RC Health Services EMT-B Final Exam Review

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

Closed abdominal injuries are those in which blunt force trauma results in injury to the abdomen without breaking the skin. MOIs include: Striking the handlebar of a bicycle or the steering wheel of a car Being struck by a wooden board or baseball bat Motorcycle crashes Falls Blast injuries Pedestrian injuries Compression Deceleration bdominal distention or swelling that occurs between the xiphoid process and the groin is often the result of free fluid, blood, or organ contents spilling into the peritoneal cavity. Swelling can also be the result of air in the form of gases from the bowel or from infection. Other signs and symptoms include: Tenderness Bruising and discoloration Another likely injury is lower rib fractures—a trauma that was forceful enough to break the ribs may also have damaged internal organs. In patients with liver and spleen injuries, and/or with bleeding into the peritoneal space, pain is referred to the shoulder. Shoulder pain can be misleading, and injury to the liver or spleen could possibly be overlooked if the shoulder is also injured. Symptoms of an abdominal aneurysm that is dissecting include pain that is described as tearing going from the abdomen posteriorly. Pain that is following the angle from the lateral hip to the midline of the groin can be the result of damage to the kidneys or the ureters. Pain primarily located in the right lower quadrant can indicate an inflamed or ruptured appendix. The genitourinary system controls: Reproductive functions The waste discharge system The urinary system controls the discharge of certain waste materials filtered from the blood by the kidneys. The male genitalia, except for the prostate gland and the seminal vesicles, lie outside the pelvic cavity. The female genitalia, except for the vulva, clitoris, and labia, are contained entirely within the pelvis. Injuries to the kidneys are not unusual and rarely occur in isolation. A penetrating wound that reaches the kidneys almost always involves other organs. A blow that is forceful enough to cause significant kidney damage often results in damage to other intra-abdominal organs. Injury to the urinary bladder, either blunt or penetrating, may result in its rupture. Urine spills into the surrounding tissues, and any urine that passes through the urethra is likely to be bloody. Blunt injuries of the lower abdomen or pelvis often cause rupture of the urinary bladder, particularly when the bladder is full and distended. Sharp, bony fragments from a fracture of the pelvis often perforate the urinary bladder. Penetrating wounds of the lower mid-abdomen or the perineum (the pelvic floor and associated structures that occupy the pelvic outlet) can directly involve the urinary bladder. Injuries of the external male genitalia include all types of soft-tissue wounds. Although these injuries are uniformly painful and generally a source of great concern to the patient, they are rarely considered life threatening and should not be given priority over other, more severe wounds, unless the rich blood supply causes significant bleeding. Pain from an injury to the testicles or another cause, such as infection or cancer, may be referred to the lower abdomen. When assessing men with lower abdominal pain, you should also consider injury or other causes of pain to the testicles The uterus, ovaries, and fallopian tubes are rarely damaged because they are small, deep in the pelvis, and well protected by the pelvic bones. They are usually not injured as a result of a pelvic fracture. An exception is the pregnant uterus. As pregnancy progresses, the uterus enlarges substantially and rises out of the pelvis, becoming vulnerable to both penetrating and blunt injuries. These injuries can be particularly severe because the uterus has a rich blood supply. You can expect to see the signs and symptoms of shock with these patients. Note also that contractions may begin. Injuries of the external female genitalia can include all types of soft-tissue injuries. Because these genital parts have a rich nerve supply, injuries are very painful. Determining the MOI will assist you in deciding if you need to call for additional resources, as in the case of sexual assault. In any case of trauma, it's important to determine the possibility of pregnancy. Assume all women of childbearing age are possibly pregnant.

1. Understand the common types of medical emergencies and provide examples of each condition.

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2. Review your understanding of the components of the Patient Assessment.

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2. Understand the general steps in medication administration.

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2. Understand the signs and symptoms seen in various respiratory conditions.

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3. Understand infectious diseases and appropriate Standard Precautions.

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3. Understand the routes of administration and how each works.

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4. Understand when can use off-line vs online medical control.

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Chapter 11: a. Dosages, indications, contraindication, side effects, therapeutic effects, unintended effects, or untoward effects

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b. Generic or trade name

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Understand both communication and documentation.

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

5. Understand how to 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.

a. Paraplegia

paralysis of the lower half of the body

g. Delirium vs dementia

Delirium and dementia are tightly related, though distinct, and often the two terms are confused in common usage. In fact, dementia is often a root cause in the manifestation of delirium, along with other contributing causes like electrolyte disorders; severe infections of the lungs, liver, heart, kidney or brain, prescription drug use and an unfamiliar environment. Delirium is a neuropsychiatric condition that occurs acutely, rather than chronically, sometimes for only hours at a time. Whereas dementia is almost always irreversible, and features a steady cognitive decline as the condition progresses, delirium is not a chronic impairment, and its acute manifestations can be effectively controlled.

Know the different components of the grieving process.

Denial, Anger/Hostility, Bargaining, Depression, and Acceptance. These stages can happen at varying times in different orders

1. Understand the different types of equipment used for moving a patient and when each is appropriate (e.g., long back board, KED, scoop stretcher, wheeled stretcher).

Describe the major physical and psychosocial characteristics for each age group. Neonate/Infant have fast pulse and respirations and 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 or mistrust. Secure attachment and anxious-avoidant attachment could develop. Toddler/Preschool Age as 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 activities to fine motor activities. Bladder control begins to develop and manifests roughly by 24 months. As language and comprehension of situations such as cause and 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 preconventional, conventional, and postconventional reasoning. Self concept and self esteem begin to develop. Adolescent vitals round off to normal adult ranges. Growth spurt occurs and sexual organs begin to develop both internally and externally. Adolescents often are trying to develop their self images and codes 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 or terrified by what others think about them. Early Adult is the 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 medication 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. Understand the different types of equipment used for moving a patient and when each is appropriate (e.g., long back board, KED, scoop stretcher, wheeled stretcher). A back board is used for a patient who must be transported in the supine or immobilized position. This is necessary for patients with suspected hip, pelvic, spinal, or lower extremity injuries or trauma. Patients on a backboard should be carried with the diamond carry. A scoop stretcher is composed of two halves that slide under the patient and lock together. This is utilized when moving a patient from the ground to a stretcher. The Kendrick Extrication Device (KED) is a vest-type device that is used to immobilize the patient until he or she is moved from a sitting position in the vehicle to a supine position on a backboard. The KED is often easier to use than the wooden short backboard. Most patients who do not have spinal injury or multisystem trauma are placed on a wheeled stretcher (spinal injury or multisystem trauma need a backboard).

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

requires that the chemical manufacturer, distributor, or importer provide Safety Data Sheets (SDSs) (formerly MSDSs or Material Safety Data Sheets) for each hazardous chemical to downstream users to communicate information on these hazards. The information contained in the SDS is largely the same as the MSDS, except now the SDSs are required to be presented in a consistent user-friendly, 16-section format. This brief provides guidance to help workers who handle hazardous chemicals to become familiar with the format and understand the contents of the SDSs.

d. Understand how epinephrine can affect any of these.

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.

3. Understand situation awareness.

During your walk, look for the following: The mechanism of injury (MOI) Downed power lines Leaking fuels or fluids Smoke or fire Broken glass Trapped or ejected patients The number of patients and vehicles involved

c. 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 wavelike manner. The beat felt in a pulse is the pressure from this new wave of blood.

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

Estimating burn size in adults See a picture of the "rule of nines" for adults. The front and back of the head and neck equal 9% of the body's surface area. The front and back of each arm and hand equal 9% of the body's surface area. The chest equals 9% and the stomach equals 9% of the body's surface area. The upper back equals 9% and the lower back equals 9% of the body's surface area. The front and back of each leg and foot equal 18% of the body's surface area. The groin area equals 1% of the body's surface area. Estimating burn size in babies and young children See a picture of the "rule of nines" for babies and young children. The front and back of the head and neck are 21% of the body's surface area. The front and back of each arm and hand are 10% of the body's surface area. The chest and stomach are 13% of the body's surface area. The back is 13% of the body's surface area. The buttocks are 5% of the body's surface area. The front and back of each leg and foot are 13.5% of the body's surface area. The groin area is 1% of the body's surface area.

Understand the difference between expressed consent, implied consent and involuntary consent.

Expressed consent is when the patient verbally or otherwise 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.

1. Understand pathophysiology, assessment and management of environmental emergencies.

Factors affecting exposure include: Physical condition Patients who are ill or in poor physical condition will not be able to tolerate extreme temperatures as well as those whose cardiovascular, metabolic, and nervous systems are all functioning well. Exertion also plays a role. For instance, a brisk walk will generate body heat when you are out in the cold, but will also produce heat when it is Children and older adults are more likely to experience temperature-related illness. Infants have poor thermoregulation at birth and do not have the ability to shiver and generate heat when needed until about 12 to 18 months. An infant's surface-area-to-mass ratio is larger than an adult's, so infants heat up and cool down faster. Older adults have a loss of subcutaneous tissues as they age, reducing the amount of insulation they have. Poor circulation also contributes to increased heat loss. Medications can also affect an older person's body thermostat, putting him or her at increased risk for temperature-related emergencies. Older patients are also at high risk for falls, and lying immobile on a hot or cold surface can rapidly lead to overexposure. Hypothermia means "low temperature" and occurs when core temperature falls below 95°F (35°C). To protect itself against heat loss, the body: Constricts blood vessels in the skin, which results in the characteristic appearance of blue lips and/or fingertips Creates additional heat by shivering If the patient is alert, is shivering, responds appropriately, and has a core body temperature is between 90°F to 95°F (32.2°C to 35°C), the hypothermia is mild. Begin passive rewarming slowly, which includes placing the patient in a warm environment; removing wet clothing; and applying heat packs or hot water bottles to the groin, axillary, and cervical regions. Turn the heat up high in the patient compartment of the ambulance. Do not place heat packs directly on the skin. You may give warm fluids by mouth, as allowed by local protocols, assuming that the patient is alert and can swallow without difficulty.

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

False vs. True Labor The timing of the contractions is a big component for recognizing the differences between true and false labor. Other differences you might notice include the contractions changing when you change positions, like stopping with movement or rest. The strength of contractions is also different, and the pain is felt in different places. It's false labor if... Contractions don't come regularly and they don't get closer together They stop with walking or resting or with changes in position They are usually weak and don't get stronger, or start strong and get weaker Usually the pain is only felt in the front It's true labor if... Contractions come and get closer together over time, lasting about 30-70 seconds each They continue regardless of movement or resting They progressively get stronger Usually they start in the back and move to the front

Understand when it is appropriate to forcibly restrain a patient.

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

ii. Understand the components of a secondary assessments and what is considered "normal"

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Understand when it is appropriate to legally release patient information.

HIPAA protects protected health information (PHI). 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 improvement 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 necessary should be released.

3. Understand how to assess the abdomen during patient assessment.

Have patient lay supine Ask patient about their last about bowel movement and if they have any problems with urination. If a female patient, ask when their last menstrual period was. If an ostomy is present note the type of ostomy, stoma color (should be pink and shiny), consistency and color of stool? Inspect: Stomach contour scaphoid, flat, rounded, protuberant? Noted pulsations at the aorta (noted in thin patients): The aortic pulsation can be noted above the umbilicus. Characteristics of the navel (invert or everted) Masses (check for hernia after auscultation), PEG tube? Auscultate for bruits (vascular sounds) at the following locations using the BELL of the stethoscope: Aorta: slightly below the xiphoid process midline with the umbilicus Renal Arteries: go slightly down to the right and left at the aortic site Iliac arteries: go few a inches down from the belly button at the right and left sides to listen Femoral arteries: found in the right and left groin. Check for hernia: have patient raise up a bit and look for hernia (at stomach area or navel area) Palpation of the abdomen: Light palpation (2 cm): should feel soft with no pain or rigidity Deep palpation (4-5 cm): feel for any masses, lumps, tenderness Urination Have you been urinating more or less often? Is there pain when you urinate? Is the color dark or unusual? Is there an unusual odor? Weight loss Have you had unexplained weight loss recently? How many pounds? Belching or flatulence Have you experienced belching or flatulence? For how long? Pain What does the pain feel like? How long have you had this pain? Is the pain constant or intermittent? Have you had similar pain in the past? Have you done anything to relieve the pain? Other Ask about any other signs or symptoms related to this complaint, such as, "Are there any changes you have noted recently that may be contributing to your pain?"

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

Hazardous materials may be involved in any of the following situations: A truck or train crash in which a substance is leaking from a tank truck or railroad tank car A leak, fire, or other emergency at an industrial plant, refinery, or other complex where chemicals or explosives are produced, used, or stored A leak or rupture of an underground natural gas pipe Deterioration of underground fuel tanks and seepage of oil or gasoline into the surrounding ground Buildup of methane or other by-products of waste decomposition in sewers or sewage-processing plants A motor vehicle crash in which a gas tank has ruptured

Understand the importance of scene safety.

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

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

Hemorrhage = bleeding. Treatment of hemorrhage should be based on the patient's presentation and mechanism of injury (MOI). The typical adult male body contains approximately 70 mL of blood per kilogram of body weight. The adult female body contains approximately 65 mL of blood per kilogram of body weight. The body cannot tolerate an acute blood loss of greater than 20% of total blood volume, or more than 2 pints (about 1 liter) in the average adult. How well a patient's body compensates for blood loss is related to how rapidly the blood loss occurs. A healthy adult can comfortably donate 1 unit (1 pint [500 mL]) of blood within 15 to 20 minutes and adapt well. If this volume of blood loss occurs during a much shorter period, symptoms of hypovolemic shock and even death might develop. In any situation, severe blood loss presents an immediate life threat. Your priority is to quickly control major external bleeding, even before you address airway and breathing concerns.

2. Understand the organs as they lie within the four quadrants.

Hollow organs, including the stomach, large and small intestines, ureters, and urinary bladder, are actually structures through which materials pass. When ruptured or lacerated, these organs spill their contents into the peritoneal cavity causing an intense inflammatory reaction and possible infection. The peritoneum may become inflamed and painful—a condition known as peritonitis. The intestines and stomach contain acid-like substances that aid in the digestive process. When these substances spill or leak into the peritoneal cavity, they cause pain and irritate the peritoneum. The first signs of peritonitis are severe abdominal pain, tenderness, and muscular spasm. Later, bowel sounds diminish or disappear as the bowel stops functioning. A patient may feel nauseated and may vomit. The abdomen may become distended and firm to touch. Infection may occur. Solid organs include the liver, spleen, pancreas, and kidneys. The absence of pain and tenderness does not necessarily mean the absence of major bleeding in the abdomen. Many solid organs, in addition to the great vessels, the abdominal aorta, and the inferior vena cava, are found in the retroperitoneal region (behind the peritoneum). This area also houses the kidneys, ureters, and urinary bladder. The majority of the pancreas is located in this region, which is why the pancreas is referred to as a retroperitoneal organ. The colon occupies the lowest portion of the retroperitoneal space.

3. Understand the differences of hyperglycemia vs hypoglycemia and how to recognize the different signs/symptoms.

Hyperglycemia is high blood sugar, while hypoglycemia is low blood sugar. Because both can cause major health problems for people with diabetes, it's important to keep blood sugar within a healthy range. Hypoglycemia-hunger,irritability,trouble concentrating,fatigue,sweating,confusion,fast, heartbeatshaking,headache Hyperglycemia-extreme thirst,dry mouth, weakness,headache,frequent urination, blurry vision,nausea,confusion,shortness of breath

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

Hyperthermia is a high core temperature, usually 101°F (38.3°C) or higher. High air temperature can reduce heat loss by radiation. High humidity reduces heat loss through evaporation. Risk factors include: The inability to acclimate to the heat Vigorous exercise, during which sweat loss can exceed 1 liter an hour, causing loss of fluid and electrolytes A heat emergency can take three forms: Heat cramps Heat exhaustion Heat stroke All three forms may be present in the same patient because untreated heat exhaustion may progress to heat stroke. Heat stroke is life threatening. People at greatest risk for a heat emergency are: Children Geriatric patients Patients with heart disease, COPD, diabetes, dehydration, and obesity Those with limited mobilityProlonged heat exposure may stress the heart, causing a heart attack. Perform a rapid scan and avoid tunnel vision. Assess the patient's mental status using the AVPU scale. The more altered the patient's mental status is, the more serious the heat emergency. Assess the airway and breathing and treat any life threats. If the patient is unresponsive: Be cautious of how you open the airway. Consider spinal immobilization if trauma is a possibility. Insert an airway and provide BVM ventilations. If circulation is adequate, assess the patient for perfusion and bleeding. Assess the patient's skin condition carefully. Treat the patient aggressively for shock by removing the patient from the heat and positioning the patient to improve circulation. If your patient has any signs of heat stroke, provide rapid transport.

4. Understand the importance of checking a blood sugar and how it relates to a patient with altered mental status.

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. 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 thoughts Inattention Memory loss Striking changes in personality and affect Hallucinations Delusions A decreased level of consciousness. Other causes of altered mental status include: Unrecognized head injury Severe alcohol intoxication 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. A helpful mnemonic to use when reviewing the possible causes of altered mental status is AEIOU TIPS: A Alcohol E Epilepsy, endocrine, electrolytes I Insulin O Opiates and other drugs U Uremia (kidney failure) T Trauma, temperature I Infection P Poisoning, psychogenic causes S Shock, stroke, seizure, syncope, space-occupying lesion, subarachnoid hemorrhage

1. Understand how to recognize and manage carbon monoxide and nerve agent poisonings.

If you suspect the presence of a toxic gas, call for specialized resources such as the hazardous materials (HazMat) team. Never approach a contaminated patient unless you have specialized HazMat training and are using the appropriate PPE. The patient may have: Burning eyes Sore throat Cough Chest pain Hoarseness Wheezing Respiratory distress Dizziness Confusion Headache Stridor (in severe cases) Seizures Altered mental status Most inhaled toxins can be treated by removing the patient from the exposure and applying oxygen. Some inhaled agents cause progressive lung damage, even after the patient has been removed from direct exposure; the damage may not be evident for several hours.

b. Behavior crisis vs psychiatric emergency

In contrast to a behavioral crisis, a psychiatric emergency occurs when a person:demonstrates agitation or violence or becomes a threat to himself or herself, or to others.

Understand the components that are needed to prove negligence.

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

2. 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 causes can cause hypoperfusion, or shock.

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

In the upper-right quadrant are the right lobe of the liver, gallbladder, duodenum, pancreas, suprarenal gland, right kidney, colon (large intestine), and the transverse ascending colon (large intestine). In the lower-right quadrant we have the cecum, appendix, most of the small intestine, the ascending colon (large intestine), right ovary (females only), right ureter, uterus, (if enlarged, females only), and the urinary bladder (if very full). In the upper-left quadrant there is the liver, spleen, stomach, upper small intestine and jejunum, pancreas (body and tail), left kidney, left suprarenal gland, transverse colon (large intestine), descending sigmoid colon (large intestine), left ovary (females only), left ureter, uterus (if enlarged, females only), and the urinary bladder (if very full). Lower-Left quadrant there is the illeum (small Intestine)

1. Understand anatomy, physiology, assessment and management of gynecologic emergencies.

Includes external and internal structures:External:Vaginal opening, urethral openingClitorisLabia majora and minoraAnusPerineumInternal:Ovaries lie on each side and produce an ovum (egg) which develops into a fetusFallopian tubes connect ovary to uterusUterus is where fetus grows during pregnancyNarrowest part of uterus is cervixVagina is lower part of birth canal When a female reaches puberty, she begins to ovulate and experience menstruation. This is called menarche, usually occurs between 11 and 16 years oldMenopause marks the end of menstrual activity and usually occurs around age 50 Each ovary produces an ovum in alternating months 1. Privacy: move patient somewhere private and have female conduct treatment/assessment if possible2. Treat excessive bleeding with pads and document how many were used3. There's a rich nerve supply so treat with sterile compresses/bandage diaper

2. Understand the role of glucose and insulin.

Insulin and glucagon are hormones that help regulate the levels of blood glucose, or sugar, in your body. Glucose, which comes from the food you eat, moves through your bloodstream to help fuel your body. Insulin and glucagon work together to balance your blood sugar levels, keeping them in the narrow range that your body requires. These hormones are like the yin and yang of blood glucose maintenance.

3. Understand the common signs of acute radiation toxicity.

Ionizing radiation is energy that is emitted in the form of rays, or particles. Radioactive material is any material that emits radiation. This material is unstable, and it attempts to stabilize itself by changing its structure in a natural process called decay. As the substance decays, it gives off radiation until it stabilizes. Energy emitted includes: Alpha radiation The least harmful penetrating type of radiation Cannot penetrate through most objects (a sheet of paper or the body's skin can easily stop it) Beta radiation Slightly more penetrating than alpha and requires a layer of clothing to stop it Gamma (x-ray) radiation Travels faster and has more energy than alpha and beta rays These rays easily penetrate through the human body and require lead or several inches of concrete to prevent penetration. Neutron radiation Neutron particles are among the most powerful forms of radiation. Neutrons easily penetrate through lead and require several feet of concrete to stop them.

4. 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.

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, the NHTSA brings in experts to create the National EMS Scope of Practice Model.

Understand the difference between a living will and a health care directive

Living wills and other advance directives are written, legal instructions regarding your preferences for medical care if you are unable to make decisions for yourself. Advance directives guide choices for doctors and caregivers if you're terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

2. Understand the role of EMS within the ICS.

Medical director At incidents that have a significant medical factor, the IC should appoint someone as the medical branch director. This person will supervise the primary roles of the medical branch: triage, treatment, and transport of injured people. Ultimately in charge of counting and prioritizing patients During large incidents, a number of triage personnel may be needed. The primary duty of the triage division or group is to ensure that every patient receives initial assessment of his or her condition. Treatment supervisor Locates and sets up the treatment area with a tier for each priority of patient Ensures that secondary triage of patients is performed and that adequate patient care is given as resources allow Transportation supervisor Coordinates the transportation and distribution of patients to appropriate receiving hospitals and helps to ensure that hospitals do not become overwhelmed by a patient surge The staging supervisor locates an area to stage equipment and responders, tracks unit arrivals, and releases vehicles and supplies when ordered by command. This position plans for efficient access to and exit from the scene and prevents traffic congestion among responding vehicles. Physicians on scene In an MCI or disaster, some areas have plans in place for physicians to be sent to the scene. Emergency physicians will: Have the ability to make difficult triage decisions Provide secondary triage decisions in the treatment area, deciding which priority patients are to be transported first The rehabilitation supervisor establishes an area that provides protection for responders from the elements and the situation. Extrication and special rescue Some MCIs or disasters require search and rescue or extrication of patients. An extrication supervisor or rescue supervisor may need to be appointed. These officers determine the type of equipment and resources needed for the situation. Morgue supervisor Works with area medical examiners, coroners, disaster mortuary assistance teams, and law enforcement agencies to coordinate removal of the bodies and even, possibly, body parts

2. Understand appropriate use of air medical.

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.Weather Typically, helicopters are unable to operate in severe weather conditions such as thunderstorms, blizzards, and heavy rain. The environment/terrain In mountainous or desert terrain, there may be too many hazards in the immediate vicinity to safely land the helicopter in the desired location. Altitude As the elevation increases, the air thins, which makes it more difficult for pilots and patients to breathe. Because of this, helicopters have a maximum limit on flight elevations. Most helicopter services are limited to flying at 10,000 feet above sea level. Airspeed limitations It takes time for helicopters to arrive on the scene because of limitations in airspeed. Typically, medivac helicopters fly between 130 and 150 mph. Cabin size Because of the helicopter cabin's confined space, helicopters are limited in the number of patients that can be safely transported and by the size of the patient that they can safely transport. Although a helicopter may be able to safely lift off with a 500-lb (227-kg) patient, because of his or her size and girth, it may be impossible to safely fit and secure the patient into the cabin area. Cost Typical medivac flights are extremely expensive compared to ambulance transports; however, the level of care may be higher and the overall transport time may be much shorter in the helicopter. The decision to request a medivac should not be based on the perceived ability of the patient to pay the bill, but rather on the medical necessity.

5. Understand headache red flags.

Most headaches are harmless and do not require emergency medical care. However, be concerned if the patient complains of a sudden-onset, severe headache or a sudden headache that has associated symptoms. Headaches with fever, seizures, or altered mental status, or following head trauma, are potentially life threatening. Complete a thorough patient assessment and transport the patient to the hospital. Treatment of a migraine headache is supportive. Always assess the patient for other signs and symptoms that might indicate a more serious condition. Applying high-flow oxygen, if tolerated, may help ease the patient's condition. When possible, provide a darkened and quiet environment because patients with migraines are sensitive to light and sound. Do not use lights and siren during transport.Management of a patient having a stroke in the field is based on supporting the ABCs and providing rapid transport to a stroke center. Depending on the location of the stroke in the brain and the signs and symptoms, the patient may: Require manual airway positioning Have difficulty swallowing and controlling secretions Use suction as needed. Provide oxygen to maintain a SpO2 level of at least 94%. Monitor oxygen saturation with a pulse oximeter. Routine use of oxygen therapy in a stroke patient is not recommended unless the patient is experiencing respiratory distress or is showing signs of hypoxia. Protect a paralyzed patient's extremities. Continuously talk to the patient and inform him or her of what is going on. Provide emotional support throughout the call. Thrombolytic therapy (blood clot-dissolving drugs) and methods to mechanically remove the blood clot may reverse stroke symptoms and even stop the stroke if given within 3 hours (drugs) or 6 hours (mechanical methods) of the onset of symptoms. These therapies may not work for all patients, and they cannot be given to patients with hemorrhagic strokes. Spend as little time at the scene as possible. If you have a choice of hospitals, transport the patient to one that is a designated stroke center. For those patients who are still having a seizure, continue to assess and treat the ABCs. It may be necessary to maintain the patient's airway with manual airway positioning. Use suction to clear the airway of any excessive secretions or vomitus. Monitor the patient's oxygen saturation level with a pulse oximeter and apply high-flow oxygen. Administer oxygen even if you are unable to get an accurate pulse oximetry reading because of the patient's seizure activity, shaking, or tremors.

1. Understand the different terms to describe different age groups.

Neonate 0-1 monthInfant 1 month-1 yearToddler 1-3 yearsPreschool Age 3-6 yearsSchool Age 6-12 years Adolescent 12-18 yearsEarly Adult 19-40 years Middle Adult 41-60 yearsOlder Adult 61 years and older

3. Understand how to assess the various special populations.

Neonate/Infant Moro reflex, Rooting reflex, sucking reflex, and palmar grasp should all be assessed. The fontalles should be checked for normal growth and development. Toddler/Preschool Age/School Age Try to keep the scene familiar by keeping family members present or finding a favorite toy 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.

5. Understand the medications used in cardiovascular emergencies.

Nitroglycerin and aspirin are used for chest pain, and oxygen is used for difficult breathing or hypoxia. Nitroglycerin should be given under the tongue, and chest pain should lessen within 5 minutes. If not, administer another dose. Nitroglycerin should not be given if blood pressure is below 100 mm/Hg or if the patient has taken medication for erectile dysfunction. Ask the patient about allergies to aspirin. Oxygen should be reconsidered when treating COPD patients.

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

Nonrebreathing masks are used for patients with adequate breathing but are suspected of hypoxia. If the patient does not tolerate the nonrebreathing mask use a nasal cannula. Patients that need to reestablish the correct partial pressure of carbon dioxide, such as those with hyperventilation, use a partial rebreathing mask. Venturi masks enable fine adjustments of the oxygen flow over a period of time. Tracheostomy masks are used for patients with tracheostomies.

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 patient.

Understand special considerations and how to communicate with various types of patients (e.g., hearing impaired, visually impaired, young, elderly, non-English speaking, etc.)

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 may be inaccurate in older patients, so you should be vigilant for any objective changes. Young patients are prone to fear and anxiety. Make the child comfortable by allowing him or 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 they can understand. Maintain trust 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 available such as pen and paper and sign language. Try to maintain continuous contact with visually impaired patients and explain in detail any treatments being performed. Take into account a guide dog if present. When treating a non-English speaking patient 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 if possible 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 (paramedic, nurse, physician). Once the staff member is ready to accept responsibility you must deliver an oral report, which consists of opening information, detailed information, any important history, responses to treatment, vital signs, and other information.

ii. OPQRST

Onset-Provocation-Quality-Radiation-Severity-Timing

4. Understand the differences between oxygen demand and supply.

Oxygen demand is how much oxygen the body requires at a given time, while oxygen supply refers to how much oxygen is available to the body at a given time. An increase in oxygen demand often triggers and increase in oxygen supply, and vice versa.

a. Understand when and how to administer Oxygen

Oxygen should be given to patients with an oxygen saturation level below 94 percent or if they have difficulty breathing.

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

Patient care transfers introduce the possibility of critical patient care errors, especially when they occur several times and in different settings along the continuum of care. Effective teams minimize the number of transfers during patient care and adhere to strict and careful guidelines when such transfers are unavoidable. Whenever the verbal transfer of care occurs, all team members should do their best to ensure: Uninterrupted critical care Whenever possible, the team member giving the report and the team member taking the report should hand off lifesaving care (such as performing chest compressions) to another team member, allowing them to focus on the transfer of care. Minimal interference The transfer of patient care should occur in a location with the least interference possible. Respectful interaction Each team member involved in the transfer must be respectful of members' different roles and recognize the importance of each role. Common priorities Both the team member giving the report and the team member taking the report must focus on their common priorities (critical assessment findings and patient care) vital for the best possible patient outcome. Common language or system Whenever possible, a mutually agreed-upon and standardized patient handoff format should be used.

3. Understand defensive driving techniques and guidelines for safe ambulance driving.

Patients should be properly restrained and Getting a feel for the proper brake pressure comes with experience and practice and stay in the extreme left-hand (fast) lane .must operate the vehicle with due regard for the safety of others and preservation of property and

2. Understand the basic principles of the mental health system.

Persons receiving mental health services should be provided assessment and treatment in the least restrictive way possible with voluntary assessment and treatment preferred. Persons receiving mental health services should be provided those services with the aim of bringing about the best possible therapeutic outcomes and promoting recovery and full participation in community life. Persons receiving mental health services should be involved in all decisions about their assessment, treatment and recovery and be supported to make, or participate in those decisions and their views and preferences should be respected. Persons receiving mental health services should be allowed to make decisions about their assessment, treatment and recovery that involve a degree of risk.

6. Understand how pertinent negatives factor in to your patient assessment.

Pertinent negatives, which require more analytical and creative thinking, are gleaned from the differential diagnosis and function to "rule out" other diagnostic possibilities. Taken together, the pertinent positives and negatives help to put the case in focus and make an argument for the most likely diagnosis

Understand physiologic, physical and psychological responses to stress.

Physiologic responses to stress involve interactions between the endocrine and nervous systems, resulting in chemical and physical responses. The fight-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 various levels of stress and how to minimize the chances of PTSD, including CISD/CISM.

Posttraumatic stress disorder occurs after a person has experienced a psychologically distressing event, and usually manifests in the form of depression, startle reactions, flashback 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 of an onsite assessment for symptoms of PTSD.

1. Understand the various components of the incident command system and how they interact.

Preparedness:The NIMS establishes measures for all responders to incorporate into their systems to prepare for their response to all incidents at any time, including: Procedures and protocols Licensure Equipment certification Communications and Information Management Effective communications, information management, and sharing are critical aspects of domestic incident management. The NIMS communications and information systems enable the essential functions needed to provide interoperability. Resource The NIMS sets up mechanisms to describe, inventory, track, and dispatch resources before, during, and after an incident. The NIMS also defines standard procedures to recover equipment used during the incident. Command The NIMS standardizes incident management for all hazards and across all levels of government. The NIMS standard incident command structures are based on three key constructs: ICS Multiagency coordination systems Public information systems Ongoing mangement the multijurisdictional, multidisciplinary NIMS Integration Center (NIC) provides strategic direction for and oversight of the NIMS. It supports routine maintenance and continuous improvement of the system in the long term, including research and development of supporting technologies.

1. Understand continuum of care.

Previous models of emergency care often consisted of providers who worked separately, passing the patient from one individual or group to the next. Gradually, emergency health care providers recognized that by working as a unified team from first patient contact to patient discharge, it was possible to improve individual and team performance; patient and provider safety; and, ultimately, patient outcome.

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

Privacy: move patient somewhere private and have female conduct treatment/assessment if possible2. Treat excessive bleeding with pads and document how many were used3. There's a rich nerve supply so treat with sterile compresses/bandage diaper

a. Be able to take that drop of blood and run it through the entire system...structure by identify how and when it is oxygenated/de-oxygenated.

Pulmonary circulation occurs between the lungs, and systemic circulation occurs throughout the body. Veins give their blood to the right atrium. Blood then flows to the right ventricle, and the tricuspid valve prevents backflow. Blood then flows from the right ventricle through the pumonic valve into the pulmonary artery. The left atrium receives oxygenated blood from the lungs. After flowing through the bicuspid valve the blood makes it to the left ventricle. The left ventricle pumps through the aortic valve into the aorta, which distributes blood to the rest of the body.

2. Understand all 'normal' vital signs for all age ranges.

Pulse, Respirations, Systolic, Temperature Neonate 90-180, 30-60, 50-70, 98-100Infant 100-160, 25-50, 70-95, 98.6-99.6Toddler 90-150, 20-30, 80-100, 98.6-99.6Preschool Age 80-140, 20-25, 80-100, 96.8School Age 70-120, 15-20, 80-110, 98.6Adolescent 60-100, 12-20, 90-110, 98.6Early Adult 60-100, 12-20, 90-140, 98.6Middle Adult 60-100, 12-20, 90-140, 98.6Older Adult 60-100, 12-20, 90-140, 98.6

a. Understand which organs are in which quadrant/region of the body.

RUQ - liver, gallbladder, portion of the colonLUQ - stomach, spleen, portion of the colonRLQ - cecum and ascending colon of the large intestine, appendixLLQ - descending and sigmoid portions of the colonmost organs are not confined to a single quadra

e. Reassessment

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

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

Remember to stage your vehicle a safe distance (usually 1 to 2 blocks) from the incident, and 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. The greatest threats facing you in a WMD attack are contamination and cross-contamination. When you suspect a terrorist or WMD event has taken place, notify the dispatcher. Vital information needs to be communicated effectively if you are to receive the appropriate assistance. Inform dispatch of: The nature of the event Any additional resources that may be required The estimated number of patients The upwind or optimal route of approach The first provider on the scene must begin to sort out the chaos and define his or her responsibilities under the incident command system (ICS). As the first person on scene, you may need to establish command until additional personnel arrive. Do not rely on others to secure your safety. It is your responsibility to constantly assess and reassess the scene for safety.

3. Understand the differences between right- and left-sided heart failure.

Right-sided heart failure occurs when fluid backs up in the body, sometimes as a result of left-sided heart failure. Right-sided heart failure is generally accompanied by jugular vein distention, edema, and an enlarged liver. Left-sided heart failure occurs when fluid backs up into the lungs, often causing pulmonary edema. The patient will have severe shortness of breath, crackles, and hypoxia.

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

STUDY PLAY Understand how to assess the various special populations. Neonate/Infant Moro reflex, Rooting reflex, sucking reflex, and palmar grasp should all be assessed. The fontalles should be checked for normal growth and development. Toddler/Preschool Age/School Age Try to keep the scene familiar by keeping family members present or finding a favorite toy 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. Describe the major physical and psychosocial characteristics for each age group. Neonate/Infant have fast pulse and respirations and 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 or mistrust. Secure attachment and anxious-avoidant attachment could develop. Toddler/Preschool Age as 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 activities to fine motor activities. Bladder control begins to develop and manifests roughly by 24 months. As language and comprehension of situations such as cause and 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 preconventional, conventional, and postconventional reasoning. Self concept and self esteem begin to develop. Adolescent vitals round off to normal adult ranges. Growth spurt occurs and sexual organs begin to develop both internally and externally. Adolescents often are trying to develop their self images and codes 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 or terrified by what others think about them. Early Adult is the 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 medication 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.

i. SAMPLE

Signs and symptoms-Allergies-Medications-Past pertinent medical history-Last oral intake-Events leading to incident

c. Signs or symptoms

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

c. Excited vs agitated delirium

Signs of agitated delirium include:diaphoresis, tachycardia, and hallucinations.

i. 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 patient is free of any 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.

1. Understand the healthcare implications for patients with special challenges.

Some examples of patients with special challenges include: Children who were born prematurely and who have associated respiratory problems Infants or small children with congenital heart disease Patients with neurologic disease (occasionally caused by hypoxemia at the time of birth, as with cerebral palsy) Patients with congenital or acquired diseases resulting in altered body function that requires medical assistance for breathing, eating, urination, or bowel function Patients with sensory deficits such as hearing or visual impairments Geriatric patients with chronic diseases requiring visitation from a home health care service An intellectual disability may be caused by: Genetic factors Congenital infections Complications at birth Malnutrition Environmental factors Prenatal drug or alcohol use (fetal alcohol syndrome) Traumatic brain injury Poisoning (eg, from lead or other toxins) Patients with intellectual disabilities are susceptible to the same disease processes 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) are general terms used to describe a group of complex disorders of brain development. Autism is a pervasive developmental disorder characterized by: Impairment of social interaction Severe behavioral problems Repetitive motor activities Verbal and nonverbal language impairment

1. Understand the risk and responsibilities of emergency response (lights and sirens).

Some local protocols require that all responses to the scene use emergency lights and siren, whereas other systems incorporate response modes based on the information received from dispatch.Patients who have experienced a seizure may have another seizure as a result of the rapid flash pattern of the emergency lighting. In cases such as this, it may be better to transport your patient without lights and siren activated to minimize external stimuli and to prevent making your patient's condition worse. Regardless of your jurisdictional requirements, as the driver of the ambulance, you need to evaluate the risk versus benefit of your response mode.Whenever a motorist yields the right-of-way, the emergency vehicle operator should attempt to establish eye contact with the other driver.

a. Organic vs functional behavioral disorders

Some of the broader categories and types of organic diseases include: Autoimmune diseases in which the body's immune system attacks its own cells and tissues, such as:Type 1 diabetesMultiple sclerosis (MS)Rheumatoid arthritisLupusPsoriasis Cancer in which abnormal cells multiply unchecked and overtake healthy cells, such as:Breast cancerMelanomaLeukemiaLymphomaLung cancerColorectal cancer Inflammatory diseases which cause acute or progressive damage to cells and tissues, such as:OsteoarthritisPelvic inflammatory disease (PID)Viral meningitis,Atherosclerosis,Fibromyalgia Many functional disorders are today being classified by their symptomatic profile. Examples include: Irritable bowel syndrome (IBS) Chronic fatigue syndrome (CFS) Fibromyalgia Temporomandibular joint pain (TMJ) Gastroesophageal reflux disorder (GERD) Interstitial cystitis

b. Suicidal patients

Suicide, taking your own life, is a tragic reaction to stressful life situations — and all the more tragic because suicide can be prevented. Whether you're considering suicide or know someone who feels suicidal, learn suicide warning signs and how to reach out for immediate help and professional treatment. You may save a life — your own or someone else's.

1. Understand the anatomy and physiology of the cardiovascular system.

Super vena cava, inferoir vena cava, right artrium, left artruim, pumonary vein, arota, tricupid valve, bicuspid valve, right ventrical, left ventricals/ is an organ system that permits blood to circulate and transport nutrients, oxygen, carbon dioxide, hormones, and blood cells to and from the cells in the body to provide nourishment and help in fighting diseases, stabilize temperature and pH, and maintain homeostasis

4. Understand the "Platinum 10" and "Golden Hour".

THE GOLDEN HOUR The term "golden hour" is widely attributed to R. Adams Cowley, founder of Baltimore's renowned Shock Trauma Institute, who in a 1975 article stated, "the first hour after injury will largely determine a critically injured person's chances for survival" - this was in an era characterised by a lack of an organised trauma system and inadequate prehospital care. Platinum 10 —is a concept familiar to all types of emergency rescue and ambulance crews and is the period during which emergency crews, upon their arrival at the scene, assess the situation and initiate treatment and transport of casualties.

ii. Understand AVPU and how to calculate

The AVPU scale determines the level of consciousness. Alert and awake, verbal stimuli, painful stimuli, and unresponsive.

5. Understand the APGAR score and how/when to use it.

The Apgar score is a scoring system doctors and nurses use to assess newborns one minute and five minutes after they're born. Medical professionals use this assessment to quickly relay the status of a newborn's overall condition. Low Apgar scores may indicate the baby needs special care, such as extra help with their breathing. Usually after birth, a nurse or doctor may announce the Apgar scores to the labor room. This lets all present medical personnel know how a baby is doing, even if some of the medical personnel are tending to the mom. A: Activity/muscle tone 0 points: limp or floppy 1 point: limbs flexed 2 points: active movement P: Pulse/heart rate 0 points: absent 1 point: less than 100 beats per minute 2 points: greater than 100 beats per minute G: Grimace (response to stimulation, such as suctioning the baby's nose) 0 points: absent 1 point: facial movement/grimace with stimulation 2 points: cough or sneeze, cry and withdrawal of foot with stimulation A: Appearance (color) 0 points: blue, bluish-gray, or pale all over 1 point: body pink but extremities blue 2 points: pink all over R: Respiration/breathing 0 points: absent 1 point: irregular, weak crying 2 points: good, strong cry

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.

i. 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, best verbal response, and best motor response.

Understand HIPAA and how it can affect your role in EMS.

The Health Insurance Portability and Accountability Act ensures patient privacy. Do not discuss findings about the patient with anyone except medical personal 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.

Understand NREMT and how it is involved in the level of training.

The National Registry of EMTs.

1. Understand the impact of age-related changes on assessment and care of geriatric patients.

The aging process is inevitably accompanied by changes in physiologic function, such as a decline in the function of the liver and kidneys. All tissues in the body undergo aging, albeit not at the same rate. The decrease in the functional capacity of various organ systems is normal, but it can affect the way a patient responds to illness.As one gets older, the alveoli in lung tissue can become enlarged and the elasticity decreases, making it harder to expel used air (air trapping). The lack of elasticity results in a decreased ability to exchange oxygen and carbon dioxide. The body's chemoreceptors, which monitor the changes in oxygen and carbon dioxide levels in the blood, slow with age. This can make the body respond more slowly to hypoxia. Loss of mechanisms that protect the upper airway include decreased cough and gag reflexes, resulting in a decreased ability to clear secretions. There is also a decrease in the number of cilia that line the bronchial tree, which lessens an older person's ability to cough and clear secretions, increasing the chance of infection. The leading cause of death from infection in Americans older than 65 years It especially affects people who are chronically and terminally ill. The process of aging causes some degree of immune suppression and increases the risk of contracting infections like pneumonia. Increased mucus production, pulmonary secretions, and the inflammatory effects of infection all interfere with the ability of the alveoli to oxygenate the blood. Maintain a high index of suspicion for any geriatric patient with signs and symptoms of possible pneumonia. Wear respiratory protection when you are assessing a patient with a potentially infectious respiratory disease. You can also place a surgical mask on the patient. A condition that causes a sudden blockage of an artery by a venous clot A patient with a pulmonary embolism will present with shortness of breath and sometimes chest pain; thus, the pulmonary embolism can be confused with a cardiac, lung, or musculoskeletal problem. The top risk factors include living in a nursing home or recent hospitalization for medical illness or surgery (especially in a lower extremity). Other factors include trauma; cancer; history of blood clots or heart failure; presence of a pacemaker or central venous catheter; paralyzed extremities; obesity; recent long-distance travel; and sedentary behavior, especially after surgery. Arteriosclerosis—a disease that causes the arteries to thicken, harden, and calcify—contributes to systolic hypertension in many older patients, which places an extra burden on the heart. Aneurysm Severe blood loss can occur when an aneurysm ruptures. Stiffening of the blood vessels, which results in a higher systolic blood pressure. As many as one-third of older patients have "silent" heart attacks in which the usual chest pain is not present. This is particularly common in women and people with diabetes. Do not assume that your patient is not having a myocardial infarction because he or she is not reporting the classic, pressure-type, substernal chest pain. Any of the following symptoms may be a manifestation of acute cardiac disease in the older patient and should be evaluated ALS personnel for an underlying cardiac disorder: Dyspnea Epigastric and abdominal pain Loss of bladder and bowel control Nausea and vomiting Weakness, dizziness, light-headedness, and syncope Fatigue Confusion

c. Understand the difference between the autonomic and somatic nervous systems.

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.

d. Understand how the body responds 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.

1. Understand the anatomy and physiology of the brain and spinal cord.

The brain is divided into three major parts: The brain stem Controls the most basic functions of the body, such as breathing, blood pressure, swallowing, and pupil constriction The cerebellum Controls muscle and body coordination Responsible for coordinating complex tasks that involve many muscles The cerebrum (the largest part) 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. The middle part controls sensation and movement. The back part processes sight. In most people, speech is controlled on the left side of the brain, near the middle of the cerebrum. Twelve cranial nerves run directly from the brain to various parts of the head. The remaining nerves join in the spinal cord and exit the brain through the foramen magnum. At each vertebra in the neck and back, two spinal nerves branch out from the spinal cord and carry signals to and from the body.

1. Understand the pathophysiology, assessment and management of bleeding.

The cardiovascular system is the main system responsible for supplying and maintaining adequate blood flow. It consists of three parts: The pump (the heart) A container (the blood vessels that reach the cells of the body) The fluid (blood and body fluids) Perfusion is the circulation of blood within an organ or tissue in adequate amounts to meet the cells' current needs for oxygen, nutrients, and waste removal. Without adequate perfusion: Cells in the brain and spinal cord start to die after 4 to 6 minutes. Remember that cells of the central nervous system (CNS) do not have the capacity to regenerate. Lungs can survive only 15 to 20 minutes. Kidneys can be damaged after 45 minutes. Skeletal muscle demonstrates evidence of injury after 2 to 3 hours. The gastrointestinal tract can tolerate slightly longer periods. These times are based on a normal core body temperature (98.6°F [37.0°C]). An organ or tissue that is kept at a considerably lower temperature may be better able to resist damage from hypoperfusion.

a. Understand the different components of the 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 all the other nerves in the body

1. Understand the anatomy, physiology, pathophysiology, assessment and management of acute diabetic emergencies, sickle cell crisis and clotting disorders.

The endocrine system helps maintain the body's homeostasis. Endocrine glands secrete messenger hormones. If a gland is not functioning normally, it may produce more hormone (hypersecretion) than needed or it may not produce enough hormone (hyposecretion). A gland may function correctly, but the receiving organ may not be responding. The brain needs two things to survive: glucose and oxygen. Insulin is necessary for glucose to enter the cells for metabolism. The pancreas produces and stores two hormones that play a major role in glucose metabolism: Glucagon Insulin A small portion of the pancreas is filled with the islets of Langerhans. Within these islets are alpha and beta cells. The alpha cells produce glucagon. Beta cells produce insulin.When a person eats, glucose levels rise. The pancreas secretes insulin, which: Allows the glucose to enter the cells to be used for energy Allows glucose to be stored in the form of glycogen for later use. Diabetes mellitus is a disorder of glucose metabolism where the body has an impaired ability to get glucose into the cells. People who do not manage their diabetes well often experience severe complications, including: Blindness Cardiovascular disease Kidney failure There are three types of diabetes: Diabetes mellitus type 1 Diabetes mellitus type 2 Pregnancy-induced gestational diabetes (which will be discussed in a later module) Treatments for diabetes include medications and injectable hormones that lower the patient's blood glucose level. These can create a medical emergency. Hyperglycemia is a state in which the blood glucose level is above normal. Hypoglycemia is a state in which the blood glucose level is below normal. Hyperglycemia and hypoglycemia can occur with both diabetes mellitus type 1 and type 2. Patients with very low and very high blood glucose levels can present with altered mental status. Patients with severe hypoglycemia are more likely to have a depressed LOC than patients with hyperglycemia. Altered mental status related to diabetic emergencies can mimic alcohol intoxication, and intoxicated patients often have abnormal glucose levels. Be thorough and check a fingerstick glucose level for all patients with altered mental status. Hypoglycemia can develop if a person with diabetes takes his or her medications as prescribed but fails to eat enough food. A person with diabetes may intentionally or accidentally take too much medication, resulting in low blood glucose levels despite normal dietary intake. All hypoglycemic patients require prompt treatment with oral glucose paste (if alert and able to protect their airway) or injection of glucose (dextrose) or glucagon by an advanced life support (ALS) provider. Type 1 diabetes is an autoimmune disorder in which the individual's immune system produces antibodies against pancreatic beta cells. Without insulin, glucose cannot enter the cell, and the cell cannot produce energy. Diabetes mellitus type 2, there are fewer insulin receptors.There is an association between obesity and increased resistance to the effects of insulin. Symptomatic hyperglycemia occurs when blood glucose levels are very high.

1. Understand scene safety and the fundamentals of extrication.

The equipment that you use and the gear that you wear will depend on the hazards you expect to encounter, as well as what you observe during your scene size-up. Each emergency responder has a distinct role at a vehicle extrication scene: EMS providers Assess patients Provide immediate medical care Triage and package patients Provide additional assessment and care as needed once patients are removed Provide transport to the ED The rescue team Secures and stabilizes the vehicle Provides safe entrance and access to the patients Safely extricates patients Provides adequate room so that patients can be removed properly Law enforcement officers Control traffic Maintain order at the scene Establish and maintain a perimeter so that bystanders are kept at a safe distance Investigate the crash or crime scene Firefighters Extinguish fire Prevent additional ignition Ensure that the scene is safe Remove spilled fuel

1. Understand the age-related assessment findings and age-related assessment and treatment modifications for pediatric specific major diseases and/or emergencies.

The five stages of human growth include: Infancy The toddler years Preschool years School-age years Adolescence The pediatric airway is smaller in diameter and shorter in length. The lungs are smaller. The heart is higher in a child's chest. The glottic opening (vocal cords) is higher and positioned more anteriorly, and the neck appears to be nonexistent. The anatomy of a pediatric airway and other important structures differs from that of an adult's in the following ways: A larger, rounder occiput, or back of the head, which requires more careful positioning of the airway A proportionately larger tongue relative to the size of the mouth and a more anterior location in the mouth The child's tongue is larger relative to the small mandible and can easily block the airway. A long, floppy, U-shaped epiglottis in infants and toddlers that is larger than an adult's relative to the size of the airway and extends at a 45-degree angle into the airway Less-developed rings of cartilage in the trachea that may easily collapse if the neck is flexed or hyperextended A narrowing, funnel-shaped upper airway compared to that of a cylinder-shaped lower airway Because of the smaller diameter of the trachea in infants, their airway is easily obstructed by secretions, blood, or swelling. Infants are obligate nose breathers, which may require diligent suctioning or reassessment and management to maintain a clear airway. These differences influence the treatment decisions that you make about pediatric patients, including whether or not intervention is needed and, if so, what procedure to use. It is important to know the normal pulse ranges when evaluating children. An infant's heart can beat as many as 160 times or more per minute if the body needs to compensate for injury or illness. This is the primary method the body uses to compensate for decreased perfusion. Children are able to compensate for decreased perfusion by constricting the vessels in the skin. Constriction of the blood vessels can be so profound that blood flow to the extremities can be diminished. Signs of vasoconstriction include: Pallor (early sign) Weak distal (eg, radial or pedal) pulses in the extremities Delayed capillary refill Cool hands or feet The pediatric nervous system is immature, underdeveloped, and not well protected. The head-to-body ratio of an infant and young child is disproportionately larger, making this population more prone to head injuries from falls or motor vehicle crashes. The occipital region is larger, which increases the momentum of the head during a fall. The subarachnoid space is relatively smaller, leaving less cushioning for the brain. The brain tissue and the cerebral vasculature are fragile and prone to bleeding from shearing forces, such as during an incidence of shaken baby syndrome. The pediatric brain requires a higher amount of cerebral blood flow, oxygen, and glucose. Glucose stores are limited in the pediatric patient. These special needs mean that the pediatric brain is at risk for secondary brain damage from hypotension and hypoxic events. Spinal cord injuries are less common in pediatric patients. Approximately 12,000 new spinal cord injuries are reported yearly in the United States. Roughly 10% of those spinal injuries occur in children younger than age 16 years. If a child's cervical spine is injured, it is most likely to be an injury to the ligaments as the result of a fall. If you suspect a neck injury, perform manual in-line stabilization or follow local protocols. The abdominal muscle structures are less developed in the pediatric patient, which results in less protection from blunt or penetrating trauma. The internal organs, such as the liver and the spleen, are proportionally larger and situated more anteriorly, so they are prone to bleeding and injury. Because the internal organs are positioned in a closer proximity to each other, there is a higher risk for multiple organ injury caused by minimal direct impact to this region, such as from a lap belt in a motor vehicle. The liver, spleen, and kidneys are more frequently injured in children than in adults. A child's bones are softer than an adult's. As a result of the active growth plates, children's bones are weaker and more flexible, making them prone to fracture with stress. The open growth plates are also weaker than ligaments and tendons, leading to length discrepancies if there is an injury to the growth plate. Because of these factors, immobilize extremities with suspected sprains or strains because they may actually be stress fractures. The bones of the infant's head are flexible and soft, which allows the head to be delivered through the birth canal and for the growth of the brain during development. Located on the front (anterior) and back (posterior) portions of the head are soft spots known as fontanelles. Each will close at particular stages of development: 18 months for the anterior suture and 6 months for the posterior suture. Some bulging is a normal assessment finding when the infant is either crying, coughing, or lying on the back or stomach. The fontanelles of an infant can be a useful assessment tool for such issues as increased cranial pressure (bulging with a noncrying infant) or dehydration (a sunken appearance). The thoracic cage in children is highly elastic and flexible because it is primarily composed of cartilaginous connective tissue. The ribs and vital organs are less protected by muscle and fat. The highly flexible ribs mean that fractures in pediatric patients are rare, unless a high-energy impact to the chest wall is encountered, such as during a motor vehicle crash. Underlying damage may still exist within the thoracic cavity without any exterior markings. The integumentary system The child's skin is thinner with less subcutaneous fat. It tends to burn more deeply and easily than an adult's, as in the case of a sunburn. Infants and children also have a larger body-surface-area-to-body-mass ratio, which can lead to significant fluid and heat losses.

a. General impression

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

1. Understand anatomy, physiology, assessment and management of face and neck injuries.

The head is divided into two parts: The cranium The face The cranium 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 temples 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.Factors that may contribute to airway obstruction include: Bleeding from facial injuries The bleeding can be very heavy, producing large blood clots in the upper airway. These clots can lead to complete obstruction, particularly in a patient who is not fully conscious. Direct injuries to the nose and mouth, the larynx, or the trachea These injuries can cause significant bleeding and/or respiratory compromise. You may need to suction the airway if you are unable to control the bleeding. Injuries may cause loosened teeth or dentures to become dislodged into the throat, where they may be swallowed or aspirated. Swelling that often accompanies direct and indirect injury to the soft tissues in the face or neck When the patient's head is turned to the side, as often is done when the patient has an altered level of consciousness or is unconscious Possible injuries to the brain and/or cervical spine that may be associated with facial injuries If the great vessels in the neck are injured, significant bleeding and pressure on the upper airway are common.Because the face and neck are extremely vascular, swelling from soft-tissue injuries may be more severe than in other injured parts of the body. A blunt injury that does not break the skin may cause a break in a blood vessel wall, leading to a hematoma. In some situations, a flap of skin is peeled back, or avulsed, from the underlying muscle and fascia.

1. Understand pathophysiology, assessment and management of orthopedic injuries.

The initial evaluation of a patient with an orthopedic injury should focus on the ABCDE,'s (airway, breathing, circulation, orthopedic and/or neurologic disability, exposure) during the primary survey of a trauma evaluation. The evaluation of orthopedic injuries follows as part of a secondary survey, unless there is active hemorrhage associated with an extremity injury or a pulseless limb. In these cases, the evaluation and management should be a part of the circulation or 'C' part of the primary survey. Once the patient is stable and the secondary survey is being performed, there should be a focused assessment of the injured extremity. For those with isolated orthopedic injuries, the assessment of neurovascular status should take priority.

b. Be able to take that bite of pizza and run it through the digestive systems understanding how the food breaks down and it passes through the system.

The mouth begins digestion through both mechanical and chemical means. Food then travels down the esophagus to the stomach, where both mechanical and chemical digestion take place. Food goes in, chyme goes out. The small intestine (duodenum, jejunum, and ileum) is the major site for the chemical breakdown of 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 bloodstream. The liver is also responsible for the detoxification of blood and the elimination of waste. The pancreas excretes enzymes for protein, carbohydrate, and fat breakdown within the duodenum. It also releases insulin and glucagon. The gallbladder stores bile.

1. Understand the anatomy of the nervous system.

The nervous system is divided into two anatomic parts: The central nervous system The peripheral nervous system The central nervous system (CNS) includes the brain and the spinal cord, including the nuclei and cell bodies of most nerve cells. Long nerve fibers link these cells to the body's organs through openings in the spinal column. These cables of nerve fibers make up the peripheral nervous system.The brain is the organ that controls the body; it is also the center of consciousness. The brain is divided into three major areas: The cerebrum Contains about 75% of the brain's total volume Controls a wide variety of activities, including most voluntary motor function and conscious thought The main part of the brain Divided into two hemispheres with four lobes The cerebellum Located underneath the cerebrum Coordinates balance and body movements The brainstem The most primitive part of the CNS Controls virtually all the functions that are necessary for life, including the cardiac and respiratory systems and nerve function transmissions The brainstem is the best-protected part of the CNS. The skull is covered by layers of muscle, superficial fascia, and thick skin. Superficial fascia connects muscle to skin and contains white blood cells used to destroy pathogens when there is an open wound. The spinal canal is surrounded by a thick layer of skin and muscles. The CNS is further protected by the 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.The peripheral nervous system has two anatomic parts: 31 pairs of spinal nerves Conduct sensory impulses from the skin and other organs to the spinal cord 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. The lumbosacral plexus controls the legs. 12 pairs of cranial nerves Emerge from the brainstem Transmit information directly to or from the brain Perform special functions in the head and face, including sight, smell, taste, hearing, and facial expressions There are two major types of peripheral nerves: Sensory nerves Endings perceive only one type of information, and carry that information from the body to the brain via the spinal cord. 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.

4. Understand the differences between sympathetic and parasympathetic responses as they relate to immunologic emergencies and the medications provided.

The parasympathetic nervous system (PNS) controls homeostasis and the body at rest and is responsible for the body's "rest and digest" function. The sympathetic nervous system (SNS) controls the body's responses to a perceived threat and is responsible for the "fight or flight" response. (PNS) Function Control the body's response while at rest. Neuron Pathways/ Longer pathways, slower system General Body Response/ Counterbalance; restores body to state of calm. Cardiovascular System (heart rate) Decreases heart rate Glycogen to Glucose Conversion No involvement (SNS) Control the body's response during perceived threat. Originates in- Thoracic and lumbar regions of spinal cord Activates response of Fight-or-flight Neuron Pathways- Very short neurons, faster system General Body Response-Body speeds up, tenses up, becomes more alert. Functions not critical to survival shut down. Glycogen to Glucose Conversion-Increases; converts glycogen to glucose for muscle energy

1. Understand the signs and symptoms of inadequate breathing.

The patient reports difficulty breathing or shortness of breath. The patient has an altered mental status associated with shallow or slow breathing. Adult patient appears anxious or restless, and pediatric patient appears sleepy or listless. Respiratory rate is too fast or slow. The breathing rhythm is irregular. The skin is pale cool, clammy, or cyanotic. Adventitious breath sounds such as wheezing, gurgling, snoring, crowing, or stridor. Decreased or noisy breath sounds. The patient cannot speak more than a few words between breaths. Accessory muscle use, retractions, or labored breathing. Unequal or inadequate chest expansion. Excessive coughing. Tripod position. The patient has pursed lips or nasal flaring.

2. Understand how and when to contact poison control.

The phone number of your regional poison center is typically listed on the inside cover of your local phone book or on the American Association of Poison Control Centers (AAPCC) website. The Poison Help hotline is 1-800-222-1222 (available 24 hours a day, 7 days a week). 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 the amount involved 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.

1. Understand anatomy, physiology, assessment of the gynecological patient.

The placenta develops while attached to the inner lining of the wall of the uterus and is connected to the fetus by the umbilical cord. After delivery of the newborn, the placenta separates from the uterus and is delivered. The umbilical cord connects the woman and fetus through the placenta. It contains two arteries and one vein. The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus, and the umbilical arteries carry deoxygenated blood from the heart of the fetus to the placenta. Oxygen and other nutrients cross from the woman's circulation through the placenta and then through the umbilical cord to support the fetus as it grows. The fetus develops inside a fluid-filled, bag-like membrane called the amniotic sac, or bag of waters. This sac contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the fetus. When the sac ruptures, usually at the beginning of labor, the amniotic fluid is released in a gush. Some women may experience a small leak rather than a gush of fluid. This fluid helps to lubricate the birth canal and remove any bacteria. A pregnancy that has reached full term is referred to as term gestation. Reproductive system Hormone levels increase to support fetal development and prepare the body for childbirth. These increased hormone levels also put the pregnant woman at an increased risk for complications from trauma, bleeding, and some medical conditions. As the size of the uterus increases, so does the amount of fluid it contains. Respiratory system Rapid uterine growth occurs during the second trimester of pregnancy. The increased size of the uterus directly affects the respiratory system. As the uterus grows, it pushes up on the diaphragm, displacing it from its normal position. As the pregnancy continues, respiratory capacity changes, with increased respiratory rates and decreased minute volumes.

i. Understand the 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 ABC's. After that you can determine whether or not the patient is a priority transport. General impression, level of consciousness, orientation, life threats, ABC's, transport decision

3. Understand the importance and ways of decontaminating equipment.

The safety of both medical providers and future patients depends on decontamination to prevent spread of disease.

5. 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 required, and the trip is often safer. Patients with altered mental status, circulation compromise, or difficulty breathing are often considered high priority transport. Air transportation is not as common, but patients who are in critical condition will benefit from the faster mode of transportation.

2. Understand anatomy, physiology, assessment and management of head and spine injuries.

The skull is composed of two groups of bones: The cranium, which protects the brain The facial bones The cranium is composed of a number of thick bones that fuse together to form a shell above the eyes and ears that holds and protects the brain. It is occupied by 80% brain tissue, 10% blood supply, and 10% CSF. The brain connects to the spinal cord through a large opening at the base of the skull called the foramen magnum. Four major bones make up the cranium. The most posterior portion of the cranium is called the occiput. On each side of the cranium, the lateral portions are called the temples or temporal regions. Between the temporal regions and the occiput lie the parietal regions. The forehead is called the frontal region. The face is composed of 14 bones: The upper, nonmoveable jawbones are called the maxillae. The cheekbones are called the zygomas. The mandible is the lower, moveable portion of the jaw. The orbit (eye socket) is made up of two facial bones: The maxilla The zygoma The orbit also includes the frontal bone of the cranium. The spinal column is the body's central supporting structure. It has 33 bones (vertebrae) and is divided into five sections: Cervical Thoracic Lumbar Sacral Coccygeal Injury to the vertebrae, depending on the level at which the injury occurs, may result in paralysis if the underlying spinal cord or nervous structures are damaged also. The front part of each vertebra consists of a round, solid block of bone called the vertebral body. The back part of each vertebra forms a bony arch. From one vertebra to the next, the series of arches forms a tunnel (spinal canal) running the length of the spinal column. The vertebrae are connected by ligaments and separated by cushions, called intervertebral disks. These ligaments and disks allow the trunk to bend forward and back, but they also limit motion so that the spinal cord is not injured. Until an injured spine is immobilized, keep it aligned as best you can to prevent further injury to the spinal cord. The spinal column itself is almost entirely surrounded by muscles. Usually you can palpate the posterior spinous process of each vertebra, which lies just under the skin in the midline of the back. The most prominent and most easily palpable spinous process is at the seventh cervical vertebra at the base of the neck.

3. Understand the functions of the somatic and autonomic nervous system.

The somatic nervous system includes everything under your voluntary control as well as one involuntary function, the somatic reflex arc (this is what a doctor tests for when tapping the tendon under your knee with rubber hammer). The SNS includes both afferent (sensory) nerves that transmit various types of information (e.g., smells, pressure and pain) to the the brain for processing and efferent (motor) nerves that direct the muscles under your control, such as those in your legs and arms, to execute certain movements, such as throwing or running. The nerves of the SNS are classified on the basis of location. For example, there are 12 pairs of cranial nerves, which originate in the head and supply the muscles of the eyes, throat and other areas within the head with both motor and sensory fibers; and 31 pairs of spinal nerves, all of which service the voluntary muscles of the trunk, pelvis, arms and legs. The neurotransmitter chemical acetylcholine is an excitatory neurotransmitter in the SNS, meaning that it tends to stimulate movements. The autonomic nervous system vs somatic nervous system distinction is functional: While the somatic nervous system is under your conscious control, none of the autonomic nervous system is. Of course, the two systems interact, with involuntary nervous-system responses permitting more energetic purposeful movements and so on. The neurotransmitter chemical acetylcholine is an inhibitory neurotransmitter in the SNS, meaning that its presence tends to damp out movements. Digestion, the beating of your heart and various internal secretions results from activities of the ANS. The sympathetic branch of the ANS has CNS components in the chest, abdomen and back. Its signals are processed in structures called peripheral ganglia (singular: ganglion) that lie close to the spinal cord. The parasympathetic branch of the ANS has its CNS portion in the head and the lower end of the spinal cord. It also has peripheral ganglia, but these are close to the target organs of nervous signals rather than close to the spine.

b. Understand the difference between the sympathetic and parasympathetic nervous

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. The parasympathetic nervous system slows down the body while recovering from danger or during digestion.

3. Understand Trauma scoring, rapid transport and destination issues.

The trauma score calculates a number from 1 to 16, with 16 being the best possible score. Glasgow Coma Scale (GCS) score The GCS is used to determine level of consciousness by evaluating and assigning point values (scores) for: Eye opening Verbal response Motor response Scores are then totaled and help to effectively predict patient outcomes. The lower the score, the more severe the extent of brain injury.Revised Trauma Score (RTS) 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 used to assess the severity of a trauma patient's injuries. Objective data used to calculate the RTS include: GCS score Systolic blood pressure (SBP) Respiratory rate (RR)

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

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.Hollow organs such as the middle ear, lungs, and gastrointestinal tract are most susceptible to pressure changes. The junction between tissues of different densities and exposed tissues, such as the head and neck, are prone to injury as well. The ear is the organ system most sensitive to blast injuries. The patient may report ringing or pain in the ears or some loss of hearing, and blood may be visible in the ear canal. Permanent hearing loss is possible. Primary pulmonary blast injuries occur as contusions and hemorrhages. When the explosion occurs in an open space, the patient's side that is toward the explosion is usually injured, but the injury can be bilateral when the patient is located in a confined space. 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 over the chest may be palpated, indicating the presence of a pneumothorax. Pneumothorax is common and may require emergency decompression. Solid organs are protected from shockwave injury but may be injured by secondary missiles or a hurled body. Hollow organs may be injured by similar mechanisms as lung tissue. Petechiae, or pinpoint hemorrhages that show up on the skin, to large hematomas are the most visible sign. Subarachnoid and subdural 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 and patients may die of massive hemorrhage without the rapid application of a tourniquet.

a. Be able to take that molecule of air and take it through the entire system.

The upper airway consists of the pharynx (nasopharynx, 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, respectively. 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.

4. Understand the causes of shock.

There are three basic causes for shock. Pump failure occurs when the heart is damaged by disease, injury, or when an 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 inadequate to fill the system and provide efficient perfusion.

1. Understand pathophysiology, assessment and management of wounds, burns and crush syndrome.

There are three types of soft-tissue injuries: 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 Open injuries, in which there is a break in the surface of the skin or the mucous membrane, exposing deeper tissues to potential contamination Burns, in which the soft-tissue damage occurs as a result of thermal heat, frictional heat, toxic chemicals, electricity, or nuclear radiation. You must be able to identify the following three types of burns: Superficial (first-degree) burns Involve only the epidermis The skin turns red but does not blister or burn through this top layer. The burn site is often painful. Sunburn is a good example of a superficial burn. Partial-thickness (second-degree) burns Involve the epidermis and some portion of the dermis These burns do not destroy the entire thickness of the skin nor is the subcutaneous tissue injured. Typically, the skin is moist, mottled, and white to red. Blisters are present. Partial-thickness burns cause intense pain. Full-thickness (third-degree) burns Extend through all skin layers and may involve subcutaneous layers, muscle, bone, or internal organs The burned area is dry and leathery and may appear white, dark brown, or even charred. Some full-thickness burns feel hard to the touch. Clotted blood vessels or subcutaneous tissue may be visible under the burned skin. If the nerve endings have been destroyed, a severely burned area may not have feeling and the surrounding, less severely burned areas may be extremely painful.

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

These injuries are due entirely to the blast itself—that is, damage to the body is caused by the pressure wave generated by the 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 injuries can amputate limbs. Damage to the body results from being struck by flying debris, such as shrapnel from the device or from glass or splinters set in motion by the explosion. Objects are propelled by the force of the blast wave and strike 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.You may find anything from petechiae to large hematomas in patients with blast injuries. Perforation or rupture of the bowel and colon is a risk. Underwater explosions result in the most severe abdominal injuries. Subarachnoid and subdural hematomas are often seen. Permanent or transient neurologic deficits may be secondary to concussion, intracerebral bleeding, or air embolism. Multisystem[You must recognize patients who fit into the classification of multisystem trauma and provide rapid treatment and transportation. Alert medical control as to the nature of the patient's injuries so that the trauma center is prepared prior to your arrival. Multisystem-trauma patients have a high level of morbidity and mortality.

4. Understand how to protect yourself in a toxicological emergency.

These values are obtained from toxicity testing using experimental animals and are used to indicate the short-term poisoning potential of a material (the lower the value, the more toxic the material). LD50 (lethal dose 50%) is the amount of a material, given all at once, which causes the death of 50% of a group of test animals. The LD50 can be determined using any route of exposure, but dermal (applied to skin) and oral (given by mouth) LD50s are most common. If the route of exposure is inhalation, the value is called an LC50, which stands for lethal (airborne) concentration 50%. Since the information provided in this section supports the conclusions drawn for Potential Health Effects, you may also see information on topics such as: Effects of Acute Exposure to Product, Effects of Chronic Exposure to Product, Irritancy of Product, Sensitization to Product, Carcinogenicity, Reproductive Toxicity, Teratogenicity and Embryotoxicity, Mutagenicity and Toxicologically Synergistic Products.

3. Understand the principles of triage.

Triage means to sort your patients based on the severity of their injuries. Primary triage is the initial triage done in the field, allowing you to quickly and accurately categorize the patient's condition and transport needs. Secondary triage is done as patients are brought to the treatment area.

1. Understand the anatomy and physiology of the abdominal cavity.

Two imaginary lines intersect at the umbilicus, dividing the abdomen into four equal areas: Right upper quadrant (RUQ) Organs commonly found in the RUQ are the liver, gallbladder, duodenum of the intestines, and a small portion of the pancreas. Left upper quadrant (LUQ) The stomach occupies most of the LUQ, 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) The left lower quadrant holds both the large and small intestines, notably the descending colon and the left half of the transverse colon. Right lower quadrant (RLQ) The right lower quadrant also holds 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. Swelling and inflammation are common because the appendix is a common source of intra-abdominal infection. Remember, right and left refer to the patient's right and left, not yours.

4. Understand the differences between Type I and Type II diabetes.

Type 1 diabetes usually appears first in children and adolescents, but it can occur in older people, too. The immune system attacks the pancreatic beta cells so that they can no longer produce insulin. There is no way to prevent type 1 diabetes, and it is often hereditary. Type 2 diabetes is more likely to appear as people age, but many children are now starting to develop it. In this type, the pancreas produces insulin, but the body cannot use it effectively.

5. Understand referred pain and locations associated with different conditions.

Ulcers In peptic ulcer disease (PUD), the protective layer of mucus lining the stomach and duodenum is eroded, allowing acid to eat into the organ itself over the course of weeks, months, or years. Most peptic ulcers are the result of infection of the stomach with Helicobacter pylori (H pylori). Gallstones The gallbladder is a storage pouch for digestive juices and waste from the liver. Gallstones can form and block the outlet from the gallbladder, causing pain. Pancreatitis The pancreas forms digestive juices and is also the source of insulin. Inflammation of the pancreas is called pancreatitis. Appendicitis-The appendix is a small recess in the large intestine and is an inflammation or infection in the appendix. Gastrointestinal hemorrhage Bleeding within the gastrointestinal tract is a symptom of another disease, not a disease itself.A gastrointestinal hemorrhage can occur in the upper or lower gastrointestinal tract. Esophagitis occurs when the lining of the esophagus becomes inflamed by infection or from the acids in the stomach. Esophageal varices-Occur when the amount of pressure within the blood vessels surrounding the esophagus increases, frequently as a result of liver failure

e. Vesicular breathing, wheezing, rhonchi, crackles/rales, stridor

Understand carbon monoxide poisoning. Carbon monoxide binds to hemoglobin and prevents oxygen from binding to hemoglobin. Symptoms include flu-like symptoms such as dizziness, nausea, headache, upset stomach, and death. Understand vesicular breathing, wheezing, rhonchi, crackles/rales, and stridor. Vesicular breaths sounds are 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/expiration ratio of 3:1. Wheezing is a high-pitched, almost musical whistling sound heard upon exhalation. Wheezing indicates obstruction or constriction of the bronchus, and usually occurs in asthma and COPD patients. Ronchi are low-pitched rattling sounds caused by secretions or mucus in the larger airway. They are common in cases of pneumonia, bronchitis, and aspiration. Crackles, also known as rales, is a crackling or bubbling sound typically heard on inspiration that results from air trying to pass through fluid in the alveoli. These sounds are common in cases of congestive heart failure and pulmonary edema. Stridor is the high-pitched sound that occurs on inspiration as air tries to pass through an obstruction in the upper airway. This indicates a partial obstruction of the trachea and occurs in patients with an anatomic or foreign body airway obstruction

ii. Understand standard precautions

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 patient is free of any 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 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.

3. Understand the signs of upper vs lower airway obstruction.

Understand the anatomy and physiology and how to determine adequate ventilations. Adequate breathing is indicated by regular, unlabored, bilateral, and equal rise and fall of the chest. Understand the signs of upper vs lower airway obstruction. Signs of upper airway obstruction include decreased or absent breath sounds and stridor. Signs of lower airway obstruction include wheezing and air crackles.

Understand the components of radio communications in regard to giving radio reports and working with online medical control.

Understand the components of radio communications in regard to giving radio reports and working with online medical control.

5. Understand signs, symptoms and adventitious breath sounds associated with specific respiratory diseases.

Understand the differences between Chronic Obstructive Pulmonary disease and Congestive Heart Failure. COPD is a long term dilation and obstruction of the airways and alveoli caused by chronic bronchial obstruction. 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. COPD patients often have a history of lung problems. They will show signs of difficult breathing such as using accessory muscles, pursed lips, and abnormal breath sounds. Understand signs, symptoms, and adventitious breath sounds associated with specific respiratory diseases. Snoring sounds are indicative of a partial upper airway obstruction, usually in the oropharynx. Wheezing indicates constriction and/or inflammation in the bronchus. Wheezing is generally heard on exhalation as a high-pitched, almost musical or whistling sound. This sound is commonly heard in patients with asthma and sometimes in patients with COPD. Crackles/rales are the sounds of air trying to pass through fluid in the alveoli. It is a crackling or bubbling sound typically heard on inspiration. These sounds are often a result of congestive heart failure or pulmonary edema. Rhonchi are low-pitched, rattling sounds caused by secretions or mucus in the larger airway. Rhonchi can be heard with infections such as pneumonia, bronhitis, or in cases of aspiration. Stridor is the high-pitched sound heard on inspiration as air tries to pass through a foreign obstruction in the upper airway. This sound indicates a partial obstruction in the airway and occurs in patients with an anatomic or foreign body airway obstruction.

6. Understand the different airway adjuncts, indications and contraindications.

Understand the different oxygen delivery devices, when, and how to use them. Nonrebreathing masks are used for patients with adequate breathing but are suspected of hypoxia. If the patient does not tolerate the nonrebreathing mask use a nasal cannula. Patients that need to reestablish the correct partial pressure of carbon dioxide, such as those with hyperventilation, use a partial rebreathing mask. Venturi masks enable fine adjustments of the oxygen flow over a period of time. Tracheostomy masks are used for patients with tracheostomies. Understand the different airway adjuncts, indications, and contraindications. An oropharyngeal airway moves the tongue out of the way and makes it easier to suction the oropharynx if necessary. Indications include unconscious patients with no gag reflex and any apneic patient being ventilated with a BVM. Contraindications include consciousness and a gag reflex. A nasopharyngeal airway is used for patients with a gag reflex Indications include patients who are unresponsive or have an altered mental status and who have a gag reflex or do not otherwise tolerate an oropharyngeal airway. Contraindications include severe head injury with blood draining from the nose and history of a fractured nasal bone.

1. What is the definition of shock?

Understand the importance of the pulse oximeter and SPO2 readings and what they can mean. A pulse oximeter measures the percentage of hemoglobin saturation. Normal SPO2 in room air should measure between 98 and 100. A percentage less than 96 in a nonsmoker 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. What is the 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 cannot be met.

6. Understand the medications used in cardiovascular emergencies.

Understand the medications used in respiratory emergencies. Patients with a history of respiratory problems usually are prescribed either a metered dose inhaler or small volume nebulizer. The medications delivered by these devices either dilate bronchioles, reduce inflammation, or decreases histamines or secretions. Side effects include increased pulse rate, nervousness, and muscle tremors. The patient may also begin coughing as the airways clear. Understand the various cardiovascular emergencies and signs, symptoms, assessment, and treatment for each. Angina pectoris, or angina, is characterized by a crushing, squeezing pain in the chest directly below the sternum. Angina can be accompanied by nausea, dizziness, shortness of breath, or sweating. It is treated with supplemental oxygen, nitroglycerin, and rest in a comfortable position. Myocardial infarction (MI) occurs when heart muscle cells begin to die as a result of lack of oxygen. Signs and symptoms are very similar to those of angina, but MI can occur at any time and lasts longer than angina. Treatment includes supplemental oxygen, nitroglycerin, and rest in a comfortable position. Cardiogenic shock and congestive heart failure can occur as a result of an AMI. Aspirin is also a common treatment for chest pain.

3. Understand Hyperventilation or hypoxia and how to recognize/treat each.

Understand the signs and symptoms of inadequate breathing. The patient reports difficulty breathing or shortness of breath. The patient has an altered mental status associated with shallow or slow breathing. Adult patient appears anxious or restless, and pediatric patient appears sleepy or listless. Respiratory rate is too fast or slow. The breathing rhythm is irregular. The skin is pale cool, clammy, or cyanotic. Adventitious breath sounds such as wheezing, gurgling, snoring, crowing, or stridor. Decreased or noisy breath sounds. The patient cannot speak more than a few words between breaths. Accessory muscle use, retractions, 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 tissues are not getting enough oxygen. Besides shortness of breath, patients with dyspnea may experience air hunger or chest tightness. Hyperventilation is the body's attempt to compensate for acidosis, but in the process hyperventilation causes alkalosis. If verbal instruction to slow breathing does not work, administer supplemental oxygen.

b. Understand outcomes for providing a patient oxygen who doesn't need it.

Understand when and how to administer oxygen. Oxygen should be given to patients with an oxygen saturation level below 94 percent or if they have difficulty breathing. Understand the outcomes for providing a patient oxygen who doesn't need it. Recent research has shown that oxygen toxicity can be a risk in a select group of patients. Oxygen free radicals that result from too much oxygen can result in tissue damage and cellular death

3. 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 maneuver for other patients.

b. Ventilation or respiration

Ventilation is merely the movement of air throughout the respiratory system, but respiration is the exchange of oxygen and carbon dioxide across the alveoli.

1. Understand the mechanics of ventilation in relation to chest injuries.

Ventilation is the body's ability to move air in and out of the chest and lung tissue. Oxygenation is the process of delivering oxygen to the blood by diffusion from the alveoli following inhalation into the lungs. Oxygen must be delivered to the cells, and carbon dioxide must be removed from the body for proper organ system function. The chest (thoracic cage) extends from the lower end of the neck to the diaphragm. In a person who is lying down or who has just completed exhalation, the diaphragm may rise as high as the nipple line. A penetrating injury to the chest may penetrate the lung and diaphragm and injure the liver or stomach. Intercostal muscles, innervated from the spinal nerves originating in the cervical region C6 and C7, allow for the active portion of ventilation to occur. A patient who has sustained a spinal cord injury in that region may be unable to move the intercostal muscles and may breathe entirely with the diaphragm (belly breathing). This is considered a clinical or positive diagnostic finding indicating cord damage at or above the level of C6 and C7. Be carful of injuries below C3,4,5 (the patient may lose control of intercostal muscles) average tidal volume is 500ml (a BVM can hold 1000-1500)

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 any treatments you would have given. The patient may allow some treatments but deny others.

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

When your body goes into anaphylactic shock, your blood pressure suddenly drops and your airways narrow, possibly blocking normal breathing. Symptoms of anaphylaxis include: skin reactions such as hives, flushed skin, or paleness suddenly feeling too warm feeling like you have a lump in your throat or difficulty swallowing nausea, vomiting, or diarrhea abdominal pain a weak and rapid pulse runny nose and sneezing swollen tongue or lips wheezing or difficulty breathing a sense that something is wrong with your body tingling hands, feet, mouth, or scalp

1. Understand the different levels of allergic reactions.

Your immune system is responsible for defending the body against bacteria and viruses. In some cases, your immune system will defend against substances that typically don't pose a threat to the human body. These substances are known as allergens, and when your body reacts to them, it causes an allergic reaction. You can inhale, eat, and touch allergens that cause a reaction. Doctors can also use allergens to diagnose allergies and can even inject them into your body as a form of treatment.

a. Wheezes

a form of rhonchus characterized by continuous high-pitched squeaking sound caused by rapid vibration of bronchial walls.

1. Understand how to assess and manage psychiatric emergencies:

rs. The patient may be aware of the danger his behavior poses (as with an overdose with the intent to die) or he may lack insight into the effects of his actions (as in the case of a manic patient who engages in reckless sexual behavior). Even if the patient perceives that his actions are dangerous, he may be bent on engaging in these behaviors despite the risks. (A patient with schizophrenia who follows command hallucinations to commit theft is an example). Because of their lack of insight and judgment, patients in psychiatric emergencies are often brought to the attention of medical professionals by people in the community, including friends, family, police officers, or even bystanders. Astute psychiatrists may also recognize psychiatric emergencies during routine outpatient care. Patients may report their inability to remain safe, either spontaneously or as elicited by the psychiatrist. When an emergency is recognized, the clinician must: • Perform a complete assessment of the concerning behavior • Reduce risk by transferring the patient to an emergency department (ED) or to a psychiatric hospital as needed • Provide or arrange for follow-up for continuity of care Agitation is a common element in many psychiatric emergencies and poses unintentional danger both to self and to others. Intentional self-endangerment is often accompanied by suicidal ideation. This article will focus on these presentations.

1. Understand pathophysiology, assessment and management of the trauma patient.

the leading cause of death in young adults is trauma. Traumatic injuries may range from small lesions to life-threatening multi-organ injury. In order to achieve the best possible outcomes while decreasing the risk of undetected injuries, the management of trauma patients requires a highly systematic approach. Prehospital trauma care involves first aid and basic life support administered by emergency services personnel. In the hospital setting, the treatment of trauma patients is traditionally divided into primary (Advanced Trauma Life Support), secondary, and tertiary surveys. Each survey consists of an algorithm designed to diagnose and manage injuries sequentially in order of decreasing morbidity and mortality. Further steps are taken to provide analgesia and determine whether patients should be transferred to specialized trauma centers as quickly as possible.

As with Chapter 6, you need to be familiar with the anatomy and physiology of all systems.

uni, dipl, null, primi, multi, bi, tri, quad/one, double, none, first, many, two, three, four/cyan, leuk, erythr, cyrrh, melan, poli, alb, chloro/blue, white, red, orange, black, gray, white, green/ab, ad, de, circum, peri, trans, epi, supra, retro, sub, infra, para, contra, ecto, endo, extra, intra, ipsi/away from, toward, down away from, around, around, through, upon, above, behind, under, below, near, against, out, within, out, within, same

c. Review all the tables

al, algia, ectomy, ic, itis, logy, logist, megaly, meter, oma, pathy/pertaining to, pain, surgical removal, pertaining to, inflammation, study of, specialist, enlargement, measurement device, tumor, disease

Identify the 11 systems and understand the major structures and functions and what each

anterior, posterior, right, left, superior, inferior, proximal, distal, medial, lateral, superficial, deep/front, back, right, left, top, bottom, nearest, farthest, middle, side, out, in

2. Understand musculoskeletal injury grading system.

1. Dislocated fingers2. Nondisplaced long bone fracture3. Displaced pelvic fracture4. Bilateral femur fracture5. Pelvic fracture with hemodynamic instability

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

1. Drugs used: Be aware of drugs used during assault2. Expect law enforcement3. History may be difficult if PT shuts downFocus on:1. Medical treatment2. Psychological care3. Preserve evidence- don't cut through clothing- don't throw anything away- preserve bloodstained clothing

b. Rhonchi

are coarse rattling respiratory sounds, usually caused by secretions in bronchial airways

c. Crackles

are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation. They are usually heard only with a stethoscope. Bilateral crackles refers to the presence of crackles in both lungs.

Be familiar with all the medical terminology as identified in this chapter:

cardi, nepr, hepat, neur, psych, thorac

a. Direction terms

cardi, nepr, hepat, neur, psych, thorac/heart, kidney, liver, nerves, mind, chest

2. Nervous system

central nervous system and peripheral nervous system

system is responsible for. In addition:

flexion, extension, abduction, adduction/bending of joint, straightening of joint, movement away from midline, movement toward midline///be able to identify=fowler position, supine, prone, recovery

b. Positions of the body

hyper, hypo, tachy, brady, pre, post/above normal, below normal, fast, slow, before, after

2. Understand the ten phases of extrication.

1. Preparation 2. Enroute to scene 3.Arrival to scene size up 4. Hazard control 5. support operations 6.gaining access 7. Emergency Care 8. Removal of patients 9. transfer of patients 10. Termination

3. Understand how to decontaminate a patient who's been exposed to a toxic substance.

if you suspect that rapid absorption has occurred: Monitor the patient's airway. Provide high-flow oxygen for any patient with respiratory distress or signs of hypoxia (SpO2 level less than 94%, cyanosis). Be alert for nausea and vomiting. Remove rings, watches, and bracelets from areas around the injection site if swelling occurs. Prompt transport to the emergency department is essential. Take all containers, bottles, and labels with the patient to the hospital. Activated charcoal is not indicated, nor is it effective, for patients who have ingested alkali poisons, cyanide, ethanol, iron, lithium, methanol, mineral acids, or organic solvents. If the patient has a decreased LOC and cannot protect his or her airway, do not give activated charcoal. If local protocol permits, your ambulance will carry plastic bottles of premixed suspension, each containing up to 50 g of activated charcoal. The usual dose for an adult or child is 1 g of activated charcoal per kilogram of body weight (more food is present). The usual adult dose is 30 to 100 g. The usual pediatric dose is 15 to 30 g for children younger than age 13. Acute cocaine overdose is an emergency because patients are at high risk for seizures, cardiac dysrhythmias, and stroke. Blood pressure measurements may be as high as 250/150 mm Hg.

4. Understand signs and symptoms of internal bleeding.

include lightheadedness, pain, shortness of breath, a rapid heart rate, and more.1 These symptoms may manifest no matter where the bleeding occurs, but there are a number of other symptoms that you may experience based on the specific location of bleeding, such as bruising around the umbilicus or flank with abdominal bleeding. Internal bleeding can vary tremendously between cases. It may be slow and insidious, or, instead, massive. It may occur with little or no symptoms, or be accompanied by shock and loss of consciousness. There may be no clear cause or source, or, such as with trauma, the cause and likelihood of internal bleeding may be obvious. Unfortunately, even in the case of trauma, internal bleeding may not be immediately evident, and a high level of scrutiny may still be needed. With internal bleeding, the amount of bleeding does not necessarily reflect the severity of the condition. Large amounts of blood may collect in some regions of the body (such as the retroperitoneum in the case of a kidney injury) before symptoms or complications occur. In contrast, even small amounts of bleeding in regions such as the brain can cause major symptoms or even death.

c. Agitated delirium

is a controversial syndrome that presents with psychomotor agitation, delirium, and sweating. It may include attempts at violence, unexpected strength, and very high body temperature. Complications may include rhabdomyolysis or high blood potassium

d. Stridor

is a high-pitched extra-thoracic breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is different from a stertor which is a noise originating in the pharynx. Stridor is a physical sign which is caused by a narrowed or obstructed airway

c. Dysarthria

is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes

d. Aphasia

is an inability to comprehend or formulate language because of damage to specific brain regions

b. Dysphagia

is difficulty in swallowing

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

1. Respiratory Failure Breathing helps bring oxygen into the body and remove CO2. Respiratory failure is when your blood doesn't have enough oxygen and/or too much CO2. Without enough oxygen or with too much CO2, your organs become weak and don't function properly. This can result in difficulties breathing, a blue tint around the face, and disorientation. Causes of respiratory failure include pneumonia, pulmonary embolism, and atelectasis. 2. Pneumonia Pneumonia is the most common cause of death for spinal cord injury patients. It's caused by respiratory infection and occurs when secretions fill the air sacs in your lungs. SCI patients often have too weak of a cough to get rid of secretion buildup. Those with pneumonia may experience shortness of breath, pale skin, fever, and excessive congestion. Patients generally respond well to antibiotics, but alternative treatments include suctioning, quad coughing, and air-pressurizing technologies. 3. Pulmonary Embolism Pulmonary embolism is when a blood clot blocks the arteries in your lungs, making it difficult to breathe. Your heart pumps blood to the lungs, where it is oxygenated and returned to the heart to get pumped throughout the rest of the body. During pulmonary embolism, blood flow is cut off and can't get oxygenated. This results in low oxygen levels in your blood, which ultimately causes your organs not to function properly. After pneumonia, pulmonary embolism is the second leading cause of death in spinal cord injury patients. Treatment typically consists of using blood thinners. 4. Sleep Apnea Sleep apnea is when your breathing becomes unstable during sleep. This causes many you wake up multiple times throughout the night and fail to get a full night's rest. Those with sleep apnea usually experience snoring and sleepiness during the day. The respiratory system already works harder while you're sleeping, but with spinal cord injury, muscle weakness and low lung volume make it even more challenging to breathe. Sleep apnea treatment usually involves the use of a continuous positive airway pressure device (CPAP) that supplies pressurized air into your airways while you sleep. 5. Atelectasis Atelectasis is when one of your lungs collapses because it is not getting enough air. This is attributed to low lung volume following spinal cord injury. Atelectasis can cause dyspnea, pneumonia, and respiratory failure; however, on its own, atelectasis is asymptomatic. The best way to treat atelectasis is to practice breathing and coughing exercises to expand lung volume.

a. MOI / NOI

is the medical condition that resulted in the patient's call for EMS services

b. Index of suspicion

is your awareness and concern for potentially serious underlying and unseen potential injuries or illnesses.

4. Understand the phases of an ambulance call.

1. preparation for call 2. dispatch 3. En route 4.Arrival on scene 5. transfer patient to abulance 6. In route to recieving city 7. At recieving faciulity (devlivery) 8. In route to station 9. Post run

a. Subcutaneous emphysema

A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues.

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

A closed chest injury is one in which the skin is not broken. This type of injury is generally caused by blunt trauma. These types of injuries often cause significant contusions in both the cardiac muscle (cardiac contusion) and the lung tissue (pulmonary contusion), impairing the function of those organs. The heart may not be able to refill with blood or blood may not be pumped with enough force out of the heart, creating a form of inadequate tissue oxygenation (cardiogenic shock). Any bruising of the lung tissue can result in exponential loss of the surface area where oxygen and carbon dioxide exchange occurs. Impairment can cause a decrease in oxygen (hypoxia) and an increase in carbon dioxide (hypercarbia) in the blood, leading to alterations of consciousness and possible death if not recognized and treated. Rib fractures create sharp broken bone ends that can lacerate lung tissue and cause further vessel damage with every movement of the chest wall. This type of bleeding can be hidden from external view and rapidly lead to hypovolemic shock. An open chest injury generally is caused by penetrating trauma. The damage is instant, but symptoms may take time to develop as the damaged vessels continue to bleed or the lung collapses from a puncture. Do not attempt to move or remove an impaled object from the patient. It may be occluding the hole in the vessel that has been punctured and if you remove the object, the patient may bleed heavily. The object will likely cause damage on removal, resulting in further injury. In blunt trauma, a blow to the chest may fracture the ribs, the sternum, or whole areas of the chest wall; bruise the lungs and the heart; and even damage the aorta. Almost one-third of people who are killed immediately in car crashes die as a result of traumatic rupture of the aorta. Although the skin and chest wall are not penetrated in a closed injury, broken ribs may lacerate the contents of the chest. Damage to the chest wall structures result in decreased ability of patients to ventilate on their own. Vital organs can be torn from their attachment in the chest cavity without any break in the skin; this condition can cause serious and life-threatening bleeding that is unseen outside the body. Note the patient's level of consciousness (LOC). Perform a rapid physical examination, looking for: Obvious injuries Blood Difficulty breathing Cyanosis Irregular breathing Chest rise and fall on only one side Accessory muscle use in the neck while breathing Extended or engorged external jugular veins If no obvious problems are seen, focus on the ABCs. Ensure that the patient has a clear and patent airway. How you assess and manage the airway depends on whether you suspect a spinal injury. Be suspicious, and protect the spine early in your care. While considering immobilization of the cervical spine, note whether the jugular veins are distended. This can be the result of a tension pneumothorax (significant, ongoing air accumulation in the pleural space) or injury to the heart that allows bleeding into the pericardium, creating a cardiac tamponade (otherwise referred to as a pericardial tamponade).

b. Focused vs Rapid Assessment

A focused assessment is usually performed on patients who are responsive or have an nonsignificant 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.

2. Understand different types of positions (e.g., prone, semi-fowlers, recovery, shock, position of comfort) and when they are used for various patients.

A position of comfort, usually a fowler or semi-fowler position, is used for patients with respiratory or chest pain, unless they are hypotensive. Patients who are in shock should be packaged in a supine position. Patients in the late stages of pregnancy should be placed on the left side if 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 and in a position 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.

7. Understand the importance of the pulse oximeter and SPO2 readings and what they can mean.

A pulse oximeter measures the percentage of hemoglobin saturation. Normal SPO2 in room air should measure between 98 and 100. A percentage less than 96 in a nonsmoker 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

a. Acute psychosis

occurred when the patient develops one ore more of the following symptoms: hallucinations, delusions, catatonia, or a thought disorder

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

Abandonment occurs when the medical provider leaves the patient alone or in the care of someone who is not competent in the care of the patient. This is done without the consent of the patient. Assault is placing the patient in fear or immediate bodily harm. Battery is unlawfully touching the patient, including providing care without consent. Negligence is the failure to provide the same care that another equally competent health care provider would have provided. Defamation is the communication of false information that damages the reputation of a person. Libel is written and slander is spoken defamation.

2. Understand the anatomy and physiology and how to determine adequate ventilation's.

Adequate breathing is indicated by regular, unlabored, bilateral, and equal rise and fall of the chest.

a. Agonal, Cheyne Stokes, or Kussmaul respirations

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

b. Function of the hypoxic 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 backup mechanism in chronic levels of minimal oxygen. Less sensitive sensors in the brain, walls of the aorta, and carotid arteries control oxygen levels via respiration. Patients with COPD generally utilize hypoxic drive, so they should be monitored if administered oxygen.

Understand the different types of medical control and how/when to use it.

An EMT is trained in basic life support and emergency services.

Differentiate: advanced directives versus do not resuscitate (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 or she be unable to make rational decisions. They can be orders for both providing and withholding care. A DNR orders medical providers to withhold CPR and ALS, but does not prevent them from providing BLS. Without a DNR healthcare providers will begin to attempt resuscitation should the patient's heart stop.

2. Understand how and AED works and when to use it.

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

3. Understand the medications used in anaphylaxis and they work on the body.

Anaphylaxis is a severe, potentially life-threatening allergic reaction. It can occur within seconds or minutes of exposure to something you're allergic to, such as peanuts or bee stings. Anaphylaxis causes your immune system to release a flood of chemicals that can cause you to go into shock — your blood pressure drops suddenly and your airways narrow, blocking breathing. Signs and symptoms include a rapid, weak pulse; a skin rash; and nausea and vomiting. Common triggers include certain foods, some medications, insect venom and latex. Anaphylaxis requires an injection of epinephrine and a follow-up trip to an emergency room. If you don't have epinephrine, you need to go to an emergency room immediately. If anaphylaxis isn't treated right away, it can be fatal

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

Angina pectoris, or angina, is characterized by a crushing, squeezing pain in the chest directly below the sternum. Angina can be accompanied by nausea, dizziness, shortness of breath, or sweating. It is treated with supplemental oxygen, nitroglycerin, and rest in a comfortable position. Myocardial infarction (MI) occurs when heart muscle cells begin to die as a result of lack of oxygen. Signs and symptoms are very similar to those of angina, but MI can occur at any time and lasts longer than angina. Treatment includes supplemental oxygen, nitroglycerin, and rest in a comfortable position. Cardiogenic shock and congestive heart failure can occur as a result of an AMI. Aspirin is also a common treatment for chest pain.

1. Understand common abdominal conditions.

Appendcitis-right lower quadrant (direct); around navel (referred); rebounding pain (pain felt on the rebound of 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 Stone-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

f. Atherosclerosis vs arteriosclerosis

Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from your heart to the rest of your body (arteries) become thick and stiff — sometimes restricting blood flow to your organs and tissues. Healthy arteries are flexible and elastic, but over time, the walls in your arteries can harden, a condition commonly called hardening of the arteries. Atherosclerosis is a specific type of arteriosclerosis, but the terms are sometimes used interchangeably. Atherosclerosis refers to the buildup of fats, cholesterol and other substances in and on your artery walls (plaque), which can restrict blood flow. Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't have any symptoms. You usually won't have atherosclerosis symptoms until an artery is so narrowed or clogged that it can't supply adequate blood to your organs and tissues. Sometimes a blood clot completely blocks blood flow, or even breaks apart and can trigger a heart attack or stroke.

3. Understand how to manage newborn care and neonatal resuscitation.

As a part of APGAR scoring, pediatricians measure the vital signs of the baby. 1st minute APGAR score predicts the immediate outcome of the baby while the 5 minute APGAR score predicts the future outcome. Hypoxic damage to the brain is irreversible. Initial Steps of Resuscitation: Dry the baby and remove the wet cloth. Keep the baby warm either by a warmer or direct skin to skin contact with mother. Assess crying and breathing while drying:- Breathing well: Crying or breathing quietly and regularly.- Not breathing well or gasping respiration. If the baby is not breathing well after initial steps Open the airway. The baby should be positioned on the back, with the Neck slightly extended in Neutral position. Clear the airway: No need of Routine suction to every baby. Sometimes improper suctioning with much pressure causes injury and bleeding. Give suction first in the oral cavity 5cm in the mouth and then in the nose up to 3cm. Do not suction more than 10 seconds at a time. Once the airway is clear, stimulate the breathing by rubbing along the spine with the hypothenar eminence of hand.

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

As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim to assess whether or not he or she is responsive. Are you OK? Can you hear me? If the patient is unconscious, you'll want to assess for normal breathing and determine if the patient has a pulse. As you know by now, the presence of a pulse but not normal breathing means you'll go right into rescue breathing. While the absence of both means you'll perform full CPR. For patients with known or suspected opiate/opioid addiction issues, the immediate course of treatment is administering naloxone, either by intramuscular injection or intranasal mist. Of course, make sure administering naloxone is allowed per your organization's regulations and protocols.The benefit of using a nasal atomizer is that it will administer the naloxone in a readily available form, like a fine mist which the patient can quickly absorb. To administer naloxone via the nasal atomizer, proceed with the following steps: Assemble the nasal atomizer per the instructions. Tilt the patient's head back slightly. Position the nasal atomizer into one nostril and briskly spray half of the amount (approximately 1cc). Position the nasal atomizer into the other nostril and spray the remaining naloxone. Wait 3-5 minutes. Continue to perform rescue breathing or CPR while waiting for the naloxone to take effect. If there isn't any change in the patient after 3-5 minutes, administer a second dose of naloxone. If a second dose doesn't revive the patient, something else is likely wrong. Either there aren't any opiates in the patient's system. Or they're unusually strong or plentiful and will require more naloxone.

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

Ask the following questions: 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 do the contractions last? Have you had 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 the patient says that she is about to deliver, she has to move her bowels, or feels the need to push, immediately prepare for a delivery and consider calling for additional resources. The fetus's head is probably pressing on the rectum, and delivery is about to occur. Never attempt to hold the patient's legs together, because this will only complicate the delivery. Do not let her go to the bathroom. Reassure her that the sensation of needing to move her bowels is normal and that it means she is about to deliver. Use standard precautions at all times. Administer oxygen to the patient if indicated. Limit distractions for yourself and the patient. Recognize when the situation is beyond your level of training. If there is any doubt, contact medical control for further guidance. If you are unsure about what to do, transport the patient even if delivery might occur during transport. Once you have determined that delivery is imminent, and you have positioned the patient in an acceptable location, open the OB kit and continue to prepare for the delivery. Third trimester bleeding:Bleeding is a heavier flow of blood. With bleeding, you will need a liner or pad to keep the blood from soaking your clothes. An ectopic pregnancy is a complication in which the fertilized and developing embryo implants outside the uterus. Possible sites of implantation include the Fallopian tube (the most common site, termed a tubal pregnancy), ovaries, cervix and in the peritoneal cavity

c. Assisted ventilation or Rescue Breathing

Assisted ventilations help the patient to breathe, and rescue breathing replaces independent breathing in the case of continuous apnea.

d. Battle's signs, raccoon eyes, jugular vein distention, or tracheal deviation.

Battle sign is bruising over the mastoid process that may indicate a skull fracture. Jugular vein distention is a visible bulging of the jugular veins in the neck that may indicate fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax. Raccoon eyes is bruising under the eyes that may indicate a skull fracture. Tracheal deviation can indicate respiratory or cardiac problems.

4. Understand the various types of chemical/nerve/biologic agents.

Biologic agents are grouped as: Viruses Bacteria Neurotoxins They may be spread in various ways. Dissemination is the means by which a terrorist will spread the agent—for example, poisoning the water supply or aerosolizing the agent into the air or ventilation system of a building. A disease vector is an animal that, once infected, spreads disease to another animal. How easily the disease is able to spread from one human to another human is called communicability. In instances when communicability is high, such as with smallpox, the person is considered contagious. Nerve agents, discovered while in search of a superior pesticide, are a class of chemical called organophosphates, which are found in household bug sprays, agricultural pesticides, and some industrial chemicals at much lower strengths than in the weaponized form. Sarin (GB) is a 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, depending on the purity Soman (GD) is twice as persistent as sarin and 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) is approximately half as lethal as sarin and 36 times more persistent. V agent (VX) is a 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.

b. 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 that are measured: the systole and the diastole. The systole occurs as the the left ventricle forces blood into the aorta, and the diastole occurs as the left ventricle relaxes and blood rushes back into it.

2. Understand the classifications of burns by age.

Burns to children are generally considered more serious than burns to adults. The reason is that infants and children have more surface area relative to total body mass, which means greater fluid and heat loss. In addition, children don't tolerate burns as well as adults do.Many burns in infants and children result from child abuse. The classic burn resulting from deliberate immersion involves the hands and wrists, as well as the feet, lower legs, and buttocks. Similarly, burns around the genitals and multiple cigarette burns should be viewed as possible abuse. Report all suspected cases of abuse to the proper authorities, especially those where a significant delay in evaluation and treatment is evident.

4. 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 obstruction. 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. COPD patients often have a history of lung problems. They will show signs of difficult breathing such as using accessory muscles, pursed lips, and abnormal breath sounds.

d. Carbon monoxide poisoning

Carbon monoxide binds to hemoglobin and prevents oxygen from binding to hemoglobin. Symptoms include flu-like symptoms such as dizziness, nausea, headache, upset stomach, and death

3. Understand the signs and symptoms:

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 widespread dilation of the vessels. Hypovolemic shock occurs as a result of inadequate blood volume. Respiratory insufficiency occurs when respirations are compromised, which leads to an inadequate supply

e. Hemiparesis

or unilateral paresis, is weakness of one entire side of the body