglobin S disease, is an inherited blood disorder that effects the RBCs. The name sickle cells comes from the first case report of the disease in 1910, when Dr. James Herrick wrote that the red blood cells looked like a sickle. The odd-shaped cells protect the individual from contracting malaria. The protection is useful to people who live in the sub-Saharan African malaria belt, but is not useful to people who do not live in regions for endemic for malaria. -There are several variants that make up this genetic disease. it is sufficient to simply understand that the issues of sickle cell can happen to any of the variants. This disease is common among people of the African, Caribbean, and South American ancestry. It is present but less common in Mediterranean and Middle Eastern people. All newborns in the US are tested for sickle cells disease shortly after birth, regardless of their race or ethnic background. -The sharp or misshapen cells lead to dysfunction in oxygen binding and unintentional clot formation. These unintentional clots may result in a blockage known as vasoocclusive crisis. -People with sickle cell disease can experience hypoxia, or lack of oxygen in the body's cells and tissues. The blockages that result from sickle cell crisis or vasoocclusive crises can result in substantial pain and organ damage, which can trigger calls to EMS for help. -The life span of normal RBCs is approximately 110 to 120 days; sickled cells have a much shorter life span. This results in more cellular waste products in the bloodstream, which can contribute to sludging (clumping) of the blood. Maintaining hydration status is important to these patients as maintaining their general health, since insufficient hydration leads to increased clumping of cells. -Many of the complications associated with sickle cell disease are very painful and potentially life threatening. In the face of these complications the sickle cell patient is also more susceptible to infections. Complications associated with sickle cell disease include: -Anemia -Gallstones -Jaundice -Splenic dysfunction -Vascular occlusion with ischemia -Acute chest syndrome (hypoxia, dyspnea, chest discomfort, and fever) -Stroke -Joint necrosis (specifically the head of the femur and humerus) -Pain crises -Acute and chronic organ dysfunction/failure -Retinal hemorrhages -Increased risk of infection -Hemophilia: is rare; according to the Hemophilia Federation of America, there are only about 20,000 Americans who have the disorder. -Hemophilia A affects mostly males. Males inherit the condition from their mother who is a carrier but does not have the disease; females only inherit the condition if their mother is a carrier and their father as the disease. -People with hemophilia A have a decreased ability to create a clot after an injury. A healthy individual will clot in as little as 13 seconds from a paper cut, and not longer than about 7 minutes from something more serious that requires direct pressure. Having an extended bleeding time from the inability to clot can be life threatening. -A patient who is otherwise healthy but has hemophilia A can have a minor trauma, such as a simple ankle sprain while playing soccer. Most people would ignore the sprain and simply continue to play the game. The patient with hemophilia A would begin to swell from uncontrollable bleeding in the region of the injury and continue to do so, making the seemingly minor injury a significant problem. -Acute bleeding from any source may be life threatening depending on where the bleeding occurs. Patients with hemophilia A typically have intravenous factor VIII replacement infusions, which help the blood clot, either close at hand or with them. Common complications of hemophilia A include: -Long-term join problems, which may require a joint replacement. -Bleeding in the brain (intracerebral hemorrhage) -Thrombosis due to treatment. -Thrombophilia: is a disorder in the body's ability to maintain the viscosity and smooth flow of blood through the venous and arterial systems. In thrombophilia, the concentration of blood creates what amounts to clogging or blockage issues. -Thrombophilia is a general term for many different conditions that result in the blood clotting more easily tan normal. This results from either inherited (genetic) disorders, medications, or other factors. Patients with cancer are at increased risk of forming life-threatening blood clots. Whatever the risk factors, the common theme is that clots can spontaneously develop in the blood of the patient. -Deep vein thrombosis (DVT): common medical problem in sedentary patients and in patients who have has recent injury or surgery. While several risk factors increase the chance that a patient will develop a DVT, there are several methods to prevent blood clot formation, including blood-thinning medications, compression stockings, and mechanical devices --- all of which you may encounter in the field. -DVT is a particular worrisome risk for patients wo have had joint replacement surgery. Be suspicious of this in a patient with a recent history of joint replacement who complains of leg swelling. Travelers, truck and long-distance bus drivers, and bedridden nursing home patients are all at higher risk for DVT because they are sedentary for long periods of time. -If DVT develops in an individual, anticoagulation therapy may be administered. A patient with DVT may be treated in the hospital with IV medications and then transitioned to oral medications before discharge. Some patients are sent home with self-administered subcutaneous injectable medications to treat or prevent DVT. Oral medications are typically administered for at least 3 months after diagnosis of a DVT to ensure another DVT does not develop. Patients prescribed medications to treat DVT are at an increased risk of bleeding complication (Gastrointestinal bleeding), and minor trauma is more likely to produce severe internal or external hemorrhage. -A life threat can develop if the clot from the DVT travels from the patient's lower extremity to the lung, causing pulmonary embolus. Pulmonary emboli can cause chest pain, difficulty breathing, or if the clots are large, sudden cardiac arrest. Assessment -Perform cervical spine immobilization, if indicated. Remember that even tough a person has a history of sickle cell disease, sick cells disease may not be causing the current problem; trauma or another type of medical emergency may be the cause. For this reason, you must always perform a thorough, careful primary assessment, paying attention to the ABCs and immediately correcting any life-threatening issues. -While you are forming your general impression, assess the patient's airway and breathing. Patients showing signs of inadequate breathing or altered mental status should receive high-flow oxygen at 12 to 15 L/min via nonrebreathing mask. A patient who is experiencing a sickle cell crisis may have increased respirations as a result of severe pain or exhibit pneumonia. If the patient is having difficulty breathing, open the airway and insert an airway adjunct, administer oxygen, and assist ventilations. Continue to monitor the airway as you provide care. -Once you have assessed the airway and breathing and have performed the necessary interventions, check the patient's circulatory status. An increased heart rate represents compensatory mechanism, in an attempt to force the sickled cells trough smaller blood vessels. -In patients with hemophilia, be alert for signs of acute blood loss such as pallor, weak pulse, and hypotension. Note any bleeding of unknown origin, such as nosebleeds, bloody sputum, and blood in the urine or stool. Owing to blood loss, patients with hemophilia may exhibit signs of hypoxia.

Understand how to assess the various special populations

Neonate/infant: Moro reflex (also known as startle reflex refers to an involuntary motor response that infants develop shortly after birth), rooting reflex, sucking reflex, and palmar grasp should all be assessed. The fontanelles should be checked for normal growth and development. Toddler/Preschool/School age: Try to keep the scene familiar by keeping family members present or finding a favorite toy/comfort item of theirs. Adolescent: If necessary take them away from family members or friends to give them the privacy needed to be fully open. Middle Adult: take into account any medications or underlying illnesses when speaking to a middle adult. Older Adult: be patient when dealing with patients with cognitive, physical, or psychological barriers.

Understand management of normal deliveries, abnormal deliveries, third trimester bleeding, spontaneous abortion/miscarriage, ectopic pregnancy, and preeclampsia/eclampsia

Normal delivery: If the patient has delivered before, she may be able to tell you whether she is about to deliver. Otherwise, her answers to the following questions will help you determine whether delivery is imminent: -How long have you been pregnant? -When are you due? -Is this your first pregnancy? -Are you having contractions? How far apart are the contractions? How long to the contractions last? -Have you as any spotting or bleeding? -Has your water broken? -Do you feel as though you need to have a bowel movement? -Do you feel the need to push? Ask these questions to help determine any potential complications: -Were any of your previous deliveries by cesarean section? -Have you had any problems in this or any previous pregnancy? -Do you use drugs, drink alcohol, or take any medications? -Is there a chance you will have multiple deliveries (having more than one baby)? -Does your physician expect any other complications? -If your patient says that she is about to deliver, says she has to move her bowels, or feels the need to push, prepare for a delivery and consider calling for additional resources. Visually inspect the vagina to check for crowning (indication that the delivery is occurring). Do not touch the vaginal area until you have determine that delivery is imminent. In general, you should touch the vaginal area only during the delivery (under certain circumstances) and when your partner is present. -Once delivery has begun, it cannot be slowed or stopped. Never attempt to hold the woman's legs together, because this will only complicate the delivery. Do not let her go the bathroom. Instead, reassure her that the sensation of needing to move her bowels is normal and that it means that she is about to deliver. Abnormal deliveries -Multiple births: Multiple births can have their own placenta, or share a placenta -Be prepared for multiple births any time it has not been ruled out by ultrasound -Request additional units -Prepare additional supplies, OB kits, BVMs, oxygen tanks -Be prepared for possible breech presentation, particularly with second baby -Multiple birth babies may be smaller and require additional resuscitation efforts -Clamp and cut an umbilical cord with possible multiple births only as a last resort -If second baby does not deliver within about q0 minutes after first, transport immediately -Prolapsed cord: occurs when the cord is the presenting part in the birth canal -Can become compressed and cut off oxygen to the baby -Instruct the mother NOT to push. This will increase pressure on the cord. -Place the mother in knee-chest position -Carefully push the presenting part of the baby away from the cord -Transport immediately -Breech presentation: occurs when the baby's buttocks or legs are the first presenting part in the birth canal -Transport immediately. Breech births present significant dangers for mother and baby -If delivery occurs, there is a high risk the head will become stuck in the birth canal -If the head is trapped, use fingers to form a "V" along vaginal wall to create space allowing the baby to breathe -Limb presentation: when a single arm or leg is the presenting part in the birth canal. -Do NOT attempt delivery of a limb presentation in the field -Place the mother in the knee-chest position and transport immediately -Postpartum hemorrhage: excessive bleeding following delivery -Blood loss of greater than about 500 mL is considered abnormal -Management of postpartum hemorrhage include uterine massage, breastfeeding, and treating for shock **Key assessments for newborns: respirations, heart rate, and color. Getting the newborn's heart rate above 100 beats per minute and keeping it there is essential** Hemorrhage -Hemorrhagic shock can develop quickly in the pregnant patient -Signs and symptoms may not be evident until the pregnant person is in severe shock -Bleeding can occur with little or no external blood loss -Bleeding may be painful or painless -Several conditions can lead to severe bleeding, including placenta previa, abruptio placenta, ectopic pregnancy, uterine rupture, and spontaneous abortion Spontaneous abortion (miscarriage): delivery of the fetus before it is capable of surviving. This is prior to about the 20th to 22nd week of pregnancy -Classic presentation includes cramping, lower abdominal pain, vaginal bleeding, and passage of tissue or clots -Assess for signs and symptoms of shock Ectopic pregnancy: occurs when the egg is implanted outside of the uterus, usually in the fallopian tube -Can lead to rupture and severe bleeding -Classic presentation is severe abdominal pain with or without vaginal bleeding -Assess for signs and symptoms of shock Preeclampsia/eclampsia: -Preeclampsia (toxemia of pregnancy) -Preeclampsia typically occurs in the third trimester -The cause is not completely understood -Signs and symptoms include sudden weight gain, visual disturbances; sudden swelling of the face, hands, or feet; headache; and hypertension -Eclampsia: occurs when the mother seizes following preeclampsia -Eclampsia is a life-threatening condition for mother and fetus.

Understand oxygen as a gas and medication Understand how/when to administer Understand the outcomes for providing a patient oxygen who does not need it

Oxygen should be given to patients with an oxygen saturation level below 94% or if they have difficulty breathing Oxygen free radicals (very reactive molecules which can react with every cellular component) that result from too much oxygen can result in tissue damage and cellular death

Understand the various levels of stress and how to minimize the chances of PTSD, including CISD/CISM

PTSD occurs after a person has experienced a psychologically distressing event, and usually manifests in the form of depression, startle reactions, flash back phenomena, and dissociative episodes. Critical incident stress management was created to decrease the likelihood of PTSD. It can take the form of a formal debriefing (CISD) or an onsite assessment for symptoms of PTSD.

Terminology: Paraplegia

Paraplegia: Paralysis of the legs and lower body

Reassessment

Reassessment is performed at different intervals throughout the assessment process, and it's purpose is to identify and treat changes in the patient's condition. Reassess life threats, vital signs, chief complaint, and interventions. Identify and treat any changes in the patients condition. Unstable Patients: Should be reassessed every 5 minutes Stable Patients: Should be reassessed every 15 minutes

Understand referred pain and locations associated with different conditions

Referred pain: other painful sensations that occur because of an irritated visceral peritoneum may be perceived at a distal point on the surface of the body, such as the back or shoulder. Locations associated with different conditions include: -Appendicitis: Right lower quadrant (direct); around navel (referred) -Cholecystitis: Right upper quadrant (direct); right should (referred) -Pneumonia: Referred pain to the upper abdomen -Injured Liver: Referred pain to the right shoulder -Injured spleen: referred pain to the left shoulder

History Taking: Sample, OPQRST

S: Signs and symptoms A: Allergies M: Medications P: Past pertinent medical history L: Last oral intake E: Events leading to incident O: Onset P: Provocation Q: Quality R: Radiation S: Severity T: Timing

"Six rights" of medication

Right patient Right medication Right dose Right route Right time Right documentation

Aphasia

The inability to produce or understand speech

Chapter 27: Understand anatomy, physiology, assessment and management of face and neck injuries

The head is divided into two parts: the cranium and the face. The cranium, or skull, contains the brain, which connects to the spinal cord through the foramen magnum, a large opening at the base of the skull. The most posterior portion of the cranium is called the occiput. On each side of the cranium, the lateral portions are called the temple or temporal regions. Between the temporal regions and the occiput lie the parietal regions. The forehead is called the frontal region. Just anterior to the ear, in the temporal region, you can feel the pulse of the superficial temporal artery. -The face is composed of the eyes, ears, nose, mouth, and cheeks. Six bones--the nasal bone, the two maxillae (upper jaw bones), the two zygomas (cheek bones), and the mandible (jaw bone)--are the major bones of the face. -The orbit of the eye is composed of the lower edge of the frontal bone of the skull, the zygoma, the maxilla, and the nasal bone. The bony orbit protects the eye from injury. By viewing the face from the side, you can see the eyeball recessed in the orbit. Only the proximal third of the nose--the bridge-- is formed by bone. The remaining two-thirds are composed of cartilage. -The exposed portion of the ear is composed entirely of cartilage that is covered by skin. The external, visible part of the ear is called the pinna. The ear lobes are the fleshy portions at the bottom of each ear. The tragus is a small, rounded, fleshy bulge immediately anterior to the ear canal. The superficial temporal artery can be palpated just anterior to the tragus. About 1 inch posterior to the external opening of the ear is a prominent bony mass at the base of the skull called the mastoid process. -The mandible forms the jaw and chin. The jaw is the lower border of the mouth, where the tongue and 32 teeth are located. Motion of the mandible occurs at the temporomandibular joint, which lies just in front of the ear on either side of the face. Below the ear and anterior to the mastoid process, the angle of the mandible is easily palpated. -The neck also contains many important structures. It is supported by the cervical spine, or the first seven vertebrae in the spinal column (C1 through C7). The spinal cord exits from the foramen magnum and lies within the spinal canal formed by the vertebrae. The upper part of the esophagus and trachea lie in the midline of the neck. The carotid arteries are found on either side of the trachea, along with the jugular veins and several nerves. -Several useful landmarks can be palpated and seen in the neck. The most obvious is the firm prominence in the center of the anterior surface, commonly known as the Adam's apple. Specifically, this prominence is the upper part of the larynx, formed by the thyroid cartilage. It is more prominent in men than in women. The other portion of the larynx is the cricoid cartilage, a firm ridge of cartilage (the only complete circular cartilage structure of the trachea) below the thyroid cartilage, which is somewhat more difficult to palpate. Between the thyroid cartilage in the midline of the neck is a soft depression, the cricothyroid membrane. This is a connective tissue (fascia) that joins the two cartilages. The cricothyroid membrane is covered at this point only by skin. -Below the larynx, several additional firm ridges are palpable in the anterior midline. These ridges are the cartilage rings of the trachea. The trachea connects he oropharynx and the larynx with the main air passages of the lungs (the bronchi). On either side of the lower larynx and the upper trachea lies the thyroid gland. Unless it is enlarged, this gland is usually not palpable. -Pulsations of the carotid arteries are easily palpable in a groove approximately 0.5 inch lateral to the larynx. Lying immediately adjacent to these arteries, but not palpable, are the internal jugular veins and several important nerves. Lateral to these vessels and nerves lie the sternocleidomastoid muscles. These muscles originate from the mastoid process of the cranium and insert into the medial border of each collarbone and the sternum at the bas of the neck. They allow movement of the head. -A series of bony prominences lie posteriorly, in the midline of the neck. They are the spines of the cervical vertebrae. The lower cervical spines are more prominent than the upper ones. They are more easily palpable when the neck is in flexion. At the base of the neck posteriorly, the most prominent spine is the seventh cervical vertebra. Primary assessment: The primary assessment focuses on identifying and managing life-threatening concerns. Threats to airway, breathing, or circulation must be treated immediately. When there is obvious, active, life-threatening external hemorrhage, it should be addressed before airway and breathing. -As you approach the patient, look for important indicators to alert you to the seriousness of the patient's condition. Is the patient interacting with the environment or lying still, making no sounds? Does the patient have have any apparent life threats such as significant bleeding? How is the patient's skin color? The general impression will help you develop an index of suspicion for serious injuries and determine your sense of urgency for medical intervention. -Injuries to the face and throat may be very obvious, such as bleeding and significant swelling, but may also be hidden under collars and hats. Because of the likelihood of of respiratory distress with these injuries, they should be recognized as early as possible. As with any injury with life-threatening bleeding, control the blood loss with direct pressure. Always consider the need for manual spinal stabilization and check for responsiveness using the AVPU scale. -Ensure that the patient has a clear and patent airway. If the patient is unresponsive or has a significantly altered level of consciousness, considering inserting a properly sized OPA. The use of an NPA is controversial, as many believe that inserting a nasopharyngeal airway into the nare of a patient with facial or head trauma carries the risk of introducing the device into the cranial vault and brain tissue. However, recent research suggests this risk is extremely small. As always, be aware of and follow your local protocols. -Quickly assess for adequacy of breathing. Palpate the chest wall for DCAP-BTLS. If penetrating trauma is discovered, place an occlusive dressing on the wound. Maintain the airway, provide supplemental oxygen, and initiate bag-valve mask (BVM) ventilation is necessary. Check for breath sounds and provide rapid transport to the hospital without delay if breath sounds are abnormal. Splinting or otherwise attempting to restrict chest wall motion is not indicated as it is ineffective and can actually impair air exchange in the lungs -If the patient you are treating has an airway or a breathing problem or significant bleeding, you must consider quickly transporting the patient to the hospital for treatment. Stabilization and maintenance of an airway and breathing an controlling bleeding can be very difficult in patients with facial or neck injuries. Avoid delays in transport and consider advanced life support backup if the transport time is long. Aa patient with signs and symptoms of internal bleeding must be transported quickly to the appropriate hospital for treatment by a physician. Internal bleeding in face and throat injuries may compromise blood flow to the brain. Bleeding from major vessels of the throat can have a serious impact on the patient's airway. The condition of a patient with visible significant bleeding or sign of significant internal bleeding may quickly become unstable. Treatment is directed at quickly addressing life threats and providing rapid transport to the closest appropriate hospital. Signs such as tachycardia, tachypnea, low blood pressure, weak pulse, and cool, moist, pale skin are signs of hypoperfusion and imply the need for rapid transport. The patient who has a significant MOI but whose condition appears stable should also be transported promptly to the closest appropriate hospital. Remember that any significant blow to the face or throat should increase your suspicion of spinal or brain injury. Be alert to these signs and reconsider your priority and transport decision if they develop. -Even if the patient has no signs of hypoperfusion or other life-threatening injuries, there is a possibility of eye injuries, which are considered serious. Therefore, the patient should be transported to the closest appropriate hospital as quickly and as safely as possible. In some situations, surgery and/or restoration of circulation to the eye will need to be accomplished within 30 minutes or permanent blindness may result. Consider transporting the patient with serious, isolated eye injuries to an eye care specialty center depending on local protocol. Do no delay transport of a seriously injured patient, particularly on with significant bleeding even if controlled, to take the patient's history or perform a secondary assessment. Further assessment can continue during transport. **Face and throat injuries increase the need for airway and breathing maintenance, so do not hesitate to place a nonrebreathing mask over facial injuries. The seal the not be as easy to maintain, but airway and breathing take priority over soft-tissue injuries. History taking: After the life threats have been managed during the primary assessment, investigate the chief complaint or history of present illness. Obtain a medical history and be alert for injury-specific signs and symptoms, as well as any pertinent negatives such a no pain or no loss of sensation. -Next, obtain a SAMPLE history from your patient. If the patient is not responsive, attempt to obtain the SAMPLE history from friends or family members who may be present. -In an unresponsive patient you will only be able to notice the signs of the patient's injuries. Any other information will need to be obtained by someone who is knowledgeable about the patient. Keep in mind that the information you obtain may or may not be accurate and may be incomplete. The person providing the information may not be able to give you the actual names of the patient's medications but might be able to provide some pertinent medical history and possibly known allergies. Secondary assessment: more detailed, comprehensive examination of the patient that is used to uncover injuries that may have been missed during dhe primary assessment. In some instances, such as a critically injured patient or a short transport time, you my not have time to conduct a secondary assessment. -If there is significant trauma that likely effects multiple systems, start with an assessment of the entire body looking for DCAP-BTLS to be sure that you have found all life threats and injuries. When this is completed, perform a detailed examination of specific areas. However, do not delay transport to complete a thorough physical examination. -In the responsive patient who has an isolated injury with a limited MOI, consider focusing your physical examination on the isolated injury, the patient's chief complaint, and the body region affected, which, in this case, is the face and throat. Ensure tat control of bleeding is maintained and note the location of the injury. Inspect open wounds for nay foreign matter and stabilize the impaled objects. -During the physical examination, use both of your hands and eyes. Your eyes will be looking for swelling, deformities of the bones, contusions, and discoloration whereas your hands will be gently palpating the face, looking and feeling for any abnormalities such as deformity or tenderness. Ask yourself the following questions: 1. Do the facial bones seem to be in alignment? 2. Does the nasal bone seem to deviate from the midline? 3. Note any variations from the abnormal facial examination; is there any facial drooping? 4. Does one eye appear to be lower than the other? If so, this is an indication of an orbital fracture. 5. Does the mandible appear to deviate toward one side or the other? -If your patient is responsive, explain exactly what you are doing and what you are looking for. Your discovery of an abnormality may actually be an old injury that the patient can tell you more about. -Assess all underlying systems. This should include the neurologic system, including the brain and major nerves; sensory organs, including the eyes and nose; respiratory system, including mouth, nose, sinuses, and airway; and circulatory system, particularly focusing on the carotid arteries and jugular veins. -When you are evaluating the eyes, start on the outer aspect of the eye and work your way in toward the pupils. Examine the eye for any obvious foreign matter. Your patient may relay this information to you also ("I have something in my eye."). Visual acuity, or the clarity of the patient's vision in each eye, is considered the vital sign of the eye. Quickly assess the patient's visual activity by gently covering one eye and holding finger up at arm's length in front of the open eye. Test for the ability to see fingers in both the injured and the uninjured eye and document your findings. Note any discoloration of the eye, bleeding in the iris area, or redness. Look for eye symmetry because asymmetry is a possible indication of a brain injury. -Look at each pupil for equal size and reaction to light. If the pupils are not symmetric, ask the patient if he or she has had any previous eye surgeries or injuries. Previous surgery or injury, rather than brain injury, may be the root cause of the pupils not appearing the same. Cataract surgery can cause unequal pupils, but when you have a patient with a suspected head injury or ocular injury, anisocoria (unequal pupils in dim light) may be present. Determine whether the unequal pupils are caused by physiologic or pathologic issues. Use of over-the-counter eye drops can change pupil size, and certain asthma inhalers can have the same effect of inadvertently sprayed into the eye. Brain injury, nerve disease, glaucoma, and meningitis are all possible causes of unequal pupils. -Dies the patient have the ability to follow your finger form side to side as well as up and down? Can the patient read normal print? Does the patient report blurry vision in either eye? Is there a new sensitivity to light? -Assess vital signs to obtain a baseline so that you can observe any changes a patient may display during treatment. A systolic blood pressure reading of less than 100 mm Hg with a weak, rapid pulse and cool, moist skin that is pale or gray should alert you to the presence of hypoperfusion in a patient who may have significant bleeding. Remember, you must be concerned with visible bleeding inside a body cavity. With facial and throat injuries, baseline information about the rate and quality of respirations and pulse is very important, as is monitoring throughout patient care. -In addition to hands-on assessment, use monitoring devices to quantify your patient's oxygenation and circulatory status. You may also use noninvasive methods to monitor the blood-pressure. It is recommended that you always assess the patient's first blood pressure with a sphygmomanometer (blood pressure cuff) and stethoscope. Reassessment: Repeat the primary assessment. Reassess vital signs and the chief complaint. Continually reassess the adequacy of the patient's airway, breathing, and circulation. Recheck patient interventions. Are the treatments you provided for problems with the ABCs still effective? This is particularly important in patients with facial or neck injuries because of the ease in which injuries can affect associated systems, such as the respiratory (airway and breathing), circulatory, and nervous systems. The patient's condition should be reassessed at least every 5 minutes. -Provide complete spinal immobilization to any patient with suspected spinal injuries. Spinal injuries should be suspected any time there is significant trauma to the face or neck. Maintain an open airway, be prepared to suction the patient, and consider an oropharyngeal airway. Whenever you suspect significant bleeding, provide high-flow oxygen. Oxygen and airway maintenance are important for all patients with face and neck injuries. If needed, provide assisted ventilation using a BVM with high-flow oxygen. -Control any significant visible bleeding. If the patient has signs of hypoperfusion, treat the patient aggressively for shock and provide rapid transport to the appropriate hospital. Do not delay transport of a seriously injured trauma patient to complete non-lifesaving treatments in the field, such as splinting extremity fractures, Instead, complete these treatments en route to the hospital. If there is no cervical spine injury suspected, the patient may be more comfortable in the sitting position during transport. -In your documentation, describe the MOI and the position in which you found the patient when you arrived at the scene. Document the method used to remove the patient from the vehicle, for example, "prolonged extrication." In patients with severe external bleeding, it is important to recognize, estimate, and report the amount of blood loss that has occurred and how rapidly or how much time has passed since the bleeding started. This can be a challenge for you, especially if the surface of the patient is on is wet or absorbs fluid or the environment is dark. Inform the hospital personnel about all of the injuries involving the patient's head and neck. Specialists may need to be called to manage injuries involving the eyes, ears, teeth, mouth, sinuses, larynx, esophagus, or large vessels. These specialists are not always in the hospital, especially during the evening or night, or in smaller hospitals, so informing emergency department personnel of all injuries involving the face and throat can save valuable time.

Terminology: Subcutaneous emphysema

The presence of air in the soft tissues produces a crackling sensation called subcutaneous emphysema.

Understand the importance and ways of decontaminating equipment

The safety of both medical providers and future patients depends on decontamination to prevent the spread of disease. Know and follow your local standard operating procedures for disinfecting equipment after each call

Sympathetic and Parasympathetic nervous system

The sympathetic nervous system controls the fight-or-flight response, increasing the activity in your muscles to enable you to perform more effectively in dangerous situations The parasympathetic nervous system slows down the body while recovering from danger or during digestion

Chapter 14: Understand the common types of medical emergencies and provide examples of each condition

-Respiratory: asthma, emphysema, chronic bronchitis -Cardiovascular: heart attack, congestive heart failure -Neurologic: seizure, stroke, syncope -Gastrointestinal: appendicitis, diverticulosis, pancreatitis -Urologic: kidney stones -Endocrine: diabetes mellitus -Hematologic: sickle cell disease, hemophilia -Immunologic: anaphylactic reaction (severe allergy) -Toxicology: substance abuse, food, plant, or chemical poisoning -Psychiatric: Alzheimer disease, schizophrenia, depression -Gynecologic: vaginal bleeding, sexually transmitted disease, pelvic inflammatory disease, ectopic pregnancy

Understand the duties of the EMT as they relate to assisting with ALS skills

As an EMT, there are many different ALS skills with which you may be able to assist. The exact list of ALS procedure and how they are to be performed will vary from system to system. In general, assisting follows a four-step process: -Patient preparation -Equipment set up -Performing the procedure -Continuing care. Assisting with placement of Advanced airways: Endotracheal (ET) intubation is the insertion of a tube into the trachea to maintain and protect the airway. The ET tube can be inserted through the mouth or through the nose. In either case, the ET tube passes directly through the larynx between the vocal cords and then into the trachea. You may also be asked to assist with the placement of other advanced airway devices. Patient Preparation: The first step in preparing a patient for ET intubation is oxygenation. Oxygenation is the process of loading oxygen molecules onto hemoglobin molecules in the bloodstream. Good oxygenation often requires BVM ventilation (including the use of an oral or nasal airway) and ensuring a proper seal, ventilation rate, volume of ventilation, and time for patient exhalation. Oxygen enters the bloodstream through a process of diffusion. The more oxygen that is available in the alveoli, the longer the patient can maintain adequate gas exchange in the lungs while the intubation procedure is being performed. This critical phase of the intubation procedure is called preoxygenation. Maintain a high-flow nasal cannula on the patient during the preoxygenation phase and leave the nasal cannula in place during the intubation attempt, a period of time when BVM ventilation and chest rise and fall is not possible. This technique, called apneic oxygenation allows for continuous oxygen delivery down the airways during all phases of the intubation procedure. Equipment Set up: Equipment sets vary depending on local protocols, provider preference, and whether direct laryngoscopy or video laryngoscopy will be used. Direct laryngoscopy is the visualization of the vocal cords using a video camera and monitor. Typically intubation sets include: -Personal protective equipment (PPE), including face mask and eye shield. -Suction unit with rigid, tonsil-tip (Yankauer) and non-rigid, whistle-tip (French) catheters -Laryngoscope handle and blade (sized for the patient) -Magill forceps -ET tube (sized for the patient) -Stylette or tube introducer (gum elastic bougie) -Water-soluble lubricant -10-mL syringe -Confirmation device(s), including waveform end-tidal CO2 monitors and/or colorimetric device -Commercial ET tube securing device -Alternate airway management devices, such as a supraglottic airway and/or cricothyrotomy kit Performing the Procedure: while the details of endotracheal intubation may vary depending on available equipment, difficulties encountered, and provider preference, you can remember the six typical steps by using the BE MAGIC mnemonic: -B~ (perform) BVM preoxygenation -E~ Evaluate for airway difficulties -M~ Manipulate the patient -A~ Attempt first-pass intubation -GI~ use a supraGlottic or Intermediate airway if unable to intubate -C~ Confirm successful intubation/ Correct any issues.

Chapter 36: Understand the healthcare implications for patients with special challenges

Developmental disability: refers to insufficient development of the brain, resulting in some level of dysfunction or impairment. Developmental disabilities can include intellectual, hearing, or vision impairments that surface during infanthood or childhood. -Intellectual disability results in the inability to learn and socially adapt at a normal developmental rate. An intellectual disability may be caused by genetic factors, congenital infections, complications at birth, malnutrition, or environmental factors. Prenatal drug or alcohol use may also cause intellectual disability, such as fetal alcohol syndrome. Other causes that may occur after birth include traumatic brain injury and poisoning. -A person with a slight intellectual impairment may appear slow to understand or have a limited vocabulary. Such patients will often behave immaturely in comparison with their peers. People with severe intellectual disabilities may not have the ability to care for themselves, communicate, understand, or respond to their surroundings. -Speaking to patients and family members will give you a good idea of how the patient will interact with you. Family or friends of the patient may also be able to supply additional medical information regarding the patient. -Because patients with intellectual disabilities may have difficulty adjusting to change or a break in routine, and emergency call that generates a room full of strangers can be overwhelming. A patient may become more difficult to interact with as his or her anxiety level increases. Make every effort to respect the patient's wishes and concern. Take as much time as necessary to calmly and clearly explain the treatment the patient is about to receive. -Patients with intellectual disabilities are susceptible to the same disease process as other patients, including diabetes, heart attack, and respiratory difficulties. Assess and treat the patient according to the chief complaint. During transport, keep the patient as calm as possible. -Autism and autism spectrum disorder (ASD): general terms used to describe a group of complex disorder of brain development that vary greatly in signs and symptoms. Autism is a pervasive developmental disorder characterized by impairment of social interaction. Other characteristics can include several behavioral problems, repetitive motor activities, and verbal and nonverbal language impairment. Some people with autism may be hyper- or hyposensitive to sensory stimuli. They may also show their pain in unusual ways, such as by humming, singing, and removing clothing. the spectrum of disability is wide. Some children with autism will grow up to be independent, whereas others will be unable to care for themselves. -Patients with autism generally have medical needs similar to those of their peers without autism. Rely on parents or caregivers for information and involve them in the treatment of the patient. As with any patient, explain what you are going to do before you do it. Move slowly, stay calm, ad perform physical examinations from distal to proximal. Demonstrate the examination on a parent or caregiver first to show the patient with autism what he or she can expect. -Down syndrome: characterized by a genetic chromosome defect resulting in mild to severe intellectual impairment. The normal somatic cell contains 23 pairs of chromosomes. In most cases, down syndrome, also known as trisomy 21, occurs when the two 21st chromosomes fail to separate, so that the ovum or sperm contains 24 chromosomes. When fertilization occurs, a triplication ("trisomy") of chromosome 21 occurs. The extra chromosome disrupts the normal course of development. -Increased maternal age and a family history of down syndrome are known risk factors for this condition. Various physical abnormalities are associated with down syndrome -- a round head with a flat occiput; and enlarged, protruding tongue; slanted, wide-set eyes; folded skin on either side of the nose, covering the inner corners of the eye; short, wide hands; a small face and features; congenital heart defects; thyroid problems; and hearing and vision problems. People with down syndrome usually do not have all of these signs, but a diagnosis can be made rapidly at birth because several of the signs can be seen. Depending on their level of intellectual disability, people with down syndrome may lead independent lives. They may be employed, vote, and get involved in their communities. -Patients with down syndrome are at increased risk for medical complications, including those that affect the cardiovascular, sensory, endocrine, musculoskeletal, dental, and gastrointestinal systems, as well as neurological development. -Because people with down syndrome often have small tongues and small oral and nasal cavities, airway management may be difficult. These patients may also have misaligned teeth and other dental problems. The enlarged tongue and dental problems can lead to speech abnormalities as well. In an emergency situation, if airway management is necessary, BVM ventilation can be challenging. In the case of airway obstruction, a jaw-trust maneuver may be all that is needed to clear the airway. In an unconscious patient, either the jaw-thrust maneuver, or a nasopharyngeal airway may be necessary. -Some people with down syndrome have epilepsy. Most seizures are tonic-clonic. Patient management is the same as with other patients with seizures. Brain injury: a patient with a prior brain injury may be difficult to assess. Patients with brain injuries may face a complex array of challenges related to the injury. In such cases, gathering a complete medical history from the patient, family, and friends will be helpful. You interaction with patients with brain injuries should be tailored to their specific abilities. Take time to speak with the patient and family to establish what is considered normal for the patient; for example, determine whether the patient has cognitive, sensory, communication, motor, behavioral, or psychologic defects. -Wen you care for a person with a prior brain injury, talk in a calm, soothing tone, and watch the patient closely for signs of anxiety or aggression. Sensory disabilities: -Hearing impaired: the two most common form of hearing loss are sensorineural deafness and conductive hearing loss. Sensorineural deafness, or nerve damage, results from a lesion or damage to the inner ear. Conductive hearing loss is caused by a faulty transmission of sound waves, which can occur when a person has an accumulation of wax inside the ear canal or a perforated eardrum. -Face the patient and speak clearly -Consider communicating in writing -A family member may be able to assist -Consider the use of more close-ended questions. -Visual impairment: may result from many different causes -- a congenital defect; disease; injury; or degeneration of the eyeball, optic nerve, or nerve pathway. -Communicate verbally what you are doing -Keep the patient informed about what is going on -Protect the patient from harm when moving them. Tracheostomy: A tracheostomy is a surgical procedure that creates an opening through the neck into the trachea. -A stoma is a surgical opening into the trachea -A tracheostomy tube can be placed in the stoma and connects to a ventilator or BVM. Tracheostomy tubes can become obstructed easily by secretions. Be prepared to suction with a French suction catheter. -Patients with a tracheostomy ventilate through their stoma, not the mouth or nose -Supplemental oxygen should be applied over the stoma using a tracheostomy mask (not common in the prehospital environment) or a nonrebreather mask. -The DOPE mnemonic can help you remember the possible causes of an airway obstruction and correct the problem: -Displaced, dislodges, or damaged tube -Obstructed tube (secretions, blood, mucus, vomitus) -Pneumothorax -Equipment failure (kinked tubing, ventilator malfunction, empty oxygen supply) Bariatrics: If transport is necessary, plan early for extra help and do not be afraid to call for additional providers and/or specialized equipment if necessary. In particular, send a member of your team to find the easiest and safest exit to use. Remember, everyone's safety is at stake. You do not want to risk dropping the patient or injuring a team member by trying to lift too much weight. Moves, no matter how simple they may seem, become far more complex when handling a patient with obesity. -Obese patient's can present challenges related to assessment, management, and transport -Many EMS systems have specialized bariatric ambulances to assist with movement and transport of obese patients -Some equipment may not be sized adequately for the patient -Airway management, ventilations, chest compressions, cervical-spine (c-spine) stabilization can be especially challenging. Terminally ill: terminally ill patients have a disease that is likely to get progressively worse until death -Hospice facilities are specialty facilities designed to provide comfort care to terminally ill patients -Make every effort to comfort terminally ill patients and their family -Local protocols for handling the death of a patient vary, so be familiar with your local or state regulations. The protocols identify whether the coroner needs to be called to report the death and, if so, who is responsible for contacting the coroner. Also, determine whether a pronouncement of death is required and, if so, who is responsible for the determination. Home care: occurs within a patient's hoe environment. Patients requiring home services represent a spectrum of special health care populations, including infants and older adults, patients with chronic illnesses, and patients with developmental disabilities. Poverty and homelessness: occurs when people are unstable to acquire and/or maintain affordable housing. The homeless population includes people with mental illness, prior brain trauma, victims of domestic violence, people with addiction disorders, and impoverished families. You may be called to care for a person who has experienced sexual assault, mental health problems, overdose, respiratory or heat or cold related illness, and wound or skin infections. -You are an advocate for all patients. Your job is to provide emergency medical care and transport patients to the appropriate facility. Remember that under the Emergency Medical Treatment and Active Labor Act (EMTALA), all healthcare facilities must provide a medical assessment and required treatment, regardless of the patient's ability to pay. You can also be an advocate by becoming familiar with the social services and resources within your community so you can refer patients to these lifelines.

Understand the "Platinum 10" and "Golden hour"

Golden hour: sometimes referred to as the "golden period". Because many injured patients require definitive care in less than an hour, the term "Golden period" is sometimes substituted. Regardless, the initial concept is that initial care must be delivered as expeditiously as possible. Platinum 10: on-scene time for critically injured patients should be less than 10 minutes.

Secondary Assessment: Understand GCS and how to calculate

The Glasgow Coma Scale provides a numeric score that is associated with the patient's relative brain dysfunction. It assesses and provides a score on the patient's eye opening and best motor response (Table 9-7)

Understand HIPAA and how it can affect your role in EMS

The Health Insurance Portability and Accountability Act ensure patient privacy. Do not discuss findings about the patient with anyone except medical personnel treating the patient, law enforcement or social agencies that may require the information by law. Avoid giving any information that may reveal the identity of the patient.

Chapter 35: Understand the impact of age related changes on assessment and care of geriatric patients

The GEMS Diamond: created to help you remember what is different about older patients. It serves as an acronym for the issues to be considered when assessing every older patient. -Geriatric patient -Present atypically -Deserve respect -Experience normal changes with age -Environmental Assessment -What is the physical condition of the home? Is the interior or exterior of the home in need of repair? Is the home secure? -Are hazardous conditions present (poor wiring, rotten floors, unventilated gas heaters, broken window glass, clutter that prevents adequate egress)? -Are smoke detectors present and functional? -Is there fecal or urine odor in the home? -Are pets well cared for? -Is food present in the home? Is it adequate and unspoiled? -Are liquor bottles present (lying empty)? -Is bedding soiled or urine-soaked? -Are there burn patterns on the walls, cabinets , and floors? -If the patient has a disability, are appropriate assistive devices (wheelchair or walker) present and in adequate condition? -Does the patient have access to a telephone? -Are medications prescribed to someone else, expired, unmarked, or from many physicians? -If the patient is living with other, is he/she confined to one part of the home? -If the patient is residing in a nursing facility, does the care appear to be adequate to meet the patient's needs? -Medical assessment -Older patients tend to have a variety of medical problems, making assessment more complex. Keep this in mind in all cases -- that is, both trauma and medical. A trauma patient may have an underlying medical condition related to the traumatic event. -Obtaining a medical history is very important in older patients -- no matter what the primary complaint is. -Primary assessment -Reassessment -Social assessment -Assess the activities of daily living (ADLs): -Eating -Dressing -Bathing -Toileting -Are these activities being provided for the patient? If so, by whom? -Are there delays in obtaining food, medication, or toileting? The patient may report this, or the environment may be suggestive of this. -Does the patient have regular visits from family members, live with family members, or live with a spouse? -If in an institutional setting, is the patient able to feed himself or herself? If not, is food still sitting on the food tray? Has the patient been lying in his/her own urine or feces for prolonged periods of time? -Does the patient have a social network? Does the patient have ways to interact socially with other on a daily basis? Special considerations in assessing a geriatric medical patient: Assessing an older person can be challenging because of communication issues, hearing and vision deficits, alteration in consciousness, complicated medical histories, and the effects of medications. Previous injury or illnesses that are not associated with the current problem may also alter the assessment findings. These may include medications that mask changes in vital signs that you might expect, such as tachycardia in shock. A previous stroke may have changed a patient's baseline level of consciousness and neurologic status. **Medical and trauma conditions are often superimposed on each other. A simple fall may have been preceded by weakness and dizziness, suggesting a serious medical condition. What looks like an obvious trauma call could easily have been caused by a serious medical emergency.** Primary assessment: Anatomic changes that occur as a person ages predispose geriatric patients to airway problems. Aging and disease can compromise a patient's ability to protect his/her airway with loss of gag reflex and normal swallowing mechanisms. Changes in LOC, dementia, poststroke weakness or paralysis can cause airway obstruction or aspiration. -Anatomic changes with aging also affect a person's ability to breathe effectively. Increased chest wall stiffness, brittle bones, weakening of the airway musculature, and decreased muscle mass contribute to breathing problems. Loss of mechanisms that protect the upper airway, like cough and gag reflexes, cause a decreased ability to clear secretions. A decrease in the number of cilia that line the bronchial tree results in the inability of the patient to remove material from the lung, which can cause infection. In some patients, the alveoli are damaged, and a lack of elasticity results in a decreased ability to exchange oxygen and carbon dioxide. -Less responsive nerve stimulation may lower the rate and strength of the heart's contractions, so lower heart rates and weaker and irregular pulses are common in older patients. Vascular changes and circulatory compromise might make it difficult to feel a radial pulse on an older patient. History taking: Remember that chronic mental status impairment is not a normal process of aging, but is caused by a pathologic or disease process. You should never accept confusion as normal. -Communications and getting an accurate SAMPLE history can be complicated. The chances are good that the chief complaint is related to a chronic medical problem and the patient may have experienced it before. Symptoms should be determined to be acute or chronic. Secondary assessment: The heart rate should be in the normal adult range, but may be compromised by medications such as beta-blockers. These medications keep the heart rate low and prevent the tachycardia that might be typically seen in dehydration or shock. Weak and irregular pulses are common in older patients. The pulse may be irregular secondary to atrial fibrillation. Circulatory compromise may make it difficult to feel a radial pulse on an older patient, and other pulse points may need to be considered. -Blood pressure tends to be higher in older patients. A geriatric patient who has a blood pressure in a normal adult range could be hypotensive. Hypertension could signal impending stroke. -Capillary refill is not a good assessment tool in older patients because of skin changes and reduced circulation of the skin. -The respiratory rate should be in the same range as in a younger adult, but remember that chest rise will b compromised by increased chest wall stiffness. -Careful interpretation on pulse oximetry data is necessary in older adults because the pulse oximetry device requires adequate perfusion to get an accurate reading.

Understand standard precautions and know the different types of personal protective equipment

The center for disease control created a set of standard precautions to protect health care workers from objects, blood, body fluids, and other potential sources of germs. PPE: gloves, gown, mask, face shield, eye protection

Understand the anatomy and physiology of the cardiovascular system

The circulatory system includes all blood vessels, capillaries, and the heart. It is also called the cardiovascular system. The heart: a muscular organ with two pumps, one on the left side and another on the right. -The left pump receives oxygenated blood from the lungs and sends it throughout the body. It is the stronger of the two pumps, with a greater workload than the right pump. -The right pump receives deoxygenated blood from the body and sends it to the lungs to drop off carbon dioxide and pick up oxygen on its way to the least heart. -Three layers of the heart muscle and pericardium -Endocardium: smooth, thin lining on the inside of the heart -Myocardium: thick muscular wall of the heart -Epicardium: outermost layer of the heart and innermost layer of the pericardium -pericardium: fibrous sac surrounding the heart. -The chambers and valves -Atria: the two upper chambers of the heart. Blood returning to the heart on both side enters the atria (atrium). the atria pump the blood into the ventricles just before the ventricles contract. This is called the "atrial kick" and helps increase cardiac output. -Ventricles: the lower and larger chambers of the heart. Ventricles receive blood from the atria and send it out of the heart during ventricular contraction. Under normal circumstances, this generates a palpable pulse. The left ventricle sends oxygen-rich blood throughout the body under high pressure. the right ventricle send oxygen-depleted blood to the lungs under low pressure. -Heart valves: one-way valves between the atria and ventricles that allow blood to move in a downward direction into the the ventricles during atrial contraction. The valves then close during ventricular contraction to prevent regurgitation of blood back into the atria. -Cardiac conduction system -The heart has it's own electrical system. It generates electrical impulses, which stimulate contraction of the heart muscle. -The heart can generate electrical impulses from three different locations. The primary power plant, the sinoatrial (SA) node, normally generates impulses between 60 to 100 times per minute in the adult. That's why the normal heart rate in adults is 60 to 100 beats per minute. -The atrioventricular (AV) junction is the backup pacemaker and generates electrical impulses at about 40 to60 per minute -The bundle of His is the final pacemaker for the heart. It generates impulses only at about 20 to 40 per minute. -The heart, like the brain, is extremely intolerant of a lack of oxygen. The heart receives its blood flow from the coronary arteries, which branch off of the aorta. -Cardiac output (circulation) will cease if the heart is unable to generate electrical impulses or if the heart is too damaged to respond tot he impulses. -Cardiac contraction -Myocardial contractility -Contractility refers to the heart's ability to contract -Adequate contractility requires adequate blood volume and muscle strength -Preload -Preload is the precontraction pressure based on the amount of blood coming back to the heart. -Increased preload leads to increased stretching of the ventricles and increased myocardial contractility -Afterload -Afterload is the resistance the heart must overcome during ventricular contraction -Increased afterload leads to decreased cardiac output -Blood flow through the cardiovascular system -Oxygen-rich blood exits the left heart through the aorta. The aorta branches off into arteries, then arterioles, and finally capillaries. On the venous side, capillaries feed into venues, the veins, and finally the superior and inferior vena cava. -Arteies always carry blood away from the heart, and veins always carry blood toward the heart. **The pulmonary artery is the one artery in the body that carries deoxygenated blood. The pulmonary vein is the only vein in the body that carries oxygen-rich blood.** -Systemic vascular resistance (SVR) -SVR is the resistance to blood flow throughout the body (excluding the pulmonary system) -SVR is determined by the size of blood vessels: -Constriction (reduced size) of blood vessels increases SVR and can cause an increase in blood pressure -Dilation (increased size) of blood vessels decreases SVR and can lower blood pressure. -Arterial Pulses -Central pulses -Carotid pulse: can be felt by palpating the carotid artery in the neck during contraction of the left ventricle -Femoral: can be felt by palpating the femoral artery in the groin area during contraction of the left ventricle -Peripheral pulses -Radial pulse: palpated is the wrist on the radial (thumb) side -Brachial pulse: palpated on the medial portion of the upper arm beneath the biceps muscle; can also be felt on the anterior medial area of the arm where the humerus meets the forearm (elbow area) Dorsalis pedis: palpated on top of the foot *From the EMT crash course book* *Link to video on blood flow of the heart listed below* https://www.registerednursern.com/how-to-remember-blood-flow-of-the-heart/ Picture on blood flow through the heart listed

Understand pathophysiology, assessment, and management of abdominal and genitourinary injuries

Types of abdominal pain: note that the level of pain does not necessarily indicate the illness's severity. Patient's can have a life-threatening abdominal emergency without severe pain. -Visceral pain -Dull, diffuse pain that is difficult to localize -Frequently associated with nausea and vomiting -Often not severe, but may indicate actual organ injury -Parietal pain -Severe, localized pain. Usually sharp and constant -The pain will often cause the patient to curl up with knees to chest -The patient is often very still and breathing shallowly to diminish pain -Referred pain: causes pain in an area of the body other than the source Causes of acute abdominal pain -Appendicitis -Caused by inflammation of the appendix -can lead to life-threatening infection and septic shock -Signs and symptoms -Nausea, vomiting, diarrhea, loss of appetite, fever -Pain may begin as diffuse, but usually localizes to right lower quadrant -Peritonitis -Peritonitis is caused by inflammation of the peritoneum (membrane lining the abdominal organs and cavity) -Signs and symptoms: nausea, vomiting, loss of appetite, diarrhea, fever -Cholecystitis -Inflammation of the gallbladder, often due to gallstones -Most often occurs in females 30 to 50 years of age -Signs and symptoms -Right upper quadrant pain -Increased pain at night -Increased pain after eating fatty foods -Referred pain to the right shoulder -Nausea and vomiting -Diverticulitis -Develops when small pouches (diverticula) along the wall of the intestine fill with feces and become inflamed and infected -Typically affects people over the age of 40 and is associated with a low-fiber diet -Signs and symptoms -Usually abdominal pain in the lower left quadrant -Fever -Weakness -Nausea and vomiting -Bleeding not common -Gastrointestinal (GI) Bleeding -Most often occurs in middle-aged patients -Most often fatal in geriatric patients -Upper GI bleeds: often due to ulcers -Lower GI bleeds: often due to diverticulitis -Signs and symptoms -Hematemesis: vomiting blood -Hematochezia: bloody stool -Dark, tarry stool -Signs and symptoms of hypovolemic shock -Gastroenteritis -Infection with associated diarrhea, nausea, and vomiting -Usually due to contaminated food or water and is not contagious -Prolonged vomiting and diarrhea can lead to hypovolemic shock -Gastroenteritis is a common cause of shock in children -Esophageal Varices -A weakening of the blood vessels lining the esophagus -The condition is frequently associated with alcoholism -Signs and symptoms -Vomiting large amounts of bright red blood -History of alcohol abuse or liver disease -Signs and symptoms of hypovolemic shock -Ulcers -Open wounds along the digestive tract, often the stomach -Signs and symptoms -History of ulcers -Abdominal pain in the left upper quadrant -Nausea and vomiting -Often elicits an increase in pain before meals and during stress -Abdominal Aortic Aneurysm (AAA) -A weakening of the wall of the aorta in the abdominal region -Weakened area is prone to rupture. A ruptured AAA will likely cause rapid, fatal bleeding -Signs and symptoms -AAA is most common in geriatric males -Tearing back pain -Signs and symptoms of hypovolemic shock -Possible pulsating abdominal mass -Patients with a suspected AAA should be transported to an appropriate facility without delay Assessment and management -Patient assessment: the assessment of abdominal injuries is one of the more difficult assessments that you will perform. The causes of the injury may be readily apparent as a result of the MOI or the visibility of a penetrating wound, but the resulting tissue damage may not be so apparent. Often, other injuries, such as a fractured bone, may be painful and distracting for the patient. The patient may not tell you about more subtle pain that could indicate an abdominal injury. Additionally, some abdominal injuries develop and worsen over time, making reassessment critical. -Primary assessment: Your goal in the primary assessment is to evaluate the patient's ABCs and then immediately care for any life threats. First perform a primary assessment. -The general impression, including an evaluation of the LOC, will help you establish the seriousness of the patient's condition. Some abdominal injuries will be obvious and graphic; however, most will be very subtle and may go unnoticed. Considering the MOI with the general impression will help you focus on the immediate problem. Remember, in some cases of trauma or blows to the abdomen, the injury may have occurred hours or even days earlier and the pain has now reached a point where it is now severe enough for the patient to seek help. -As you approach the trauma patient with a suspected closed abdominal injury, important indicators will alert you to the seriousness of the patient's condition. Is the patient awake and interacting with his or her surroundings, or is he or she lying still, not making sounds? Does the patient have any apparent life threats? What color is the patient's skin? Is he or she appropriately or inappropriately responding to you? Your general impression will help you develop an index of suspicion for serious injuries and determine how urgently your patient needs care. -Trauma patients with closed abdominal injuries may have what appear to be minor injuries; however, you must not be distracted from looking for more serious hidden injuries. For example, an abrasion to the abdomen may appear to be a superficial injury when in actuality it may be the only outward clue that abdominal organs or injured. -Check for responsiveness using the AVPU scale. Ask the alert patient about his or her chief complaint. Unresponsiveness may indicate a life-threatening condition. You should administer high-flow oxygen via a nonrebreathing mask to trauma patients whose LOC is less than alert and oriented and provide rapid transport to the ED. -In trauma patients, life-threatening external hemorrhage must be addressed before airway or breathing concerns. Next, ensure the patient has a clear and patent airway. If spinal injury is suspected, prevent the patient from moving by having a team member hold the patient's head still and verbally remind the patient not to move. Patients may report feeling nauseous, and they may vomit. Remember to keep the airway clear of vomitus so that is not aspirated into the lungs, especially in a patient who is unconscious or who has an altered LOC. Turn the patient on one side, stabilizing the spin if necessary, and try to clear any material from the throat and mouth. Note the nature of the vomitus: undigested food, blood, mucus, or bile. -You must also quickly assess the patient for adequate breathing. A distended abdomen or pain may prevent adequate inhalation. When the guarded respirations decrease the effectiveness of the patient's breathing, providing supplemental oxygen with a nonrebreathing mask will help improve oxygenation. If the patient's LOC is decreased and respirations are shallow, consider supplementing respirations with a BVM. Use airway adjuncts as necessary to ensure a patent airway and assist with breathing -If you suspect shock, evaluate the patient's pulse and skin color, temperature, and condition to determine the stage of shock. Treat the patient aggressively by providing oxygen, positioning the patient supine, and keeping the patient warm. Wounds should be covered and bleeding should be controlled as quickly as possible. -History taking: Once you have identified and treated life threats, you can then gather a history from the patient. You should clarify the chief complaint and MOI, as well as any associated signs and symptoms. You can quickly assess the patient's chief complaint with a simple inspection, noting the position in which he or she is lying. -Secondary assessment: Usually you will perform the physical examination on all patients with abdominal injuries in the same manner as follows: -Remove or loosen clothes to expose the injured regions of the body. Inspect the patient for bleeding before removing clothing to prevent damaging any exposed tissues, such as in the case of an evisceration -Provide privacy as needed or wait until you are in the back of the ambulance -The patient without suspected spinal injury should be allowed to stay in the position of comfort -- with the legs pulled up toward the abdomen. This position will relieve some of the tension on the abdomen and thus provide pain relief. -For a patient with spinal injury, place padding such as blankets or pillows under his or her knees to help alleviate tension on the abdominal wall. Keep in mind that you can worsen the spinal injury if you are too aggressive when placing these items. -The patient with suspected spinal injury should not be forced to lie flat for the physical examination or transport. The fetal position may provide the patient with the most comfort during the physical examination or transport -Examine the entire abdomen including all posterior, anterior, or lateral surfaces. This is a critical step when patients have an injury with an entrance wound. Examine the axillae (armpits) for entrance wounds. -Use DCAP-BTLS to help identify specific sign and symptoms of injury. Inspect and palpate the abdomen for the presence of deformity, which may be subtle in abdominal injuries. Look for the presence of contusions and abrasions, which can help localize focal points of impact and may indicate significant internal injury. -Reassessment: repeat the primary assessment and vital signs. Reassess the interventions and treatment you have provided to the patient. Identify trends in pain, vital signs, and the progress of treatments to determine whether the patient's condition is improving or worsening. Adjustment in care can be based on the objective findings

Chapter 31:Understand pathophysiology, assessment and management of orthopedic injuries

Types of injuries -Fractures -Open fractures: fractures with an associated open soft tissue injury -Closed fracture: fracture where the skin is not broken -Signs and symptoms: pain, swelling, deformity, tenderness, loss of function, possible weak or absent distal pulses and crepitus (the sound or feeling of fractured bone rubbing together) -Strain -Stretching injury to a muscle or tendon -Signs and symptoms: pain and tenderness -There is usually little bleeding with a strain, so swelling and discoloration will likely be minimal -Sprain -Injury to a ligament -Frequently involve the shoulder, knee, or ankle joints -Signs and symptoms -Pain and tenderness: immediately -Swelling and deformity: delayed -Dislocation -The movement of a bone out of its normal position in a joint -The bone may return to its normal position or remain out of joint -Signs and symptoms: pain, deformity, loss of function, possible weak or absent distal pulses. -Dislocations often have associated sprains and strains -Potential limb-threatening injuries -Any orthopedic injury resulting in loss of circulation distal to the injury is a high-priority injury. The limb is at risk until circulation is restored. -Signs of orthopedic injury with loss of distal circulation: absence of distal pulses, pale distal to injury, cool distal to injury, delayed capillary refill distal to injury. -Potential life-threatening injuries: -Pelvic fractures -One in five hip fracture patients die within a year of the injury -Hip fracture patients are at risk for hypovolemic shock, embolism, pneumonia, and sepsis -Most hip fractures occur in the geriatric population due to falls -Pelvic binders are commercial splints used in some EMS systems to stabilize pelvic fractures and reduce bleeding -Femur fractures -A single femur fracture can cause hypovolemic shock -Femur fracture patients are at an increased risk of pulmonary embolism -Fractures to multiple smaller long bones can combine to cause hypovolemic shock -Amputations -Control bleeding -Wrap amputated part in a sterile dressing and place in plastic bag and keep cool -Do not delay transport o a high-priority patient for an amputated part. Assessment and management -Primary assessment: The primary assessment should focus on identifying and managing life-threats. Treating the patient according to his or her LOC and ABCs is always the priority. Threats to airway, breathing, and circulation are considered life-threatening and must be treated immediately to prevent mortality. Significant bleeding, internal or external, is an immediate life threat. If the patient has obvious life-threatening external hemorrhage, it should be addressed first (even before airway and breathing), and then begin treating the patient for shock as quickly as possible. For example, if you are unable to control arterial bleeding from extremities by using direct pressure, apply a tourniquet (if possible). Arterial bleeding from a compound fracture should be treated prior to giving oxygen. -When evaluating the patient's LOC and orientation, check for responsiveness using the AVPU scale, and assess mental status by asking the patient about his or her chief complaint. If the patient is alert, this should help direct you to any apparent life threats. An unresponsive patient may have an underlying life-threatening condition. You should administer high-flow oxygen via a nonrebreathing mask (or a BVM, if indicated) to all patients whose LOC is less than alert and oriented, and provide rapid transport to the ED. -Handling injured extremities during assessment and transport: Recall that fractures can break through the skin and cause external bleeding. This may occur during initial injury or during manipulation of the extremity while preparing for splinting or transport. Careful handling of the extremity minimizes this risk. If external bleeding is present, bandage the extremity quickly to control bleeding. The dressing that cover the wound and bone should be kept clean to reduce the potential for bone infection. The bandage should be secure enough to control bleeding without restricting circulation distal to the injury. Monitor bandage tightness by assessing the circulation, sensation, and movement distal to the bandage. Swelling from fractures and internal bleeding may cause bandages to become too tight. If bleeding cannot be controlled, quickly apply a tourniquet. -History taking: After life threats have been managed during the primary assessment, investigate the chief complaint. Obtain a medical history and be alert for injury-specific signs and symptoms and for any pertinent negatives, such as no pain or loss of sensation. -Obtain a SAMPLE history for all trauma patients. How much and in what detail you explore this history depends on the seriousness of the patient's condition and how quickly you need to transport. For patient's wit simple fractures, dislocations, or sprains, it is easier to obtain a sample history. At the scene you may have access to family members and others who have information about the patient's history. -OPQRST can be of limited use in cases of severe injury and is usually too lengthy when matters of airway, breathing, circulation, and rapid transport require immediate attention. However, OPQRST may be useful when the MOI is unclear, the patient's condition is stable, or details of the injury are uncertain. -Secondary assessment: If significant trauma has likely affected multiple systems, start with a secondary assessment of the entire body to be sure that you have found all of the problems and injuries. Begin with the head and work systematically toward the feet, checking the head, abdomen, extremities , and back. The goal is to identify hidden and potentially life-threatening injuries. The secondary assessment will also help you to prepare for packaging and rapid transport. Knowing if an arm or leg is broken will be important when log rolling and securing the patient onto a backboard. -Use the DCAP-BTLS approach to assess the musculoskeletal system. Identify any extremity deformities that likely represent significant musculoskeletal injury, and stabilize them appropriately. Contusions and abrasions may overlie more subtle injuries and should prompt you to carefully evaluate the stability and neurovascular status of the limb. The presence of puncture wounds or other signs of penetrating injury should alert you to the possibility of an open fracture. Associated burns must be identified and treated appropriately. Palpate for tenderness, which, like contusions or abrasions, may be the only significant signs of underlying musculoskeletal injury. -When lacerations are present in an extremity, and open fracture must be considered, bleeding controlled, and dressings applied. Careful inspection for swelling with comparison with the opposite limb may also reveal otherwise occult musculoskeletal injury. You may find a hematoma in the zone of injury during the assessment. -If your assessment reveals no external signs of injury, ask the patient to move each limb carefully, stopping immediately if a movement causes pain. Skip this step in your evaluation if the patient reports neck or back pain; even slight motion could cause permanent damage to the spinal cord. -Determine a baseline set of vital signs, including pulse rate, rhythm, and quality; blood pressure; skin condition; and pupil size and reaction to light. These need to be obtained as soon as possible. Your patient may appear to be tolerating the injury well until you reassess these vital signs and they indicate otherwise. Trending these vital signs help you to understand whether your patient's condition is improving or worsening over time, particularly during long transports. Shock or hypoperfusion is common in musculoskeletal injuries; therefore this baseline information is very important in assessing your patient's condition. -Reassessment: Repeat the primary assessment to ensure your interventions are working as they should. Perform a reassessment every 5 minute for unstable patients and every 15 minutes for stable patients. -Because trauma patients often have multiple injuries, you must assess their overall condition, stabilize the ABCs, and control any serious bleeding before further treating the injured area. In a critically injured patient, secure the patient to a backboard to immobilize the spine, pelvis, and extremities and provide prompt transport to a trauma center. In this situation, a secondary assessment with extensive evaluation and splinting of the limb injuries in the field is a waste of valuable time. Perform the primary assessment and transport, reassessing the patient en route to the ED. -If the patient has no life-threatening injuries, you may take extra time at the scene to stabilize the patient's overall condition and more completely evaluate the injury. If possible, gently and carefully remove the patient's clothing to look for open fractures or dislocations, severe deformity, swelling, and/or ecchymosis. -When you have finished assessing the extremity, apply a secure splint to stabilize the injury prior to transport. The joint above and below the site of injury should be included in the splint. To minimize the potential for complications, the splint should be well padded. A comfortable and secure splint will reduce pain, reduce shock, and minimize compromised circulation. A good rule is to check the patient's circulation, motor function, and sensation before and after splinting. -It is important to document the presence or absence of circulation, motor function, and sensation distal to the injury before you move an extremity, after manipulation or splinting of the injury, and on arrival at the hospital. Do not rely on your memory for details from situations, your memory is unreliable. Always document your findings.

Understand when to use the head-tilt-chin-lift vs. jaw-thrust maneuver

Use the jaw-thrust maneuver to open the airway of a patient with a suspected spinal injury. Use the head-tilt-chin-lift for other patients

Understand the signs and symptoms seen in various respiratory conditions

-Asthma: wheezing on inspiration/expiration, bronchospasm -Anaphylaxis: flushed skin/hives (urticaria), generalized edema, decreased BP (hypotension), laryngeal edema with dyspnea, wheezing -Bronchiolitis: shortness of breath, wheezing, coughing, fever, dehydration, tachypnea (increased breathing rate), tachycardia -Bronchitis: Chronic cough (with sputum production), wheezing, cyanosis, tachypnea -Congestive heart failure (CHF): dependent edema, crackles (pulmonary edema), orthopnea (shortness of breath/difficulty breathing when lying down), Paroxysmal nocturnal dyspnea (condition that triggers sudden shortness of breath during sleep) -Common cold: cough, runny or stuffy nose, sore throat -Croup: fever, barking cough, Stridor, **mostly seen in pediatric patients** -Diphtheria: difficulty breathing and swallowing, sore throat, thick/gray buildup in throat or nose, fever -Emphysema: barrel chest, pursed lip breathing, dyspnea on exertion, cyanosis, wheezing/decreased breath sounds -Epiglottis: dyspnea, high fever, Stridor, drooling, difficulty swallowing, severe sore throat, tripod or sniffing position -Influenza type A (flu): cough, fever, sore throat, fatigue -Pertussis (whooping cough): coughing spells, "whooping" sound, fever -Pneumonia: dyspnea, chills, fever, cough, green/red/rust-colored sputum, localized wheezing or crackles -Pneumothorax: sudden chest pain with dyspnea, decreased breath sounds (affected side), subcutaneous emphysema -Pulmonary embolus: sharp chest pain, sudden onset, dyspnea, tachycardia, clear breath sounds initially -Tension pneumothorax: sever shortness of breath, decreased/altered LOC, neck vein distention, tracheal deviation (late sign), hypotension; signs of shock (late sign) -Respiratory syncytial virus (RSV): cough, wheezing, fever, dehydration -Tuberculosis (TB): cough, fever, fatigue, productive/bloody sputum **Table 15-3 in book**

Understand the differences between chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF)

-COPD is a long term dilation and obstruction of the airways and alveoli caused by chronic bronchial constriction. COPD patients often have a history of lung problems. They will show signs of difficult breathing; such as in using accessory muscles, pursed lips, and abnormal breath sounds. -CHF is a disease of the heart that is associated with shortness of breath, edema, and weakness. Patients with CHF experience wheezing and rapid respirations. They also experience elevated blood pressure and edema **Table 15-4 in the book**

Chapter 15: Understand the signs and symptoms of inadequate breathing

-Difficulty breathing or shortness of breath. -Altered mental status with shallow or slow breathing -Adult patients appears anxious or restless -Pediatric patients appear sleepy or listless (lacking energy) -Respiratory rate is too fast or too slow -Breathing is irregular -The skin is pale, cool, clammy, or cyanotic -Adventitious (extra sounds that are heard over normal breath sounds) breath sounds; such as wheezing, gurgling, snoring, crowing, or Stridor -Decreased or noisy breath sounds -The patients cannot speak more than a few words between breaths Accessory muscle use, retractions (Intercostal retractions; due to reduced air pressure inside your chest), or labored breathing -Unequal or inadequate chest expansion -Excessive coughing -Tripod position -The patient has pursed lips or nasal flaring

Understand hyperventilation or hypoxia, and how to recognize/treat each

-Hypoxia occurs when the body's cells and tissue are not getting enough oxygen. Besides shortness of breath, patients with dyspnea may experience air hunger or tightness. -Hyperventilation is the body's attempt to compensate for acidosis (excessively acid condition of the body fluids or tissues), but in the process hyperventilation causes alkalosis (condition in which the body fluid have excess base [alkali]. This is the opposite of acidosis). If verbal instruction to slow breathing does not work, administer supplemental oxygen.

Terminology: Organic vs. functional behavioral disorders Behavior crisis vs. psychiatric emergency Excited vs. agitated delirium

-Organic: is a temporary or permanent dysfunction of the brain caused by a disturbance in physical or physiologic functioning of brain tissue. Caused by: illness, traumatic brain injury, seizure disorders, drug or alcohol abuse/OD/withdrawal, brain diseases, such as Alzheimer dementia or meningitis. -Functional disorders: a physiological disorder that impairs bodily function even when the body seems structurally normal. Something has gone wrong, but the root cause cannot be identified. Examples: depression/anxiety and schizophrenia. The chemical or physical basis of these disorders does not alter the appearance of the patient. -Behavior crisis: or psychiatric emergency happens when a patient becomes agitated, violent or uncooperative, or is a danger to themselves or others. Excited delirium: also known as agitated delirium is a condition of impairment in cognitive function that can present with disorientation, hallucinations, or delusions.

Understand the different levels of choking

-Partial obstruction: can still get air in. Be prepared to assist if patient becomes unconscious, but encourage patient to keep coughing until the obstruction is cleared -Complete obstruction: can not get air in, immediate life threatening emergency. Never do a blind finger sweep, suction if needed, do a finger sweep only if you can see the obstruction -Child: kneel on one knee behind the child and circle both of your arms around the child. Perform abdominal thrusts. -Infant: deliver 5 back slaps repeated by 5 chest thrusts. Do no use abdominal thrusts in infants. -Adult: Heimlich thrust maneuver. Do abdominal thrusts in responsive adults, but chest thrusts in adults in late stages of pregnancy -Begin CPR in any patient that becomes unresponsive

Understand how to recognize and manage shock/difficulty breathing associated with anaphylactic reaction

-Place the patient in a position of comfort, generally in a high-fowler position, in an effort to maximize ventilations. This will help perfusion to the brain while easing respiratory effort. However, if signs of shock emerge, the patient should be placed in the supine position as tolerated. -Quickly listen to the lungs on each side of the chest. Do not hesitate to initiate high flow oxygen therapy. For a patient in severe respiratory distress, you may have to assist ventilations using a bag-valve mask (BVM), attached to a high concentration of oxygen. This can be done in an unresponsive patient or a patient with an altered level of consciousness. The positive-pressure ventilations you provide will force air beyond the swelling in the airway and into the lungs while you await more definitive treatment. -Although respiratory complaints are most common, some patients in anaphylaxis may not present with severe respiratory symptoms, but mainly with signs and symptoms of circulatory distress, such as hypotension. Palpating for the presence of and quality of a radial pulse will help you quickly identify how the circulatory system is responding to the reaction. -Assess for a rapid pulse rate; pale, cool, cyanotic, or red, moist skin; and delayed capillary refill, all of which may indicate hypoperfusion. Treatment for shock includes oxygen, proper positioning, (recumbent or supine as tolerated), and preventing the loss of body heat. The definitive treatment for shock resulting from anaphylaxis is epinephrine.

Components of a patients assessment

-Scene size-up -Primary assessment -History taking -Secondary assessment -Reassessment

Common suffixes -al -algia -ectomy -ic -itis -logy -logist -megaly -meter -oma -pathy

-al — pertaining to — syncopal — pertaining to sycope -algia — pertaining to pain — arthragia — joint pain -ic — pertaining to — diaphoretic — pertaining to diaphoresis -ectomy — surgical removal of — appendectomy — surgical removal of appendix -itis — inflammation — epiglottis — inflammation of the epiglottis -logy — study of — cardiology — study of the heart -logist — specialist — pulmonologist — specialist in diseases of the lung -megaly — enlargement — cardimegaly — enlargement of the heart -meter — measuring instrument — sphygmomanometer — instrument used to measure blood pressure -oma — tumor — lymphoma — cancer of the lymphatic system -pathy — disease — nephropathy — disease of the kidneys

Understand how to assess the abdomen of a patient during patient assessment

1. Explain to the patient what you are going to do in terms of assessing the abdomen. 2. Place the patient in a supine position with the legs drawn up and flexed at the knees to relax the abdominal muscles, unless there is any trauma, in which cases the patient will remain supine and stabilized. Determine whether the patient is restless or quiet, and whether motion causes pain. 3. Expose the abdomen and visually assess it. Does the abdomen appear distended (enlarged)? Do you see any pulsating masses (indicating an aortic aneurysm)? Is there bruising to the the abdominal wall? Are there any surgical scars? 4. Ask the patient where the pain is most intense. Palpate in a clockwise direction beginning with quadrant AFTER the one the patient indicates in tender or painful; end with the quadrant the patient indicates is tender or painful. If the most painful area is palpated first, the patient may guard against further examination, making your assessment more difficult and less reliable. 5. Remember to be very gentle when palpating the abdomen. Occasionally, and organ within the abdomen will be enlarged and very fragile. Rough palpation could cause further damage. If you see a pulsating mass, do not touch it; doing so could cause the aorta to rupture. 6. Palpate the four quadrants of the abdomen gently to determine whether each quadrant is tense (guarded) or soft when palpated. 7. Note whether the pain is localized to a particular quadrant or diffuse (widespread). 8. Palpate and wait for the patient to respond, looking for a facial grimace or a verbal "ouch." Do not as the patient "Does it hurt here?" as you palpate. 9. Determine whether the patient exhibits rebound tenderness (may be tender when direct pressure is applied, but very painful when pressure is released). This is and indicator of peritonitis. When you are palpating for rebound tenderness, you should use extreme caution. 10. Determine whether the patient can relax the abdominal wall on command. Guarding or rigidity may be present, which can indicate peritoneal irritation.

Understand headache red flags

A patient who as a headache associated with any of the following should be evaluated for a potentially life-threatening condition. -Sudden onset of symptoms -Explosive/thunderclap pain -Altered mental status - Age >50 -Depressed immune system (known to be at higher risk for infection -Neurologic deficits -Neck stiffness/pain -Fever -Changes in vision -One-sided paralysis or weakness

Understand the importance of pulse oximeter and Spo2 readings and what the can mean

A pulse oximeter measures the percentage of hemoglobin saturation. Normal Spo2 in room air should measure between 98-100. A percentage less than 96 inn a non-smoker usually indicates hypoxia. Unless the patient has a chronic condition in which below 90 is normal, the patient should be treated at percentages less than 90. Patients experiencing stroke or heart attack should be given oxygen when saturation is below 94. Pulse oximeter is unable to distinguish between oxygen saturation and carbon monoxide saturation. Therefore in cases of carbon monoxide poisoning, the Spo2 can be normal in the context of hypoxia.

Prefixes describing position Ab Ad De Circum Peri Trans Epi Supra Retro Sub Infra Para Contra Ecto Endorse Extra Intra Ipsi

Ab — away from — abduction — away from the point of reference Ad — to, toward — adduction — toward the center De — down from, away — decay — to waste away Circum — around/about — circumferential burn — a burn around the entire area (arm) Peri — around — pericardium — sac around the heart Trans — across/through/beyond — transvaginal — across or through the vagina Epi — above/upon — epigastric — abover or over the stomach Supra — above/over — suprasternal notch — top of the sternum Retro — behind — retroperitoneal — the area behind the peritoneum Sub — under/beneath — subcutaneous — behind the skin Infra — below/under — infraclavicular — below the clavicle Para — near, beside, beyond, apart from — parasternal — beside the sternum Contra — against, opposite — contraindicated — something that is not indicated Ecto — out/outside — ectopic pregnancy — pregnancy where embryo attaches outside of uterus Endo — within — endoscopy — examining inside of someone's body (with endoscope) Extra — outside — extraneous — outside the organism and not belonging to it Intra — inside — intrauterine — within the uterus Ipsi — same — ipsilateral — on or accepting the same side

Generic Name: Aspirin Trade name: Bayer

Action: Anti-inflammatory agent and anti-fever agent; prevents platelets from clumping, thereby decreasing formation of new clots. Indications: relief of mild headache, pain, muscle aches, chest pain of cardiac origin Contraindications: hypersensitivity; recent bleeding Routes: PO Side effects: Nausea, vomiting, stomach pain, bleeding, allergic reaction Interactions: caution should be used in patients who are taking anticoagulants Adult dose: 160 to 325 mg; 160 to 325 mg chewable tablets for chest pain Administration concerns: Do not administer for pain caused by trauma or for fevers in children; patients with chest pain must be able to chew tablet

Medications: Generic name: Activated charcoal Trade name: Actidose with sorbitol

Action: absorbs toxic substances in the digestive tract Indications: most oral poisonings; overdose Contraindications: decreased LOC; overdose of corrosives, caustics, or petroleum substances Routes: PO Side effects: nausea, vomiting, constipation, black stools Interactions: bonds with and inactivated most medications/substances in the digestive tract Adult dose: 1 to 2/kg Administration concerns: stains (protect patient and provider clothing); do not give when giving other PO medications

Common over the counter (OTC) medications: Generic name: Acetaminophen Trade name: Tylenol

Action: analgesic ( pain reliever) and fever reducer Indications: relief of mild pain or fever, headache, muscle aches Contraindications: hypersensitivity Routes: PO Side effects: Allergic reaction Interactions: take caution to avoid potential overdosing, many OTC medications contain acetaminophen Adult dose: 500 to 1000 mg every 4 hours as needed; dose is weight based for children Administration concerns: weight of child is more important than age

Generic name: Diphenhydramine Trade name: Benadryl

Action: antihistamine (blocks histamine) Indications: mild allergic reactions Contraindications: asthma, glaucoma, pregnancy; hypertension; infants Routes: PO Side effects: sleepiness (although can stimulate children), dry mouth and throat Interactions: do not take with alcohol or monoamine oxidase (MAO) inhibitors (type of psychiatric medicine) Adult dose: 25 to 50 mg Administration concerns: can use in severe allergic reaction; however, epinephrine is administered first

Generic name: Nitroglycerin Trade name: Nitrostat, Notromsit

Action: dilates blood vessels Indication: chest pain of cardiac origin Contraindications: hypotension, use of sildenafil (viagra) or another treatment for erectile dysfunction within the previous 24 hours, head injury Routes: SL tablet or spray Side effects: headache, burning under tongue, hypotension Interactions: increases dilating effects of other blood vessel dilating medications Adult dose: 0.3 to 0.4 mg-Sl; 0.4 mg spray Administration concerns: ensure ALS is en-route

Generic name: Ibuprofen Trade name: Advil, Motrin, Nuprin

Action: non-steroidal anti-inflammatory drug that reduces inflammation and fever, analgesic Indications: mild pain or fever, headache, muscle aches Contraindications: hypersensitivity Routes: PO Side effects: nausea, vomiting, stomach pain, bleeding, allergic reaction Interactions: do not take with aspirin Adult dose: 200 to 400 mg every 4 to 6 hours; dose is weight based in children Administration concerns: do not take for pain caused by trauma; weight of child is more important than age

Generic name: Oxygen Trade name: none

Action: reverses hypoxia; provides oxygen to be absorbed by lungs Indications: hypoxia or suspected hypoxia Contraindications: very rarely used in patients with COPD; do not use near open flames as oxygen will support combustion Routes: Inhalation Side effects: decreased respiratory effort in rare cases in patients with COPD Interactions: can support combustion Adult dose: use oxygen delivery devices to administer 28% to 100% oxygen Administration concerns: no open flames nearby, do not withhold oxygen from patients in respiratory distress

Generic name: Naloxone Trade name: Narcan, Evzio auto-injector

Action: reverses respiratory depression secondary to opioid overdose Indication: opioid poisoning Contraindications: hypersensitivity Routes: IM, IN Side effects: nausea, vomiting Interactions: additional doses may be required for severe opioid overdoses Adult dose: 0.4 mg auto-injector; 2 mg IN Administration concerns: patients may wake up combative

Generic Name: common fast-acting MDI medications Trade name: Albuterol, [Proventil, ventolin]

Action: stimulates nervous system, causing bronchodilation Indications: asthma, difficulty breathing with wheezing Contraindications: hypersensitivity, tachycardia (relative), chest pain of cardiac origin Routes: inhalation Side effects: hypertension, tachycardia, anxiety, restlessness Adult Dose: 1 to 2 inhalations; wait 5 minutes before repeating dose Interactions: increase effects of other nervous system stimulants Administration concerns: patient must be able to inhale all medication in one breath; coach patient to hold breath for 5 seconds after inhalation

Generic a name: oral glucose Trade name: glutose

Action: when absorbed, provides glucose for cell use Indications: low blood glucose (hypoglycemia) Contraindications: decreased LOC, nausea, vomiting Routes: PO Side effects: nausea, vomiting Interactions: none Adult dose: 1/2 to 1 tube Administration concerns: patient must bee awake, have control of airway, and be able to follow commands

Understand the anatomy and physiology and how to determine adequate ventilations

Adequate breathing is indicated by regular, non-labored, bilateral and equal rise and fall of the chest. Upper airway: includes Nasopharynx, nasal air passage, pharynx, oropharynx, mouth, epiglottis Lower airway: Includes Trachea, carina, main bronchi, smaller bronchi, bronchioles, and alveoli

Understand the classifications of burns by age

Adults -Severe burns -Full-thickness burns involving the hands, feet, face, upper airway, or genitalia or circumferential burns of other areas -Full-thickness burns covering more than 10% of the body's total surface area -Partial-thickness burns covering more than 30% of the body's total surface area -Burns associated with respiratory injury (smoke inhalation or inhalation injury -Burns complicated by fractures -Burns on patients younger than 5 years or older than 55 years that would be classified as moderate on young adults -Moderate burns -Full-thickness burns involving 2% to 10% of the body's total surface area (excluding hands, feet, face, genitalia, and upper airway) -Partial-thickness burns covering 15% to 30% of the body's total surface area -Superficial burns covering more than 50% of the body's total surface area -Minor burns -Full-thickness burns covering less than 2% of the body's total surface area -Partial-thickness burns covering less than 15% of the body's total surface area -Superficial burns covering less than 50% of the body's total surface area Infants and Children -Severe burns -Any full-thickness burn -Partial-thickness burns covering more than 20% of the body's total surface area -Moderate burns -Partial-thickness burns covering 10% to 20% of the body's total surface area -Minor burns -Partial-thickness burns covering less than 10% of the body's total surface area

Chapter 10: Understand various terminology Agonal Cheyne Stokes Kussmaul Respiration

Agonal gasps: occur when the heart stops but the brain still send signals to the lungs. These occasional gasping breaths do not supply enough oxygen, and artificial ventilations and chest compressions should be applied if necessary Cheyne Stokes: respiration's are periods of increased depth and rate alternating with periods of apnea. This is common in patients with strokes and head injuries Kussmaul Respiration's: deep, rapid respiration's that are common in patients experiencing metabolic acidosis

Function of the hypoxia drive and understand which patients use it and when

Although the brain stem normally regulates the amount of carbon dioxide in the blood and CSF via respiration, hypoxic drive serves as a back-up mechanism in chronic levels of minimal oxygen. Less sensitive sensors in the brain, walls of the aorta, carotid arteries control oxygen levels via respiration. Patients with COPD generally utilize hypoxic drive, so they should be monitored if administered oxygen

Differentiate: advanced directives versus DNR orders and understand what happens in the place of no DNR present at the scene

An advanced directive is a written document that specifies medical treatment for a competent patient, should he/she be unable to make rational decisions. They can be orders for both providing and with-holding care. A DNR orders medical providers to withhold CPR and ALS, but does not prevent them from providing BLS. Without a DNR present, healthcare providers will begin to attempt resuscitation should the patient's heart stop

Understand infectious disease and appropriate standard precautions

An infectious disease is a medical condition caused by the growth and spread of small harmful organisms within the body. Appropriate standard precautions: - hand hygiene; wash hands after patient contact, removing gloves, touching blood or other body fluids, exertions or contaminated items - Gloves: always wear gloves when coming in contact with a patient - Gown: when contact of EMTs clothes and blood/body fluids is anticipated - Mask/eye protection/face shield: during procedures where splashes of blood/body fluids is likely to happen

Carbon Monoxide Poisoning

An odorless, tasteless, and highly poisonous gas that results from incomplete oxidation of carbon in combustion. Carboxyhemoglobin: has carbon monoxide instead of the normal oxygen bound to it. Carbon monoxide has a much stronger binding to hemoglobin than oxygen. Carboxyhemoglobin is formed in carbon monoxide poisoning and leads to oxygen deficiency in the body. *Carboxyhemoglobin decreases the capacity of oxygen in the blood.*

Understand the complications of neck injuries as it relates to the respiratory system

An open neck injury can be life-threatening. If the veins of the neck are open to the environment, they may suck air in. If enough air is sucked into a blood vessel, it can actually block the flow of blood into the lungs and cause cardiac arrest. This condition is called air embolism. To control bleeding and prevent the possibility of air embolism, cover the wound with an occlusive dressing. Apply manual pressure, but do not compress bot carotid vessels at the same time; if you do, this may impair circulation to the brain and cause a stroke. Secure a pressure dressing over the wound by wrapping roller gauze loosely around the neck and then firmly through the opposite axilla. -Use caution with patients suffering from a neck injury depending on the MOI involved. Immobilize the C-spine if indicated, including placing a cervical collar. The cervical collar may assist with holding a dressing in place over a neck wound.

Understand the various cardiovascular emergencies and signs, symptoms, assessment and treatment for each

Angina Pectoris or angina: can result from spasm of an artery, but is most often a symptom of atherosclerotic coronary artery disease. Angina occurs when the heart's need for oxygen exceeds its supply, usually during periods of physical or emotional stress when the heart is working hard. A large meal or sudden fear may trigger an attack. When the increased oxygen demand goes away, the pain typically goes away. The pain is usually described as crushing, squeezing or "like somebody is standing on my chest." It is usually felt in the mid portion of the chest, under the sternum. However, it can radiate tot he jaw, arms (frequently the left arm), the mid-portion of the back or the epigastrium (the upper-middle region of the abdomen). The pain usually lasts from 3 to 8 minutes, rarely longer than 15 minutes. Can be associated with shortness of breath, nausea, or sweating. It usually disappears promptly with rest, supplemental oxygen, or nitroglycerin (NTG), all of which decrease the need or increase the supply of oxygen to the heart. **Keep in mind that it can be difficult, even for physicians in hospitals, to distinguish between the pain of angina and the pain of an AMI. Patients experiencing chest pain or discomfort, therefore, should always be treated as if they are having an AMI** The pain of an AMI signals the actual death of cells in the area of the heart muscle where blood flow is obstructed. Once dead, the cells can not be revived. Instead, they will eventually turn to scar tissue and become a burden to the beating heart. This is why fast action is so critical in treating a heart attack. The sooner the arterial blockage can be cleared, the fewer the cells that may die. About 30 minutes after blood flow is cut off, some heart muscle cells begin to die. After about nearly two hours, as many as half of the cells in the area can be dead; in most cases after 4 to 6 hours, more than 90% will be dead. An AMI is more likely to occur in the larger, thick-walled left ventricle, which needs more blood and oxygen than the right ventricle. Signs and symptoms of Acute Myocardial Infarction include: -Sudden onset of weakness, nausea, and sweating, without and obvious cause -Chest pain, discomfort, or pressure that is often crushing or squeezing and that does not change with each breath -Pain, discomfort, or pressure in the lower jaw, arms, back, abdomen, or neck -Irregular heartbeat and syncope (fainting) -Shortness of breath, or dyspnea -Nausea/vomiting -Pink frothy sputum (indicating possible pulmonary edema) -Sudden death The pain of an AMI differs from the pain of angina in three ways: -It may or may not be caused by exertion but can occur at any time, sometimes when a person is sitting quietly or even sleeping -It does not resolve in a few minute; rather, it can last between 30 minutes and serval hours. -It may or may not be relieved by rest or nitroglycerin The physical findings of AMI vary, depending on the extent and severity heart muscle damage. The following are common: -General appearance: The patient will often appear frightened. There may be nausea, vomiting, and a cold sweat. The skin is often pale or ashen gray because of poor cardiac output and the loss of perfusion, or blood flow through the tissue. Occasionally, the skin will have a bluish tint, called cyanosis; this is the result of poor oxygenation of the circulating blood. -Pulse: Generally, the pulse rate increases as a normal response to pain, stress, fear or actual injury to the myocardium. Because dysrythmias are common in an AMI, you may feel and irregularity or even a slowing of the pulse. the pulse may also be dependent on the area of the heart that has been affected by the AMI. Damage to the inferior area of the heart often presents with bradycardia. -Blood pressure: Blood pressure may fall as a result of diminished cardiac output and diminished capability of the left ventricle to pump. However, most patients with an AMI will have a normal or, possibly , elevated blood pressure. -Respiration:The respiratory rate is usually normal unless the patient has CHF. In that case, respirations may become rapid and labored with a higher likelihood of cyanosis and possibly frothy sputum. A complaint of difficulty breathing is common with cardiac compromise, so even if the rate seems normal, look at the work of breathing, and treat the patient as if respiratory compromise were present. -Mental Status: Patients with AMIs often experience confusion or agitation and sometimes experience an almost overwhelming feeling of impending doom. If a patient tells you "I think I am going to die," pay attention. An Acute Myocardial Infarction can have three serious consequences: -Sudden death -Cardiogenic shock -Congestive heart failure (CHF) Cardiogenic Shock: often caused by a heart attack. The heart lacks enough power to force the proper volume of blood through the entire circulatory system. Signs and symptoms of cardiogenic shock include: -Anxiety or restlessness as the brain comes relatively starved for oxygen. The patient may report "air hunger." Think of the possibility of shock when the patient says that he or she cannot breathe. Obviously, the patient can breath, because he or she can talk. However, the patient's brain is sensing that it is not getting enough oxygen. -As the shock continues, the body tries to send blood to the most important organs, such as the and heart, and away from less important organs, such as the skin. Therefore, you may see pale, cool, clammy skin in patients with shock. -As the school gets worse, the body will attempt to compensate by increasing the amount of blood pumped through the heart. Therefore, the pulse rate will be higher than normal. In severe shock, the heart rate usually, but not always, is greater than 120 beats/min. As the shock progresses, the pulses may become irregular and weak. -Shock can also present with rapid and shallow breathing, nausea and vomiting, and a decrease in body temperature. -Finally, as the heart and other organs begins to malfunction, the blood pressure will fall below normal. A systolic blood pressure less than 90 mm Hg is easy to recognize, but it is a late finding that indicates decompensated shock. It is very important though not to assume that is not present just because the blood pressure is normal (compensated shock). Treatment of cardiogenic shock -Position the patient comfortably. Some patients will be more comfortable in a semi-Fowler position (head and knees slightly elevated); however, patients with a low blood pressure may not tolerate a semi-upright position and may be mor comfortable and more alert in a supine position. -Administer high flow oxygen -Assist ventilations as necessary -Cover the patient with sheets or blankets as necessary to preserve body heat. Be sure to cover the top of the patient's head in very cold weather, as this is where much heat is lost -Provide prompt transport to the ED. Congestive Heart failure (CHF): occurs when the ventricular heart muscle is so permanently damaged that it can no longer keep up with the return flow of blood from the atria. CHF can occur at any time after a myocardial infarction, in the setting of heart valve damage, or as a consequence of long-standing high blood pressure. Any condition that weakens the pumping strength of the heart may cause CHF and this often happens between the first few hours and the first few days after a heart attack. Just as the pumping function of the left ventricle can be damaged by coronary artery disease, it can also be damaged by diseased heart valves or chronic hypertension. In any of these cases, when the muscle can no longer contract effectively, the heart tries other ways to maintain and adequate cardiac output. Two specific changes in heart function occur: The heart rate increases, and the left ventricle enlarges in an effort to increase the amount of blood pumped each minute. When these adaptions can no longer make up for the decreased heart function, CHF eventually develops. It is called "congestive" heart failure because the lungs become congested with fluid once the left side of the heart fails to pump the blood effectively. Blood tends to back up in the pulmonary veins, increasing the pressure in the capillaries of the lungs. When the pressure in the capillaries exceeds a certain level, fluid (mostly water) passes through the walls of the capillary vessels and into the alveoli. This condition is called pulmonary edema. It may occur suddenly, as in an AMI, or slowly over months, as in chronic CHF. sometimes, in patients with an acute onset of CHFm sever pulmonary edema will develop, in which the patient has oink, frothy sputum and severe dyspnea. If the right side of the heart is damaged, fluid collects in the body, often showing up as swelling in the feet and legs. The collection of fluid in the part of the body that is closest to the ground is called dependent edema. The swelling causes relatively few symptoms other than discomfort. However, chronic dependent edema may indicate underlying heart disease even in the absence of pain and other symptoms. Since the right side of the heart supplies the preload for the left side of the heart, right heart failure can result in an inadequate supply of look to the left ventricle resulting in a drop in the systemic blood pressure. it is important to realize that some patients may present with signs of both left-sided and right-sided heart failure because left-sided failure often leads to right-sided failure. Signs and symptoms of CHF: -The patient finds it easier to breathe when sitting up. When the patient is lying down, more blood is returned to the right ventricle and lungs, causing further pulmonary congestion. -Often, the patient is agitated. -Chest pain may or may not be present -The patient often has distended neck veins that do not collapse even when the patient is sitting -The patient may have swollen ankles from dependent edema (backup of fluid) -The patient generally will have high blood pressure, a rapid heart rate, and rapid respirations -The patient will usually be using accessory breathing muscles of the neck and ribs, reflecting the additional hard work of breathing -The skin is usually pale or cyanotic and sweaty -The fluid surrounding small airways may produce rales (crackles), best heard by listening to either side of the patient's chest, about midway down the back. In severe CHF, these soft sounds can be heard even at the top of the lung. Treatment of CHF: treat a patient with CHF the same way as a patient with chest pain. -Take vital signs, and give oxygen by nonrebreathing mask with an oxygen flow of 10 to 15 L/min. Medical control may, either by protocol or in response to your request, order the use of continuous positive airway pressure (CPAP) to move some of the fluid out of the lungs to provide better oxygenation. -Allow the patient to remain sitting in an upright position with the legs down. -be reassuring; many patients with CHF are quite anxious because they feel as if they cannot breathe. -Patients who have had problems with CHF before will usually have specific medications for its treatment. gather these medications, and take them along to the hospital. -Nitroglycerin may be of value in reducing pulmonary edema if the patients systolic blood pressure is more than 100 mm Hg. If the patient has been prescribed nitroglycerin, and medical control or standing orders advise you to do so, you can administer it sublingually. -Prompt transport to the ED is essential

Chapter 18: Understand common abdominal conditions

Appendicitis: Right lower quadrant (direct); around navel (referred); rebound tenderness (pain felt on the rebound after palpation Cholecystitis: Right upper quadrant (direct); right shoulder (referred) Ulcer: Upper midabdomen or upper part of back Diverticulitis: Left lower quadrant Abdominal aortic aneurysm (ruptured or dissecting): Low part of back and lower quadrants Cystitis (inflammation of the bladder): Lower midabdomen (retropubic) Kidney infection: Costovertebral angle Kidney stones: Right or left flank, radiating to genitalia Pancreatitis: Upper abdomen (both quadrants); back Pneumonia: Referred pain to the upper abdomen Hernia: Anywhere in the abdominal area Peritonitis: Anywhere in the abdominal area

Understand the importance of asking female patients if they could be pregnant, identifying her last menstrual cycle, and asking about sexual activity.

Asking about the patients last menstrual cycle will help determine of the patient is possibly pregnant. If the patient is sexually active, ask her about birth control and also about symptoms of pregnancy. Asking about the possibility of pregnancy is important because treatment could vary and the receiving hospital needs to know so they can prepare with appropriate staff if the patient is or thinks she may be pregnant.

Assisted ventilations or Rescue breathing

Assisted Ventilations: help the patient to breathe Rescue breathing: replaces independent in the case of continuous apnea

Atherosclerosis vs arteriosclerosis

Atherosclerosis: a disorder in which calcium and cholesterol build up, forming plaque inside the walls of the blood vessels. Arteriosclerosis: the thickening and hardening of the walls of the arteries

Understand: - Battle signs - Raccoon eyes - jugular vein distinction - tracheal deviation

Battle Signs: bruising over the mastoid process that may indicate a skull fracture Raccoon Eyes: ruining under the eyes that may indicate a skull fracture Jugular Vein Distention: visible bulging of the jugular veins in the neck that may indicate fluid overload, pressure in the chest, cardiac tamponade or tension Tracheal Deviation: can indicate respiratory or cardiac problems

Understand the components of radio communication in regards to giving radio report and working with online medical control

Begin the radio report with the patient's gender, age, chief complaint, and level of consciousness. Next, provide a brief elaboration on the patients chief complaint, assessment findings, SAMPLE history, initial vital signs and the most recent set of vital signs. Describe any treatment and responses to treatment. Provide ETA and mode of transportation

Understand pathophysiology, assessment and management of multisystem trauma and blast injuries

Blast injuries: Although most commonly associated with military conflict, blast injuries are also seen in civilian practice in mines, shipyards, chemical plants and, increasingly, in association with terrorist activities. As with any explosion there is a risk of contamination of patients from environmental contaminants, toxic chemicals, or dirty bombs. People who are injured in explosions may be injured by any of four different mechanisms. -Primary blast injuries: These injuries are due to entirely the blast itself; that is, damage to the body is caused by the pressure of the wave generated by explosion. When the victim is close to the blast, the blast wave may cause disruption of major blood vessels and rupture of eardrums and major organs, including the lungs. Hollow organs are the most susceptible to the pressure wave. In some cases, pressure wave can amputate limbs. -Secondary blast injuries: Damage to the body results from being struck by flying debris, such as shrapnel form the device or from glass or splinters, which have been set in motion by the explosion. Objects are propelled by the force of the blast wave and stroke of the victim causing injury. These objects can travel great distances and be propelled at tremendous speeds, up to nearly 3,000 mph for conventional military explosives. -Tertiary blast injuries: These injuries occur when the patient is hurled by the force of the explosion against a stationary object. A blast wind (sudden change in the surrounding atmosphere) creates a pressure wave. This can cause the patient's body to be hurled or thrown, resulting in further injury. This physical displacement of the body is also referred to as ground shock when the body impacts the ground. -Quaternary blast injuries: This category of miscellaneous injuries include burns form hot gases or fires started by the blast; respiratory injury from inhaling toxic gases; suffocation; poisoning; medical emergencies incurred as a result of the explosion; crus injuries from the collapse of buildings; contamination of wounds from environmental, chemical, or toxic substances; and mental health changes. -Most patients who survive an explosions will have some combination of the four types of blast injuries mentioned. -Organs that contain air, such as the middle ear, lung, and gastrointestinal tract, are most susceptible to pressure changes. The junction between tissues of different densities and exposed areas such as head and neck tissues are prone to injury as well. The ear is the organ system that is most sensitive to blast injuries. The tympanic membrane evolved to detect minor changes in pressure and will rupture at pressures of 5 to 7 pounds per square inch above atmospheric pressure. Thus, the tympanic membranes are a sensitive indicator that you can use to help determine the possible presence of other blast injuries. The patient may report ringing in the ears, pain in the ears, or some of hearing, and blood may be visible in the ear canal. Dislocation of structural components of the ear, such as the ossicles conforming the inner ear, may occur. Permanent hearing loss is possible. The findings can be used to assist in triaging patients as they indicate the risk of pressure injuries to the lungs. -Pulmonary blast injuries are defined as pulmonary trauma (consisting of contusions and hemorrhages) that results from short-range exposure to the detonation of explosives. When the explosion occurs in an open space, both lungs are usually injured. Primary blast injury is often characterized by lack of external visible injuries and thus can go unrecognized. The patient may report tightness or pain in the chest and may cough up blood and have tachypnea or other signs of respiratory distress. Subcutaneous emphysema (crackling under the skin) can be detected over the chest through the use of palpation, indicating air in the thorax. Pneumothorax is a common injury and may require emergency decompression (which is covered is chapter 29) in the field for your patient to survive. Pulmonary edema may ensue rapidly. If there is any reason to suspect lung injury in a blast victim (even just the presence of a ruptured eardrum), administer oxygen. Avoid giving oxygen under positive pressure, however (that is, by demand valve), because that may simply increase the damage to the lung. Be cautious as well with intravenous fluids, which may be poorly tolerated in patients with this type of lung injury and result in pulmonary edema. -One of the most concerning pulmonary blast injuries is arterial air embolism, which occurs on alveolar disruption with subsequent air embolization into the pulmonary vasculature. Even small air bubbles can enter a coronary artery and cause myocardial injury. Air embolisms to the cerebrovascular system can produce disturbances in vision, changes in behavior, changes in state of consciousness, and a variety of other neurologic signs. -Solid organs are relatively protected from shock wave injury but may be injured by secondary missiles or a hurled body. Hollow organs, however, may be injured by the same mechanisms that damage lung tissue. Petechiae, or pinpoint reddish-purple hemorrhages that sow up on the skin, to large hematomas may be found. Perforation or rupture of the bowel and colon is at risk. Underwater explosions result in the most severe abdominal injuries. -Neurologic injuries and head trauma are the most common causes of death from blast injuries. Subarachnoid (beneath the arachnoid layer covering the brain) and subdural (beneath the outermost covering of the brain) hematomas are often seen. Permanent or transient neurologic deficits may be secondary to concussion, intracerebral bleeding, or air embolism. Instant but transient unconsciousness, with or without retrograde amnesia, may be initiated not only by head trauma, but also by cardiovascular problems. Bradycardia and hypotension are common after an intense pressure wave from an explosion. -Extremity injuries, including traumatic amputations, are common. Patients with traumatic amputation by postblast wind are likely to sustain fatal injuries secondary to the blast. In present day combat, improved body armor has increased the number of survivors of blast injuries from shrapnel wounds to the torso. The number of severe orthopaedic and extremity injuries, however, has increased. In addition, whereas body armor may limit or prevent shrapnel from entering the body, it also "catches" more energy form the blast wave, possibly resulting in the victim being thrown backward, thus increasing the potential for spine and spinal cord injury. Multisystem Trauma: a term that describes a person who has been subjected to multiple traumatic injuries involving more than one body system such as head and spinal trauma, chest and abdominal trauma, or chest and multiple extremity trauma. You must recognize patients who fit into this classification and provide rapid treatment and transport, and alert medical control as to the nature of the patient's injuries so that the trauma center is prepared prior to you arrival. Multisystem trauma patients have a high level of morbidity and mortality; therefore, they require teams of physicians to treat their injuries.

Circulatory system: be able to take that drop of blood and run it through the entire circulatory sister, structure by structure and identify how and when it is oxygenated/deoxygenated

Blood flow through the heart: The inferior and superior vena cava returns blood to the right side of the heart into the right atrium. The right atrium pumps blood into the right ventricle through the tricuspid valve. The right ventricle, pumps deoxygenated blood to the pulmonary arteries into the lungs through the pulmonary valve. (The carbon dioxide and oxygen exchange takes place between the alveoli and the pulmonary capillaries). Oxygen-rich blood from the lungs returns to the left side of the heart through the pulmonary veins into the left atrium. The left atrium then pumps blood into the left ventricle through the bicuspid valve, which then pumps blood into the aorta through the aortic valve for circulation throughout the body.

Understand what is happening regarding measuring blood pressure in the body; what is contracting/relaxing for the measurements

Blood pressure is the force the blood exerts on the arterial walls. there are two main phases measured: the systolic and diastolic. The systolic occurs as the left ventricle forces blood into the aorta, the diastolic occurs as the left ventricle relaxes and rushes blood back into it

Per rectum (PR)

By rectum Enteral:rapid Most often used in children-easier administration- more reliable absorption

Understand appropriate use of air medical

Calling for a Medivac: Every agency has specific criteria for the type of patient who may receive medical evacuation and how and when to call for a medivac. These basic guidelines will help you understand the process better: -Why call for a medivac? The transport time to the hospital by ground ambulance is too long considering the patient's condition. Road, traffic, or environmental conditions limit or completely prohibit the use of a ground ambulance. The patient requires advanced care that you are unable to provide, such as administering pain medications or other specialized medications and inserting advanced airways. There are multiple patients who will overwhelm resources at the hospital reachable by ground transport. The helicopter may respond directly to the scene or it may be called to the hospital to transfer a patient to a facility with the capacity to provide definitive care for the patient's condition. -Who receives medivac? Medical evacuations should be used for patients with time-dependent injuries or illnesses. Patients suspected of having a stroke, heart attack, or serious spinal cord injury, such as injuries sustained in a motor vehicle crash or while diving into a swimming pool or horseback riding, often require medivac service. Serious conditions that may require the use of helicopter medivacs may be found in remote areas and involve scuba diving accidents, near drownings, or skiing and wilderness accidents. Other patients who may require medical evacuation are trauma patients, candidates for limb replantation (for amputations), and patients requiring air transport to a burn center, a hyperbaric chamber center, or a venomous bite center. Because specific criteria vary by service, familiarize yourself with the criteria in your system used to call for this lifesaving service. -Whom do you call? Generally, your dispatcher must be notified first. In some regions, after the medivac has been initiated, the ground EMS crew may be able to access the flight crew on a specially designated radio frequency for one-on-one communications. If available, it is important to keep this frequency clear of chatter and lengthy communications. You may be asked to give a brief presentation or update on the patient's condition. In this case, you should gather your thoughts and speak clearly and concisely, avoiding information that is not pertinent.

Understand the signs and symptoms Cardiogenic Obstructive Distributive Hypovolemic Respiratory insufficiency

Cardiogenic shock: occurs as a result of heart or pump failure Obstructive shock: occurs from a mechanical obstruction that prevents adequate blood flow or perfusion Distributive shock: occurs as a result of wide spread dilation of the vessels Hypovolemic shock: occurs as a result of inadequate blood volume Respiratory insufficiency: occurs when respiration's are compromised, which leads to an inadequate supply of oxygen

Understand both communication and documentation

Communication is the transfer of information between two people and can be verbal or non verbal. It is essential in creating a positive relationship between you and your patients and coworkers. Documentation is the recorded portion of patient interaction that becomes part of the patients permanent record. This is important in maintaining the continuum of care.

Word roots that describe color Cyan/o Leuk/o Erythr/o Cirrh/o Melan/o Poli/o Alb Chlor/o

Cyan/o — blue — cyanosis — blue discoloration of the skin Leuk/o — white — leukocyte — white blood cells that fight infection Erythr/o — red — erythrocytes — red blood cells that contain hemoglobin to carry oxygen Cirrh/o — yellow/orange — cirrhosis — inflammation of the liver causing yellow-orange pigmentation of the liver Melan/o — black — melena — black, tarry stool typically caused by upper GI bleeding Poli/o — gray — poliomyelitis — an acute viral disease that attacks the motor neurons of the central nervous system (brain) Alb — white — albino — a person lacking skin pigmentation (very white hair, very pale skin, non pigmented iris) Chlor/o — green — chlorophyll — green pigmentation in leaves used in photosynthesis

Understand defensive driving techniques and guidelines for safe ambulance driving

Defensive driving tactics: -The quality of patient care is far more important than the speed of the response. Do not sacrifice safety for speed. -Everyone must be properly restrained whenever the vehicle is traveling. -All equipment should be properly secured. -Emergency vehicles should usually travel in the far left lane. -Always know what is next to you while driving. -Scan the road frequently and several car lengths ahead of you. -Allow several vehicle lengths distance between you and the vehicle ahead of you, when possible. -Anticipate unexpected actions from other motorists. -Always assume other drivers do not see or hear you. -Pass on the left when possible. -Use extreme caution when backing up. Always use a spotter. -Remember you have blind spots and minimize them as best as you're able. -Recognize that ambulances typically have a high center of gravity. Take corners carefully. -Be especially cautious while driving in bad weather, poor visibility, and at night. -Use daytime running lights according to local protocol. -Lights and sirens should be used together. -Recognize fatigue as a significant threat to safe vehicle operation. Guidelines for safe ambulance driving: -Select the shortest and least congested route to the scene at the time of dispatch. -Avoid routes with heavy traffic congestion; know alternative routes to each hospital during rush hours. -Avoid one-way streets; they may become clogged. Do not go against the flow of traffic on a one-way street , unless absolutely necessary. -Watch carefully for bystanders as you approach the scene. Curiosity seekers rarely move out of the way. -Park the ambulance in a safe place once you arrive at the scene. If you park facing into traffic; turn off your headlights so they do not blind oncoming motorists, unless they are needed to illuminate the scene. If the vehicle is blocking part of the road, keep on your warning lights to alert oncoming motorists. -Drive within speed limit while transporting patients, except in the rare extreme emergency. -Go with the flow of traffic. -Always drive defensively. -Always maintain a safe following distance. Use the "4-second rule": stay at least 4 seconds behind another vehicle in the same lane. -Maintain an open space or cushion in the lane next you as an escape route in case the vehicle in front of you stops suddenly. -Use your siren if you turn on the emergency lights. -Always assume other drivers will not hear the siren or see your emergency lights. -Always exercise due regard for person and property.

Delirium vs. Dementia

Delirium: is a sudden change in mental status, consciousness, or cognitive processes, and is marked by the inability to focus, think logically, and maintain attention; (is a symptom, not a disease) Dementia: is the slow onset of progressive disorientation, short-ended attention span, and loss of cognitive function. It is a chronic, generally irreversible condition. It is also the result of many neurologic conditions.

Know the different components of the grieving process

Denial Anger/hostility Bargaining Depression Acceptance These stages can happen at varying times in different orders

Different types of medical control — how/when to use it

Direct or online medical control: a type of medical control in which the physician speaks directly with emergency care providers at the scene of an emergency Indirect or offline medical control: a type of medical control that includes education, protocol review and quality improvement for emergency care providers

Understand the role of EMS within the ICS

EMS functions of ICS: Preparedness: -EMS agencies should have written disaster plans that are routinely practiced, reviewed, and improved. -EMS facilities should have adequate resources to be fully self-sufficient for at least 72 hours -A plan should be in place to assist families of EMS responders so responders can focus on their job. Scene Size-up: -What is this incident? Confirm incident location, identify scene safety considerations, estimate number of casualties. -What do you need to do? First priorities are personal safety, partner safety, other rescuer's safety, patients' safety, bystanders' safety, and public's safety. -What resources do you need to do it? Incident command is established by the highest-ranking person on the scene. Request additional resources as needed. Medical Incident Command Functions: -Triage: -Triage is the sorting of patients based on the severity of injury. -The triage supervisor identifies the number and severity of patients. -On larger incidents, several responders may be needed to conduct triage. -During triage, patients are moved to the appropriate treatment area. -Treatment does not begin until all patients are triaged. -Treatment: -The treatment supervisor establishes the necessary treatment areas based on patient priorities. -Secondary triage should be completed within each treatment area. -Treatment area personnel assist with movement of patients to the transportation area. Transportation: -The transportation supervisor coordinates transportation of patients to the appropriate destinations. -Transportation supervisor must ensure receiving hospitals are not overwhelmed. -Staging: the staging supervisor is needed on larger incidents when numerous vehicles, agencies, or apparatus will be arriving on the scene. -Rehabilitation: the rehabilitation supervisor establishes a safe location for the rest and recovery of responders. This is typically needed on incidents that are prolonged or work intensive. -Extrication and special rescue: -An extrication supervisor may be needed on certain incidents. -An extrication supervisor determines the personnel and equipment needed.

Understand what is happening regarding taking a pulse; what are you feeling with each pulsation

Each pulsation is a contraction of the heart. As the heart contracts, blood is forced through arteries in a wave-like manner. the beat felt in a pulse is the pressure from this new wave of blood

Understand how to decontaminate a person who has been exposed to a toxic substance

Emergency treatment for a typical contact poisoning includes the following two steps; -Avoid contaminating yourself or others -While protecting yourself from exposure, remove the irritating or corrosive substance from the patient as rapidly as possible. -Remove all clothing that has been contaminated with poisons or irritating substances. If a dry powder has been spilled, thoroughly brush off the chemical (avoid creating a dust cloud), flush the skin with clean water for 15 to 20 minutes, and the wash the skin with soap and water. If a liquid material has been spilled on a patient, flood the affected part for 15 to 20 minutes. If the patient has a chemical agent in the eyes, irrigate them quickly and thoroughly. To avoid contaminating the other eye as you irrigate the affected eye, make sure the fluid runs from the bridge of the nose outward. Initiate this action on the scene and continue it during transport. Keep in mind that you may have to help the patient keep his or her eyes open. -Many chemical burns occur in industrial settings, where safety showers and specific protocols for handling surface burns are available. If you are called to such a scene, a HazMat team should be available to assist you. Always ensure you, your team members, and the exposed patient are thoroughly decontaminated prior to transport. Failure to do so will result in the risk of contaminating the entire emergency department and staff.

Understand the medications used in anaphylaxis and how they work on the body

Epinephrine: the body normally produces epinephrine. Epinephrine is a sympathomimetic hormone, this means it mimics the sympathetic (fight or flight) response. Epinephrine has various properties that cause the blood vessels to constrict, which reverses vasodilation and hypotension; this, in turn, elevates the diastolic pressure and improves coronary blood flow. Other properties of epinephrine increase cardiac contractility and relieve bronchospasm in the lungs. Because epinephrine has immediate action, it can rapidly reverse the effect of anaphylaxis. Epinephrine is prescribed by a physician and come predosed in an epinephrine auto-injector (EpiPen). In some EMS systems, you may be authorized to carry epinephrine as part of your regular on-board medications; in others, you may be permitted to help patients self-administer their own medication. Refer to local protocols or consult online medical control.

Understand the Cincinnati Prehospital Stroke Scale and how to appropriately assess each component (FAST) mnemonic

F: Facial droop (ask the patient to smile; look for a droop on either side. A: Arm drift (ask the patient to close his/her eyes and hold arms out with palms up, then watch for one to drift down. S: Speech (ask the patient to repeat a simple phrase, then listen for slurred speech T: Time (note the time the patient was last seen acting normally)

Understand how to measure contractions and how to differentiate between true/false labor

False labor (Braxton-Hicks Contractions): -Contractions are not regular and do not increase in intensity or frequency. Contractions come and go. -Pain and contractions start and stay in the lower abdomen -Physical activity or a change in position may alleviate the pain and contractions -Bloody show, if present, is brownish -If leakage of fluid occurs, it is usually urine. It will be in small amounts and smell of ammonia True labor: -Contractions, once started, consistently get stronger and closer together -Pain and contractions may start in the lower lower back and "wrap around" to the lower abdomen -Physical activity may intensify the contractions. A change in position does not relieve contractions. -The bloody show is pink or red and generally accompanied by mucus. -The amniotic sac may have broken just before the contractions started or it may break during contractions. A moderate amount of fluid that may smell sweet will be present, and fluid will continue to leak.

Medical terms Flexion Extension Abduction Adduction

Flexion: bending of joint Extension: straightening of joint Abduction: movement away from midline Adduction: movement toward midline

Understand when it is appropriate to forcibly restrain a patient

Forcible restrain is necessary when the patient is combative and poses a risk to him/herself or others. This must be in agreement with the laws of the specific state you are operating within

Directional terms Front Back Right Left Top Bottom Closest Farthest Middle Side In Out

Front — anterior — ventral — front surface of body Back — posterior — dorsal — back surface of body Right — right — the patient's right Left — left — the patient's left Top — superior — closest to head Bottom — inferior — closest to feet Closest — proximal — closest to point of attachment Farthest — distal — farthest from point of attachment Middle — medial — closest to midline Side — lateral — farthest from midline In — superficial — closest to surface of the skin Out — deep — farthest from surface of skin

Understand when it is appropriate to legally release patient information

HIPAA protects protected health information. It is legally permissible to release this information to other healthcare providers who are also treating the patient. PHI can be used for training of internal quality improvements as long as any information relating to the identity of the patient is protected. The court may require you to disclose information such as in child abuse cases. Only the minimum amount of information should be released

Understand the importance of scene safety

Hazards on scene could harm the EMS provider and prevent him/her from providing quality care

Understand the anatomy, physiology, assessment and management of head and spine injuries

Head injuries include trauma to the scalp, skull or brain. -Scalp injuries: -Scalp injuries can be open or closed -The scalp is highly vascular and bleeds heavily when lacerated. -Skull fractures: -Skull fractures indicate the potential for injury to the brain. -Linear fracture: most skull fractures are linear fractures and do not present with deformity or depression. -Depressed fractures: may be noticeable upon palpation. there is an increased risk of brain injury due to bone being displaced into brain tissue. -Basal skull fracture: occur at the base of the skull. Cerebrospinal fluid (CSF) may leak from nose or ears. Signs may include battle's sign (bruising behind the ears) and raccoon eyes (bruising under the eyes). Brain injuries: -Concussion -A concussion temporarily causes brain function to be disrupted in some manner. -Signs and symptoms typically occur rapidly and gradually improve. -Signs and symptoms may include altered LOC that gradually improves, brief loss of consciousness, nausea, vomiting, irritability, repetitive questioning, vision problems, and amnesia. -Anterograde amnesia: can't remember what happened after the injury -Retrograde amnesia: can't remember events before the injury -Cerebral contusion: -Often accompanied by edema and/or concussion injury -Signs and symptoms may include signs of a concussion and at least one of the following: decreasing mental status, unresponsive, pupillary changes,, changes in vital signs, or obvious behavioral abnormalities. -Epidural hematoma -Bleeding beneath the skull but above the dura mater -Typically includes significant arterial bleeding -Extremely dangerous due to increase in intracranial pressure -Often accompanied by a temporal skull fracture -Signs and symptoms: -Patient may experience a brief loss of consciousness, wakes up, then LOC deteriorates -Worsening LOC, headache, seizures, vomiting, posturing, hypertension, bradycardia, changes in respirations, pupillary changes -Subdural hematoma -Bleeding above the brain (beneath the dura mater and above the arachnoid meningeal layer) -Often caused by venous bleeding following a cerebral contusion -Signs and symptoms: vomiting, decreasing LOC, pupillary changes, unilateral (one side of the body) weakness or paralysis, hypertension, changes in respirations, headache, and seizures -Subarachnoid hemorrhage: -Bleeding within the subarachnoid space -This type of injury allows blood to enter the cerebrospinal fluid (CSF) -Can be due to trauma or ruptured aneurysm -Signs include headache and stiff neck, and neurological impairment such as decreased LOC and seizures -Intracerebral hemorrhage -Bleeding within the brain tissue -Patients can deteriorate rapidly -High mortality (risk of death) rate -Herniation syndrome -The pressure within the skull is called intracranial pressure (ICP). Herniation when the brain is compressed due to excessive ICP -Remember, the brain is an enclosed space. There is little extra space to accommodate swelling and bleeding -Severe herniation will force the brain down toward the foramen magnum -Signs of ICP -Cushing's response, or Cushing's reflex -Hypertension -Bradycardia -Altered respiratory pattern -Mortality rates are high for ICP patients. In attempt to temporarily reduce dangerously high ICP, higher ventilation rates may be indicated. Consult local protocol and medical direction. Spinal Injuries: -Mechanism of injury (MOI) for spinal trauma -Flexion: extreme forward (chin-to-chest) movement of head -Extension: extreme backward movement of head, such as might occur in a rear-impact accident -Compression: compression of head against the body, such as a diving injury -Rotation: extreme lateral (side-to-side) movement -Distraction: stretching of spinal column and cord, such as a hanging -Lateral bending: extreme bending of head to the side (ear to shoulder) -Penetrating injury: gunshot wounds, stab wounds, etc. -Signs and symptoms of spinal injury: -Spinal column injury is likely to produce pain or tenderness -Spinal cord injury is likely to produce motor and/or sensory deficits. -Motor deficits: weak or absent grips, pushes, pulls, etc. -Sensory deficits: inability to feel or sense touch -Paraplegia: paralysis of the lower extremities -Quadriplegia: paralysis of all extremities -Transected (severed) cord -Paralysis below the level of injury -Loss of bladder or bowel control -Possible respiratory arrest if high cervical injury -Note that patients with trauma to C5 or above are at high risk for respiratory paralysis. Rapid intervention and artificial ventilations may be needed. -Neurogenic shock: -Any of the above signs and symptoms -Hypotension without tachycardia -Priapism (involuntary penile erection Spinal shock is a condition that can present with any of the above signs and symptoms, but typically resolves within about 24 hours. Patient Assessment: You should suspect a possible head or spinal injury any time you encounter one of the following mechanisms of injury: -Motor vehicle crashes (including motorcycles, snowmobiles, and all-terrain vehicles -Pedestrian-motor vehicle crashes -Fall >20 feet (adult) -Fall >10 feet (pediatric) -Blunt trauma -Penetrating trauma to the head, neck, back, or torso -Rapid deceleration injuries -Hangings -Axial loading injuries (injuries where load is applied along the vertical or longitudinal axis of the spine; for example, falling from a height and landing on the feet in an upright position) -Diving accidents Primary assessment: The primary assessment should focus on identifying and managing life-threatening concerns. Threats to circulation, airway, or breathing are considered life threatening and must be treated immediately to prevent mortality. Life-threatening external hemorrhage must be addressed before airway and breathing concerns. -Most head injuries are considered mild and result in no or limited permanent disability. A smaller percentage of head injuries are considered moderate, and the patient is left with some permanent disabilities. A still smaller percentage of head injuries are considered severe, and many patients with a severe head injury die before ever reaching the hospital or are left in a comatose state despite hospital intervention. There will be a number of patients with head or spine injuries that will not require much intervention other than a thorough assessment and continued observation while being transported to the hospital. In these patients you may choose to take some time at the scene to provide careful spine immobilization before transport. In patients who have problems with ABCs or have other conditions for which you decide a rapid transport to the closest appropriate hospital is needed, rapid immobilization of the spine and quick loading into the ambulance may be indicated. Reduction of on-scene time and recognition of a critical patient increase the patient's chances for survival or a reduction in the amount of irreversible damage. -Spinal immobilization: -Manual immobilization -Manual cervical-spine (c-spine) precautions must be taken immediately if spinal injury is suspected. -Manual c-spine cannot be released until the patient's head is completely immobilized by other means. -A cervical collar is NOT a substitute for manual stabilization -Spinal immobilization techniques -Long spine board -Can be used for supine or standing patients -Often used if rapid extrication is needed due to potential problems related to airway, breathing, circulation, etc. -Half spine board -Can be used for seated patients, such as during extrication from a vehicle -Use of these devices may require additional time to apply. You must determine if the patient's condition requires more rapid extrication. History taking: After the life threats have been managed during the primary assessment, investigate the chief complaint. Obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives such as no pain or no loss of sensation. Secondary Assessment: Examine the entire body using DCAP-BTLS and examine the head, chest, abdomen, extremities, and back. Check perfusion, motor function, and sensation in all extremities prior to moving the patient. Make sure that you do not move any body parts excessively. Determine whether strength in each extremity is equal by asking the patient to squeeze your hands and to gently push each foot against your hands. -Monitor the patient for changes in LOC, including signs of confusion, disorientation or deteriorating mental status. Determine whether there is decreased movement and/or numbness and tingling in the extremities. Look for blood or CSF leaking from the ears, nose, or mouth and for bruising around the eyes and behind the ears. -Assess pupil size and reaction to light. Unequal pupil size after a head injury in an unconscious patient often signals a serious problem. The brain controls the diameter of the pupils and how quickly they react. If an injury has occurred on one side of the brain, just one pupil will dilate. Developing blood clots may be compressing the brain, causing one pupil to dilate nd indicating that the brain is at extreme risk of sustaining catastrophic damage. -For a patient with a head injury, perform a neurologic examination. Perform a baseline assessment using the Glasgow coma scale (GCS) and record the time. -If there is a potential spine injury, examine the spine. To start, inspect for DCAP-BTLS and check the extremities for circulation, motor, or sensory problems. If there is an impairment, note the level. Reassessment: Repeat the primary assessment. Reassess vital signs and the chief complaint. Reassess the ABCs. And recheck patient interventions.

Understand the anatomy, physiology, and assessment and management of neurologic emergencies

Headache: One of the most common complaints of pain you will hear from patients is a headache. Because a headache is subjective, it may be a symptom of another condition or it may be considered a neurologic condition on its own. Three types of headaches include: Tension headaches, Migraines, and Sinus headaches -Tension headache: caused by muscle contractions in the head and neck and are attributed to stress. Patients usually describe the pain as squeezing, dull, or an ache. This type of headache typically does not have associated symptoms and usually does not require medical attention. -Migraines: thought to be caused by changes in blood vessel size in the base of the brain. Both adults and children can experience migraine headaches. Women are three times more likely as men to experience migraines. Frequently, the patient will have a history of migraines and will tell you this episode is similar to one in the past. Pain from a migraine headache is usually described as pounding,throbbing, or pulsating. Migraines are often associated with nausea and vomiting and may be preceded by visually warning signs such as flashing lights or partial vision loss. These headaches can last for several hours to days. -Sinus headaches: caused by pressure that is result of fluid accumulation in the sinus cavities.patients may also have cold-like signs and symptoms of nasal congestion, cough, and fever if they have a sinus infection. Patients may also report increased pain when they bend over or when their heads are moved forward. This type of headache is usually self-limiting, and prehospital emergency care is not required. Although most headaches are not life-threatening, some patients with a chief complaint of headache will require medical attention. Hemorrhagic stroke (bleeding in the brain), Brian tumor, and meningitis are serious neurologic conditions that include headache as a symptom. Be concerned of the patient reports a sudden-onset, severe headache or a sudden-onset headache that has associated symptoms. Headaches accompanied by fever, stiff neck, seizures, or altered mental status or following head trauma are potentially life-threatening and require and complete assessment and transport to the hospital. Stroke: A cerebrovascular accident (CVA), or stroke is an interruption of blood flow to an area within the brain that results in the loss of brain function. In the context of a total lack of oxygen, brain cells stop functioning and begin to die within minutes. Medical science currently has little to offer in the way of treatment once brain cells are dead. However, when oxygen levels are decreased, but not absent, because an insufficient amount of blood is getting through, brain cells may be damaged more slowly. It may take several hours or more for brain cells to die in this situation. When brain cells die or are injured, severe disability may result. For example, if cells that are responsible for controlling the left arm are starved for oxygen, the patient will not be able to move that arm. The brain cells will develop ischemia, a reduction of blood supply that results in inadequate oxygen being supplied to the brain cells. This causes those cells to stop functioning. If normal blood flow is restored to that area of the brain in time, the cells will not die and the patient may regain full use and control of the arm. The two main types of stroke are ischemic and hemorrhagic. -Ischemic stroke: Most common type of stroke, accounting for more than 80% of all strokes. Occurs when blood flow to a particular part of the brain is stopped by a blockage (blood clot) inside a blood vessel. This blockage may be due to thrombosis, where a clot forms at the site of the blockage, or an embolus, where a clot forms in a remote area (such a diseased heart) as with coronary artery disease, atherosclerosis in the blood vessels is often the cause of an ischemic stroke. -Atherosclerosis: is a disorder in which calcium and cholesterol build up, forming plaque inside the walls of the blood vessels. This plaque may obstruct blood flow and interfere with the vessels' ability to dilate. Eventually, atherosclerosis may cause complete occlusion of an artery. In other cases, atherosclerotic plaque in the carotid artery in the neck ruptures. A blood clot forms forms over the crack in the plaque. Sometimes, it grows large enough to completely block all of the blood flow in that artery. the parts of the brain supplied by the artery are deprived of oxygen and stop functioning. -Even if the blockage in the carotid artery is not complete, smaller pieces of the blood clot may embolism (break off and be carried by the normal flow of blood) deep into the brain, where they may become lodged in a smaller branch of a blood vessel. This cerebral embolism then blocks blood flow. Depending on the location of the lodged blood clot, the patient's symptoms can vary widely, from nothing at all to complete paralysis. -Hemorrhagic stroke: Hemorrhagic strokes account for 13% of all strokes. Occurs as a result of bleeding inside the brain. In hemorrhagic strokes, a blood vessel ruptures and the accumulated blood then forms a blood clot, which compresses the brain tissue next to it. The compression prevents oxygenated blood from getting into the area, and the brain cells begin to die. Cerebral hemorrhages are often fatal. -hemorrhagic stroke commonly occurs in people experiencing stress or exertion. The people at highest risk for hemorrhagic stroke are those with very high blood pressure or long term untreated elevated blood pressure. Many years of high blood pressure weaken the blood vessels in the brain. If a blood vessel ruptures, the bleeding in the brain will increase the pressure inside the cranium. Proper treatment of high blood pressure can help prevent this long-term damage to the blood vessels, decreasing the risk of this devastating complication. -Some people Ron with a weakness in the walls of an artery. An aneurysm, a swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall, may develop. The most notable symptom of a ruptured aneurysm is often a sudden onset, severe headache, typically described by the patient as the worst headache he/she has ever had. The headache is caused by the irritation of blood on the brain tissue after the artery swells and ruptures. A hemorrhagic stroke in an otherwise healthy young person is often caused by a weakness in a blood vessel called a berry aneurysm. This type of aneurysm resembles a tiny balloon (or berry) that juts out from the artery. When the aneurysm is overstretched and ruptures, blood spurts into an area between two of the coverings of the brain called the subarachnoid space. These types of strokes are called subarachnoid hemorrhages. If the patient gets to the hospital quickly, surgical repair of the aneurysm may be possible. However, like other brain bleeding and cerebral hemorrhage, this condition is often fatal. -Transient Ischemic Stroke: In a patient with coronary artery disease, blood flow to the heart muscle may be obstructed, causing chest pain (angina), which is considered a warning sign of a potential myocardial infarction. Similarly, when blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the patient may exhibit signs of a stroke. When the stroke-like symptoms resolve on their own in less than 24 hours, the even is called a transient ischemic stroke (TIA). Some people call these mini strokes. As with angina, no actual death of tissue (infarction) occurs with a TIA. However, since symptoms of a TIA can last up to 24 hours, you may not be able to differentiate between a stroke and a TIA. -Although most patients with TIAs do well, every TIA is an emergency. It may be a warning sign that a more significant stroke may occur in the future. Approximately one-third of patients who have a tIA will experience a stroke soon after the TIA. For this Eason, all patients with a TIA should be evaluated by a physician to deeming whether preventive action should be taken. -If the left cerebral hemisphere has been affected by a stroke, the patient may exhibit a speech disorder called aphasia, the inability to produce or understand speech. Speech problem can vary widely. Some patients will have trouble understanding speech but will be able to speak clearly. You can detect this problem by asking the patient a question such as "what day is today?" The patient may respond with an inappropriate answer such as, "Green." The speech is clear, but it does not make sense. other patients will be able to understand the question, but cannot produce the right sounds to provide an answer. Strokes that affect the left side of the brain can also cause paralysis of the right side of the body. -if the right cerebral hemisphere of the brain is not getting enough blood, the patient will have trouble moving the muscles on the left side of the body. Usually, the patient will understand language and be able to speak, but the words may be slurred and hard to understand. Interestingly, patients with right hemisphere strokes may be completely oblivious to thief problems. If you ask the patient to lift their left arms and they cannot, they will lift their right arms instead. patients will seem to have forgotten that their left arms even exist. This symptom is called neglect. Patients with conditions affecting the back part of the cerebrum may neglect certain parts of their vision. Generally, this hard to detect in the field because patients compensate without conscious effort. Nevertheless, be aware of the possibility. Sit or stand on the patients "good" side because he or she may be unable to see things on the "bad" side. neglect and lack of pain causes many patients who have had strokes to delay seeking help. A patient may be unaware that he or she has a problem until someone points out that some part of the patient's body is not functioning properly. -Signs and symptoms of a stroke include: facial drooping, sudden weakness or numbness in the face, arm, leg, or one side of the body; decreased or absent movement and sensation on one side of the body, lack of coordination (ataxia) or loss of balance, sudden vision loss in one eye; blurred or doubled vision, difficulty swallowing (a primary reason for good airway management in a patient with a stroke), decreased level of responsiveness, speech disorders, aphasia; difficult expressing thoughts or inability to use the right words (expressive aphasia) or difficulty understanding spoken words (receptive aphasia), slurred speech (dysarthria), sudden or severe headache, confusion, dizziness, weakness, combativeness, restlessness, tongue deviation, coma. Brain tumor: early signs of increased intracranial pressure include headache, vomiting, altered mental status and seizures. Increasing intracranial pressure may also be caused by a hemorrhagic stroke, a tumor or head trauma that may have occurred hours or days before the event. during your patient assessment, ask if the patient has experienced any recent head trauma. Meningitis: A central nervous system infection in which the patient may complain of headache, stiff neck, fever, and sensitivity to light. This is a serious condition requiring prompt medical attention. Use standard precautions, and provide supportive care of the ABCs. Provide a quiet, darkened environment when possible. Consider not using lights and sirens. Seizures: a neurologic episode caused by a surge of electrical activity in the brain. It can take the form of a convulsion, characterized by generalized, uncoordinated muscle activity, and/or can be associated with a temporary alteration in consciousness. An estimated 2-3 million people in the United States have epilepsy, which is a common cause of seizures. Seizures are classified into two basic groups, generalized and partial (focal). -Generalized (tonic-clinic) seizure: results from abnormal electrical discharges from large areas of the brain, usually involving both hemispheres. It is typically characterized by unconsciousness and a generalized severe twitching of the body's muscles that lasts several minutes or longer. In other cases, the seizure may simply be characterized by brief lapse of consciousness in which the patient seems to stare and not respond to anyone. This type of seizure does not involve any changes in motor activity and is called a petit mal or absence seizure. -Partial (focal) seizure: begins in one part of the brain. Partial seizures are classified as simple or complex. -In a simple partial seizure, no change occurs in the patient's LOC. patients may report numbness, weakness, or dizziness. The senses may also be involved; the patient may report visual changes and unusual tastes or smells. A simple partial seizure may also cause twitching of the muscles and extremities that spreads slowly from one part of the body to another, but it is not characterized by the dramatic severe twitching and muscle movements seen in a generalized seizure. The patient may also experience brief paralysis. -In a complex partial seizure, the patient has an altered mental status and does not interact normally with his or her environment. This type of seizure results from abnormal discharges from the temporal lobe of the brain. Other signs may include lip smacking, eye blinking, and isolated convulsions or jerking of the body or one part of the body such as an arm. the patient may experience unpleasant smells and visual hallucinations, exhibit uncontrollable fear, or exhibit repetition physical behavior such as constant sitting and standing. -Some seizures occur on only one side of the body. others begin on one side and gradually progress to a generalized seizure that affects the entire body. Depending on the type of seizure, the patient may have no loss of consciousness but still experience muscle tremors. Most people with lifelong or chronic seizures tolerate the events reasonably well without complications, but in patients, seizures may signal life-threatening conditions. Often a patient may experience a warning sign prior to the event. This is referred to as an aura. This can include visual changes (flashing lights or blind spots in the field of vision) or hallucinations (seeing, hearing, or smelling things that are not actually present). People with a history of seizures recognize their auras and usually take steps to minimize injury, such as sitting or lying down, knowing what is about to happen. however, be aware that auras do not occur prior to every seizure, and not all patients with a seizure disorder experience and aura. -A generalized seizure is usually characterized by sudden loss of consciousness followed by chaotic muscle movement and tone. The patient may experience a tonic phase, usually lasting only seconds, in which there is a period of constant muscle contraction and trembling, tongue biting, bladder incontinence, or bowel incontinence. During a generalized seizure , the patient may exhibit bilateral movement characterized by a cycle of muscle rigidity and relaxation. Throughout a generalized seizure, the patient typically exhibits tachycardia, hyperventilation, sweating, and intense salivation; however, other responses are also possible. -Generalized seizures typically last less than 5 minutes and are followed by a lengthy period (5 to 30 minutes or more) called a postictal state, in which a person is unresponsive at first and gradually regains consciousness. The postictal state is over when the patient regains a complete return of his or her level of consciousness. In most cases, the patient will gradually begin to recover and awaken but appear dazed, confused, and fatigued. In contrast, an absence seizure may last for just seconds, after which the patient fully recovers with only a brief lapse of memory of the event. -Seizures lasting more than 5 minutes are likely to progress to status epilepticus, which describes seizures that continue every few minutes without the person regaining consciousness or last longer than 30 minutes. Recurring or prolonged seizures should be considered life-threatening situations in which patients need emergency medical care. If the patient does not regain consciousness or the seizure continues, protect the patient from self-harm, and call for ALS backup. These patients need advanced airway management and medication to stop the seizure. -Causes/medications used to treat seizures. -Some seizure disorders, such as epilepsy, are congenital. Other types of seizures may b caused by high fevers, structural problems in the brain, or chemical problems in the body. In addition, a percentage of the population will experience a seizure for which cannot be determined (idiopathic). -Epileptic (Type): caused by congenital origin -Structural (Type): caused by tumor (benign or cancerous), infection (brain abscess), scar tissue from injury, head trauma, stroke -Metabolic (Type): caused by hypoxia, abnormal blood chemical values, poisoning, drug overdose, sudden withdrawal from alcohol or medications -Febrile (Type): caused by sudden high fever -Epileptic seizures can usually be controlled with medications. Medications used most often to treat seizures include the following: -Leveticetam (Keppra) -Phenytoin (Dilantin) -Phenobarbital -Carbamazepine (Tegretol) -Valproate (Depakote) -Topiramate (Topamax) -Clonazepam (Klonopin) -Patients with epilepsy will often have seizures if they stop taking their medications or if they do not take the prescribed dose on a regular basis. Phenytoin, a drug that is used to control seizures, may itself cause seizures if the person takes too much. You must transport a child who has had a febrile seizure because this condition needs to be evaluated in the hospital. It is possible that a second seizure may occur. If it does, the patient requires rapid transport to the hospital so possible causes can be identified. -The importance of recognizing seizures. -Regardless of the type or cause of a seizure, it is important for you to recognize the when a seizure is occurring or whether one has already occurred. You must also determine if this episode differs from any previous ones. -Because most seizures involve a vigorous twitching of the muscles, the muscles use a lot of oxygen. This excessive demand consumes oxygen that is needed for vital functions of the body. As a result there is a buildup of acids in the bloodstream, and the patient may turn cyanotic from the lack of oxygen. In a patient with diabetes, the blood glucose level may decrease because of the excessive muscular contraction of a seizure. If your local protocol allows, closely monitor the blood glucose level after a patient with diabetes has a seizure. -Also look for other problems associated with the seizure. If the patient has fallen during the seizure, he/she may have been injured; head injury is the most serious possibility. -The postictal state: After the seizure has stopped, the patient's muscles relax, becoming almost flaccid, or floppy, and the breathing becomes labored in an attempt to compensate for the buildup of acids in the bloodstream. By breathing faster and more deeply, the body can balance the acidity in the bloodstream. Once the patient regains a normal level of consciousness, the postictal state is over. -Syncope: Seizures are often mistaken for syncope (fainting); fainting typically occurs while standing and seizures may occur in any position. -Altered Mental Status: Most common neurologic emergency. Means the patient is not thinking clearly or is incapable f being aroused. Some patients will be unconscious; other patients will be alert, but confused. Different causes include; hypoglycemia, hypoxemia, intoxication, delirium, drug overdose, unrecognized head injury, brain infection, body temperature abnormalities, brain tumors, and overdoses and/or poisonings. -Hypoglycemia: Because oxygen and glucose are needed for brain function, hypoglycemia can mimic conditions in the brain associated with stroke. The patient may have hemiparesis similar to that seen with a stroke. A patient who has had a stroke may be alert and attempting to communicate normally, whereas a patient with hypoglycemia almost always has an altered or decreased level of consciousness. Patients with hypoglycemia commonly, but not always, take medications that lower their blood glucose level. If the patient appears to have signs and symptoms of stroke and altered mental status, report your findings to medical control and treat the patient accordingly. Do not give patients with a decreased level of consciousness anything by mouth. In a patient with hypoglycemia, mental status is not likely to improve, even after several minutes. Consider the possibility of hypoglycemia in a patient who: has had a seizure, especially if the patient has a history of diabetes has altered mental status after an injury such as a motor vehicle crash, even when there is the possibility of an accompanying head injury look for medical identification jewelry or medications that might confirm your suspicions. -Delirium: Delirium is a symptom, not a disease. It presents as a new complaint, rather than a long-standing alteration in behavior. It is a temporary state that often has a physical or mental cause (eg, infection, changes in medications, hypoxia) and may be reversed with proper treatment. -Signs and symptoms include: confusion and disorientation, disorganized thought, lack of attention/distracted, memory loss, striking changes in personality, hallucinations, delusions, decreased LOC. -The patient may experience a rapid alteration between mental states such as lethargy and agitation. Symptoms of delirium may mimic intoxication, drug abuse, or severe psychologic disorders such as schizophrenia. -Other causes of altered mental status: Be prepared for difficult patient encounters and follow local protocols for dealing with these situations. -In most cases, a patient who appears intoxicated is just that; however, you must consider other causes as well. A person with chronic alcoholism may have decreased liver function, blood clotting, and immune system abnormalities, causing a predisposition to intracranial bleeding, brain and bloodstream infections, and hypoglycemia. -Infections in the brain and bloodstream are life threatening and require immediate medical attention. Patients may not demonstrate the typical signs of infection, such as fever, particularly if they are very young, very old, or have an impaired immune system. -Assessment: As you approach the patient, gather information from the scene (is this medical or trauma related?) and note the patient's body position and level of consciousness. -Unless your arrival time is 1 minute or less, most seizures will be over by the time you arrive. If the seizure is still occurring, the potentially life-threatening condition of status epilepticus may be present. If the patient is in a postictal state, he or she may be unresponsive or starting to regain awareness of the surroundings. -Determine the patient's LOC using the AVPU scale. Evaluate the airway of an unresponsive patient to make sure it is patent and will remain patent. If the patient requires assistance maintaining an airway, consider an oropharyngeal or nasopharyngeal airway. Be prepared to provide suction. Position the patient to prevent aspiration. -If you determine that the patient cannot protect his or her airway, place the patient in the recovery position to help prevent secretions from entering the airway. -Check for foreign body obstruction. Assess the patient's breathing. -All patients with altered mental status, regardless of the cause, should receive high-flow oxygen. Ventilate the patient at the appropriate rate with the proper volume. Deliver each breath during a period of 1 second (just enough to produce visible chest rise) at a rate of 10 to 12 breaths/ min. Do not hyperventilate the patient. Check the pulse. -If the patient is unresponsive, immediately begin CPR and AED if no pulse is found. -If the patient is responsive, determine whether the pulse is fast or slow, weak or strong. -Evaluate the patient quickly for external bleeding.

Understand how heat loss occurs in the body and how the rate/amount can be modified in an urgent situation

Heat Loss: -Conduction: direct transfer of heat through contact with a colder structure. Example: bare feet on a cold floor -Convection: loss of heat to passing air. Example: standing in a cold breeze -Evaporation: loss of heat through evaporation of water from the skin. Example: getting out of the pool or shower -Respiration: in a cold environment, exhaled air has been warmed within the body. That heat is lost in exhalation -Radiation: transfer of radiant heat. Example: entering a walk-in freezer Rate/amount modification: -Increase or decrease heat production: one way for the body to increase its heat production is to increase the rate of metabolism of its cells; the body can accomplish this through shivering (active heat). Also, people often have a natural urge to move around when they are cold. When a person is hot, he or she tends to reduce the level of activity, thus reducing heat production -Move to an area where heat loss is decreased or increased: the most obvious way to decrease heat loss form radiation and convection is to move out of a cold environment and seek shelter from the wind. The same hold true for a patient who is too hot. Simply moving the patient into the shade can reduce the ambient temperature by 10 degrees or more. If you cannot move the patient, create shade and increase air movement by fanning the patient. -Wear the appropriate clothing for the environment: To avoid eat loss in cold environments, wear layers of clothing that provide good insulation, such as wool, down, and synthetic fibers. Protective clothing traps perspiration and prevents evaporation, which prevents cooling. Keep the head, hands, and feet covered, and remove wet clothing if possible. To encourage heat loss in hot environments, wear lightweight, loose-fitting clothing, particularly around the head and neck.

Common prefixes Hyper Hypo Tachy Brady Pre Post

Hyper — over, excessive, high — hyperventilation — fast ventilations Hypo — under, below normal — hypo-perfusion — below normal blood flow to vital organs Tachy — rapid, fast — tachycardia — fast heart rate Brady — slow — bradypnea — slow breathing Pre — before — prenatal — occurring before birth Post — after, behind — post surgical — occurring after surgery

Understand the differences of hyperglycemia and hypoglycemia and how to recognize the different signs and symptoms

Hyperglycemia: is a state in which the blood glucose level is above normal. Signs and symptoms below: -Onset: gradual (hours to days) -Skin: warm and dry -Infection: Common Gastrointestinal tract -Thirst: intense -Hunger: present and increasing -Vomiting/abdominal pain: common Respiratory System -Breathing: with diabetic ketoacidosis (DKA) there are rapid, deep (Kussmaul) respirations. -Odor of breath: with DKA there may be a sweet, fruity odor Cardiovascular system -Blood pressure: normal to low -Pulse: rapid, weak, and thready Nervous system -Consciousness: restlessness, possibly progressing to coma; abnormal or slurred speech; unsteady gait Treatment - Response: gradual, within 6-12 hours following medical treatment Hypoglycemia: is a state in which the blood glucose level is below normal -Onset: rapid (within minutes) -Skin: pale, cool, and moist -Infection: uncommon Gastrointestinal tract -Thirst: absent -Hunger: absent -Vomiting/abdominal pain: uncommon Respiratory system -Breathing: normal; may become shallow or ineffective if hypoglycemia is severe and mental status is depressed. -Odor of breath: normal Cardiovascular system -Blood pressure: normal to low -Pulse: rapid, weak Nervous system -Consciousness: irritability, confusion, seizure or coma; unsteady gait Treatment -Response: Immediate improvement after administration of glucose

Understand hypovolemic shock because of bleeding and associated signs symptoms for both internal and external bleeding.

Hypovolemic shock: condition in which low blood volume results in inadequate perfusion and even death, might develop. External bleeding: Injuries and some illnesses can disrupt blood vessels and cause external bleeding. You should consider bleeding to be severe if: -The patient has a poor general appearance and has no response to external stimuli -Assessment reveals signs and symptoms of shock (hypoperfusion) -You note significant amount of blood loss -The blood loss is rapid and ongoing -You cannot control the bleeding -It is associated with a significant MOI Internal bleeding: The most common symptom of internal bleeding is pain. Significant internal bleeding will generally cause swelling in the area of bleeding, but swelling is often undetected until massive blood loss has occurred. Internal bleeding is most common in head, extremity, and pelvic injuries and is often associated with significant abdominal trauma. Intra-abdominal bleeding will often cause pain and distention. Bleeding into the chest cavity or lung may cause dyspnea, tachycardia, hemoptysis (the coughing up of bright red blood), and hypotension. A hematoma, a mass of blood that has collected in the soft tissues beneath the skin, indicates bleeding into soft tissues and may be the result of a minor or a severe injury. Bruising or ecchymosis may not be present initially, and the only sign of severe pelvic or abdominal trauma may be redness, skin abrasions, or pain. -Bleeding form any body opening, however slight, is serious. It usually indicates internal bleeding that is not easy to see or control. Bright red bleeding from the mouth or rectum or blood in the urine (hematuria) may suggest serious internal injury or disease. Nonmenstrual vaginal bleeding is always significant. -Other signs and symptoms of internal bleeding in trauma and medical patients include the following: -Hematemesis: the vomiting of blood. The vomitus may be bright red or dark red. If the blood has been partially digested, the vomitus may look like coffee grounds. -Melena: black, foul-smelling, tarry stool that contains digested blood -Pain, tenderness, bruising, guarding, or swelling. These signs and symptoms may mean that a closed fracture is bleeding -Broken ribs, bruises over the lower part of the chest, or a rigid, distended abdomen. The signs and symptoms may indicate a lacerated spleen or liver. Patients with an injury to one these organs may have referred pain in the right shoulder (indicating the liver is injured) or left shoulder (indicating the spleen is injured). Suspect internal abdominal bleeding in a patient wit referred pain. -The first sign of hypovolemic shock is a change in mental status, such as anxiety, restlessness, or combativeness. In nontrauma patients, weakness, faintness, or dizziness on standing is another early sign. Changes in skin color or pallor (pale skin) are often seen in both trauma and medical patients. Later signs of hypovolemic shock suggesting internal bleeding include the following: -Tachcycardia -Weakness, fainting, or dizziness at rest -Thirst -Nausea and vomiting -Cold moist (clammy) skin -Shallow, rapid breathing -Dull eyes -Slightly dilated pupils that are slow to respond to light -Capillary refill time longer than two seconds in infants and children -Weak, rapid (thready) pulse -decreasing blood pressure -Altered lever of consciousness -Patients with the signs and symptoms, particularly in the setting of significant MOI, require prompt transport, preferably to a trauma center.

Understand the components needed to prove negligence

In order to prove negligence there must be a duty, breach of duty, damages, causation. The plaintiff can use res ipsa loquitor and negligence per se to win a case of negligence

Understand the mechanism of injury and injuries that can be sustained from an incendiary and explosive device.

Incendiary and explosive devices come in various shapes and sizes. Incendiary devices are weapons used to start fires. Terrorists use flamethrowers, chemicals, Molotov cocktails, or other explosive devices for this purpose. Although you are not required to recognize all of the possible types of explosive devices, including improvised explosive devices (IED), it is important for you to be able to identify an object you believe is a potential device, notify the proper authorities, and safely evacuate the area. Always remember that there is a possibility of a secondary device when you are responding to the scene of an incendiary or explosive device call. Mechanism of injury: the type and severity of wounds sustained from incendiary and explosive devices primarily depend on the patient's distance from the epicenter of the explosion. Patients close to the epicenter of the explosion are likely to suffer from all wound-causing agents of the munitions. Patients who are farther away from the epicenter are likely to experience a combination of blast injuries from the explosion and penetrating trauma injuries from primary and secondary projectiles created by the explosion. Blast injuries occur in a number of ways: -Primary blast injury: due solely to the direct effects of the pressure wave on the body. The injury from the primary blast is seen almost exclusively in the hollow organs of the body -- the lungs, intestines and inner ears. An injury to the lungs causes the greatest morbidity and mortality. -Secondary blast injury: penetrating or non-penetrating injury that results from being struck by flying debris, such as ordnance projectiles or secondary missiles, that has been set in motion by the explosion. Objects are propelled by the force of the blast and strike the victim, causing injury. -Tertiary blast injury: results from whole-body displacement and subsequent traumatic impact with environmental objects (trees, building, or vehicles). Other indirect effects include crash injury from the collapse of structures (buildings, bunkers, or tunnels). -Quaternary blast injury: any other injury caused by a blast occurs in this way. This includes toxic inhalation of combustion gases, burns, a medical emergency (like a myocardial infarction) sustained while fleeing the scene of an explosion, and even a mental health disorder that develops immediately after or days to weeks after detonation of an explosive device.

Chapter 11: Pharmacology

KNOW YOUR MEDICATIONS

Understand the risk of "labeling" a patient

Labeling a patient is assuming that you know what the problem is when arriving on the scene. This could cause a serious condition to be overlooked, especially in patients who frequently call EMS for the same condition

Understand the difference between libel, slander, assault, battery, abandonment, negligence and their implications

Libel: written Slander: Spoken Assault: placing the patient in fear or immediate bodily harm Battery: unlawfully touching the patient; including proving care without consent Abandonment: occurs when the medical provider leaves the patient alone or in the care of someone else who is not competent in the care of the patient. Negligence: the failure to provide the same care that another equally competent health care provider would have provided Defamation: the communication of false information that damages the reputation of a person

Chapter 8: Understand the different types of equipment used for moving a patient and when each is appropriate Long backboards KED Scoop stretcher Wheeled stretcher

Long backboards: Used for a patient to must be transported in the supine or immobilized position. This is necessary for patients with suspected hip, pelvis, spinal or lower extremity injuries or trauma. Patients on a backboard should be carried with the diamond carry. KED: The Kendrick extrication device is a vest type device that is used to immobilize the patient until he/she is moved from the sitting position in the vehicle to a supine position on a backboard. The KED is often easier to use than the wooden short backboard. (Rarely ever used) Scoop Stretcher: composed of two halves that slide under the patient and locked together. This is utilized when moving a patient from the ground to a stretcher. Wheeled stretcher: Patient's who do not have a spinal injury or multi-system trauma are placed on a wheeled stretcher. (Spinal injury or multi-system trauma are placed on a backboard first)

Understand the use of Material Safety Data Sheets (MSDS) (now called Safety Data Sheets as per OSHA)

Material Safety Data Sheets (MSDS): a common source of information about a particular chemical. Essentially, the MSDS provides basic information about the chemical makeup of a substance, the potential hazards it presents, appropriate first aid in the event of an exposure, and other pertinent data for safe handling of the material. The MSDS will typically include the following details: -The name of the chemical, including any synonyms for it. -Physical and Chemical characteristics of the material. -Physical hazards of the material. -Health hazards of the material. -Signs and symptoms of exposure. -Routes of entry. -Permissible exposure limits -Responsible-party contact -Precautions for safe-handling (including hygiene practices, protective measures, and procedures for cleaning up spills or leaks) -Applicable control measures, including personal protective equipment -Emergency and first-aid procedures -Appropriate waste disposal. All facilities that use or store chemicals are required by law to have an MSDS on file for each chemical used or stored in the facility. Many sites, especially those that stock many different chemicals, may keep this information archived on a computer database. Although the MSDS is not a definitive response tool, it is a key piece of the puzzle. The MSDS can also be obtained from the transporting vehicle.

Understand the medications used in respiratory emergencies

Medications used in respiratory emergencies: includes generic drug name, trade name, action, indications, and use. Seen in picture listed (Table 15-6 in book).

Understand musculoskeletal injury grading system

Minor injures: -Minor sprains -Fractures or dislocations of digits Moderate injuries: -Open fractures of digits -Nondisplaced long bone fractures -Nondisplaced pelvic fractures -Major sprains of of a major joint Serious injuries: -Displaced long bone fractures -Multiple hand and foot fractures -Open long bone fracture -Displaced pelvic fractures -Dislocations of major joints -Multiple digit amputations -Laceration of major nerves or blood vessels Severe, life-threatening injuries (survival is probable) -Multiple closed fractures -Limb amputations -Fractures of both long bones of the legs (bilateral femur fractures) Critical injuries (survival is uncertain) -Multiple open fractures of the limbs -Suspected pelvic fracture with hemodynamic instability.

Describe the major physical and psychosocial characteristics for each age group.

Neonate/Infant: fast pulse/respirations. Grow relatively quickly. The airway is still small and developing, so they often have breathing problems. They generally use the sinuses and diaphragm to breathe. The immune system is largely built through passive immunity from the mother. Psychosocial development focuses on the formation of either trust/mistrust. Secure/anxious avoidant attachment could develop. Toddler/Preschool: Passive immunity fades, the child will develop more infections. Growth and vitals begin to level off and they begin to make the transition from gross motor to fine motor activities. Bladder control begins to develop and manifests roughly by 24 months. As language and comprehension of situations such as cause/effect develop, the child will begin to learn a lot. Separation anxiety from parents usually peaks. School age: Vital signs begin to come close to normal adult vital signs. permanent teeth develop and activity in both brain hemispheres increases. The child begins to learn pre-conventional, conventional, and post-conventional reasoning. Self-concept and self-esteem begin to develop. Adolescent: Vital signs round off to normal adult ranges. Growth spurt occurs and sexual organs begin to develop both internally and externally. They are often trying to develop their self image/code of ethics. They often try to take control of their life in the form of demanding privacy or controlling certain aspects of their lives. they are often embarrassed/terrified by what others think about them. Early adult: Stage of optimal body function. however subtle changes also occur as the body generally weakens. Work, family, and stress dominate this age group as early adults attempt to settle down. Middle adult: Vision, hearing, and cardiovascular health begin to deteriorate. Diseases such as cancer and diabetes become more prominent. As they approach the middle of their expected life, they may begin to think about accomplishing life goals and dealing with empty nest syndrome or caring for older adults. They may have financial stress, but generally have physical, emotional, and psychological reserves. Older adult: vital signs vary with their medications and overall health at that age. Overall body function declines as the body ages into its final stages of life. They need a good support system from friends and family to function independently and free from isolation or depression. Older adults need to be reminded of their worth in wisdom.

Chapter 7: Understand the different terms used to describe different age groups

Neonate: 0-1 month Infant: 1 month to 1 year Toddler: 1 to 3 years Preschool age: 3 to 6 years School age: 6 to 12 years Adolescent: 12 to 18 years Early adult: 19 to 40 years Middle adult: 41 to 60 years Older adult: 61 years and older

Understand the different oxygen delivery devices; when and how to use them

Nonrebreather mask: used for patients with adequate breathing, but are suspected of hypoxia, if the patient a patient does not tolerate the nonrebreather, use a nasal cannula Patients that need to re-establish the correct partial pressure of carbon dioxide (hyperventilation) use a partial nonrebreather mask Venturi makes enable fine adjustment of the oxygen flow over a period of time. Used for patients who have a hypoxic drive to breathe, but also need supplemental oxygen Tracheostomy masks are used for patients with tracheostomy's

Chapter 2: Understand the importance of personal safety and what it means during a call

Nutrition, stress, sleep, family, and other factors influence the quality of care the EMS provider gives to the patients. Eat healthy, and stay consistent with meals, get enough sleep, spending time with family and exercise regularly will help eliminate stress on the job. Talking with someone about the job could also help with eliminating stress.

Chapter 4: Understand special considerations and how to communicate with various types of people

Older patients should be assumed to be able to think clearly and provide an accurate medical history. Approach the patient slowly and calmly and show the patient that you are confident and in charge of the situation. Subjective findings maybe inaccurate in older patient's, so you should be vigilant for any objective changes. Young patients are prone to fear and anxiety. Make the child comfortable by allowing him/her a familiar object or a family member at the appropriate time. Young patients should be informed of procedures well in advance and in terms that they can understand. Maintain trues and modesty in younger patients. When treating a hearing impaired patient, try to locate a hearing aid if possible. Do not attempt to shout, and position your face in front of the patient, so they can read your lips if possible. Have other forms of communication, such as pen/paper and sign language. Try to maintain continuous contact with visually impaired patients and explain in detail and treatment being performed. Take into account a guide dog if present. When treating non English speaking patients try to assess how much English they can speak. Use hand gestures and common medical terms in their own language. Attempt to find a translator or use a smart device to translate

Understand transfer of care in regard to what level of professional you may hand off your patient and the components of a successful transfer of care

Once at the hospital, a member of the hospital staff will take responsibility of the patient from you. You can only transfer a patient to a member who is at least your level of training (Paramedic, nurse, physician). Once the staff member is ready to accept responsibility, you must deliver an oral report, which consists of opening detailed information, and important history, responses to treatment, vital signs, and other information.

Understand how to measure body surface area as it relates to burns in all ages

Once quick way to estimate the surface area that has been burned is to compare it to the size of patient's palm, which is roughly equal to 1% of the patient's total body surface area. This technique is called the rule of palm. Another useful measurement system is the rule of nines, which divides the body into sections, each of which is approximately 9% of the total surface area. Remember that the head of an infant or child is relatively larger than the head of an adult, and the legs are relatively smaller. When you calculate the extent of burn injury, include only partial-thickness (second-degree and full-thickness (third-degree) burns. Document superficial (first-degree) burns, but do not include them in the body surface area estimation of extent of burn injury.

Understand the different airway adjuncts, indications and contraindications

Oropharyngeal: moves the tongue out of the way and makes it easier to suction the oropharynx if necessary. Indications: unresponsive patients without a gag reflex. Contraindications: conscious patients or any patient with an intact gag reflex Nasopharyngeal: used to prevent the tongue from obstructing the airway in patients who may not be able to protect their own airway.

Chapter 39: Understand the various components of the incident command system and how the interact

Overview of the National Incident Management System (NIMS): -NIMS provides an adaptive, standardized, approach to any domestic incident. -NIMS standardizes the command structure, terminology, training, etc. -Standardization allows for effective communication and interaction among multiple and divers agencies at local, state, and federal levels. -The adaptability of NIMS allows it to be used with any type of domestic incident (terrorism, natural disaster, hazardous materials, etc.) of any size. The ICS is one component of the NIMS. The fie major components of NIMS are as follows: -Preparedness: helps agencies and responders proactively prepare for an incident. -Communications and information: coordinates effective communication and information sharing -Command and Management: provides oversight of the incident for all participating agencies. -Resource management: coordinates acquisition, tracking, and recovery of resources and equipment needed during an incident. -Ongoing Management: coordinates continuous quality improvement of NIMS. NIMS practices: -Coordinate efforts through a unified command or single command system to reduce duplication of effort and freelancing. -Use "clear text" communications to facilitate interagency efficiency. -Limit span of control to no more than seven workers per supervisor. NIMS roles and responsibilities: -Command section: include incident commander (IC), public information officer (PIO), safety officer, liaison officer. -Finance section: tracks all expenditures during an incident. This section is usually only needed for large incidents. -Logistics: responsible for most of the things that actually allow and IMS to function. This includes the necessary communications equipment, medical supplies, food, water, facilities, shelter, etc. -Operations: responsible for tactical operations on larger incidents. On smaller, incidents, this responsibility usually rests with the IC. -Planning: helps to develop an action plan for the incident and solve problems as they arise during the incident.

Chapter 34: Understand the age-related assessment findings and age-related assessment and treatment modifications for pediatric specific major diseases and/or emergencies

Pediatric Assessment Triangle (PAT): -Appearance (TICLS) -Abnormal findings here indicate a possible neurological problem -Assess for TICLS -Tone: assess for movement, muscle tone, listlessness, etc.. -Interactivity: assess for alertness, reactivity to stimulus, interaction with the environment -Consolability: can the child be consoled by the parents or caregivers -Look: is the child able to fix his/her gaze, or do they appear "out of it" -Speech or cry: assess speech in older children, strength of cry in younger patients -Work of breathing -Abnormal findings here indicate a respiratory problem -Assess how hard the child is working to breathe; look for signs and symptoms such as accessory muscle use, abnormal lung sounds, grunting, tripod positional breathing, head bobbing, and nasal flaring -Circulation to skin -Abnormal findings here indicate a possible cardiac problem or shock -Assess skin color: pale, cyanotic, mottled, flushed, jaundice -Key points about the PAT -The PAT is intended to be a quick, visual assessment to help determine which pediatric patients require rapid intervention and transport -You should be able to complete the three key assessments and identify high priority patients in about 30 seconds. Respiratory Emergencies and Management: Respiratory problems are the leading cause of cardiopulmonary arrest in the pediatric population. Failure to recognize and treat declining respiratory status will lead to death. A pediatric patient in respiratory distress still has the compensatory mechanisms and the ability to exchange oxygen and carbon dioxide. During respiratory distress, the pediatric patient is working harder to breathe and will eventually go into respiratory failure if left untreated. Respiratory failure occurs when the pediatric patient has exhausted all compensatory mechanisms and waste products begin to collect. If this is not treated, a total shutdown of the respiratory system will occur --respiratory arrest. -In the early stages of respiratory distress, you may note changes in the pediatric patient's behavior, such as combativeness, restlessness, and anxiety. As the body attempts to maximize the amount of air going into the lungs, the work of breathing increases. As discussed previously, the signs and symptoms of increased work of breathing include nasal flaring, abnormal breath sounds, accessory muscle use, and the tripod position. -As the pediatric patient progresses to possible respiratory failure, the efforts to breathe decrease; the chest rises less with inspiration. The body has used up its available energy stores and cannot continue to support the extra work of breathing under these conditions. At this point, without care, cyanosis may develop (a late signs) Be aware not all pediatric patients develop cyanosis. You should be just as concerned about a pediatric patient with pale skin as one with blue skin. -Changes in behavior will also occur until the pediatric patient demonstrates an altered LOC. The pediatric patient may experience periods of apnea (absence of breathing). As the lack of oxygen becomes more serious, the heart muscle itself becomes hypoxic and slows down. This leads to bradycardia -- almost always an ominous sign in pediatric patients. If the heart rate is fast you need to investigate the cause. However, if the heart rate is slow (less than 60 beats/min) or absent, especially in an unconscious infant or child, you must begin CPR immediately. Without aggressive airway management, bradycardia may quickly progress to cardiopulmonary arrest. -Of course, respiratory failure does not always indicate airway obstruction. It may indicate trauma, nervous system problems, dehydration (often caused by vomiting and diarrhea), or metabolic disturbances. For example, a pediatric patient with diabetes might have a glucose level that is too high or too low, or a pediatric patient might have a pH imbalance, as can happen with some rare pediatric diseases. Regardless of the cause, your first step is always to ensure adequate oxygenation and ventilation. -Never forget that a pediatric patient's condition can progress from respiratory distress to respiratory failure at any time. For this reason, you must reassess the pediatric patient frequently. - A child or infant in respiratory distress needs supplemental oxygen. Anxiety, agitation, or crying may increase the effort or work of breathing, so use whichever method seems least upsetting to the pediatric patient -- mask, blow-by, or nasal cannula. You may need to get creative by distracting the pediatric patient with games, a toy, or conversation. Assist ventilation with a BVM and 100% oxygen for infants and children who are in possible respiratory failure. -Allow the pediatric patient to remain in a comfortable position. For a small child, this may mean sitting on the parent's or caregiver's lap. Give nothing by mouth, in case the patient's condition deteriorates suddenly. If the patient's condition progresses to respiratory failure, begin assisted ventilations immediately and continue to provide supplemental oxygen. Airway obstruction: Children, especially those younger than 5 years, can (and do) obstruct their airway with any object that they can fit in their mouth, such as hot dogs, balloons, grapes, or coins. In cases of trauma, the child's teeth may have been dislodged into the airway. Blood, vomitus, or other secretions can cause mild or severe airway obstruction. -Airway obstructions can also be caused by infections, including pneumonia, croup, epiglottis, and bacterial tracheitis. Consider infection as a possible cause of airway obstruction if a pediatric patient has congestion, fever, drooling, and cold symptoms. -Obstruction by a foreign body may involve the upper or lower airway, and may be partial or complete. Signs and symptoms that are frequently associated with a partial upper airway obstruction include decreased or absent breath sounds and stridor. Stridor is usually caused by swelling of the area surrounding the vocal cords or upper airway obstruction. Infants or children with a complete airway obstruction will have absent breath sounds and become rapidly cyanotic. -Signs and symptoms of a lower airway obstruction include wheezing and/or crackles. The best way to auscultate breath sounds in pediatric patients is to listen on both sides of the chest at the level of the armpit. -Immediately begin treatment of the pediatric patient with an airway obstruction. If the patient is conscious and coughing forcefully and you know for sure that there is a foreign body in the airway -- that is, if someone actually saw the object go into the child's mouth -- encourage the child to cough to clear the airway. If the material in the airway does not completely block the flow of air, the pediatric patient may be able to breathe on his/her own without any intervention. In such cases, do not intervene except to provide supplemental oxygen. Allow the pediatric patient to remain in whatever position is most comfortable, and monitor his/her condition during transport. -If you see signs of a severe airway obstruction however, you must attempt to clear the airway immediately. These signs and symptoms include the following -Ineffective cough (no sounds) -Inability to speak or cry -Increasing respiratory difficulty, with stridor -Cyanosis -Loss of consciousness -If an infant is conscious with a complete airway obstruction, perform up to 5 back blows followed by 5 chest thrusts. Continue until the obstruction clears. -If a child older than one is conscious with a complete airway obstruction, perform abdominal thrusts (Heimlich maneuver). Continue until the obstruction clears. -If there is a reason to believe than an unconscious child has a foreign body obstruction and there are no suspected spinal injuries, open the airway using the head-tilt-chin-lift maneuver and look inside the mouth to see whether the obstructing object is visible. If the object is visible, try to remove it using a finger sweep motion. Never use finger sweeps if you cannot see the object because you may push it further into the airway. -Chest compressions are recommended to relieve a severe airway obstruction in an unconscious pediatric patient. Chest compressions increase the pressure in the chest, creating an artificial cough that may force a foreign body from the airway. Asthma: a condition in which the smaller air passages (bronchioles) become inflamed, swell, and produce excessive mucus, which leads to difficulty breathing. Asthma is a true medical emergency if not promptly identified and treated. Common causes (triggers) for an asthma episode include upper respiratory infection, exercise, exposure to cold air or smoke, and emotional stress. -Children with asthma will wheeze as they attempt to exhale through partially obstructed lower air passages; you may be able to hear loud wheezing without a stethoscope. In other cases, the airways are completely blocked and no air movement is heard. In severe cases, cyanosis and/or respiratory arrest may quickly develop. Asthma patient in respiratory distress will typically assume a position of comfort, such as the tripod position, to allow for maximum respiratory effort -If possible, allow the pediatric patient to assume a position of comfort in the parent's or caregiver's lap. Avoid overexciting the pediatric patient because this may worsen the condition. Administer supplemental oxygen via a route that is tolerated by the child. Allow the parent or caregiver to assist the team by gathering any medications, calming the pediatric patient, or by holding blow-by oxygen or a nonrebreathing mask. -A bronchodilator (albuterol, a beta-2 agonist) via a metered-dosed inhaler (MDI) wit a spacer mask device may be administered based on local agency protocols. Often the parents or caregivers have attempted multiple dosages of albuterol via the MDI or nebulizer. In this case, ALS providers should be dispatched immediately to meet you en route for additional medication administration and advanced care. -If you must assist ventilations in a pediatric patient wo is having an asthma attack, use slow, gentle breaths. Remember, the problem in asthma is getting the air out of the lungs, not into them. Resist the temptation to squeeze the reservoir bag hard and fast. -A prolonged asthma attack that is unrelieved may progress into a condition known as status asthmaticus. The pediatric patient is likely to be frightened, frantically trying to breathe, and using all the accessory muscles. Status asthmaticus is a true emergency. Administer oxygen and provide rapid transport to the ED. -The effort to breathe during an asthma attack is very tiring, and the pediatric patient may be exhausted by the time you arrive. An exhausted pediatric patient may have stopped feeling anxious or even struggling to breathe. It may look as if this patient is recovering; however, he or she is at a very critical stage and is likely to stop breathing. Aggressive airway management, oxygen administration, and prompt transport are essential in this situation. Consider calling for ALS backup. Follow local protocol. Pneumonia: a general term that refers to an infection of the lungs. Pneumonia is often a secondary infection; it occurs during or after treatment for a pre-existing infection such as a cold. It can also be caused by direct lung injuries such as from an accidental ingestion of a chemical or a submersion incident. Children with disease causing immunodeficiency are at an increased risk of pneumonia developing. You will notice that the incidence of this type of virus is greatest during the fall and winter months, affecting a large number of the pediatric population. -Often pediatric patients will present with unusually rapid breathing, or will breathe with grunting or wheezing sounds. Additional signs and symptoms include nasal flaring, tachypnea, and hypothermia or fever. The patient may also exhibit unilateral diminished breath sounds or crackles over the infected lung segments. Assess the work of breathing by observing for signs of accessory muscle usage. Pneumonia is particularly serious in infants because they have an increased oxygen demand and less respiratory reserve than older children or adults. For a pediatric patient with suspected pneumonia, your primary treatment will be supportive. Monitor the patient's airway and breathing status, and administer supplemental oxygen if required. If the child is wheezing, administer a bronchodilator if permitted in your EMS system. A diagnosis of pneumonia must be confirmed in the hospital setting with a chest x-ray, followed by the administration of antibiotics as the primary treatment. Croup: Croup (laryngotracheobronchitis) is an infection of the airway below the level of the vocal cords, usually caused by a virus. This disease is typically seen in children between ages 6 months and 3 years. It is easily passed between children. the disease starts with a cold, cough, and low-grade fever that develops over two days. The hallmark signs of croup are stridor and a seal-bark cough, which is a signal of significant narrowing of the air passage of the trachea that may progress to significant obstruction. Peak seasonal outbreaks of this disease occur in the late fall and during the winter. Croup often responds well to the administration of humidified oxygen. Bronchodilators are NOT indicated for croup and can make the child worse. Epiglottitis: Epiglottitis (supraglottitis) is an infection of the soft tissue in the area above the vocal cords. Bacterial infection is the most common cause. Infants and children are the most common age groups diagnosed with epiglottitis, but it occurs in patients of all ages. Since the development of a vaccine against one organism that causes epiglottitis, the incidence of the disease has dramatically decreased. In preschool- and school-aged children especially, the epiglottis can swell to two to three times its normal size. This puts the airway at risk of complete obstruction. Patients with epiglottitis typically look very sick. The condition usually develops in otherwise healthy children, and symptoms are relatively sudden in onset. Children with this infection look ill, report a very sore throat, and have a high fever. They will often be found in the tripod position and drooling. Bronchiolitis: a specific viral illness of newborns and toddlers, often caused by respiratory syncytial virus (RSV) that causes inflammation of the bronchioles. RSV is highly contagious and spread through droplets when the pediatric patient coughs or sneezes. RSV is more common in premature infants and results in copious secretions that may require suctioning. The virus can also survive on surfaces, including hands and clothing. The infection tends to spread rapidly through schools and in child care centers. -Bronchiolitis occurs during the first 2 years of life an is more common in boys. These infections are most widespread in the winter and early spring. Bronchioles become inflamed, swell, and fill with mucus. The airways of infants and young children can become easily blocked. -When assessing a pediatric patient, look for signs of dehydration -- infants with RSV often refuse liquids. If the RSV has progressed to bronchiolitis, shortness of breath and fever may be present. -Approach the pediatric patient with a calm demeanor and allow for a position of comfort. Treat airway and breathing problems as appropriate. Humidified oxygen is helpful if available. Consider calling for ALS backup and transport to the appropriate hospital. Pertussis: also known as whooping cough, is a communicable disease caused by a bacterium that is spread through respiratory droplets. The typical signs and symptoms are similar to a common cold: coughing, sneezing, and a runny nose. As the disease progresses, the coughing becomes more severe and is characterized by the distinctive whoop sounds heard during inspiration. Infants infected with pertussis may develop pneumonia or respiratory failure. To treat pediatric patients, keep the airway patent (open) and transport. Because pertussis is contagious, follow standard precautions, include wearing a mask and eye protection. Cardiopulmonary arrest: cardiac arrest in infants and children is most often associated with respiratory failure and respiratory arrest. Compared with adults, children are affected differently when it comes to decreasing oxygen concentrations. An adult becomes hypoxic and the heart develops and dysrhythmia that leads to sudden cardiac death. This is often in the form of ventricular fibrillation and is the reason that an AED is the treatment of choice. Children, on the other hand, become hypoxic and their hearts slow down, becoming more and more bradycardic. The heart will beat slower and more weakly until no pulse is felt. Any child who is breathing very poorly with a slowing heart rate must be ventilated with high concentrations of oxygen early to try to oxygenate the heart before cardiac arrest occurs. Shock: a condition that develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs of the body. This results in organ failure and eventually cardiopulmonary arrest. The early stage of shock, while the body can still compensate for blood loss is called compensated shock. The late stage, when blood pressure is falling, is called decompensated shock. -In pediatric patients, the most common causes include: -Traumatic injury with blood loss (especially abdominal) -Dehydration from diarrhea and vomiting -Severe infection -Neurologic injury, such as severe head trauma -A severe allergic reaction to an allergen (anaphylaxis), such as an insect bite or food allergy -Disease of the heart -A collapsed lung (tension pneumothorax) -Blood or fluid around the heart (cardiac tamponade or pericarditis) -Pediatric patient respond differently than adults to fluid loss. They may respond by increasing their heart rate, increasing respirations, and showing signs of pale skin (pallor) or blue skin (cyanosis). -Signs of shock in infants and children are as follows: -Tachycardia -Poor capillary refill (>2 seconds) -Mental status change -Begin treating shock by assessing the ABCs, intervening immediately as required; do not wait until you have performed the complete assessment to take action. If there is an obvious life-threatening external hemorrhage, the order becomes CAB, because bleeding is the most critical step. If cardiac arrest is suspected, the order also becomes CAB because chest compressions are essential. Pediatric patients in shock often have increased respirations but do not demonstrate a fall in blood pressure until shock is severe. -When you assess circulation, pay particular attention to the following: -Pulse: assess both the rate and quality of the pulse. A weak, "thready" pulse is a sign that there is a problem. The appropriate rate depends on age; generally, except in the case of a newborn, anything over 160 beats/min suggests shock -Skin changes: Assess the temperature and moisture of the hands and feet. How does this compare with the temperature of the skin on the trunk of the body? Is the skin dry and warm, or cold and clammy? -Capillary refill time: squeeze a finger or toe for several seconds until the skin blanches, and then release it. Does the fingertip return to its normal color within 2 seconds or is it delayed? -Color: assess the patient's skin color. Is it pink, pale, ashen, or blue? -Changes: changes in pulse rate, color, skin signs, and capillary refill time are all important clues suggesting shock -Blood pressure is the most difficult vital sign to measure in pediatric patients. The cuff must be the proper size -- two thirds the length of the upper arm. The value for normal blood pressure is also age specific. Remember that blood pressure may be normal with compensated shock. Low blood pressure is a sign of decompensated shock, requiring care from an ALS team and rapid transport. -Part of your assessment should also include talking to the parents or caregivers to determine when the signs and symptoms first appeared and whether any of the following has occurred: -Decrease in urine output (with infants, are there fewer than 6 to 10 wet diapers) -Absence of tears, even when the child is crying -A sunken or depressed fontanelle (infant patient) -Changes in LOC and behavior **Limit your management to these simple interventions. Do not waste time performing field procedures. Ensure that the airway is open; prepare for artificial ventilation; control bleeding; and give supplemental oxygen by mask or blow-by method as tolerated. Continue to monitor airway and breathing. Place the pediatric patient in a position of comfort. Keep the pediatric patient warm with blankets and by turning up the heat in the patient compartment. Provide rapid transport to the nearest appropriate facility and continue monitoring vital signs en route. Call for ALS backup as needed. Allow a parent or caregiver to accompany the pediatric patient whenever possible.** Anaphylaxis: also called anaphylactic shock, is a life-threatening allergic reaction tat involves a generalized multisystem response to an antigen (foreign substance). Anaphylaxis is characterized by airway swelling and the dilation of blood vessels. Common causes include insect bites or stings, medications, and food. -A pediatric patient in anaphylactic shock will have hypoperfusion as well as additional signs such as stridor and/or wheezing, with an increased work of breathing. The pediatric patient will also have an altered appearance with restlessness, agitation, and sometimes a sense of impending doom. Hives, and intensely skin rash, are usually present. -Maintain the airway and administer oxygen via a route that is tolerated. If the pediatric patient is in stable condition, allow the parent or caregiver to assist in the positioning of the patient, oxygen delivery, and keeping the patient calm. Increased agitation and crying, combined with an increased work of breathing, may lead to increased bronchoconstriction. Based on local protocol, assist the parent or caregiver with administering a prescribed epinephrine auto-injector, if available. The administration of epinephrine is the highest priority in infants and children with signs and symptoms of anaphylaxis. The pediatric epinephrine auto-injector (EpiPen Jr) is supplied in a dose of 0.15 mg and is given intramuscularly in the lateral thigh. Provide rapid transport to the hospital. Seizures: is the result of disorganized electrical activity in the brain, causes which are listed below: -Child abuse -Electrolyte imbalance -Fever -Hypogylcemia (low blood glucose level) -Infection -Ingestion -Lack of oxygen -Medications -Poisoning -Seizure disorder -Recreational drug use -Head trauma -No cause can be found -Seizures in infants can be subtle, consisting only of an abnormal gaze, sucking motions, or "bicycling" motions. In older children, seizures are more obvious and typically consist of repetitive muscle contractions and unresponsiveness. Once a seizure has stopped, the patient's muscles relax, becoming almost flaccid (floppy), and the breathing becomes labored (fast and deep). This is the postictal state. The longer and more intense a seizure is, the longer it will take for the imbalance to correct itself. Likewise, the longer and more severe seizures will result in longer postictal unresponsiveness and confusion. Once the pediatric patient regains a normal LOC, the postictal state is over. -Seizures that continue every few minutes without regaining consciousness or last longer than 30 minutes are referred to status epilepticus. Recurring or prolonged seizures should be considered potentially life-threatening situations in which pediatric patients need emergency medical care. If the pediatric patient does not regain consciousness or continues to seize, protect the pediatric patient from harming himself or herself and call for ALS backup. These pediatric patients need advanced airway management and medication to stop the seizure. -Securing a protecting the airway are your priorities. Position the head to open the airway. Clear the mouth with suction. Consider placing the pediatric patient in the recovery position if the pediatric patient is actively vomiting and suction is inadequate to control the airway. Provide 100% oxygen by nonrebreathing mask or blow-by method. If there are no signs of improvement, begin BVM-ventilation with appropriately sized equipment with supplemental oxygen. Some parents or caregivers will have given the child a rectal dose of diazepam (Diastat) to stop the seizure prior to your arrival. Monitor breathing and LOC carefully in these patients. Transport the pediatric patient to the appropriate facility. Sudden Infants death syndrome: The death of an infant or a young child is called sudden infant death syndrome (sids) when, after a complete autopsy, the cause of death remains unexplained. -Although it is impossible to predict SIDS, there are several known risk factors: -Mother younger than 20 years -Mother smoked during pregnancy -Low birth weight -Deaths as the result of SIDS can occur at any time of the day; however these children are often discovered in the morning when the parents or caregivers go in to check on the infant. If you are the first provider at these scene of suspected SIDS, you will face three tasks: assessment of the scene, assessment and management of the patient, and communication and support of the family. Patient assessment and management: SIDS is a diagnosis of exclusion. All other potential causes must first be ruled out, a process of that can be time-consuming for physicians. An infant who has been a victim of SIDS will be pale or blue, not breathing, and unresponsive. Other causes for such a condition include the following: -Overwhelming infection -Child abuse -Airway obstruction from a foreign object or as a result of infection -Meningitis -Accidental or intentional poisoning -Hypoglycemia -Congenital metabolic defects -Regardless of the cause, assessment and management of the infant remain the same. Remember that what you find in assessing the infant and the scene may provide important diagnostic information. -Begin with an assessment of the ABCs, and provide interventions as necessary. Depending on how much time has passed since the child was discovered, he or she may show signs of postmortem changes. These include stiffening of the body, called rigor mortis, and dependent lividity, which is the pooling of blood in the lower parts of the body or those that are in contact with the floor or bed. -If the child shows such signs, call medical control. In some EMS systems, a victim of SIDS may be declared dead on the scene. Deciding whether to start CPR on a child who shows clear signs of rigor mortis or dependent lividity can be very difficult. Family members may consider anything less as withholding critical care. In this situation, the best course of action may be to initiate CPR and transport the patient to the nearest ED, where the family can receive more extensive support (follow local protocols). If there is no evidence of postmortem changes, begin CPR immediately. -As you assess the infant, pay special attention to any marks or bruises on the child before performing any procedures, including CPR. Also, note any intervention such as CPR that was done by the parents or caregivers before you arrived. Scene Assessment: Your assessment of the scene should include the following: -Signs of illness, including medications, humidifiers, or thermometers -The general condition of the house -Signs of poor hygiene -Family interaction. Do not allow yourself to be judgmental about family interactions at this time. Note and report any behavior that is clearly not within the acceptable range, such as physical or verbal abuse. -The site where the infant was discovered. Note all items in the infant's crib or bed, including pillows, stuffed animals, toys, and small objects. Meningitis: an inflammation of the tissues called the meninges, that cover the spinal cord and brain. It is caused by bacteria, viruses, fungi, or parasites. If left untreated, meningitis can lead to permanent brain damage or death. You must be able to recognize a pediatric patient who may have meningitis. -Meningitis can occur in both children and adults, but some pediatric patients are at a greater risk than others, as follows: -Males -Newborn infants -Children with compromised immune systems (such as HIV/AIDS or cancer) -Children who have an history of brain, spinal cord, or back surgery -Children who have had head trauma -Children with shunts, pins, or other foreign bodies within their brain or spinal cord. -At especially high risk are children with a ventriculoperitoneal (VP) shunt. VP shunts drain excess fluids from around the brain into the abdomen. These children with special needs have tubing that can usually be seen a felt just under the scalp. -The signs and symptoms of meningitis vary, depending on the age of the patient. Fever and altered LOC are common symptoms of meningitis in patients of all ages. Changes in the LOC can range from a mild or severe headache to confusion, lethargy, and/or an inability to understand commands or interact appropriately. The child may also experience a seizure, which may be the first sign of meningitis. Infants younger than 2 to 3 months can have apnea, cyanosis, fever, a distinct high-pitched cry, or hypothermia. -In describing children with meningitis, physicians often use the "meningeal irritation" or "meningeal signs" to describe pain that accompanies movement. Bending the neck forward or back increases the tension within the spinal canal that stretches the meninges, causing a great deal of pain. This results in the characteristic stiff neck of children with meningitis, who will often refuse to move their neck, lift their legs, or curl into a c-position, even if coached to do so. One sign of meningitis in an infant is increasing irritability, especially when being handled. Another sign is a bulging fontanelle without crying. -One form of meningitis deserves special attention. Neisseria meningitidis is a bacterium that causes a rapid onset of meningitis symptoms, often leading to shock and death. Children with N meningitidis typically have small, pinpoint, cherry-red spots or larger purple or black rash. This rash may be on part of the face or body. These children are at serious risk of sepsis, shock, and death. -All pediatric patients with possible meningitis should be considered contagious. Therefore, follow standard precautions whenever you suspect meningitis and follow up with the hospital to learn the patient's final diagnosis. If you have been exposed to saliva and respiratory secretions from a child with N meningitidis, you should receive antibiotics to protect yourself and others from the bacteria. This is particularly true if you managed the pediatric patient's airway. If you were not in close contact with the pediatric patient or his/her respiratory secretions, you do not need treatment. -Provide these pediatric patients with supplemental oxygen and assist with ventilations if needed. Reassess the pediatric patient's vital signs frequently as you transport the patient to the highest level of service available.

Chapter 25: Understand the pathophysiology, assessment and management of bleeding

Perfusion: circulation of blood within an organ or tissue in adequate amounts to meet the cells' current needs for oxygen, nutrients, and waste removal. Blood enters an organ or tissue first through the arteries, then the arterioles, and finally the capillary beds. As it passes through the capillaries, the blood delivers nutrients and oxygen to the surrounding cells and picks up the wastes they have generated. -Blood must pass through the cardiovascular system fast enough to maintain adequate circulation throughout the body and to avoid clotting, yet slow enough to allow each cell time to exchange oxygen and nutrients for carbon dioxide and other waste products. -All organs and organ systems of the human body depend on adequate perfusion to function properly. Some organs require a rich supply of blood and do not tolerate interruption of blood supply for even a few minutes without sustaining damage. If perfusion to these organs is interrupted, then dysfunction and failure of that organ system will occur. The death of and organ system can quickly lead to the death of the patient. Emergency medical care is designed to support adequate perfusion of these critical organs and organ systems (table 25-1 in book), until the patient arrives at the hospital. Primary Assessment: when you treat a patient with significant blood loss from a visible wound or with suspected internal bleeding, do not be distracted from identifying and managing life threats, which is the focus of your primary assessment. As you approach a trauma patient, note important indicators that may signal the seriousness of the patient's condition. Be aware of obvious signs of injury or distress, such as facial grimace. Determine the patient's gender and age. -Perform a rapid exam of the patient, look for life threats, and treat them as you find them. If the patient has obvious, life-threatening external bleeding, remember to address it first (even before airway and breathing) by controlling it quickly; then assess the ABCs and provide treatment. If direct pressure is ineffective in controlling massive hemorrhage from an arm or leg, the patient may require a tourniquet before the airway is opened. Next, assess skin color: cool, moist skin that is pale or gray suggests a perfusion problem. Determine the patient's level of consciousness using the AVPU scale (awake and alert, responsive to verbal stimuli, responsive to pain, unresponsive). Does the patient have a patent (open) airway? If the patient is able to speak, then this indicates the airway is patent. What is the mental status of the patient? These indicators will help you assess how sick the patient is, which will help you develop and index of suspicion for serious illness or injuries related to internal bleeding. -Consider the need for spinal immobilization. At the same time, ensure a patent airway, look for adequate breathing, and check for breath sounds. If necessary, provide the patient wit high-flow oxygen or assist ventilation with a bag-valve mask (BVM) or nonrebreathing mask, depending on the patient LOC and rate and quality of breathing. If the patient is unconscious, the airway may be obstructed. Insert an oropharyngeal (oral; OPA) airway to secure the airway. -Quickly assess pulse rate and quality; determine the condition, color, and temperature of the skin; and check the capillary refill time to help establish the potential for shock, if needed by applying oxygen, improving circulation, and maintaining a normal body temperature. -The results of your initial general impression and your assessment f the ABCs will help you decide whether to manage the patient on scene or transport immediately and manage the patient en route to the hospital. If the patient as signs and symptoms of internal bleeding or airway or breathing problems, provide rapid transport to the most appropriate facility. The condition of patients with significant bleeding will quickly become unstable. Signs such as tachycardia, tachypnea, low blood pressure, weak pulse, and clammy skin are signs of impending circulatory collapse and indicate the need for rapid transport. History taking: after the primary assessment is complete, investigate the chief complaint and be alert for signs or symptoms of other injuries due to the MOI and/or NOI. Remember, internal bleeding can be found in both medical and trauma patients. If signs and symptoms of internal bleeding are not obvious, look more carefully during the patient assessment process. In a responsive trauma patient with an isolated injury and a limited MOI, consider a detailed physical examination of the specific area before you assess vital signs and obtain a history. -When you encounter a patient who is bleeding, avoid focusing on solely on the bleeding. With significant trauma, assess the entire patient, looking for the source of the problem, any preexisting illness, and other issues. -If the patient is responsive, obtain a SAMPLE history (signs and symptoms, allergies, medications, pertinent past medical history, last oral intake, events leading up to the illness or injury). It is important to as the patient if he or she takes blood-thinning medications because bleeding is generally more profuse and difficult to control in patients who take blood thinners. Blood thinners are often prescribed for patients with a history of stroke, pulmonary embolism, or heart attack. Common blood thinners include aspirin, warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis), and clopidogrel (Plavix). -If the patient is unresponsive, obtain medical history information from medical alert tags or ask family members or bystanders if they have any information. Look for signs and symptoms of hypoperfusion and determine how much blood loss as occurred. Secondary assessment: Unless you discover a life-threatening condition during the patient assessment, next conduct a secondary assessment, which is a detailed, comprehensive examination of the patient to uncover injuries or illness that may have been missed during the primary assessment. Record vital signs, complete and assessment of pain, and attach appropriate monitoring devices to quantify oxygenation and circulatory status. In some instances, such as a critically injured patient or a short transport time, there may not be time to conduct a secondary assessment. -Assess all areas for DCAP-BTLS to identify underlying or secondary injuries. For isolated injuries such as pain in the ankle, assess that area only (detailed physical examination). When examining the head, be alert for uncontrolled bleeding form large scalp lacerations. In the abdomen, feel all four quadrants for tenderness or rigidity. In the extremities, record pulse, motor, and sensory functions. -Obtain baseline vital signs; this allows you to more easily identify any changes that may occur during treatment. In an adult patient, a systolic blood pressure of less than 100 mm Hg with a weak, rapid pulse and cool, moist skin that is pale or gray are signs of hypoperfusion that require immediate attention. -In geriatric patients and patients who take certain blood pressure medications, the pulse rate may not increase with early shock; therefore, try to determine the patient's baseline blood pressure and quickly obtain a medical history and list of medications to help you better assess the patient's condition. Reassessment: Because the signs and symptoms of internal bleeding are often slow to develop, it is important to reassess the patient frequently. Children especially will compensate well for blood loss and then "crash" quickly. The reassessment is your best opportunity to determine whether your patient's condition is improving or getting worse and to determine the effectiveness of any interventions and treatments. Reassess an unstable patient every 5 minutes and a stable patient every 15 minutes. -Whenever you suspect significant bleeding, either external or internal, provide high-flow oxygen. If significant bleeding is visible, control external bleeding. Using multiple methods to control external bleeding usually works best. If the patient has signs of hypoperfusion, provide aggressive treatment for shock and rapid transport to the appropriate hospital. If internal bleeding is suspected, apply high-flow oxygen via a nonrebreathing mask and provide rapid transport to the hospital. -Do not delay transport of a patient to complete an assessment, particularly when significant bleeding is present, even if bleeding is controlled. The assessment can be started during transport. -In patients with severe external bleeding, it is important to recognize, estimate, and report the amount of blood loss that has occurred and how rapidly or over what period of time it occurred. Your transfer report at the hospital should update hospital personnel on how your patient has responded to your care. Be sure you paperwork reflects all of the patient's injuries and the care you have provided.

Understand how to protect yourself in a toxicologic emergency

Personal Protective Equipment (PPE) levels indicate the amount and type of protective gear that you need to prevent injury from a particular substance. The four recognized protection levels, A,B,C, and D, are as follows. -Level A: the most hazardous, requires fully encapsulated, chemical-resistant protective clothing that provides full body protection, as well as SCBA and special, sealed equipment. -Level B: requires non-encapsulated protective clothing or clothing that is designed to protect against a particular hazard. Usually this clothing is made of material that will let only limited amounts of moisture and vapor pass through (nonpermeable). Level B also requires eye protection and breathing devices that contain their own air supply, such as SCBA. -Level C: like level B, requires the use of nonpermeable clothing and eye protection. In addition, face masks that filter all inhaled outside air must be used. -Level D: requires a work uniform, such as coveralls, that affords minimal protection. All levels of protection require the use of gloves. Two pairs of rubber gloves are needed for protection in case one pair must be removed because of heavy contamination.

Understand physiologic, physical, and physiological responses to stress

Physiologic: involves interactions between the endocrine and nervous systems resulting in chemical and physical responses. The flight-or-flight response includes changes to the dilation of blood vessels, respiration rate and blood flow to certain areas of the body. There are acute, delayed and cumulative stress reactions

Understand the different types of positions and when they are used for various patients. Prone Semi-Fowler Recovery Shock Position of comfort

Position of comfort: usually a Fowler/semi-Fowler position is used for patients with respiratory or chest pain, unless they are hypotension. Shock: Patients who are in shock should be placed supine and kept warm Patients in late stages of pregnancy should be placed on the left side if they are hypotensive or uncomfortable when placed in the supine position. The recovery position is used for patients who are unresponsive and are not suspected to have any pelvic, spine, or hip injury. Nauseated or vomiting patients should be placed in a position of comfort that is easy to manage the airway. Obese patients should be placed in a position of similar patients, as long as their dignity is maintained.

Understand the phases of an ambulance call

Preparation phase: inspect the ambulance everyday and after each shift change. Dispatch: determine the nature of the call, location, and number of patients. En Route to scene: -Notify dispatch you are responding -Operate the ambulance according to state and local laws and agency policies. -All emergency vehicle operators must drive with due regard for the safety of others. Arrival at scene/patient contact: -Notify dispatch you are on scene. -Upon arrival at a scene, the ambulance should be positioned to allow for safe egress and patient loading. -If necessary, use the ambulance as a barrier to protect the scene. -The ambulance may be used to provide additional lighting if needed. Patient transfer to the ambulance: the patient must be properly secured for transport. Transport to receiving facility: -Notify dispatch you are transporting the patient and specify where. -Notify the receiving hospital according to local protocol. -Determine whether emergency transport is warranted. -Confirm patient is being transported to appropriate receiving facility. Arrival at hospital/transfer of care: -Notify dispatch you have arrived at the hospital. -Provide verbal report to appropriate hospital personnel of equal or higher medical authority. -Provide copy of written patient care record. -Obtain signature verifying transfer of care. Postpartum phase/return to service: -Ensure all necessary equipment is restocked and ready for use on next call. -Ensure ambulance and equipment is adequately cleaned, disinfected, or sterilized per local protocol.

Understand the ten phases of extrication

Preparation: Ensure appropriate training, equipment, etc. En Route to scene: similar to those of an ambulance call. -Notify dispatch you are responding -Operate the ambulance according to state and local laws and agency policies. -All emergency vehicle operators must drive with due regard for the safety of others. Arrival: -Position vehicle in a safe location. Use vehicle to increase scene safety if needed. -Assess the scene for hazards, number of patients, etc. -Perform a 360-degree walk-around if safe to do so. Control of hazards -Examples include traffic, downed power lines, fuel leaks, and hazardous materials. -It is common practice to disconnect the vehicle's battery during extrication operations. Do not attempt this without proper training. Electric vehicles and alternative-fuel vehicles can present special challenges and hazards. Support ops: Examples include scene lighting, helicopter landing zones, and staging areas. Gaining access: -EMTs without additional training do not typically gain access to patients if there are special hazards, specialized tools, or equipment required. -EMTs may assist in keeping the patient safe while rescuers attempt to gain access to extricate the patient. This may include providing eye protection or covering with a blanket. Patient care: -If safe to do so, patient care may begin before extrication is completed. -Perform a standard primary assessment by taking manual cervical-spine (c-spine) precautions and assessing airway, breathing, and circulation (ABCs). Removal of patient: -Simple access: gaining access to the patient without any tools or the need to break the glass. -Complex access: -Complex access requires the use of special tools and training. -EMTs without additional training should not attempt complex access. -Extrication: the removal of the patient from entrapment. -Entrapment: when a person is trapped in an enclosed space. -Removing the patient from a damaged vehicle, especially with c-spine precautions, can be challenging and labor intensive. Several rescuers are often required. -Emergency move: used when the scene is dangerous and the patient must be moved immediately and before providing patient care. -Urgent move: -Used when the patient has potentially life-threatening injuries or illness and must be moved quickly for evaluation and transport. -Rapid extrication: -And urgent move for patients in a motor vehicle. -Requires multiple rescuers and a long backboard. -Patient is rotated onto a long spine board with manual c-spine and removed from vehicle. Patient transfer: once the patient is freed, perform a complete assessment. Conclusions of extrication: units return to service.

Understand the basic principles of the mental health system

Professional counselors: are there for marital/parenting issues Psychologists: handle the more serious issues, such as clinical depression. They have specialized training dealing with more complex psychological conditions Psychiatrist: prescribes medication for the more severe conditions like, schizophrenia or bipolar disorder. Most psychological disorders can be handled through outpatient visits; however, some people require hospitalization in psychiatric units.

Understand the causes of shock

Pump failure: occurs when the heart is damaged by disease, injury, or when and obstruction prevents it from functioning. The heart may not generate enough energy to move the blood through the system. Low fluid volume: often a result of bleeding, leads to inadequate perfusion. The blood vessels can dilate excessively so that the blood within them, even though it is of normal volume, is adequate to fill the system, and provide efficient perfusion

Digestive system: Understand which organs are in which quadrant/region of the of the body

RUQ: liver, gallbladder, portion of the colon LUQ: stomach, spleen, portion of the colon RLQ: cecum, and ascending colon of the large intestine, appendix LLQ: descending and sigmoid portions of the colon (Most organs are not confined to a single quadrant)

Understand the organs as they lie within the four quadrants

Right upper quadrant (RUQ): liver, gallbladder, duodenum of the intestines, and a small portion of the pancreas. Left upper quadrant (LUQ): the stomach occupies most of this quadrant but it shares this space with the spleen. The pancreas occupies some of this space but is mostly posterior to the region. Left lower quadrant (LLQ): holds both the large and small intestines, notable the descending colon and the left half of the transverse colon. Right lower quadrant (RLQ): Also hold portions of the large and small intestines that include the ascending colon and the right half of the transverse colon. The distal end of the descending colon, called the appendix, is located in this region.

Chapter 38: Understand scene safety and the fundamentals of extrication

Safety during vehicle extrication: -The EMT's primary responsibilities at a scene involving vehicle extrication or special operations are personal safety and delivery of patient care once it is safe to do so. -Do not attempt extrication procedures you have not been trained for or are equipped to handle. -As always, gloves and eye protection are required. -Leather gloves should also be used over (not instead of) regular gloves if handling glass, sharp objects, rope, etc. -Federal law requires EMS workers wear an approved highly reflective traffic safety vest when working on roadways, around traffic, or at an accident scene. Arrival and Scene size-up -Use only essential warning lights, because too many light tend to distract or confuse motorists. -Do not park in an area where you will be blocked in. If law enforcement or fire units have blocked the roadway, position your unit so that the back of the ambulance is pointing toward the scene to facilitate patient transport. -Sometimes the scene at a crash is complicated by the presence of hazardous materials. A hazardous material is any substance that is toxic, poisonous, radioactive, flammable, or explosive and can cause injury or death with exposure. Therefore, always park uphill and upwind from the hazard. -Before exiting your vehicle at an emergency scene, put on proper protective gear. Be alert for any vehicles that might cause injury to you. Do not assume that motorists will always heed the warning lights. -Before proceeding, make sure that the scene is properly marked and protected. Request assistance from law enforcement and/or fire personnel, who should close the road or divert traffic safely around the scene with cones, flares, or barricade tape.

Chapter 12: Definition of shock

Shock describes a state of collapse and failure of the cardiovascular system. When the circulation of blood in the body becomes inadequate, the oxygen and nutrient needs of the cells can not be met

Understand the sign of upper vs. lower airway obstruction

Signs of upper airway obstruction: decreased or absent breath sounds and Stridor. Signs of lower airway obstruction: wheezing and air crackles

Chapter 13: Understand the components of AHA 2015 high quality BLS CPR for both one-and two-rescuer Adult Child Infant

Single rescuer (any age): 30:2 - 30 compressions- two breaths Two-rescuer (infants/children): 15:2 - Rate of compressions: 100-120 per minute - Depth: at least 2 inches for adults, but no more than 2.4 inches - at least 1/3 depth of chest for infants and pediatric patients - about 2 inches for pediatric - about 1 1/2 inches for infants - Allow full chest recoil between compressions

Dysarthria

Slurred speech

Understand the functions of the somatic and autonomic nervous systems

Somatic (voluntary) nervous system: The part of the nervous system that regulates or control our voluntary activities, including almost all coordinated muscular activities. The mechanism of the somatic nervous system is simple. The brain interprets the sensory information that it receives from the peripheral and cranial nerves and responds by sending signals to the voluntary muscles. Autonomic (involuntary) nervous system: The functions that occur without conscious effort are regulated by this system. The autonomic nervous system controls the functions of many of the body's vital organs, over which the brain has no voluntary control. The autonomic nervous system is divided into two sections: the sympathetic and the parasympathetic nervous system. When confronted with a threatening situation, the sympathetic nervous system reacts to the stress with the fight-or-flight response. This response causes the pupils to dilate, smooth muscle in the lungs to dilate, heart rate to increase, and blood pressure to rise. This response also causes the body to shunt blood to vital organs and to skeletal muscle. During this time of stress, a hormone called epinephrine (also known as adrenaline) is released, which is responsible for much of these activities inside the body. The parasympathetic nervous system has the opposite effect on the body, causing blood vessels to dilate, slowing the heart rate, and relaxing the muscle sphincters. When this portion of the autonomic nervous system is activated, the body shunts all blood to the organs of digestion. As the body attempts to maintain homeostasis (balance), these two divisions of the autonomic nervous system tend to balance each other so that basic body functions remain stable and effective.

Scene size up: Understand standard precautions

Standard precautions are protective measures developed by the CDC that protect medical personnel from infection from contaminated objects. This usually includes PPE, which varies depending on the call. Standard precautions should be taken before patient contact, usually before you even step out of the vehicle

Primary assessment: Understand AVPU and how to calculate

The AVPU scale determines level of consciousness A: Alert and Awake V: Verbal Stimuli P: Painful Stimuli U: Unresponsive

Understand how and when to contact poison control

The American Association of Poison Control Centers (AAPCC) supports the nation's poison centers in their efforts to prevent an treat poison exposures. The phone number of your regional poison center is typically listed on the inside cover of your local phone book or on the AAPCC website. The telephone number for the Poison Help hotline is 1-800-222-1222 (available 24 hours a day, 7 days a week). Staff members at every center have access to information about virtually all of the commonly used medications, chemicals, and substances that could possibly be poisonous These experts know the appropriate emergency treatment for each, including the antidote, if there is one. -If you believe a patient has been poisoned, immediately provide the poison center with all relevant information: when the poisoning occurred; evidence found at the scene; a description of the suspected poison, including amount involved; and the patient's size, weight, and age. If necessary, medical control can contact the regional poison center for you and relay specific instructions back to you. Follow your local protocols. -A medical toxicologist is a physician who specializes in caring for patients wo have been poisoned. these specialist work in special facilities called medical toxicology treatment centers, located throughout the United States. At times, your medical control may divert a patient who meets certain poisoning criteria to one of these centers instead of the closest hospital. -You and your medical control center should know the telephone number of your regional poison center and have it available in the event you encounter an unexpected case of poisoning.

Understand the Apgar score and how/when to use it

The Apgar score is the standard scoring system used to assess the status of a newborn. This system assigns a numeric value (0, 1, or 2) to five areas of activity of the newborn: -Appearance: shortly after birth, the skin of a light-skinned newborn and the mucous of a dark-skinned newborn should turn pink. Newborns often have cyanosis of the extremities for a few minutes after birth, but hands and feet should "pink up" quickly. Blue skin all over or blue mucous membrane signal a central cyanosis. -Pulse: measure the pulse by chest auscultation. If a stethoscope is not available, you can measure pulsations with your fingers at the brachial pulse. A newborn with no pulse requires immediate CPR -Grimace or irritability: grimacing, crying, or withdrawing in response to stimuli is normal and indicates that the newborn is doing well. Test this by snapping a finger against the sole of the newborn's foot. -Activity or muscle tone: the degree of muscle tone indicates the oxygenation of the tissues. Normally, the hips and knees are flexed at birth, and, to some degree, the newborn will resist attempts to straighten them. A newborn should not be floppy or limp. -Respirations: Normally, a newborn's respirations are regular and rapid with a good, strong cry. If the respirations are slow, shallow, or labored, or if the cry is weak, the newborn may have respiratory insufficiency and need assistance with ventilation. Complete absence of respirations or crying is obviously a very serious sign; in addition to assisted ventilation, CPR may be necessary. -The total of the five numbers is the Apgar score. A perfect score is 10. The Apgar score should be calculated a 1 minute and again at 5 minutes after birth. Most newborns will have a score of 7 or 8 at 1 minute and score of 8 to 10 at 5 minutes. Apgar scoring system: -Appearance -Entire newborn is pink (2) -Body is pink, but hands and feet remain blue (1) -Entire newborn is blue or pale (0) -Pulse -More than 100 beats/min (2) -Fewer than 100 beats/min(1) -Absent pulse (0) -Grimace or irritability -Newborn cries and tries to move foot away from finger snapped against sole of foot (2) -Newborn gives a weak cry in response to stimulus (1) -Newborn does not cry or react to stimulus (0) -Activity or muscle tone -Newborn resists attempts to straighten hips and knees (2) -Newborn makes weak attempts to resist straightening (1) -Newborn is completely limp, with no muscle tone (0) -Respiration -Rapid respirations (2) -Slow respirations (1) -Absent respirations (0)

Understand the anatomy and physiology of the brain and spinal cord

The Brain: the brain is the body's computer. It controls breathing, speech, and all other body functions. All thoughts, memories, needs, and desires reside in the brain. Some parts of the brain receive input from senses, including sight, hearing, taste, smell, and touch. Other parts control muscles and movement; others control the formation of speech. The brain is divided into three major parts: the brain stem, the cerebellum, and the cerebrum, which is the largest part. The brain stem: controls the most basic functions of the body, such as breathing, blood pressure, swallowing, and pupil constriction. The cerebellum: located just behind the brain stem, controls muscle and body coordination. The cerebellum is responsible for coordinating complex tasks that involve many muscles, such as standing on one foot without falling, walking, writing, picking up a coin, and playing the piano. The Cerebrum: located above the cerebellum, is divided down the middle into the right and left cerebral hemispheres. Each hemisphere controls activities on the opposite side of the body. The front part of the cerebrum controls emotion and thought, and the middle part controls sensation and movement. The back part of the cerebrum processes sight. In most people, speech is controlled on the left side of the brain, near the middle of the cerebrum. -Messages sent to and from the brain travel through nerves. Twelve cranial nerves run directly from the brain to various parts of the head, such as the eyes, ears, nose, and face. The remaining nerves join in the spinal cord and exit the brain through a large opening in the base of the skull called the foremen magnum. At each vertebra in the neck and back, two nerves, called spinal nerves brainchild out from the spinal cord and carry signals to and from the body.

Understand the use of the Emergency Response Guidebook (ERG) when involved in a hazardous materials situation.

The DOT's Emergency Response Guidebook (ERG) offers a certain amount of guidance for responders operating a HazMat incident. This guide is updated every 3 to 4 years and provides information on approximately 4,000 chemicals. The US DOT and the secretariat of Communications and Transportation on Mexico, along with Transport Canada, jointly developed the Emergency Response Guidebook. **You can download a free copy of the ERG via the Pipeline and Hazardous Materials Safety Administration (PHMSA) website**.

Terminology - MOI/NOI: Mechanism of injury/Nature of illness - Index of suspicion

The MOI/NOI is the medical condition that resulted in the patients call for EMS The Index of suspicion is your awareness and concern for potentially serious underlying and unseen potential injuries or illnesses

NREMT- how is it involved in the level of training

The National Registry of EMTs: certification exam used to ensure all health care providers have at least the same basic level of knowledge and skill

Chapter 30: Understand the anatomy and physiology of the abdominal cavity

The abdomen is divided into four general quadrants. Two imaginary lines intersect the umbilicus, dividing the abdomen into four equal areas. These areas are the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and left lower quadrant (LLQ). -The abdomen contains both hollow and solid organs, any of which may be damaged. Hollow organs, including the stomach, large and small intestine, ureters, and urinary bladder, are actually structures through which materials pass. -The solid organs, as their name suggests are solid masses of tissue. They include the liver, spleen, pancreas, and kidneys. It is here that much of the chemical work of the body -- enzyme production, blood cleansing, and energy production -- takes place. **Quadrant location of organs found in next question**

Understand major structures in the gastrointestinal and urologic systems and quadrants location of organs

The abdominal cavity contains solid and hollow organs that make up the gastrointestinal, genital, and urinary systems. -Solid organs include the liver, spleen, pancreas, kidneys, and ovaries (in women). Technically organs such as the kidneys, ovaries, and pancreas are retroperitoneal (behind the peritoneum). However, because they lie next to the peritoneum, they can cause abdominal pain. -An injury to a sold organ can cause shock and bleeding because of the amount of blood vessels that the organ contains. -Hollow organs include the gallbladder, stomach, small intestine, large intestine, and urinary bladder. -If there is a perforation of these hollow organs, the contents of the organ will leak and contaminate the abdominal cavity. -In the right upper quadrant (RUQ), the major organs are the liver, the gallbladder, and a portion of the colon. Most of the liver lies in this quadrant, almost entirely under the protection of the 8th to 12th ribs. The liver fills the entire anteroposterior depth of the abdomen in this quadrant. Therefore, injuries in this area are frequently associated with injuries of the liver. -In the left upper quadrant (LUQ), the major organs are the stomach, the spleen, an a portion of the colon. The spleen is almost entirely under the protection of the let rib cage, whereas the stomach may sag well down into the left lower quadrant when full. The spleen lies in the lateral and posterior portion of this quadrant, under the diaphragm and immediately in front of the 9th to 11th ribs. The spleen is frequently injured, especially when these ribs are fractured. -The right lower quadrant (RLQ), contains two portions of the large intestine: the cecum, the first portion into which the small intestine (ileum) opens, and the ascending colon. The appendix is a small, tubular structure that is attached to the lower border of the cecum. - In the lower left quadrant (LLQ) lie the descending and the sigmoid portions of the colon. Several organs lie in more than one quadrant. The small intestine, for instance, occupies the central part of the abdomen around the umbilicus, and the parts of it lie in all four quadrants. The pancreas lies just behind the abdominal cavity on the posterior abdominal wall in both upper quadrants. The large intestine also traverses the abdomen, beginning in the RLQ and ending in the LLQ as it passes through all four quadrants. The urinary bladder lies just behind the pubic symphysis in the middle of the abdomen and therefore, lies in both lower quadrants and the pelvis.

Autonomic and somatic nervous system

The autonomic nervous system controls involuntary body functions, while the somatic nervous system controls voluntary functions. The autonomic nervous system is split into the sympathetic and parasympathetic nervous systems

Secondary Assessment: Understand the components of a secondary assessment. And what is considered "normal"

The basic components of a secondary assessment include a physical examination, patient's history, and vital signs

Understand how the body responds to blood volume lost

The body automatically expands or contracts its vessels to accommodate for any changes in blood pressure in an effort to maintain perfusion to the entire body. When blood is lost, vessels will constrict to maintain the same pressure

Understand the role of glucose and insulin

The brain needs two things to survive: glucose and oxygen. Insulin in necessary for glucose to enter the cells for metabolism. Without the proper balance of hormones (without enough insulin), the cell does not get fed. The pancreas produces and stores two hormones tat play a major role in glucose metabolism: glucagon and insulin. A small portion of the pancreas is filled wit the islets of Langerhans. Within these islets are alpha and beta cells. The alpha cells produce glucagon and the beta cells produce insulin.

Chapter 6: Central and Peripheral nervous systems

The central nervous system consists of the brain and spinal cord. The cerebrum, cerebellum, and brain stem control specific aspects of body functioning, and the spinal cord transmits these signals to the rest of the body. The peripheral nervous system consists of the nerves outside of the brain and spinal cord

Chapter 41: Understand the continuum of care

The concept of consistent patient care across the entire health care team from first patient contact to patient discharge; working together with a unified goal, results in improved individual and team performance, better patient and provider safety, and improved patient outcome.

Chapter 23: understand the anatomy, physiology, assessment and management of gynecologic emergencies.

The female reproductive system includes internal and external structures. The external female genitalia consist of the vaginal opening just posterior to the urethral opening. The labia majora and labia minora are fold of tissue that surround the urethral and vaginal openings. At the anterior end of the labia is the clitoris, and at the posterior end is the anus. The perineum is the area of tissue between the vagina and the anus. The labia are extremely vascular and can be injured, but because of their location, they seldom are except in cases of sexual abuse. -In terms of internal structures, the ovaries are the primary female reproductive organ. The ovaries are located on each side of the lower abdomen and reproduce and ovum or egg, that if fertilized, will develop into a fetus. The fallopian tubes connect each ovary to the uterus. The uterus is the muscular organ where the fetus grows during pregnancy. The narrowest portion of the uterus, the cervix, opens into the vagina. The vagina is the outermost cavity of a women's reproductive system. and forms the lower part of the birth canal. -When a female reaches puberty, she begins to ovulate and experience menstruation. Ovulation is the cycle in which the ovum is released. The onset of menstruation is called menarche and usually occurs between the ages of 11 and 16 years, although it can occur earlier or later. Any female who has reached menarche is capable of becoming pregnant. Women continue to experience the cycle of ovulation and menstruation until they reach menopause, which marks the end of menstrual activity. Women reach menopause at widely varying ages, but it commonly occurs around the age of 50 years. -Each ovary produces an ovum in alternating months and releases it into the fallopian tube. Some women experience minor cramping pain during ovulation when an ovum is released. The pain is sometimes described as dull pain on one side of the lower abdomen. For some women the pain is severe enough to keep them bedridden during this time. The quality and severity of the pain vary for each women. -The process of fertilization begins in the vagina, where sperm from the male penis are deposited into the female reproductive tract. The sperm pass through the cervix into the uterus and eventually up the fallopian tubes. As the ovum moves slowly down the fallopian tube, sperm moving up the tube can surround it, and one sperm fertilizes it. When an ovum is fertilized in the fallopian tube, the developing embryo travels into the uterus where the lining of the walls of the uterus has become engorged with blood in anticipation of receiving a fertilized ovum. Here, the embryo attaches to the uterine wall and continues to grow. -If the ovum is not fertilized in the fallopian tube, it continues to travel into the uterus. Because fertilization has not occurred within about 14 days of ovulation, the lining of the uterus begins to separate and menstruation occurs. The menstrual flow consists of blood from the separated lining of the uterus and lasts about 1 week. Female hormones produced primarily in the ovaries control the process of ovulation. Assessment and management of gynecologic emergencies include: -Primary assessment: The general impression is an important aspect of all patient assessments. As you approach the patient, you should quickly determine if her condition is stable or unstable. Use this information to help you as you proceed further with the assessment. Use the AVPU scale to determine the patient's LOC. -Always evaluate the airway and breathing immediately to ensure they are adequate, and treat any airway or breathing problem that is identified according to established guidelines and local protocol. Identifying and treating life threats take precedence over all other assessment and treatment. -It is important to carefully assess the circulation in all patients. palpate a pulse and evaluate skin color, temperature, and moisture to help identify the patient who might have blood loss. If the patient as experienced significant blood loss because of vaginal bleeding, she may not demonstrate obvious signs of shock, but may still be hypovolemic. If the patient has a weak or rapid pulse or has pale, cool, or diaphoretic skin, place the patient in a supine position. Cover the patient to keep her warm, and then transport to the nearest appropriate receiving facility for treatment. -Most cases of gynecologic emergencies are not life threatening; however, if signs of shock exist because of bleeding, then rapid transport is necessary. The remainder of the assessment can be performed en route to the hospital. -History taking: Begin by asking about the patient's chief complaint, but realize some of the questions you as may be considered extremely personal. Be sensitive to the patient's feelings and ensure her privacy and dignity are protected. Gynecologic emergencies can be highly embarrassing for the patient, and many women may be extremely uncomfortable with discussing their sexual history in front of stranger or even close family members. An adolescent girl may want to keep her sexual history from her parents. -For a report of abdominal pain, ask specific questions about onset, duration, quality, and radiation. Provoking or relieving factors and associated symptoms such as syncope, light-headedness, nausea, vomiting, and fever are also relevant. For a report of vaginal bleeding as about onset, duration, quantity (number of sanitary pads soaked), and associated symptoms such as syncope and light-headedness. -Obtain a SAMPLE history beginning with her current symptoms. Make not of any allergies she has or any over-the-counter or prescription medications she is taking, such as birth control pills and any birth control devices she uses. Ask the patient about medical conditions, and ask specifically about her last menstrual period. This will help determine if the patient is possibly pregnant. Ask about the possibility of sexually transmitted diseases and the possibility of pregnancy. Find out when she last ate or drank and what event led up to her calling for EMS. Use her NOI, her chief complaint, and her answers to your other questions to lead further questioning. For example, if she answers that she is sexually active, ask her about birth control and also about symptoms of pregnancy. If she has vaginal bleeding, ask her how many sanitary pads she is using per hour. This information can help create an estimate of blood loss. -Secondary assessment: The secondary assessment may be performed on scene, en route to the ED or, in some instances, not at all. If the patient is critically ill or injured or the transport time is short, you may not have time to conduct this part of the patient assessment. -Pertinent secondary assessment findings should include: -Vital signs: blood pressure, pulse, skin color, orthostatic vital signs -Abdomen: distention and tenderness -Genitourinary: visible bleeding -Neurologic: mental status -Your physical examination of a gynecologic patient should be limited and professional. Only examine the genitalia if it is necessary to do so to treat the patient. Few women are comfortable with having their body exposed to a crowd of family, neighbors, EMT's, police officers, or firefighters. Limit the personnel present to only those required to perform necessary tasks; show the patient that you respect her by being an advocate for her modesty. You also serve as role model for other EMS providers when you act this way. -The population of women over the age of 65 is growing and, even though they are past their childbearing years, many will have other gynecologic problems. They may have concerns specific to hormone replacement therapy, have an increased risk of cancer, or could be suffering from internal physical changes in the female organs caused by age, for example pelvic floor prolapse and urinary incontinence. Although these problems cannot be treated in the prehospital environment, perform and record a thorough assessment and treat any of the patient's immediate needs. -Focus your physical examination on the NOI and the patient's chief complaint. If vaginal bleeding is the NOI, you should visualize the bleeding ask about it's quality and quantity. Use external sanitary pads to control the bleeding, and keep the possibility of hypoperfusion and shock in mind. Always ask if there is pain associated with the vaginal bleeding or discharge. Neve insert anything into the vagina to control bleeding, including a tampon. -Vaginal discharge is another condition that should be observed if possible. Make observations about the discharge, and ask the patient about any qualities she noticed and the history of the discharge. -Fever, nausea, and vomiting are common with many medical conditions but should be considered especially significant with gynecologic emergencies. Fever should always be considered a sign of infectious process. Any report of syncope on the part of the patient, especially if she reports vaginal bleeding, is considered significant. Treat the patient reporting this symptom as being in sock until proven otherwise. -Assess the patient's vital signs, including heart rate, rhythm, and quality; respiratory rate, rhythm, and quality; skin color, temperature, and condition; capillary refill time; and blood pressure. Consider obtaining orthostatic vital signs if bleeding is know or suspected. Pay attention to the presence of tachycardia and hypotension, which could indicate hemorrhagic shock. -Use the appropriate monitoring devices, such as pulse oximetry, to track the patient's condition. Also consider using noninvasive blood pressure monitoring to continuously track the patient's blood pressure. Assess the patient's first blood pressure manually with a blood pressure cuff and stethoscope. remember, pulse oximetry readings may not be accurate in the setting of hypovolemia. -Reassessment: Repeat the the primary assessment. Reassess the patient's vital signs and the chief complaint. Reassess the patient's vital signs every 5 minutes to identify hypoperfusion from excessive blood loss. If the patient shows any signs of shock, begin treatment and rapid transport. -How is the patient's condition improving wit the interventions? Identify and treat any changes in the patient's condition. For example, if the patient appears to be losing consciousness, position her in the supine position, and perform a reassessment. Finally, pay specific attention to the needs of your patient, and respect her desire for conversation or silence. Provide her with calm reassurance. Explain to her that the hospital staff will be sympathetic to her condition and will be well qualified to treat her. -There are very few interventions that can or should be done for a patient with a gynecologic emergency. If the patient has vaginal bleeding, treat her for hypoperfusion or shock. Keep her warm, place her in a supine position, and provide her with supplemental oxygen even if she is not experiencing difficulty breathing. Consider advanced life support intercept for fluid replacement, the transport to the nearest appropriate receiving facility. -Notify staff at the receiving hospital of all relevant information, including the possibility of pregnancy, so a proper response can be prepared. Carefully document the patient's condition, her chief complaint, the scene, and all interventions, especially in cases of sexual assault.

Understand anatomy, physiology, assessment of the gynecological patient.

The female reproductive system includes the ovaries, fallopian tubes, uterus, cervix, vagina, and breasts. The ovaries are two glands, one on each side of the uterus, that are similar in function to the male testes. Each ovary contains thousands of follicles and each follicle contains an egg. -Immediately following ovulation, the endometrium (the lining of the inside of the uterus) begins to thicken in preparation for the potential implantation of a fertilized egg. -The uterus is a muscular organ that encloses and protects the developing fetus. During labor, it produces contractions and ultimately helps to push the fetus through the birth canal. The birth canal is made up of the vagina and the lower third, or neck of the uterus, called the cervix. -The vagina completes the passageway from the uterus to the outside world for the newborn. The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal. It is about 3 to 5 inches (8 to 12 cm) in length, beginning at the cervix and ending as an external opening of the body. The areas between the vagina and the anus is called the perineum -As the fetus continues to develop, it requires increasingly more nourishment and support. The placenta, a disk-shaped structure attached to the uterine wall that provides nourishment to the fetus, develops while attached to the inner lining of the wall of the uterus and is connected to the fetus by the umbilical cord. -The umbilical cord contains two arteries and one vein. The umbilical vein carries oxygenated blood from the placenta to the hearts of the fetus, and the umbilical arteries carry deoxygenated blood from the heart of the fetus to the placenta. Anatomical and physiological changes in pregnancy -Reproductive changes -The uterus requires a much larger blood supply during pregnancy. -The enlarging uterus displaces other internal structures. -Respiratory changes -Respiratory rate increases slightly, but oxygen demand increases significantly. -In third trimester, the diaphragm frequently is compressed by the enlarging uterus. -The pregnant patient is at risk for developing hypoxia rapidly -Cardiovascular changes -Cardiac workload increases, resulting in faster resting heart rate -Blood volume increases, but plasma increase is greater. This leads to relative anemia -Signs and symptoms of shock are masked during pregnancy -Postural hypotension is common, increasing the risk of syncope. -Gastrointestinal and urinary changes -The pregnant patient typically has undigested food in the stomach -Pregnancy increases the risk of nausea and vomiting. -Pregnancy increases urinary frequency, and the pregnant patient is at risk of bladder injury due to displacement. -Musculoskeletal changes -The woman's center of gravity changes, increasing the risk of a fall injury. Primary Assessment: form a general impression as to whether the patient is in active labor and, if so, whether you have time to assess for imminent delivery and address other possible life threats. Perform a rapid examination of the patient to assess for airway, breathing, and circulation problems. The chief complaint may be "the baby is coming!" Take a moment to confirm whether the fetus will be delivered in the next few minutes or whether you have time to continue to evaluate the situation. When trauma or medical problems such as vaginal bleeding, or seizures are the presenting complaint, evaluate these first, then assess the impact of these problems on the fetus. -External and internal bleeding are potential life threats to the patient and should be assessed early. Blood loss after pregnancy is expected, but significant blood loss is not. Quickly assess for any potential life-threatening bleeding, and begin treatment immediately. Assess the skin for color, temperature, and moisture, and check the pulse to determine if it is too fast or too slow. If there are signs of shock, control the bleeding, administer oxygen, and keep the patient warm. -If delivery is imminent, you must prepare to deliver at the scene. The ideal place to deliver is in the security of your ambulance or the privacy of the woman's home. The area should be warm and private with plenty of room to move around. -If the delivery is not imminent, prepare the patient for transport and perform the remainder of the assessment en route to the ED. Administer oxygen. Women in the second and third trimesters of pregnancy should be transported lying on their left side when possible to prevent supine hypotensive syndrome. History taking: Regardless of whether the patient is in active labor, is having an obstetric emergency, or is a pregnant patient with another complaint, obtain a thorough history that includes her expected due date, and complications she is aware of, and if she has been receiving prenatal care, and a complete medical history. Obtain a SAMPLE history. -If her water has broken, ask whether the fluid was green. Green fluid is due to meconium (fetal stool). The presence of meconium can indicate newborn distress, and it is possible for the fetus to aspirate meconium during delivery. Secondary Assessment: Perform a complete assessment of the major body systems as needed, with emphasis on the patient's chief complaint. Assess for fetal movement by asking the patient whether she can feel the fetus moving. If the patient is in labor, the physical examination should focus on contractions and possible delivery. Assess the length and frequency of contractions by asking the patient and by placing your and on the abdomen. -The secondary assessment of a pregnant patient should include a complete set of vital signs and pulse oximetry. Vital signs should include pulse; respirations; skin color, temperature, and condition; and blood pressure. Be especially alert for tachycardia and hypotension (which could mean hemorrhage or compression of the vena cava) or hypertension (possibly indicating preeclampsia). Hypertension, even when mild, may indicate more serious problems. Reassessment: As time allows, repeat the primary assessment with a focus on the patient's ABCs and vaginal bleeding, particularly after delivery. Obtain another set of vital signs and compare the results of those obtained earlier. Frequent reassessment of vital signs may identify hypoperfusion from excessive blood loss as a result of delivery. Recheck interventions and treatments to whether they were effective. **If a pregnant patient has a pulse oximetry level of 94% or lower, the fetus will by hypoxic too.** **Thorough documentation is essential, especially in the case of a newborn where delivery occurred in the field. In this situation, you will have two patient care reports to complete**

Understand various terminology: General impression

The general impression is the overall initial impression that assesses the priority of patient care. It is based on the patients surroundings, the mechanism of injury, signs and symptoms, and chief complaint

Understand the signs and symptoms of internal bleeding

The most common symptom of internal bleeding is pain. Significant internal bleeding will generally cause swelling in the area of bleeding, but swelling is often undetected until massive blood loss has occurred. Other signs and symptoms of internal bleeding in trauma and medical patients include the following: -Hematemesis: the vomiting of blood. The vomitus may be bright red or dark red. If the blood has been partially digested, the vomitus may look like coffee grounds. -Melena: Black, foul-smelling, tarry stool that contains digested blood. -Pain, tenderness, bruising, guarding or swelling: These signs and symptoms may mean that a closed fracture is bleeding. -Broken ribs, bruises over the lower part of the chest, or a rigid, distended abdomen: The signs and symptoms may indicate a lacerated spleen or liver. Patients with an injury to one of these organs may have referred pain in the right shoulder (indicating the liver is injured) or left shoulder (indicating the spleen is injured). Suspect internal abdominal bleeding in a patient with referred pain.

Be able to take a bite of pizza and run it through the entire digestive system understanding how the food breaks down and passes through the system

The mouth begins digestion through both mechanical and chemical means. Food then travels down the esophagus tot eh stomach, where both mechanical and chemical digestion takes place. Food goes in, chyme comes out. The small intestine (duodenum, jejunum, ileum) is the major site for the chemical breakdown oof food. Here, major absorption of water, fats, proteins, carbohydrates, and vitamins takes place. The large intestine is responsible for more water absorption and the formation of feces. Bacterial digestion of food also takes place in the large intestine. The anus/rectum is the last portion of the large intestine. A sphincter controls the release of feces. The liver produces bile, which assists with carbohydrate, protein, and fat metabolism of nutrients in the blood stream. The liver is also responsible for the detoxification of blood and the elimination of waste. Pancreas excretes enzymes for protein, carbohydrate, and fate breakdown within the duodenum. It also releases insulin and glycogen. The gallbladder stores bile.

Chapter 28: Understand the anatomy of the nervous system

The nervous system is divided into two anatomic parts: the central nervous system and the peripheral nervous system. The Central nervous system (CNS) includes the brain and spinal cord, including the nuclei and cell bodies of most nerve cells. Long nerve fibers link these cells to the body's various organs through openings in the spinal column. These cables of nerve fibers make up the peripheral nervous system. Central Nervous System: The CNS is composed of the brain and spinal cord. The brain is the organ that control the body; it is divided into three major areas: the cerebrum, the cerebellum, and the brain stem. -The cerebrum, which contains about 75% of the brain's total volume, controls a wide variety of activities, including most voluntary motor function and conscious thought. It is the main part of the brain and is divided into two hemispheres with four lobes. Underneath the cerebrum lies the cerebellum, which coordinates balance and body movements. The most primitive part of the CNS, the brainstem, controls virtually all the functions that are necessary for life, including the cardiac and respiratory systems and nerve transmissions. Deep within the cranium, the brainstem is the best-protected part of the CNS. -The spinal cord, the other major portion of the CNS, is mostly made up of fibers that extend from the brain's nerve cells. The spinal cord carries messages between the brain and the body via the gray and white matter of the spinal cord. Gray matter is composed of neural cell bodies and synapses, which are connections between nerve cells. White matter consists of fiber pathways. -Protective coverings: The cells of the brain and spinal cord are soft and easily injured. Once damaged, they cannot be regenerated or reproduced. Therefore, the entire CNS is contained within a protective framework. -The thick, bony structures of the skull and spinal canal withstand injury very well. The skull is covered by layers of muscle, superficial fascia, and thick skin, which usually bears hair. Superficial fascia connects the muscle to the skin and contains white blood cells that are used to destroy pathogens when there is an open wound. The spinal canal is also surrounded by a thick layer of skin and muscles. -The CNS is further protected by meninges, three distinct layers of tissue that suspend the brain and the spinal cord within the skull and the spinal canal. The outer layer, the dura mater, is a tough, fibrous layer that closely resembles leather. This layer forms a sac to contain the CNS, with small openings through which the peripheral nerves exit. -The inner two layers of the meninges, called the arachnoid and the pia mater, are much thinner than the dura mater. They contain the blood vessels that nourish the brain and spinal cord. Cerebral spinal fluid (CSF) is produced in a chamber inside the brain, called the third ventricle. CSF is located in the subarachnoid space below the arachnoid, which is a web-like structure. There is approximately 125-150 mL of CSF in the brain at any one time. CSF primarily acts as a shock absorber. The brain and spinal cord essentially float in this fluid buffered from injury. The brain depends on a rich supply of oxygenated blood to function properly. When this supply is interrupted, even for a short periods of time, serious damage to the brain tissue may occur. -When an injury does penetrate all of these protective layers, clear, watery CSF may leak from the nose, the ears, or an open skull fracture. Therefore, if a patient with a head injury has what looks like a runny nose or reports a salty taste in the back of the throat, you should assume that the fluid is CSF. -Ironically, the closed bony structure of the skull (which is similar to a vault) and the meninges, the very layers of tissue that isolate and protect the CNS, may lead to serious problems in closed head injuries. Severe injury may cause bleeding within the skull, referred to as intracranial hemorrhage. Such bleeding causes increased pressure inside the skull and compresses softer brain tissue. In many cases, only prompt surgery can prevent permanent brain damage. Peripheral Nervous System: The peripheral nervous system has two anatomic parts: 31 pairs of spinal nerves and 12 pairs of cranial nerves. -The 31 pairs of spinal nerves conduct sensory impulses from the skin and other organs to the spinal cord. They also conduct motor impulses from the spinal cord to the muscles. Because the arms and legs have so many muscles, the spinal nerves serving the extremities are arranged in complex networks. The brachial plexus controls the arms, and the lumbosacral plexus controls the legs. -Cranial nerves are the 12 pairs of nerves that emerge from the brainstem and transmit information directly to or from the brain. For the most part, they perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions. There are two major types of peripheral nerves. The sensory nerves, with endings that perceive only on type of information, carry that information from the body to the brain via the spinal cord. The motor nerves, one for each muscle, carry information from the CNS to the muscles. The connecting nerves, found only in the brain and spinal cord, connect the sensory and motor nerves with short fibers, which allow the cells on either end to exchange simple messages.

Primary assessment: Understand timing and order

The primary assessment should be done as soon as you greet the patient and begin your assessment. The goal of the primary assessment is to address any immediate or eminent life threats. Assess the LOC and ABCs.After that you can determine whether or not the patient is a priority transport. General Impression, LOC, orientation, life threats, ABCs, transport decision

Understand how pertinent negatives factor in to your patient assessment

The process of gathering a patient's past medical history, history of present illness, and signs and symptoms is important, but sometimes just as important are the signs and symptoms that the patient does not have. These important negative findings are referred to as pertinent negatives. Often, a patient's complaint would be expected to be associated with a number of related findings. Examples include chest pain with shortness of breath, palpitations, and sweating or severe allergic reaction with itching, hives and trouble breathing. The absence of these findings is relevant, and should be reported and documented. Pertinent negatives are often helpful in identifying a patient's problems and choosing an appropriate treatment. **Pertinent negatives: negative findings that warrant no care or intervention.**

Understand scene time and types of transport

The scene time is the time interval that begins when EMS arrives on scene and ends when the ambulance leaves for the hospital. Critical patients should have a scene time of 10 minutes or less. Critical patients should be used with lights and sirens. However, for patients who are not critical; lights and sirens are not requires, and the trip is often safer. Patients with an altered mental status, circulation compromise, or difficulty breathing are often considered high priority transport. Air transportation is not as common, but patients who are win critical condition will benefit from the faster mode of transportation

Respiratory System: be able to take that molecule of air through the respiratory system

The upper airway consists. Of the pharynx (nasopharyngeal, oropharynx, laryngopharynx), and the epiglottis. Air passes through the pharynx to the trachea and past the larynx. The trachea splits at the carina into bronchi, which then divide further into bronchioles and alveoli. These alveoli within the lungs are the functional units that exchange oxygen and carbon dioxide. The parietal and visceral pleura line the chest wall and lungs. A thin layer of fluid separates these linings. When the diaphragm and intercostal muscles contract and the chest wall expands, the lungs also expand. the difference in pressure allows air to flow in. ventilation and respiration result in oxygen and carbon dioxide being transferred between blood and the environment. Oxygen and carbon dioxide travel between the alveoli and blood via diffusion

Chapter 37: Understand the risk and responsibilities of emergency response (lights and sirens)

Three basic principles govern the use of warning lights and sirens on an ambulance: -The unit, to the best of your knowledge, must be on a true emergency call -Audible and visual warning devices must be used simultaneously. -The unit must be operated with due regard for the safety of all others, on and off the roadway. Carefully consider when to use or not use your siren. In general, the siren does not really help you as a driver, nor does it help other motorists. Motorists who drive the speed limit with the windows up, the radio on, and the air conditioner or heater set on high may not hear the siren until the ambulance is very close. If the radio is on loud, they may not hear the siren at all. -If you do have to turn on the siren, tell the patient before you do. Be especially mindful not to increase the speed of the ambulance just because the siren is in use. Always travel at a speed that allows you to stop safely at all times, especially so you are prepared for drivers who do not give you the right-of-way. Never assume that warning lights and siren will allow you to drive through a congested area without stopping or slowing down. Slow down to ensure all drivers are stopping as you approach an intersection, and proceed with caution. Remember, the siren is a request that other drivers give you the right-of-way: it does not magically clear traffic. However, driving through a busy intersection against a directional signal without using the siren may also be dangerous and may violate your state law. In these high-risk situations, use all tools at your disposal to ensure nearby traffic is aware of your presence and that the danger is decreased to the greatest degree possible. -Some ambulance headlights are equipped with a high-beam flasher unit. These are very visible, effective warning devices for clearing traffic in front of the vehicle.

Transcutaneous (transdermal)

Through the skin Parenteral:slow Adhesive patch

Understand how to assess and treat a patient with a suspected overdose.

To best determine the severity of the patient's condition, first obtain a general impression of the patient, assess his or her level of consciousness, and determine any life threats. With substance abuse and poisonings, do not assume a conscious, alert, and oriented patient is in stable condition and has no apparent life threats. The patient may have a harmful or even lethal amount of poison in is or her system that has not had time to produce systemic reactions. A primary assessment that reveals a patient with signs of distress and/or altered mental status gives you early confirmation that the poisonous substance is causing systemic reactions. -Quickly ensure that the patient has an open airway and adequate ventilation. If the patient has any difficulty breathing, begin oxygen therapy. In situations where a patient may have an inhalation injury (typically carbon monoxide and/or cyanide poisoning), place the patient on high-flow oxygen regardless of the pulse oximetry reading. If the patient is unresponsive to painful stimuli, consider inserting an airway adjunct to ensure an open airway. Have suction readily available; these patients are susceptible to vomiting. You may also have to assist a patient's ventilations with a BVM because some substances act as depressant on the body's systems. -Once the airway and breathing have been assessed and appropriate interventions performed, assess the patient's circulatory status. You will find variations in a patient's circulatory status depending on the substance involved. Assess the pulse and skin condition. Some poisons are stimulants, and others are depressants. Some poisons will cause vasoconstriction and other vasodilation. Although bleeding may not be obvious, alterations in consciousness may have contributed to trauma and bleeding. -Consider prompt transport for patients with obvious alterations in the ABCs or for patients you have determined have a poor general impression. -Do not judge the patient for becoming exposed to a poisonous substance, especially if the exposure was an incident of self-harm. Always treat the patient with respect and compassion.

Chapter 40: Understand the risks and responsibilities of operating on the scene of a natural or man-made disaster.

To determine the potential for a terrorist attack, make the following observations on every call: -Type of location: is the location a monument, infrastructure, government building, or a specific type of location such as a temple? Is there a large gathering? Is there a special event taking place? -Type of call: is there a report of an explosion or suspicious device nearby? Are there reports of people fleeing the scene? -Number of patients: are there multiple victims with similar signs and symptoms? This is probably the single most important clue that a terrorist attack or an incident involving a WMD has occurred. -Victims' statements: this is probably the second best indication of a terrorist or WMD event. Are the victims fleeing the scene giving statements such as, "Everyone is passing out," "There was a loud explosion," or "There are a lot of people shaking on the ground." If so, something is occurring that you do not want to rush in to, even if it is questionable as to whether or not it is a terrorist event. -Preincident indicators: has there been a recent increase in violent political activism? Are you aware of any credible threats made against the location, gathering, or occasion? Scene Safety: remember to stage your vehicle a safe distance (usually 1 to 2 blocks) from the incident, wait for law enforcement personnel to advise you that the scene has been made secure. If you have any doubt that it may not be safe, do not enter. When dealing with a WMD scene, assume you will not be able to enter the scene where the event has occurred -- nor do not want to. The best location for staging is upwind and uphill from the incident. Wait for assistance from those who are trained in assessing and managing WMD scenes. Expect that a perimeter will be created, usually by law enforcement personnel, in an effort to isolate the scene, prevent further contamination of evidence, and protect rescuers and the public from further damage. Also remember the following rules: -Failure to park your vehicle at a safe location can place you and your partner in danger. Always have an escape plan determined before hand, in case the scene becomes unsafe. -If your vehicle is blocked in by other emergency vehicles or damaged by a secondary device (or event), you will be unable to provide transportation for victims or escape yourself. Terrorist have been known to plant additional explosives that are set to explode after the initial bomb. This type of secondary device is intended primarily to injure responders and to secure media coverage because the media generally arrive on scene just after the initial response. Secondary devices may include various types of electronic equipment such as cell phones or pagers that are designed to detonate when they are activated. Responder safety (Personnel protection): The best form of protection from a WMD agent is preventing yourself from coming into contact with the agent. The greatest threats facing you in a WMD attack are contamination and cross-contamination. Contamination with an agent occurs when you have direct contact with the WMD or are exposed to it. Cross-contamination occurs when you come into contact with a contaminated person who has not yet been decontaminated.

Understand how to manage newborn care and neonatal resuscitation

To determine whether the newborn requires resuscitation, begin by assessing for term gestation, good muscle tone, and crying/breathing. Follow standard precautions, and always put on gloves before handling a newborn. The normal respiratory and cardiovascular physiologic responses expected are that the newborn will begin to breathe spontaneously within 15 to 30 seconds after birth, and the heart rate will be 120 beats/min or higher. If you do not observe these responses, gently tap or flick the soles of the newborn's feet or run the back to stimulate breathing. Many newborns require some form of stimulation that will encourage them to breathe air and begin circulating blood through the lungs. These measures include positioning the airway, drying, warming, suctioning, and tactile stimulation. To maximize the effects of these measures, follow these tips: -Position the newborn on his or her back with a towel or blanket under the shoulders so that the head is down and the neck is slightly extended -If necessary, suction the mouth and then the nose using a bulb syringe or suction device with an 8- or 10-French catheter. Suction both sides of the back of the mouth, where secretions tend to collect, but avoid deep suctioning of the mouth and throat; this can cause the heart rate to slow down. Aim blow-by oxygen at the newborn's mouth and nose during resuscitation. -In addition to vigorously drying the newborn's head, back, and body with dry towels, you may rub the newborn's back and gently flick or slap the soles of his/her feet. -If the newborn does not breathe after 10 to 15 seconds of stimulation, begin resuscitation efforts -You should be properly equipped for resuscitation measures in case the newborn is in distress. Most of the equipment and supplied needed to resuscitate a newborn can be found in your OB kit. Other items you may need are clean, dry towels; and infant blanket; a BVM with a 450-mL reservoir; and masks in both newborn and premature sizes. Resuscitation for a newborn who is not breathing: Table 33-2 -Assess and support -Temperature (warm and dry) -Airway (position and suction) -Breathing (stimulate to cry) -Circulation (heart rate and skin color) -Basic life support intervention -Dry and warm the newborn -Clear the airway with a bulb syringe if needed -Stimulate the newborn if he/she is unresponsive -Use a BVM to ventilate the newborn if needed. This is seldom required -Perform chest compressions if there is not pulse or if the heart rate is <60 after 30 seconds of ventilation and heart rate is not increasing. Additional resuscitation efforts: observe the newborn for spontaneous respirations, skin color, and movement of the extremities. If the respiratory effort appears appropriate, evaluate the heart rate by palpating the pulse at the brachial artery or by listening to the newborn's chest with a stethoscope. The heart rate is the most important measure in determining the need for further resuscitation. -If chest compressions are required, use the hand-encircling technique for two-person resuscitation. Perform BVM ventilation during a pause after every third compression. Avoid giving a compression and ventilation simultaneously, because one will decrease the effectiveness of the other. Cardiac arrest in neonates is nearly always the result of ventilation compromise. Use a compression-to-ventilation ratio of 3:1, which will yield a total of 120 "actions" per minute (90 compressions and 30 ventilations). Remember that adequate ventilation is absolutely critical to the successful resuscitation of the neonate. -Transport any newborn who requires more than routine resuscitation to a hospital with a level of III or neonatal intensive care unit, if available in your area. If a level III neonatal intensive are unit is not available in your area, provide rapid transport to the closest appropriate facility. -About 12 % to 16% of deliveries are complicated by the presence of meconium in the amniotic fluid. Meconium can be thick or thin. If the newborn aspirated thick meconium, significant lung disease and even death can occur. If you see meconium in the amniotic fluid or meconium staining and the newborn is not breathing, consider quickly suctioning the newborn's mouth ten nose after delivery before providing rescue ventilation. Additional neonatal resuscitation efforts -If the heart rate is more than 100 beats/min, then keep the newborn warm. Transport the newborn. Assess the newborn continuously. -If the heart rate is 60 to 100 beats/min, then begin assisted ventilation with a BVM and room air. -Reassess the newborn after 90 seconds and if the heart rate and respirations are not normal, begin to ventilate with 100% oxygen. Continue to reassess the newborn. Call for ALS backup if available. Keep the newborn warm. -If the heart rate is fewer than 60 beats/min, then begin assisted ventilation with a BVM and 100% oxygen -Reassess the newborn every 90 seconds until heart rate and respirations are normal. -Begin chest compressions. Call for ALS backup if available -If the heart rate does not increase, medication and ALS will be needed Follow these steps when assessing a newborn: -Quickly calculate the Apgar score (described later) to establish a baseline on the newborn's status. -Stimulation should result in an immediate increase in respiration rate. If not, you must begin ventilations with s BVM. Unlike adults, in whom sudden cardiac arrest may precede respiratory arrest, newborns who are in cardiac arrest, usually have had respiratory arrest first. Therefore, it is essential to keep the newborn ventilating and oxygenating well. -If the newborn is breathing well, check the pulse rate by feeling the brachial artery or auscultating the chest with a stethoscope. The pulse rate should be at least 100 beats/min. If it is not, begin ventilations with a BVM. This alone may increase the newborn's heart rate. Reassess respirations and heart rate at least every 30 seconds to make sure that the pulse rate is increasing and respirations are becoming spontaneous. -Assess the newborn's oxygenation via pulse oximetry and observe for central cyanosis. If central cyanosis is present or the oxygen saturation does not improve, administer blow-by oxygen by holding the oxygen tubing or an oxygen mask close to the newborn's face. Set the oxygen flow rate at 5 L/min -Remember that you now have two patients. Request a second unit as soon as possible if you determine that the newborn is in any distress and will require resuscitation. -In situations where assisted ventilation is required, you should use a newborn BVM. Cover the newborn's mouth and nose with the mask, and begin ventilation with high-flow oxygen at a rate of 40 to 60 breaths/min. Make sure you have a good mask-to-face seal. Use gentle pressure to make sure the chest rise with each ventilation. You may need to bypass the pop-off valve to accomplish this, especially during the first few breaths. -If the newborn does not begin breathing in his/her own or does not have an adequate heart rate, continue CPR and rapidly transport. Once CPR has been started, do not stop until the newborn responds with adequate respirations and heart rate or is pronounced dead by a physician. DO NOT GIVE UP! many newborns have survived without brain damage after prolonged periods of effective CPR. If the newborn presents in distress, do not take time to assess the Apgar score -- begin resuscitation immediately.

Understand how to treat/manage a patient who as been sexually assaulted.

Treatment/management of a sexual assault victim includes: -Document the patient's history, assessment, treatment, and response to treatment in detail, because you may have to appear in court as long as 2 to 3 years later. Do not speculate. Record only the facts. -Complete the SAMPLE history objectively -Follow any crime scene policy established by your system to protect the scene and any potential evidence for police, particularly policies regarding evidence collection. If the patient will tolerate being wrapped in a sterile burn sheet, this may help investigators find hair, fluid, or fiber from the alleged offender. -Do not examine the genitalia unless there is major bleeding. If an object has been inserted into the vagina or rectum, do not attempt to remove it. -Whenever possible, reduce the patient's anxiety by using an EMT who is the same gender as the patient. - Discourage the patient from bathing, voiding, or cleaning any wounds until after the hospital staff has completed an assessment. Handle the patient's clothes as little as possible, placing clothing and any other evidence in paper bags. If the patient insists on urinating, ask the patient to do so in a sterile container (if available). Also, deposit the toilet paper in a paper bag. Seal and label the bag for law enforcement. This can be critically important evidence. If possible, transport the patient to a hospital with specialized staff such as sexual assault nurse examiners (SANE) who can fully evaluate these patients perform medical and forensic examinations, and provide all aspects of medical and supportive care for these patients.

Understand the principles of triage

Triage overview: -Primary triage: -Primary triage is done quickly to determine the patient's basic condition and needs. -Primary triage is typically done whenever the patient is located -The patient's condition is identified through the use of a triage tag and avoids accidental duplication of effort. -Secondary triage: this assessment is done once the patient arrives in the appropriate treatment area. -Triage categories: -Immediate (red tag): -Immediate patients are the highest patient priority. -Immediate patients have primary assessment problems or exhibit signs and symptoms of head injury or shock. -Delayed (yellow tag): -Delayed patients are the second priority patient. -Delayed patients require treatment and transport but not immediately. -Minor (green tag): -Minor patients are the third patient priority. -Minor patients require little or no treatment by EMS personnel. -Minor patient's are also referred to as "walking wounded". -Dead or dying (black tag): -Dead or dying patients are the last patient priority. -Also referred to as "expectant" patients because they are either deceased or have a very low chance of survival. -Depending on available resources, expectant patients may include cardiac arrest, respiratory arrest, or those with severe head injuries. -Expectant patients should be treated only after all other patients have been cared for. START triage: -Simple Triage and Rapid Treatment (START) was developed in Newport Beach, California, and allows for easy, rapid triage of patients with an MCI. -START triage uses a RPM approach to triage by quickly evaluating the patient's Respirations, Perfusion, and Mental status. -START triage step one: -Direct all patients capable of moving to a central location. -Those able to follow the command and move to the assigned location are collectively triaged as minor (green tag) or "walking wounded." -START triage step two: -Move from patient to patient and begin triage using the RPM method. -Respirations: -If not breathing, manually open the airway. If patient does not begin breathing spontaneously, triage as Expectant (black tag) and move to the next patient. -If the patient begins to breathe, triage as Immediate (red tag), place in recovery position, and move to the next patient. -If the patient is breathing spontaneously above 30 breaths per minute or below 10 breaths per minute, triage as Immediate, and move to next patient. -If the patient is spontaneously breathing 10 to 30 times per minute, move immediately to the next triage step with that patient. -Perfusion: -Assess radial pulse to determine perfusion status. Avoid assessing the radial pulse on an upper extremity with local trauma that may affect distal circulation in only that extremity. -If the radial pulse is absent, triage as Immediate and move to the next patient. -If the radial pulse is present, move immediately to the next triage step with that patient. -Mental Status: -This is the final step in the RPM triage process and evaluates the patient's ability to follow a simple command. -If the patient is unable to follow simple commands, triage as Immediate and move to the next patient. -If the patient can follow simple commands, triage as Delayed (yellow tag) and move to the next patient. -Special populations: -Patients with special needs, such as children, that cannot be triaged effectively with START should be moved as soon as possible to a treatment area for secondary triage. -Certain MCIs such as incidents involving hazardous materials or weapons of mass destruction may require additional scene safety precautions such as patient decontamination or law enforcement assistance before triage can occur. -JumpSTART: -JumpSTART is for pediatric patients up to 8 years of age. -The JumpSTART algorithm is very similar to the START algorithm, but it is adapted to the physiological differences in children. -If the pediatric patient is apneic with a palpable pulse, then 5 rescue breaths are attempted. After 5 rescue breaths, spontaneous breathing = IMMEDIATE and continued apnea =DECEASED. -Patients with breathing rates less than 15 or over 45 are triaged as IMMEDIATE.

Understand the differences between type 1 and type 2 diabetes

Type 1: is an autoimmune disorder in which the individual's immune system produces antibodies against pancreatic beta cells. Essentially, this disease is about the missing pancreatic hormone insulin. Insulin is the "key" to the "door" of the cell. Without insulin, glucose cannot produce energy. Type 1 diabetes is the most common metabolic disease of childhood. A patient with new-onset type 1 diabetes will have symptoms related to eating and drinking: -Polyuria: more frequent urination -Polydipsia: severe thirst, increase in liquid consumption -Polyphagia: severe hunger, increased food intake -Weight loss -Fatigue Type 2: is caused by resistance to the effects of insulin at the cellular level. Recall that we described insulin as the key to the door of the cell. insulin resistance means the lock is unable to accept the key. As a review, in type 1 diabetes no insulin is produced, so there are no keys. In type 2 diabetes there are fewer insulin receptors, so there are not enough locks. -Obesity predisposes people to type 2 diabetes; there is an association between obesity and increased resistance to the effects of insulin. As the number of obese people continues to rise, so does the number of patients with type 2 diabetes.

Subcutaneous (SC)

Under the skin Parenteral:slow Given into the fatty tissue between the skin and the muscle

Sublingual (SC)

Under the tongue Enteral:rapid Enter through the oral mucosa under the tongue and is absorbed into the bloodstream within minutes

Number Prefixes Uni- Dipl- Null- Primi- Multi- Bi- Tri- Quad- Tetra- Quint- Sexti- Septi- Oct- Nona- Deca- Semi- Hemi- Ambi- Pan-

Uni — one — unilateral — one side Dipl — two/double — diplopia — double vision Null — none — nullipara — never given birth Primi — first — primigravida — pregnant for the first time Multi — many — multiparous — given birth to more than one offspring at a time Bi — two — bilateral — pertaining to both sides Tri — three — trigeminy — irregular heartbeat of two normal beats followed by one premature beat Quad — four — quadriplegic — paralysis of all four extremities Tetra — four — tetralogy of fallot — a congenital defect involving four anatomic abnormalities of the heart Quint — five — quintipara — five pregnancies resulting in 5 live births Sexti — six — sextuplets — six offspring of the same pregnancy Septi — seven — septuplets — seven offspring of the same pregnancy Oct — eight — octigravida — pregnant for the eighth time Nona — nine — nonan — occurring on the ninth day Deca— ten — decagram — measurement of ten grams Semi — half — semiconscious — partially conscious Ambi — both — ambidextrous — able to use either hand equally Hemi — half/one sided — hemiplegia — paralysis on one side of the body Pan — all/entire — pandemic — an epidemic over a wide area

Ventilation or respiration

Ventilation: merely the movement of air throughout the respiratory system Respiration: the exchange of oxygen and carbon dioxide across the alveoli

Vesicular breathing Wheezing Rhonchi Crackles/rales, Stridor

Vesicular breath sounds: heard over most of the lungs' surface. they are soft and low pitched with a rustling quality during inspiration and are even softer during exhalation. They have an inspiration/exhalation ratio of 3:1 Wheezing: high-pitched, almost musical whistling sound heard upon exhalation. Wheezing indicates obstruction or constriction of the bronchus, usually occurs in asthma/COPD patients. Rhonchi: low-pitched, rattling sounds caused by secretions or mucus in the larger airway. They are common in cases of pneumonia, bronchitis, and aspiration Crackles/Rales: crackling/bubbling sound typically heard on inspiration that results from air trying to pass through the alveoli. These sounds are common in cases of congestive. Heart failure and pulmonary edema. Stridor: high-pitched sound that occurs on inspiration as air tries to pass through an obstruction in the upper airway. This indicates partial airway obstruction of the trachea, and occurs in patients with an anatomic or foreign body airway obstruction.

Understand all "normal" vital signs for all age ranges

Vital signs for all age ranges as seen in picture listed

Hemiparesis

Weakness on one side of the body

Understand documentation of patient refusal and legal implications

When the patient refuses treatment, the patient refusal document must be completed and signed by you, the patient and a witness. The event must still be documented in a PCR, including and treatments you would have given. The patient may allow some treatments, but deny others.

Understand pathophysiology, assessment and management of the trauma patient

When you are assessing trauma incidents, the MOI is a crucial element of history taking. Be alert to the extent of damage to the interior and exterior of the vehicles involved in crashes. Use this observation paint a picture of the scene in written and verbal communication. Patient assessment: Identifying life-threatening illnesses and injuries as soon as possible has proven to improve patient outcomes. As an EMT, you must apply this knowledge as well as the appropriate assessment skills to assess, triage, manage, and transport patients with traumatic injuries to the most appropriate facility. The major components of patient assessment include: -Scene size-up -Primary assessment -History taking -Secondary assessment -Reassessment -When you are caring for a patient who as experienced a significant MOI and the patient is considered to be in critical or serious condition, you should rapidly perform a physical examination. With a patient who has experienced a nonsignificant MOI, focus on the chief complaint while assessing the patient as a whole. The human body is divided into areas (or systems) based on body function, and its internal organs ore subject to unseen injuries when force is applied to the body. For example, the brain may have bruising, the heart and lungs may have bruising or unseen bleeding, and the organs of the abdomen may have life-threatening bleeding. Injuries to the head: The brain lies well protected within the skull. However, when the head is injured from trauma, disability, and unseen injury to the brain may occur. The brain itself may tear or become bruised, causing bleeding. The blood vessels around the brain may also tear and produce bleeding. Bleeding or swelling inside the skull from brain injury is often life-threatening; therefore, your assessment must include conducting frequent neurologic examinations. Neurologic assessments coupled with the patient's level of consciousness will often provide details on subtle changes in the patient's condition. Some patients will not have obvious signs or symptoms, such as changes in pupillary size and reactivity, of unseen brain injury until minutes or hours after the injury as occurred. Injuries to the neck and throat: The neck and throat contain many structures that are susceptible to injuries from trauma that could be serious or deadly to your patients. In this region of the human body, the trachea (or windpipe) may become torn or swell after an injury to the neck or deviate after an injury to the lungs. These types of injuries may result in an airway problem that could quickly become a serious life threat because they interfere with the patient's ability to breathe; therefore, your assessment must include frequent physical examination looking for DCAP-BTLS in the region. In addition, you should also assess for jugular venous (vein) distention and tracheal deviation (late sign of injury) -The neck also contains large blood vessels that supply the brain with oxygen-rich blood. When a neck injury occurs, swelling may prevent blood flow to the brain and cause injury to the central nervous system, even though the brain may not have been directly affected by the initial force that caused the injury to the neck. If a penetrating injury to the neck results in an open wound, the patient may have significant bleeding, or air may be drawn into the circulatory system. If air enters the veins, this may result in an air embolism, which may lead to cardiac arrest if the air enters the heart. Occlusive dressings must be used to keep this from happening. A crushing injury to the upper part of the neck may cause the cartilages of the upper airway and larynx to fracture. The can lead to leakage of air into the soft tissue of the neck. When air is trapped in subcutaneous tissue (subcutaneous emphysema), it produces a crackling sounds or feeling when palpated, called subcutaneous crepitation. Either air in the circulation or an airway cartilage fracture may cause rapid death. Injuries to the chest: The chest contains the heart, the lungs, and the large blood vessels of the body. When injury occurs to this area of the body, many life-threatening injuries may occur. For example, blunt trauma to the chest can fracture ribs or the sternum. When ribs are broken and the chest wall does not expand normally during breathing, this interferes with the body's ability to obtain sufficient amounts of oxygen for the cells. Bruising may occur to the heart and cause an irregular heart beat. Depending on the severity of the trauma, the large blood vessels of the heart may be torn inside the chest, causing massive unseen bleeding that can quickly kill the trauma patient. In some chest injuries the lungs can become bruised, thus interfering with normal oxygen exchange in the body. -Some chest injuries result in air collecting between the lung tissue and the chest wall. As air accumulates in this space, the lung tissue becomes compressed, again interfering with the body's ability to effectively exchange oxygen. This injury is called a pneumothorax. If left untreated or unrecognized, the lung tissue becomes squeezed under pressure until the heart is also squeezed and can no longer pump blood. This condition is called a tension pneumothorax and is a life-threatening emergency. In some patients bleeding in this portion of the chest develops. Instead of air collecting in this space, blood collects here and causes interference with breathing. This condition is called a hemothorax and it also poses a threat the patient's life. -A penetration or perforation of the integrity of the chest is called an open chest wound. As air enters the chest cavity, the natural pressure balance within the chest cavity is no longer equal. If left untreated, shock and/or death will result. Regardless of the particular injury, it is imperative that you reassess a trauma patient's chest region every 5 minutes. The assessment should include DCAP-BTLS, lung sounds, and chest rise and fall. Some patients will have obvious signs or symptoms such as absent breath sounds or respiratory difficulty immediately. Injuries to the abdomen: The abdomen is an area of the human body that contains many vital organs to body function. These organs also require a very high amount of blood flow so they can perform the functions necessary for life. The organs of the abdomen and retroperitoneum (the space immediately behind the true abdomen) can be classified into two simple categories: solid and hollow. The solid organs include the liver, spleen, pancreas, and kidneys. The hollow organs include the stomach, the large and small intestines, and urinary bladder. -When injuries from trauma occur in this region of the body, serious and life-threatening problems may occur. The solid organs may tear, lacerate, or fracture. This causes serious bleeding in the abdomen that can quickly cause death. Be alert for a trauma patient who reports abdominal pain -- it may be a symptom of abdominal bleeding. Also be alert to vital signs that begin to worsen; this can be a sign of serious, unseen bleeding inside the abdominal region of the body. -When hollow organs of the body have been injured, they may rupture and leak toxic chemicals used for digestion into the abdomen. This not only causes pain, but a life-threatening infection also may eventually develop. -The abdomen also contains large blood vessels that supply the organs of this region and the lower extremities with oxygen-rich blood. Occasionally these vessels rupture or tear and cause serious unseen bleeding that may cause death. Some patients particularly healthy young adults, are able to compensate longer than others from blood loss; therefore, you should always maintain a high index of suspicion with the MOI suggests injury to the abdominal region. This is best accomplished by reassessing the abdominal region using DCAP-BTLS.

Chapter 29: Understand the mechanics of ventilation in relation to chest injuries

When you inhale, the intercostal muscles between the ribs contract, elevating and expanding the rib cage. At the same time, the diaphragm contracts or flattens and pushes the contents of the abdomen down. The intrathoracic pressure inside the chest decreases, creating a negative pressure differential. Air then enters the lungs through the nose and mouth, which is the path of least resistance from the ambient air space to the upper and lower airway. When you exhale, the intercostal muscles and diaphragm relax, and the tissues move back to their normal positions, allowing air to be exhaled. In a normal respiratory system, relaxation of the thoracic muscles and the diaphragm is a relatively passive function. Normal physiology dictates that the body should not have to work to breathe when in a resting state. When you are assessing the patient, you should be able to recognize when there is an increase in the work of breathing and equate that with respiratory distress and a life threat. - Note that the nerves supplying the diaphragm (the phrenic nerves) exit the spinal cord at C3, C4, and C5. A patient whose spinal cord is injured below the C5 level may lose the power to move the intercostal muscles, but the diaphragm should still be able to contract. The patient will still be able to breathe because the phrenic nerves remain intact, but the injury may cause belly breathing. Patients with spinal cord injuries at C3 or above can lose their ability to breathe entirely. -Tidal volume is the amount of air in milliliters (mL) that is moved into or out of the lungs during a single breath. The average tidal volume for a man is approximately 500 mL. If you multiply this amount of air by the number of breaths/min, the result is called the minute ventilation or minute volume (the amount of air moved through the lungs in 1 minute). If you change either of these numbers (increase or decrease the rate or volume), then you can affect the amount of air moving through the system. For example, if you move 600 mL at the normal rate of 12 breaths/min, then the minute volume is 7200 ml (7.2 L). If you increase the ventilation rate by four extra breaths a minute then the minute volume is 9600 mL (9.6 L). Conversely, if the amount of tidal volume decreases, then the minute volume will drop along with it. -This information is important because if the patient is only able to inhale small amounts of air (in the case of a chest injury or a reactive airway pathology), the patient will need to exceed the normal respiratory rate range of 12 to 20 breaths/min to make up the difference in the minute volume. Remember that the average bag-valve mask (BVM) consists of a self-inflating bag that contains 1,000 to 1500 mL of air. This device can quickly overinflate the lungs, causing gastric distention, and impair the function of the lungs. Overventilation can also increase intrathoracic pressure (pressure inside the chest), reducing cardiac output and potentially worsening chest injuries such as pneumothorax. In addition, there is the risk of causing acid-base imbalance and blood gas imbalance by "blowing off" carbon dioxide faster than the body needs to get rid of it.