Emergency Medical

Technician – Basic

Course Manual
Life Support Training International
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 Life Support Training International

Emergency Medical Technician - Basic (EMT-B) Course Manual

This work is protected by copyright in The Philippines and internationally. No part of

this course may be reproduced without the written permission of Life Support Training

International (LSTI). All rights reserved.

This first edition produced 2010.

Edited by Craig Barrett, BA, PG Dip Ed, EMT-B

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 Editor’s Note

Welcome to the first edition of the Emergency Medical Technician-Basic manual published by
Life Support Training International. The manual aims to help you on your journey to becoming a
competent EMT-B by providing you as much information as possible to supplement the lectures

provided by LSTI.

As you proceed through the manual, please note that all information was current at the time of
publishing. As new treatments and protocols are released, your lecturers will update you to keep

you current with worldwide standards.

For the Philippines, the prehospital care system is about to undergo significant changes with the
passing of the EMS Bill by the Philippine Senate.

This book is dedicated to Aidan and Joann Tasker-Lynch, without whom the EMS industry in the
Philippines would still be poorly developed. It is their vision and dedication to prehospital care
and the Filipino EMT that gives us all hope for nation-wide professional EMS services, with
world-class Filipino EMTs providing the best possible care for the Filipino people.

On a final note, as a graduate of LSTI Batch 67, I congratulate you on your decision to become
an EMT. It is a difficult but immensely rewarding course you are to undertake, and hopefully it is

the beginning of a career you will be passionate about.

Craig Barrett, EMT-B

LSTI-Batch 67

Quezon City 2010

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Contents

Chapter Page

1 EMS In The Philippines 1

2 Roles and Responsibilities of the EMT 10
3 Medico-Legal and Ethical Issues in EMS 20
4 Ambulance Vehicles and Equipment 28
5 Medical Terminology in EMS 37
6 Infection Control and the EMT 48
7 Anatomy for EMTs 57
8 Health, Hygiene, Fitness and Safety of the EMT 71
9 Patient Assessment 75
10 Communication and Documentation 110
11 Airway Management 123
12 The Basic ECG 155
13 The Automated External Defibrillator 164
14 Environmental Emergencies 178
15 Bleeding and Shock 200
16 Poisoning and Substance Abuse 212
17 Diabetic Emergencies 225
18 Infectious Diseases 236
19 The Acute Abdomen 247
20 Burns 252
Appendices

Appendix 1 ERC Guidelines (2010)

 Chapter 1: EMS In The Philippines

Chapter 1:
EMS In The Philippines
Outline

 Life Support Training International

 Philippine Society of Emergency Medical Technicians
 PSEMT Affiliations
 PSEMT Membership Grades
 LSTI Academic Policies and Procedures

Life Support Training International

L
ife Support Training International is the Philippines’ industry leader in all
levels of instruction in pre-hospital emergency medical care and is
dedicated to the spread of knowledge in handling all traumatic and
medical emergencies.

Our consultants have been involved in developing Emergency Medical Services

Systems (EMSS) in various parts of the world, ranging from the United Kingdom
to the Middle East, the Western Pacific Region and, indeed, here in The
Philippines. In the Philippines, we work closely with Emergency Medicine
Consultants from the University of the Philippines, Philippines General Hospital,
Department of Emergency Medicine. Life Support Training International is
heavily involved with the Philippine Heart Association, being active members of
both the Expanded Council on Resuscitation and the National Emergency
Medical Services Council. We are also the founding executive members of the
Philippine Society of Emergency Medical Technicians, which is a society
dedicated to developing a National Emergency Medical Services System
throughout The Philippines.

Our faculty is composed of only the most qualified and experienced instructors
ranging from trained Trauma Surgeons and fully registered Emergency Medical

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Chapter 1: EMS In The Philippines

Technicians and Paramedics - WE GIVE YOU ONLY THE VERY BEST. Our
standards of training meet with the highest of international standards and
great care is taken to mould the courses to meet your specific requirements.
We will help students to develop the essential knowledge, skills and
confidence in order to be able to provide essential Emergency Life Support in
times of crisis.

Life Support Training International is currently The Philippines only fully

certified training and assessment center for the Philippine Society of
Emergency Medical Technicians and, internationally, the Australasian Registry
of Emergency Medical Technicians (AREMT) and the Technical Education and
Skills Development Authority (TESDA).

WHEN THEY DEPEND ON YOU

YOU CAN ALWAYS DEPEND ON US!

Philippine Society of Emergency Medical Technicians

The Philippine Society of Emergency Medical Technicians (PSEMT) is a non-

profit, non-political, non-union body which is dedicated to the cause of
pushing for the introduction of an effective National Ambulance System for all
citizens of The Philippines, irrespective of social status, cultural background,
religious beliefs or political affiliations.

The development of a first-class Emergency Medical Services System in The

Philippines is our prime objective, as this is absolutely essential in order to
form an integral link in the chain of delivering quality care to the ill and
injured. We must accept, however, that any chain is only as strong as its
weakest link, and with this in mind, the Philippine Society of Emergency
Medical Technicians has recognized that excellence can only be achieved
through education, training and maintenance of the highest standards. Our
National Training, Research and Development Council, has developed
comprehensive training guidelines which clearly outline the standards required
of all those seeking the implementation of truly professional standards of Pre-
Hospital Emergency Medical Care, and these standards will be required of
anyone seeking membership of the Society.

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 Chapter 1: EMS In The Philippines

It is clearly recognized that any Pre-Hospital Care System involving EMTs

requires the support and clinical supervision of physicians. The Society has
established a National Executive Council composed of some of the foremost
physicians and experts in the field of Pre-Hospital Emergency Care. This
council will formulate the legal framework for pre-hospital care professionals
to carry out their vital role. As outline above, the Society has established a
National Training, Research and Development Council, which is tasked with,
not only setting the Society’s Training Standards, but also establishing a
National Examination System to ensure that these standards are achieved and
maintained. This council has also been tasked to carry out continuing research
and development in the field of Pre-Hospital Emergency Care to ensure that
members are keep abreast of advances in equipment and techniques.

We are pleased to announce that, due to our adherence to the highest of

international standards and practice, the Philippine Society of Emergency
Medical Technicians was, in March 2007, awarded direct and complete
reciprocity with the Australasian Registry of Emergency Medical Technicians
(AREMT). The AREMT is an Australian-based pre-hospital professional body,
which bases its standards on both the US Department of Transport and
European models of pre-hospital care. Due to this recognition, the Filipino
EMT is justifiably and proudly acknowledged as a world-standard professional.

PSEMT Affiliations

American College of Emergency Physicians

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Chapter 1: EMS In The Philippines

Emergency Care and Safety

Institute

Australasian Registry of
Emergency Medical Technicians

International Liaison Committee

on Resuscitation

Philippine Heart Association

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 Chapter 1: EMS In The Philippines

PSEMT Membership Grades

The following are the grades of membership for the PSEMT:

 ASSOCIATE MEMBER
 BASIC EMERGENCY MEDICAL TECHNICIAN - EMT (B)
 EMERGENCY MEDICAL TECHNICIAN, DEFIBRILLATOR TRAINED - EMT (D)
 EMERGENCY MEDICAL TECHNICIAN, INFUSION & INTUBATION TRAINED -
EMT (I & I)
 ADVANCED EMERGENCY MEDICAL TECHNICIAN - EMT (A)
 REGISTERED EMERGENCY MEDICAL TECHNICIAN, PARAMEDIC - REMT (P)
 REGISTERED EMERGENCY MEDICAL SERVICES INSTRUCTOR - REMSI

Associate Membership

This level will allow entry to all that hold current First Aid and Basic Life Support
Provider certificates from a Recognized Training Agency. The minimum requirement
will be thirty-two hours of instruction in First Aid, with a further eight hours in Basic
Life Support.

Basic Emergency Medical Technician - EMT (B) “Certification”

This is the initial entry grade for all professional pre-hospital care providers. This
grade is inclusive of ambulance staff and nursing personnel who can demonstrate
appropriate training and experience in line with PSEMT/PBEMT published standards.
Entry may be afforded to applicants who are outside the full time professional
sector on achievement of the following requirements:

 Completion of a PSEMT/PBEMT approved 280 hour training course and the

achievement of the required pass mark in all sections of the National Final
Examination.
 Proof of a minimum of 250 hands-on patient management in the preceding
twelve months. This must be confirmed by the applicant’s Officer-In-Charge
and duly approved by the Society’s National Executive Committee.
 Completion of a minimum of 40 hours continuous medical education.
 Submission of a personal log of experience gained.
 Successful completion of National Examinations.

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The minimum age shall be 20 years.

Emergency Medical Technician, Defibrillator - EMT (D) “Certification”

All applicants must be a certified Emergency Medical Technician (EMT) with a

minimum of three (3) months full-time post-EMT (B) certification experience,
which must include emergency response duties. They must have successfully
completed the prescribed defibrillation module, and examinations thereof,
which will include all the content as outlined in the Society’s National Syllabus.

Re-registration will be required on an annual basis and all applications thereof

must be accompanied by a competency certificate duly countersigned by an
Emergency Medical Practitioner who has been approved by PSEMT/PBEMT.

Emergency Medical Technician Advanced - EMT (A) “Registration”

Entry requirement must be that of EMT (I & I) with not less than six (6) months
post-certification experience. In addition to this, all applicants must have
successfully completed two hundred hours instruction in Advanced Cardiac
Life Support and Advanced Trauma Management and the examinations
thereof.

Re-registration will be required on an annual basis and all applications thereof

must be accompanied by a competency certificate duly countersigned by an
Emergency Medical Practitioner who has been approved by PSEMT/PBEMT.

Registered Emergency Medical Technician Paramedic - EMT (P)

“Registration”

The minimum entry criteria for Paramedic training is EMT Advanced (A), in
accordance with the standards set out by the PSEMT/PBEMT, with at least six
(6) months post-certification experience. All applicants must have successfully
completed the three hundred and sixty (360) hour Advanced Clinical Training
modules. This level will only be available to those who complete a minimum of
seven hundred and fifty (750) hours actual operational experience per year.

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Re-registration will be required on an annual basis and all applications thereof

must be accompanied by a competency certificate duly countersigned by an
Emergency Medical Practitioner who has been approved by PSEMT/PBEMT.

Registered Emergency Medical Services Instructor - REMSI

This level has yet to be defined.

Exemptions

Exemptions from some requirements may be considered based on

alternative qualifications and experience. Requests for exemption will be
reviewed by the PSEMT National Training, Research and Development
Council and the PBEMT. Their decision will be considered final.

LSTI Academic Policies and Procedures

Course Performance Rating

Students’ overall performances are evaluated via the following:

 Weekly Examinations 10%

 Attendance and Timekeeping 10%
 Final Written Examination 45%
 Final Practical Examination 35%

Passing grade is set at 75% in all written and practical examinations. In

accordance with the Philippine Heart Association (PHA), a minimum passing
grade of 80% is required for the Basic Life Support (BLS) written examination.
BLS certification is a mandatory requirement for the issuance of EMT
certification.

Payment of Tuition Fees

Training fees may be paid on an instalment basis, but must be paid in full,
whether or not the candidate chooses to complete the course - in other words,
all students who start the course are obliged to pay in full, irrespective of the
outcome thereof.

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Chapter 1: EMS In The Philippines

Reservation fee - PHP5000 (Non-refundable)

Weekly payment - PHP3000 (Week 2-6 inclusive)

LSTI meticulously enforces the payment schedule given to students on the first
day of the class. Students should follow the schedule diligently.

Life Support Training International reserves the right to terminate the training
of any student who fails to honor the set payment schedule.

Weekly Assessment

Every Monday morning, starting week 2, an assessment/examination shall be

conducted to gauge the student’s performance and knowledge. All policies
regarding examinations, payment of fees etc. are applicable.

Final Examinations

The final examination is done under the strict supervision of the Philippine
Society of Emergency Medical Technicians (PSEMT) and the Australasian
Registry of Emergency Medical Technicians (AREMT).

The high standards of training shall not be compromised in any way, and as
such:

Any cheating, or perceived attempt to cheat, in the Final Examinations will

be subject to immediate disqualification, and those involved will forfeit
any chance to re-sit the exam.

Students must settle all outstanding accounts before the Final Examination.
Non-payment or incomplete payment of tuition fees will result in forfeiture of
the student’s chance to take the examination.

Re-Sit/Re-Examination

In the case of failures, re-sit/re-examination shall be done at a time and date

designated by the PSEMT/AREMT. All students are obliged to follow the
scheduled examination date.

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 Chapter 1: EMS In The Philippines

For the EMT Final Written Examination PSEMT/AREMT policy allows for a
maximum of two (2) sits only (1 exam and 1 re-sit).

For the Basic Life Support Written Examination, a maximum of three (3) sits are
allowed (1 exam and 2 re-sits). No EMT certification can be awarded to a
candidate without successful completion of both practical and theoretical
examinations in Basic Life Support.

Validity of the re-sit/re-examination is limited to within one (1) year from the
time the student finishes the course. If a student fails to re-sit or take the Final
Examination within this grace period, he/she shall forfeit their right to retake
said Final Examination.

Under no circumstances will a candidate who has failed the final examinations
and re-sit be accepted for retraining at LSTI.

Students who fail all the re-sits/re-examinations shall not be awarded any
certificate of proficiency.

In accordance with PSEMT/AREMT policies, repetition of the EMT-Basic Course

is also not permitted.

Smoking is strictly
prohibited in and
around the
training facility at
all times.

Please put all your litter in the

numerous garbage receptacles
provided around the training
facility for student use.

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Chapter 2: Roles and Responsibilities of the EMT

C h a p te r 2 :
Roles and
Responsibilities of the
E MT
Outline

 The Star of Life

 The Emergency Medical Services System
 Components of the Emergency Medical Services System
 Roles and Responsibilities of the EMT
 Professional Attributes

The Star of Life

J
ust as physicians have the caduceus, and pharmacists the mortar and
pestle, Emergency Medical Services have the ‘Star of Life’, a symbol
whose use is encouraged by both the American Medical Association
and the Advisory Council within the Department of Health and Human
Services. On road maps and highway signs, the Star of Life indicates the
location or access to qualified emergency care services.

The Star of Life was designed by Leo Schwartz, EMS Branch Chief at the
National Highway Traffic Safety Administration (NHTSA) USA. The star of life
was created in 1973 as a common symbol to be used by US emergency
medical services (EMS) and medical goods pertaining to EMS.

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 Chapter 2: Roles and Responsibilities of the EMT

The symbol’s six-barred cross represents the six-system function of

Emergency Medical Services. The staff in the center of the symbol
represents medicine and healing. According to Greek mythology, the staff
belonged to Asclepius, the son of Apollo (god of light, truth and
prophesy), who learned the art of healing.

The Emergency Medical Services S

Regulation and Policy

Laws that allow the system to exist.

Resource Management

Centralized coordination of resources (i.e. hospitals) to have equal access to basic

emergency care and transport by certified personnel in a licenced and equipped
ambulance, to an appropriate facility.

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Chapter 2: Roles and Responsibilities of the EMT

Human Resources and Training

All personnel who ride ambulances should be trained at the minimum level
using a standardized curriculum.

Transportation

Safe, reliable ambulance transportation is a critical component.

Communications

There must be an effective ccommunications system, beginning with a

universal access number

Public Information and Education

Efforts to educate the public about their role in the EMS system and
prevention of injuries.

Medical Direction

Involvement of EMS physicians in all aspects of pre-hospital emergency

medical care practice.

Trauma Systems

Development of more than one trauma center. Triage and transfer guidelines
for trauma patients, rehabilitation programs, data collection and means for
managing and assuring the quality of the system.

Evaluation

Program for improving the EMS system.

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 Chapter 2: Roles and Responsibilities of the EMT

Roles and Responsibilities of the EMT

 Personal Safety

An EMT is no good if he or she becomes another victim.

 Safety of the Crew, Patient and Bystanders

 Patient Assessment

Finding out what is wrong with your patient to be able to undertake

emergency medical care.

 Patient Care

Preparation for action or a series of actions to take that will help the
patient deal with and survive illness or injury.

 Lifting and Moving

Effective and safe application of patient handling procedures to avoid

self-inflicted and career-ending injuries.

 Transport

A serious responsibility in ambulance operations, even more so with a

patient on board.

 Patient Advocacy

Moral responsibility to speak on behalf of the patient’s need of attention

for a particular cause. Must develop a rapport that will give understanding
of the patient’s condition.

Professional Attributes of the EMT

Appearance

Excellent personal grooming and a neat clean appearance to instil confidence

in patients.

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Chapter 2: Roles and Responsibilities of the EMT

Knowledge and Skills

A successful completion of EMT-B training and the knowledge to know:

• The use and the maintenance of common emergency

equipment.

• How and when to assist the administration of medications

approved by medical direction or protocol.

• How to clean, disinfect and sterilize non-disposable equipment.

• Personal safety and security measures, as well as for other

rescuers, the patient and bystanders.

• The territory and terrain within the service area.

• Traffic laws and ordinances concerning emergency

transportation of the sick and injured.

Physical Demands

Good physical health and good eyesight to properly assess the patient and drive
safely.

Temperament and Abilities

• A pleasant personality

• Leadership ability

• Good judgement

• Good moral character

• Stability and adaptability

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 Chapter 2: Roles and Responsibilities of the EMT

Components of Emergency Medical Services Systems – In Depth

The following 15 components have been identified as essential to an EMS system:

• Communication

• Training

• Manpower

• Mutual Aid

• Transportation

• Accessibility

• Facilities

• Critical Care Units

• Transfer of Care

• Consumer Participation

• Public Education

• Public Safety Agencies

• Standard Medical Records

• Independent Review and Evaluation

• Disaster Linkages

The above design has proved proficient in many aspects, including medical direction and
accountability, prevention, rehabilitation, financing and operational and patient care
protocols. EMS systems continued to be refined in the 1980s and 1990s.

Successful EMS systems are designed to meet the needs of the communities they serve.
The state provides laws that broadly outline what is prudent, safe and acceptable. To be
effective, EMS systems must be planned and operated at the local level.

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Chapter 2: Roles and Responsibilities of the EMT

Communities need to identify their individual needs and resources, develop funding
mechanisms, and become involved at all levels in structuring the system. A governing
body or council should be established to organize, direct and coordinate all system
components. The council consists of representatives from the local medical, EMS,
consumer and public safety agencies to ensure consensus in developing policies and
settling disputes. The EMS system must provide equal access to all, and remain
protected from forces that serve the interests of only one group.

Medical Direction

Physician input, leadership and oversight in ensuring that medical care provided is safe,
effective and in accordance with accepted standards. Physicians must be empowered and
imvolved in planning, implementing, overseeing and evaluating all components of the
system. Medical direction is characterized as either immediate (on-line) or organisational
(off-line).

On-line medical direction provides EMTs with consultation in the field, either in person or,
more commonly, via radio or telephone communication. This responsibility is delegated
medical director to physicians who staff local Emergency Departments. The base station
facility providing on-line control is required to monitor all advanced life support (ALS)
communications, provide field consultations, and notify receiving facilities of incoming
patients. Physicians providing on-line direction should be appropriately trained and
familiar with the operations and limitations of the system.

The medical director assumes authority and responsibility for off-line medical direction. In
cooperation with the local medical community, the medical director is responsible for
developing standards, protocols, policies and procedures; developing training programs;
issuing credentials and providing evaluations; and implementing a process for continuous
quality improvement.

Communications

A comprehensive communications plan is essential to provide the community access to

system dispatch and to provide the EMT access to medical direction and additional
resources. The establishment of a universal access number (911 in the US and Canada or
999 in the UK for example) has greatly improved the system’s accessibility. Additional
advancements have been made with enhanced systems, such as the enhanced 911

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 Chapter 2: Roles and Responsibilities of the EMT

system, which automatically provide the dispatcher with the caller’s address and
telephone number. Using enhanced systems, callers can obtain services even if they are
unable to communicate with dispatch. Emergency medicine dispatch includes assessment
of patient location and status, as well as the provision of pre-arrival instructions.

Ground vehicles provide most EMS transportation. Ambulances should be constructed

according to federal or national standards, and be appropriately equipped to provide
basic or advanced level of care. Air transport, such as a helicopter or airplane, may also be
either BLS or ALS. Air transport is used to transport patients over greater distances,
decrease total pre-hospital time or to reach patients in poorly accessible locations.
Operational standards are established to delineate the equipment needed, the number of
personnel and the level of certification required, as well as the response-time criteria and
the destination for each transport.

On-line medical direction should be obtained in all calls that result in transport. This
includes:

• Decision to transport;

• Patient refusal of care; and

• Triage to a lower level of care.

Otherwise, the provider may be perceived as practicing without a licence, and could be
charged with an offence.

Transportation

Inter-facility transportation occurs once the patient has been examined and stabilized.
Patients are transported in compliance with regional protocols and federal, national or
state laws (e.g. Consolidated Omnibus Budget Reconciliation Act [COBRA] and Emergency
Medical Treatment and Active Labor Act [EMTALA] in the US). Legislation dictates that
medically unstable patients be transferred only when the transfer is expected to have a
positive effect on outcome.

Patients should be transported to the closest, most appropriate facility. Receiving facilities
are required to have the capabilities to treat the patients, stabilize their condition, and
improve their outcome. Stable patients may be transported to the hospital of their choice,
as long as the transport meets regional point-of-entry protocols, has the approval of on-
line medical control, and does not necessarily overburden the system.

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Chapter 2: Roles and Responsibilities of the EMT

Specialized resources to care for the severely injured are not available in every hospital.
Local communities need to establish regional protocols to provide clear guidance for the
transport of unstable patients to categorized facilities. Unstable patients with special
problems, such as burns or trauma, can be transported to regionally designated hospitals,
bypassing closer facilities.

Training Standards

Providers must be trained to meet the expectations and requirements in programs that
comply with regional and national standards. Training includes didactic, clinical and field
components. Most states require that candidates pass written and practical examinations
prior to certification. Additionally, EMTs are required to receive continuing didactic and
clinical education to maintain certification.

Education is also used to reinforce proper patient care, update standards and protocols,
and remedy perceived deficiencies in patient care. Physician involvement is essential to
assure appropriate utilizations of skills and equipment. The EMS system also provides
community education, such as public courses in CPR, first aid, child safety and EMS access.

Protocols

Protocols are developed to deal with operational, administrative and patient care issues.
They define a standardized, acceptable approach to commonly encountered problems.
Protocols should reflect regional and national standards, as well as the uniqueness and
limitations of the local environment. The medical director has the responsibility to address
protocols dealing with patient care, such as triage and treatment.

Triage assesses the condition of each patient, sorts patients into treatment categories, and
optimizes use of field resources for treatment and transport. In addition, triage addresses
the level of provider during multiple casualty incidents to facilitate the screening,
prioritization, treatment and transport of patients.

Treatment protocols describe the authority and responsibilities of providers and offer
guidance for medical evaluation and care. Optimal care and medical accountability require
standardized protocols, algorithms and standing orders that outline specific actions
providers can take without contacting a physician for orders. Any deviation from these
standing orders must be considered a breach of duty and must result in an audit. On-line
medical direction is crucial in systems, requiring decision-making to provide guidance and
assume some of the patient-care responsibilities.

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Continuous Quality Improvement

Continuous quality improvement (CQI) is the sum of all activities undertaken to assess
and improve the products and services EMS provides. The goal is to influence patient
outcomes positively by delivering products timely, consistent, appropriate,
compassionate and cost-effective systems. CQI ensures that the field staff provides the
highest quality of care and that the system supports this goal. Quality should be
monitored from within the EMS system and by an external, independent and unbiased
body that involves the consumer, government and medical communities. Standardized
protocols, policies, performance and documentation are invaluable in constructing a
successful CQI process.

Quality evaluation is prospective, concurrent and retrospective. Prospective evaluation

is most effective process to ensure quality in EMS, because it has the potential to
prevent mistakes. The system must be scrutinized constantly to determine areas
requiring refinement and improvement. When goals and standards are not met, CQI
staff members must identify the problem, establish and implement a corrective course
of action, and measure the outcome. Concurrent evaluation occurs on scene or on-line.
Staff members observe performance, encourage positive behavior and correct
problems before bad habits develop. Retrospective evaluation is the least valuable and
most time-consuming. It includes critique sessions and reviews of patient encounter
tapes and charts.

Disaster Preparedness

The EMS system is an integral part of disaster preparedness and planning. It plays an
important role in initial response and transportation, and is essential in establishing a
regional disaster preparedness plan in coordination with public safety agencies,
government and the medical community. The plan should address disaster
management, communication, treatment and designation of casualties. Periodic
disaster drills serve to assess performance, refine management and educate personnel
and the community.

Public support is invaluable in constructing a successful EMS system; involvement is

required to plan a system that works for everyone. Consumers need to be well
informed of the benefits of having an EMS system and how to gain access to it.

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Chapter 3: Medico-Legal and Ethical Issues in EMS

Chapter 3:
Medico-Legal and Ethical
Issues in EMS
Outline

 Definitions
 Patient Bill of Rights
 Ethical Implications
 Right of Refusal
 Legal Aspects
 Crime Scenes
 EMS Code of Ethics

Definitions

ETHICS - The science of right and wrong, of moral duties and of ideal behaviour.

MEDICAL ETHICS - The part of ethics that deals with the health care of human
beings.

Patient Bill of Rights

 The patient has the right to considerate and respectful care.

 The patient has the right to refuse treatment to the extent permitted by law
and to be informed of the medical consequences of his or her action.
 The patient has the right to expect that all communications and records
pertaining to his or her care should be treated as confidential.
 The patient has the right to expect continuity of care.

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 Chapter 3: Medico-Legal and Ethical Issues in EMS

In the Philippines, the Patient Bill of Rights is known as Title 111: Declaration of Rights.

Good Samaritan Law

 Protects a person from liability for acts performed in good faith, unless those
acts constitute gross negligence.
 Does not prevent one from being sued, although it may provide some
protection against losing a lawsuit if one has performed to the standard of
care for an EMT-B.
 Different standards may be held in different legal jurisdictions.

Medical Direction

The legal right to function as an EMT-B is contingent upon medical direction.

The EMT-B must:

 Follow standing orders and protocols

 Establish telephone and radio communications
 Communicate clearly and completely and follow orders given
in response
 Consult medical direction for any question about the scope
and direction of care

Duty to Act

The obligation to provide care. May be implied or formal.

IF ON-DUTY:

 legally obligated

IF OFF-DUTY:

 may stop and help; or

 may pass the scene and call for help; or
 may pass the scene and make no attempt to call for help.

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Ethical Responsibilities

 Serve the needs of the patients with respect for human dignity, without
regard to nationality, race, gender, creed or status.
 Maintain skill mastery.
 Keep abreast of changes in EMS which affect patient care.
 Critically review performances.
 Report with honesty.
 Work harmoniously with others.

Patient Consent and Refusal

Types of Consent

 Expressed consent
 Implied consent
 Consent to treat a minor or mentally incompetent adult

Advance Directives

 “Living Will”, DNR/DNAR

 Instructions written in advance documenting the wish of the chronically or
terminally ill patient not to be resuscitated and legally allows the EMT-B to
withhold resuscitation.
 Usually accompanied by a doctor’s written orders.
 Associated problems:
 More useful in an institutional setting.
 More than one physician may be required to verify the patient’s
condition.
 Scrutiny of an advance directive may be time consuming.

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Refusal of Treatment

Competency

A competent adult is defined as one who is lucid and capable of making

an informed decision.

Protecting yourself:

Do the following before you leave the scene:

Remember:
 Try to persuade the patient to accept treatment or
transport to a hospital. A competent adult is
 Make sure that the patient is able to make a defined as one who is lucid
rational informed decision. and capable of making an
 Consult medical direction as required by local informed decision.
protocol.
 If the patient still refuses, have them sign a refusal form.
 Before you leave, encourage the patient to seek help if certain
symptoms develop.

Other Legal Aspects

Abandonment and Negligence

Abandonment One stopped providing care for the patient without ensuring that
equivalent or better care would be provided

Negligence The care one provides deviates from the accepted standard of care
and this results in further injury to the patient

In order to establish negligence, it must be proved that:

 The EMT-B had a duty to act;

 The patient was injured, either physically or psychologically;
 The EMT-B violated the standard of care expected.
 The EMT-B’s action or lack thereof caused or contributed to the
patient’s injury.

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Confidentiality

Do not speak to the press, your family, friends or other members of the public about
details of the emergency care you provided to a patient.

Releasing confidential information requires a written release form signed by the

patient or a legal guardian.

Instances when an EMT-B is allowed to release confidential information:

 Another health care provider needs to know the information to continue medical
care;
 As requested by the police as part of a potential criminal investigation;
 As required on a third-party billing form;
 As required by legal subpoena;
 When a patient signs a release form.

Special Situations

Donors and Organ Harvesting

A legal signed document is required, such as a signed donor care sticker affixed to a
driver’s licence or an organ donor card.

To provide assistance in organ harvesting:

1. Identify the patient as a potential donor.

2. Communicate with medical direction regarding the possibility of organ
donation.
3. Provide emergency care that will maintain the vital organs.

Dying and Deceased Patients

If the person is obviously dead, you may be required to leave the body at the scene if
there is any possibility that the police will have to investigate.

In other situations, you may be required to arrange for transport of the body so that a
physician can officially pronounce the patient dead.

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Medical Identification Insignia

A patient with a serious medical condition may be wearing a medical identification

tag (bracelet, necklace or card).

Crime Scenes

General guidelines - a potential crime scene is any scene that may require police
support.

If you suspect a crime is in progress or a criminal is still active at a scene, do not

attempt to provide care to any patient. Try to avoid any item at the scene that may
be considered evidence.

Basic Guidelines for the EMT at a Crime Scene

 Touch only what you need to touch.

 Move only what you need to move.

 Do not use the phone unless authorised by the police.

 Observe and document anything unusual at the scene.

 If possible, do not cut through holes in the patient’s clothing.

 Do not cut through any knot in a rope or tie.

 If the crime is rape, do not wash the patient or allow the patient to wash,
change their clothing, use the bathroom or take anything by mouth.

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The EMT Code of Ethics

Professional status as an Emergency Medical Technician and Emergency Medical

Technician-Paramedic is maintained and enriched by the willingness of the individual
practitioner to accept and fulfil obligations to society, other medical professionals, and
the profession of Emergency Medical Technician. As an Emergency Medical Technician-
Paramedic, I solemnly pledge myself to the following code of professional ethics:

A fundamental responsibility of the Emergency Medical Technician is to conserve life, to

alleviate suffering, to promote health, to do no harm, and to encourage the quality and
equal availability of emergency medical care.

The Emergency Medical Technician provides services based on human need, with
respect for human dignity, unrestricted by consideration of nationality, race creed, color,
or status.

The Emergency Medical Technician does not use professional knowledge and skills in
any enterprise detrimental to the public wellbeing.

The Emergency Medical Technician respects and holds in confidence all information of a
confidential nature obtained in the course of professional work unless required by law
to divulge such information.

The Emergency Medical Technician, as a citizen, understands and upholds the law and
performs the duties of citizenship; as a professional, the Emergency Medical Technician
has the never-ending responsibility to work with concerned citizens and other health
care professionals in promoting a high standard of emergency medical care to all
people.

The Emergency Medical Technician shall maintain professional competence and

demonstrate concern for the competence of other members of the Emergency Medical
Services health care team.

An Emergency Medical Technician assumes responsibility in defining and upholding

standards of professional practice and education.

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The Emergency Medical Technician assumes responsibility for individual professional
actions and judgment, both in dependent and independent emergency functions, and
knows and upholds the laws which affect the practice of the Emergency Medical
Technician.

An Emergency Medical Technician has the responsibility to be aware of and participate

in matters of legislation affecting the Emergency Medical Service System.

The Emergency Medical Technician, or groups of Emergency Medical Technicians, who

advertise professional service, do so in conformity with the dignity of the profession.

The Emergency Medical Technician has an obligation to protect the public by not
delegating to a person less qualified, any service which requires the professional
competence of an Emergency Medical Technician.

The Emergency Medical Technician will work harmoniously with and sustain confidence
in Emergency Medical Technician associates, the nurses, the physicians, and other
members of the Emergency Medical Services health care team.

The Emergency Medical Technician refuses to participate in unethical procedures, and

assumes the responsibility to expose incompetence or unethical conduct of others to
the appropriate authority in a proper and professional manner.

The EMT Code of Ethics was written by Dr. Charles Gillespie and adopted by the
National Association of EMTs in 1978.

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Chapter 4: Ambulance Vehicles and Equipment

Chapter 4:

Ambulance Vehicles and

Equipment
Outline

 Introduction

 North American Ambulance Designs

 European Ambulance Designs

 Paramedic Fast Response Vehicles

 Helicopter Emergency Medical Services (HEMS)

 Standard Ambulance Equipment

 Daily Checks of Ambulance Equipment

 Cleanliness

 Phases of an Ambulance Call

 Emergency Driving

 Ambulance Hygiene

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Introduction

M
odern ambulances have evolved into sophisticated vehicles, with modern
safety features such as ABS brakes and airbags. Many newer ambulances
look similar to older vehicles, with changes related to the use of new
lightweight materials and increased safety features. Ambulances now are often
equipped with GPS and computer dispatch systems. Ambulances are equipped
according to their role - basic transport, Intermediate Life Support (ILS), Advanced Life
Support (ALS), or Mobile Intensive Care Unit (MICU).

North American Ambulance Designs

Ambulance vehicle designations in the USA are governed by federal laws and
standards.

In America, an ambulance is defined as a vehicle used for emergency medical care

that provides:

 A driver’s compartment.
 A patient compartment to accommodate an emergency medical services provider
(EMSP) and one patient located on the primary cot so positioned that the primary
patient can be given intensive life-support during transit.
 Equipment and supplies for emergency care at the scene as well as during
transport.
 Safety, comfort, and avoidance of aggravation of the patient’s injury or illness.
 Two-way radio communication.
 Audible and Visual Traffic warning devices

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There are three basic ambulance specifications in North America:

 TYPE I AMBULANCE - a cab chassis furnished with a modular ambulance body.

 TYPE II AMBULANCE - a long wheelbase van, with integral cab-body.
 TYPE III AMBULANCE - a cutaway van with integrated modular ambulance body.

European Ambulance Designs

European ambulances are generally manufactured on an individual service

requirement basis. The general cab-chassis is similar to the North American Type II
vehicle but the interior is generally built to the customer’s specific requirements.
Fibreglass is used extensively in the manufacture of European vehicles - this promotes
vehicle handling characteristics as well as reducing overall weight and fuel
consumption.

Paramedic Fast Response Vehicles

These vehicles are utilized to deliver Advanced Life Support quickly and efficiently at
the scene of any emergency. The vehicle is either dispatched at the same time as an
ambulance unit or in advance of the ambulance unit when resources are limited and
demands on the service are high. Paramedic Fast Response Units are mobilized to
achieve early stabilization of the patient and rely heavily on ambulance follow-up for
transportation of the victim/s to the receiving medical facility.

Helicopter Emergency Medical Services (HEMS)

Helicopter Emergency Medical Services (HEMS) units are basically used for trauma and
high-dependency transfers. HEMS are particularly useful for the pickup of patients in
isolated areas where access by other forms of air, sea or road transport is difficult or just
not possible at all. It should be said that HEMS units are extremely costly to set up and

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run. Due to the high cost factor, HEMS units are usually run on a regional or national
basis as opposed to local operations.

Standard Ambulance Equipment

Monitoring Equipment:

BP Cuff / NIBP, Stethoscope, ECG Monitor Defibrillator, Vital Signs Monitor, Pulse
Oximeter, Thermometer.

Airway Equipment:

Oxygen Cylinder, Regulator, Flowmeter, Automated Transport Ventilator / Resuscitator,

Bag Valve Mask, Suction unit, Guedal Airways, Combitubes, Laryngeal Mask Airway,
Endotracheal Tubes.

Immobilisation / Splinting Equipment:

Scoop Stretcher, Vacuum Mattress, Extrication Device (KED), Cervical Collars, Head
Immobilizer, Extremity Splints, Traction Splint, Straps and harnesses.

Others:

Stretcher

Carry chair

Entonox

Medical Bag

Medical disposables according to checklist

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Daily Checks of Ambulance Equipment

It is the duty of the driver and assistant to check the vehicle and equipment according to the
checklist when reporting for duty. As emergency care professionals, we are dealing with
people’s lives each time we respond to a call, and a faulty vehicle or equipment could result in
the loss of a life that could have been saved. When checking equipment it is also vital to ensure
that all the equipment on the ambulance is clinically clean. The safety of the crew also depends
on any faults with the vehicle being noted and corrected.

Duties of Driver

 Check all fluid levels – fuel, engine oil, radiator coolant, automatic transmission fluid,
battery water levels before starting the vehicle. Also check for leaks under the vehicle.

 Check lights – headlights, taillights, direction indicators, rotators, flashers, sirens, etc.

 Check communications equipment – vehicle radio and handheld radio

 Check tyres for pressure, wear and damage.

 Check brakes – both foot and handbrakes

 Check all windows and mirrors

 Check all door latches and handles

 Check all seatbelts / passenger restraints

When checking the vehicle it is important to remember that the most engine wear occurs
during the first 30 seconds after start up, before the oil is circulated through the engine. DO
NOT rev the engine immediately on or after start up.

It is also important to remember that diesel engines with a turbo need to idle before shut
down. NEVER rev a turbo engine before turning off the ignition, as it can cause damage to
the turbo bearings, loss of power and shorten the life of the engine.

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Duties of Attendant

 Check equipment according to the checklist, making sure that all the equipment is
complete and in good working order.

 Check medical disposables according to checklist, noting expiry dates.

 Check oxygen cylinders are full, and that gauges and flowmeters are working.

 Make sure batteries are charged for any battery powered equipment such as ECG
monitors, pulse oximeters, etc.

 Make sure that the patient compartment, equipment and supplies are clinically
clean and thoroughly hygienic.

 Make sure that you know exactly how each item of equipment works, and the
trouble-shooting procedures for that item of equipment.

Cleanliness

Cleanliness of the vehicle, both inside and out serves two purposes. The first is that a
clean vehicle portrays a professional image. The second and more important function is
to ensure that both the crew and patients are protected from the transmission of
infection and communicable diseases by contaminated surfaces, linen, equipment, etc. It
is vitally important to clean the interior surfaces with approved disinfectants, as a surface
which appears clean, can harbour bacteria and viruses.

Phases of an Ambulance Call

1. Daily pre-run vehicle and equipment preparation

 Ambulance maintenance benefits:

• decreases vehicle downtime

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• improves response times to the scene

• safer emergency and non-emergency responses

• improves transport times to a medical facility

• safer patient transports to a medical facility

 Daily inspection of the vehicle

 Ambulance equipment

 Personnel

2. Dispatch

 Location of call.

 Nature of call.

 Name, location and callback number of the caller.

 Location of the patient.

 The number of patients and severity of the problem.

 Any other special problems or circumstances that may be pertinent.

3. En route to the scene.

4. At the scene.

5. En route to the receiving facility.

6. At the receiving facility.

7. En route to the station.

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8. Post run.

Emergency Driving

Emergency Driving Privileges

 Exceed the posted speed limit for the area as long as you are not
endangering lives or propery.
 Drive the wrong way down a one-way street or drive down the opposite side
of the road.
 Turn in any direction at an intersection.
 Park anywhere as long as you do not endanger lives or property.
 Leave the ambulance standing in the middle of a street or intersection.
 Cautiously proceed through a red flashing signal.
 Pass other vehicles in a no-passing zones.

Warning and Emergency Lights

 Warning lights must be activated at all times when responding to an

emergency call.
 Lights should be used even when you are not using the siren.
 Ambulance emergency lights should be high enough to cast a beam above the
traffic.

Ambulance Hygiene

After every call

 Strip used linens from the stretcher and place them in a plastic bag or designated
receptacle.

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 In an appropriate receptacle, dispose of all disposable equipment used for

patient care.

 Disinfect all non-disposable equipment used for patient care.

 Clean the stretcher with germicidal solution.

 If there is any spoilage or contamination in the ambulance, clean it up.

 Air out the ambulance with all doors and windows open for 15 minutes.

At least once a day:

 Empty the ambulance of the stretcher and equipment boxes.

 Disinfect the oxygen humidifier and refill with clean water.

 Scrub all the interior surfaces with soap and water.

 Scrub again with germicidal solution, then air out again to let everything dry.

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 Chapter 5: Medical Terminology in EMS

Chapter 5:
Medical Terminology in
EMS
Outline

 Words describing location

 Words describing position
 Medical terms by body systems
 Common medical abbreviations

Words Describing Location

Imaginary vertical line down the middle of the front

Midline surface of the body

Anterior Toward the front

Posterior Toward the back

Superior Above; toward the head

Inferior Below; toward the feet

Medial Nearer the midline of the body

Lateral Farther from the midline of the body

Proximal Nearer the point of attachment to the body

Farther from the point of attachment to the body
Distal (or the heart)

Internal Inside

External Outside

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Superficial Near the surface

Deep Remote from the surface

Words Describing Position

Erect Standing upright

Recumbent Lying down

Supine Lying face up

Prone Lying face down

Lateral Lying on the side

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Medical Terms By Body Systems

HEENT – Head, Ears, Eyes, Nose & Throat

Occipital - back of the head

Photophobia - intolerant of light

Phonophobia - intolerant of sounds

Diplopia - double vision

Epistasis - nosebleed

Rhinorrhea - runny nose or nasal discharge

Otorrhea - discharge from the ear

Tinnitus - ringing noise in the ear

NCAT - normocephalic, atraumatic

PERRL - Pupils Equal Round and Reactive to Light

Erythema - redness

Purulent - consisting of pus

Injected - blood vessel congestion, such as red eye

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Coronary & Pulmonary

Cor - Coronary (the heart)

Pulm - Pulmonary (respiratory system)

CTAB no rrw - Clear to auscultation bilaterally, no rales, ronchi or

wheezes

SOB - Shortness of Breath (dyspnea)

Productive cough - phlegm producing

Wheezing - high pitched sounds

Hemoptysis - coughing up blood

Pleuritic - worse with deep inspiration

Rales - crackles

Ronchi - wheezes/whistling sounds

Retractions - visible skin retractions with inspiration

Tachypnea - rapid breathing

Abdomen (Abd) or Gastrointestinal (GI)

Anorexia - loss or lack of appetite

Post-prandial - after eating

Emesis - vomiting

NBNB - non-bloody, non-bilious

Hematemesis - bloody emesis

Hematochezia - bloody stool

BRBPR - Bright Red Blood per Rectum

Melena - tarry black stool

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BS - bowel sounds (normoactive, hyperactive, hypoactive, absent)

TTP - tender to palpation, often more so in a single quadrant

Guarding - hard abdomen when palpated

Rebound - worse pain as examining hand is quickly pulled away

Genitourinary (GU)

Dysuria - painful urination

Hematuria - blood in the urine

Musculoskeletal & Extremities

MS - Musculoskeletal

Ext - Extremities

Myalgias - muscle aches

Arthralgias - joint aches

Edema - swelling

Skin

Pruritic - itchy

Macule - flat discoloration <10mm in diameter

Bumps:

Papule - bump 5mm or less

Nodule - well defined bump >5mm

Plaque - raised area

Sacs:

Vesicle - fluid filled sac <5mm

Bulla - fluid filled sac >5mm

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Pustule - sac filled with pus

Erythema - redness

Common Medical Abbreviations

AED Automated External Defibrillator

a.c. Before meals

ASA Aspirin

AMA Against medical advice

AMI Acute myocardial infarction

ASHD Arteriosclerotic heart disease

b.i.d. Twice a day

BP Blood pressure

BS Breath sounds, bowel sounds, or blood sugar

BVM Bag-valve-mask

c/o Complaining of

Ca Cancer/carcinoma

cc Cubic centimeter

CC Chief Complaint

CHF Congestive heart failure

CO Carbon monoxide

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COPD Chronic obstructive pulmonary disease (emphysema,

chronic bronchitis)

CPR Cardiopulmonary resuscitation

CSF Cerebrospinal fluid

CVA Cerebrovascular accident

CXR Chest X-ray

d/c Discontinue

DM Diabetes mellitus

DOA Dead on arrival

DOB Date of birth

Dx Diagnosis

ECG, EKG Electrocardiogram

e.g. For example

ETA Estimated time of arrival

ETOH Alcohol (ethanol)

Fx Fracture

GI Gastrointestinal

GSW Gun shot wound

gtt. Drop

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GU Genitourinary

GYN Gynecologic

h, hr. Hour

H/A Headache

HEENT Head, ears, eyes, nose, throat

Hg Mercury

h/o History of

hs At bedtime

HTN Hypertension

Hx History

ICP Intracranial pressure

ICU Intensive Care Unit

IM Intramuscular

IO Intraosseous

JVD Jugular venous distension

KVO Keep vein open

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L Left or Liter

LAC Laceration

LOC Level of consciousness

LR Lactated Ringers solution

mcg Micrograms

MS Morphine sulphate, multiple sclerosis

NAD No apparent distress

NC Nasal cannula

NKA No known allergies

npo Nothing by mouth

NRB Non-rebreather mask

NS Normal saline

NSR Normal sinus rhythm

NTG Nitroglycerin

N/V Nausea / vomiting

O2 Oxygen

OB Obstetrics

OD Overdose

OR Operating room

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PCN Penicillin

PEA Pulseless electrical activity

PERL Pupils equal and reactive to light

PID Pelvic inflammatory disease

PND Paroxysmal nocturnal dyspnea

po By mouth

PRN As needed

PSVT Paroxysmal supraventricular tachycardia

Pt Patient

PTA Prior to arrival

PVC Premature ventricular contraction

q.h. Every hour

q.i.d. Four times a day

R Right

r/o Rule out

Rx or Tx Treatment

SIDS Sudden Infant Death Syndrome

SOB Shortness of breath

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stat. immediately

SVT Supraventricular tachycardia

TIA Transient ischemic attack

t.i.d. Three times a day

TKO To keep open

V.S. Vital signs

x Times

w/o or s without

WNL Within normal limits

y/o or y.o. Years old

Symbols

Δ change

+ Positive

- Negative

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Chapter 6: Infection Control and the EMT

Chapter 6:
Infection Control and the
EMT
Outline

 Overview
 The Chain of Infection
 Stages of Infection
 Methods of Transmission
 Defenses against Infection
 Diseases That Pose A Threat To EMS Workers
 Body Substances Isolation (BSI)
 Exposure Control Plan
 Reservoirs – Portals of Exit
 Susceptible Defenses of a Susceptible Host
 Hand Washing
 Recommended Use of Personal Protective Equipment by Situation

Overview

Infection Control

Procedures to reduce infection in patients and health care personnel.

Infection

The growth of an organism in a susceptible host with or without signs and

symptoms of illness.

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Communicable Disease

Any disease that can be spread from one person to another or to a person
from contaminated objects.

The Chain of Infection

1. Etiologic Agent/Causative Agent

2. Reservoir
3. Portal of exit from reservoir
4. Method of transmission
5. Portal of entry to the susceptible host
6. Susceptible host

Stages of Infection

Incubation Period

Interval between entrance of pathogen into body and appearance of first symptoms (e.g.,
chickenpox, 2-3 weeks; common cold, 1-2 days; influenza, 1-3 days; mumps, 15-18 days).

Prodromal Stage

Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to
more specific symptoms (during this time, microorganisms grow and multiply, and client may
be more capable of spreading disease to others).

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Illness Stage

Interval when client manifests signs and symptoms specific to type of infection (e.g., common
cold manifested by sore throat, sinus congestion, rhinitis; mumps manifested by earache, high
fever, parotid and salivary gland swelling).

Convalescence

Interval when acute symptoms of infection disappear (length of recovery depends on severity of
infection and client’s general state of health; recovery may take several days to months).

Methods of Transmission

 Direct contact
 Contact with contaminated materials
 Inhalation of infected droplets (TB, Meningitis)
 The bite of an infected animal, human or insect
 Puncture by contaminated needle
 Transfusion of contaminated blood products

Defenses against Infection

 Normal flora
 Body system defenses
 Inflammation
 Immune response (acquired immunity)

Diseases that pose a threat to Health Care Providers

 HIV
 Hepatitis B and C
 Tuberculosis
 Syphilis
 Meningitis
 Rabies (Philippines)

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Rabies

Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is
caused by a virus. Rabies infects domestic and wild animals, and is spread to people through
close contact with infected saliva (via bites or scratches). The disease is present on nearly every
continent of the world but most human deaths occur in Asia and Africa (more than 95%). Once
symptoms of the disease develop, rabies is fatal.

Rabies is widely distributed across the globe. More than 55 000 people die of rabies each year.
About 95% of human deaths occur in Asia and Africa.

Wound cleansing and immunizations, done as soon as possible after suspect contact with an
animal and following WHO recommendations, can prevent the onset of rabies in virtually 100%
of exposures. Once the signs and symptoms of rabies start to appear, there is no treatment and
the disease is almost always fatal.

Hepatitis B

Hepatitis B is the most common serious liver infection in the world. It is caused by the hepatitis
B virus (HBV) that attacks the liver. This disease is more infectious than AIDS because it is very
easily transmitted by blood, a single virus particle can cause disease. It is transmitted through
infected blood and other body fluids like seminal fluid, vaginal secretions, breast milk, tears,
saliva and open sores. Once infected with the hepatitis B virus, approximately 10% of the people
develop a chronic permanent infection. It is very common in Asia, Africa and the Middle East.
The overall incidence of reported Hepatitis B is 2 per 10,000 individuals, but the true incidence
may be higher, because many cases do not cause symptoms and go undiagnosed and
unreported.

Tuberculosis

Left untreated, each person with active TB disease will infect on average between 10 and 15
people every year. But people infected with TB bacilli will not necessarily become sick with the
disease. The immune system “walls off” the TB bacilli which, protected by a thick waxy coat, can
lie dormant for years. When someone’s immune system is weakened, the chances of becoming
sick are greater.

• Someone in the world is newly infected with TB bacilli every second.

• Overall, one-third of the world’s population is currently infected with the TB bacillus.

Globally, the Philippines’ rate of TB infection is ninth among 22 high burden countries and ranks
third in the Western Pacific region (WHO, 2004).

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Meningitis

Meningitis is inflammation of the thin tissue that surrounds the brain and spinal cord, called
the meninges. There are several types of meningitis. The most common is viral meningitis,
which you get when a virus enters the body through the nose or mouth and travels to the
brain. Bacterial meningitis is rare, but can be deadly. It usually starts with bacteria that cause a
cold-like infection. It can block blood vessels in the brain and lead to stroke and brain
damage. It can also harm other organs.

Meningitis is more common in people whose bodies have trouble fighting infections.
Meningitis can progress rapidly. Symptoms include:

• sudden fever

• severe headache

• stiff neck

Body Substances Isolation

Wear mask and protective eyewear in situations where droplets of body fluids may spray
onto mucus membranes.

Wear gloves when in contact with blood or bodily fluids.

Wear a gown in situations where it is likely that droplets of blood or body fluids will be
sprayed on your working clothes.

Immediately and thoroughly wash or other skin surfaces that come into contact with blood or
body fluids.

To prevent needle stick injuries, dispose of all use needles in a puncture-resistant container
with a secured lid.

Use mouthpieces, resuscitation bags or ventilation equipment when providing resuscitation.

Do not provide direct patient care when you have open and oxidative skin lesions.

Exposure Control Plan

A comprehensive plan that helps employees reduce their risk of exposure or acquisition
of communicable diseases.

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Determination of Exposure - this area should define who is at risk at comining in contact with
blood or body fluids.

Education and Training - this area should explain why a qualified individual has to answer
questions about CD and why infection control is required

Hepatitis Vaccination Program - outlines the immunization schedules for EMT personnel.

Personal Protective Equipment - should list the PPE and should be of good quality.

Changing and Disinfection Practices - should describe how to care for and maintain vehicle
and equipment.

Post-Exposure Management - should identify who to notify when you believe you have been
exposed.

Body Fluids and the Risk of Hepatitis B/C or HIV

Primary Risk

Blood

Semen

Vaginal Secretions

Secondary Risk

Synovial Fluid

CSF Fluid

Amniotic Fluid

No Risk

Sweat

Tears

Saliva

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Feces

Vomitus

Nasal Secretions

Sputum

Reservoirs – Portals of Exit

Respiratory Tract

 nose, mouth, through sneezing, coughing, breathing, talking, ET tubes

and tracheostomies.

Gastro-Intestinal Tract

 mouth, saliva, vomitus, feces, anus, drainage tubes, ostomies

Urinary Tract

 urethral meatus, urine, urinary diversion, ostomies

Reproductive Tract

 vaginal discharges, vagine, semen, urine

Blood

 open wound, needle puncture site, any disruption of intact skin or

mucous membrane

Susceptible Defenses of a Susceptible Host

Hygiene

Good personal hygiene and maintaining the intactness of the skin and mucus
membrane retains a barrier against microorganisms entering the body.

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Immunization

The immunologic system is a major defense against infection.

Nutrition

Adequate nutrition enhances the health of all body tissues, helps keep the skin intact
and promotes the skin’s ability to repel microorganisms.

Fluid

Adequate fluid intake flushes the bladder and urethra

Rest and Sleep

Adequate rest and sleep are essential to health and preserving energy.

Stress

Predisposes people to infection.

Personnel Protective Equipment

 Vinyl latex gloves

 Heavy duty gloves for cleansing
 Protective eyewear
 Mask - including pocket mask for CPR
 Cover gown
 Ventilatory equipment

Handwashing

Purposes:

1. To reduce the number of microorganisms onto the hands.

2. To reduce the risk of transmission of infectious organisms to one’s self.
3. To reduce the risk of transmission of microorganisms and cross-contamination
to patients

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Recommended Use of Personal Protective Equipment by Situation

Task or Activity Disposable Gown Mask Protective

Gloves Eyewear
Bleeding control Yes Yes Yes Yes
with spurting
blood
Bleeding control Yes No No No
with minimal
blood
Emergency Yes Yes Yes, if splashing Yes, if splashing
childbirth is likely is likely
Blood drawing At certain times No No No

Starting an IV Yes No No No
line
Endotracheal Yes No No, unless No, unless
intubation splashing is splashing is
likely likely
Oral/nasal Yes No No, unless No, unless
suctioning, splashing is splashing is
manually likely likely
clearing airway
Handling and Yes No, unless No No
cleaning soiling is likely
instruments with
microbial
contamination
Measuring blood No No No No
pressure
Measuring No No No No
temperature
Giving an No No No No
injection

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Chapter 7:
Anatomy for EMTs
Outline

 Body Organization
 Anatomical Planes and Directions
 Metabolism
 Skeletal System
 Circulatory System
 Respiratory System
 Nervous System
 Muscular System
 Body Cavities
 The Abdomen

Body Organization

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Anatomical Planes and Directions

Metabolism

Metabolism refers to the chemical and energy transformations which occur in the body.

In the human body, carbohydrates, proteins and fats are oxidised to produce CO2, H2O
and form available energy (adenosine triphosphate - ATP) which is essential for life
processes.

At the cellular level, the production of energy takes place in the mitochondria when
oxygen and pyruvate are combined.

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 Aerobic Metabolism

In aerobic metabolism, there is sufficient oxygen entering the cell to react with and convert the
available pyruvate into ATP.

 Anaerobic Metabolism

In anaerobic metabolism, there is no oxygen or insufficient oxygen entering the cell and little or
no utilisation of pyruvate. The remaining pyruvate converts into lactic acid and cellular acidosis
occurs, invariably leading to cell damage or death. As little as 10% of ATP is produced during
anaerobic metabolism.

Skeletal System

 Gives form to the body

 Protects vital organs
 Consists of 206 bones
 Acts as a framework for attachment of muscles
 Designed to permit motion of the body
 The skeletal system can be divided into two parts: the axial skeleton and the
appendicular skeleton

The Spine

The spine supports the skull and gives attachment to the ribs. It is a column of 33 irregular
bones called vertebrae.

Discs of cartilage between the vertebrae:

 allow limited movement

 prevent friction
 act as shock absorbers.

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The Skeletal System

The Circulatory System

The circulatory system is a closed system which transports essential food, oxygen and
water to the cells of the body and removes the waste products they produce.

The circulatory system consists of three parts:

 The heart
 Blood vessels
 Blood

These three parts are sometimes referred to as:

 Pump
 Pipes
 Fluid

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Normal Heart Rates

Adults 60 to 100 bpm

Children 70 to 150 bpm

Infants 100 to 160 bpm

Electrical Control Mechanism

Heart contraction is controlled by nerve stimuli which originate in the sino-atrial node (the
‘pacemaker’), passing down the Bundle of His and radiating throughput the heart muscle.

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Physiology of the Circulatory System

Pulse

 The wave of blood through the arteries formed when the left ventricle contracts.
 Can be felt where an artery passes near the skin surface and over a bone.

Blood Pressure

 Amount of force exerted against walls of arteries.

 Systole: Left ventricle contracts.
 Diastole: Left ventricle relaxes.

Perfusion

 Circulation of blood within an organ or tissue.

 If inadequate, the patient goes into shock.

Blood Vessels

There are five types of blood vessels:

 Arteries
 Arterioles

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 Veins
 Venules
 Capillaries

Arteries carry blood away from the heart. The blood is moved along by the heartbeat and
the artery walls. Arteries have a strong outer wall and a thick muscle layer to withstand
high pressure.

Veins carry blood to the heart by the action of the surrounding muscles and by the suction
of the heart. Veins have thinner walls and are provided with valves, to stop the blood
flowing in the wrong direction.

Arterioles and venules dilate or contract to control the blood flow into and out of the
capillary bed.

Capillaries allow for the interchange of gases and the transfer of nutrients and waste
products. Capillaries have very thin walls consisting of a single layer of cells only. They are
semi-permeable to permit the passage of substances between the blood and the tissues.

Respiratory System

 Extracts oxygen from the atmosphere and transfer it to the bloodstream in the lungs
 Excretes water vapour and CO2
 Maintains the normal acid-base status of the blood
 Ventilates the lungs

Normal Breathing Rates

Adults 12 to 20 breaths/min

Children 15 to 30 breaths/min

Infants 25 to 50 breaths/min

Inspired Air

The air we breathe in contains approximately:

 79% nitrogen
 20% oxygen

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 0.04% carbon dioxide

 1% inert gases
 water vapour - variable

Expired Air

The air we breathe out contains approximately:

 79% nitrogen
 16% oxygen
 4% carbon dioxide
 1% inert gases
 water vapour to saturation

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Exchange of Gases

External respiration

 takes place in the lungs. Oxygen from inhaled air is absorbed into the blood via the
capillaries of the lung. Carbon dioxide is released from the blood into the lungs and
is exhaled.

Internal respiration

 takes place in the tissues.

The Diaphragm

 Has characteristics of both voluntary and involuntary muscles

 Dome-shaped muscle
 Divides thorax from abdomen
 Contracts during inhalation
 Relaxes during exhalation

Mechanisms of Breathing

Inhalation

 Diaphragm and intercostal muscles contract, increasing the size of the thoracic
cavity.
 Pressure in the lungs decreases.
 Air travels to the lungs.

Exhalation

 Diaphragm and intercostal muscles relax.

 As the muscles relax, all dimensions of the thorax decrease.
 Pressure in the lungs increases.
 Air flows out of the lungs.

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Normal Breathing Characteristics

 Normal rate and depth

 Regular rhythm
 Good breath sounds in both lungs
 Regular rise and fall movements in the chest
 Easy, not labored

Infant and Child Anatomy

 Structures less rigid

 Airway smaller
 Tongue proportionally larger
 Dependent on diaphragm for breathing

The Nervous System

The nervous system controls the body’s voluntary and involuntary actions.

 Somatic nervous system - regulates voluntary actions

 Autonomic nervous system - controls involuntary body functions

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The Brain

The brain is the highest level of the nervous system and is continuous with the spinal
cord. It is divided into three main parts:

Cerebrum

 motor centres control all the voluntary muscles.

 sensory centres receive sensory signals from the skin, muscles, bones and joints.
 control of the autonomic nervous system is buried deep in the cerebrum, in the
thalamus and hypothalamus
 regulates the central nervous system, and is pivotal in maintaining consciousness
and regulating the sleep cycle.

Cerebellum

 responsible for the maintenance of balance, muscle coordination and muscle tone.

Brainstem

 the nerve connections of the motor and sensory systems from the main part of the
brain to the rest of the body pass through the brain stem.
 regulation of cardiac and respiratory function.

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Divisions of the Nervous System

Central Nervous System

 Consists of the brain and the spinal cord

Peripheral Nervous System

 Links the organs of the body to the central nervous system.

 Sensory nerves carry information from the body to the central nervous system.
 Motor nerves carry information from the central nervous system to the muscles of
the body.

Nerves

There are four types of nerves:

1. Cranial nerves connect the sense organs (eyes, ears, nose, mouth) to the brain.
2. Central nerves connect areas within the brain and spinal cord.
3. Peripheral nerves connect the spinal cord with the limbs.
4. Autonomic nerves connect the brain and spinal cord with the organs (heart, stomach, intestines,
blood vessels, etc.).

Muscular System

 Gives the body shape

 Protects internal organs
 Provides for movement
 Consists of more than 600 muscles

Three Types of Muscles

1. Skeletal (voluntary) muscle

 Attached to the bones of the body.
2. Smooth (involuntary) muscle
 Carries out the automatic muscular functions of the body.
3. Cardiac muscle
 Involuntary muscle.

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 Has own blood supply and electrical system.

 Can tolerate interruptions of blood supply for only very short periods.

Body Cavities

The Abdomen

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Chapter 8:
Health, Hygiene, Fitness
and Safety of the EMT
Outline

 Traits of a Good EMT

 Healthy Lifestyle of an EMT
 The Food Pyramid for Filipino Adults
 Body Mechanics
 Guidelines for Preventing Back Injuries
 EMS and Back Injuries

Traits of a Good EMT

 Neat and clean - to promote confidence in both patients and

bystanders and to reduce the possibility of contamination.
 Physically fit - should be in good health and fit to carry out duties.
 Emotionally and mentally fit - should be able to cope with stress at
work and able to overcome unpleasant aspects of any emergencies.

Healthy Lifestyle of an EMT

 Nutrition - to perform efficiently, an EMT should eat nutritious food to fuel the
body and make it run. Physical exertion and stress are part of an EMT‟s job and
require high energy output.
 Exercise and relaxation - a regular program of exercise will enhance the benefits of
maintaining nutrition and adequate hydration.
 Balancing work, family and health - as an EMT you will often be called to assist the
sick and the injured any time of the day or night. Shift work may be required to be
apart from loved ones for long periods of time. Never let the job interfere

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excessively with your own needs. Find a balance between work and family. Make sure that you
have the time that you need to relax with family and friends.

The Food Pyramid for Filipino Adults

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Body Mechanics

The efficient coordinated and safe use of the body to produce motion and maintain
balance during activity.

Proper movement promotes body musculoskeletal functioning, reduces the energy

required for a task, and maintains balance, thereby reducing fatigue and decreasing the
risk of injury.

Three Basic Elements of Body Mechanics

1. Body Alignment (Posture) - when the body is well-aligned, balance is achieved

without undue strain on the joints, muscles, tendons or ligaments. Proper body
alignment also enhances lung expansion and promotes efficient circulatory,
renal and gastrointestinal function.
2. Balance (Stability) - good body alignment is essential to body balance. A person
maintains balance as long as the line of gravity passes through the centre of
gravity and the base of support.
3. Coordinated Body Movement - body mechanics involves the integrated
functioning of the musculoskeletal and nervous system as well as joint mobility.

Guidelines for Preventing Back Injuries

1. Be consciously aware of your posture and body mechanics.

2. Minimize lumbar lordosis as much as possible:
 when standing for a period of time, periodically flex one hip
and knee and rest your foot on an object if possible.
 when sitting, keep your knees slightly higher than your hips.
 unless you have a pillow or other support beneath your
abdomen, avoid sleeping in the prone position.
3. Exercise regularly to maintain overall physical condition, including
exercises that strengthen the pelvic, abdominal and lumbar muscles.
4. Apply principles of body mechanics when moving objects:
 Spread your feet apart to provide a wide base of support.
 Place your feet appropriately in the direction in which the
movement will occur.
 Push, pull, roll or slide objects rather than lifting them
whenever possible.

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 Avoid twisting the spine by pushing or pulling an object, directly away from or
toward the body and squarely facing the direction of movement.
 When lifting objects, distribute the weight between the large muscles of the
arms and legs.
5. Wear clothing that allows you to use good body mechanics and wear comfortable
low-heeled shoes that provide good foot support and will not cause you to slip,
stumble and turn your ankle.

EMS and Back Injuries

 “One in four EMS workers will suffer a career ending back injury within the first 4
years of service. The number one physical reason for leaving EMS,” (mytactical.com,
EMS Back Injury Facts, 2007).
 “Back injury from improper lifting is the number one injury suffered by pre-hospital
care providers,” according to New Mexico‟s EMT training manual.
 “Almost one in two workers(47%) have sustained a back injury while performing
EMS duties,” (National Association of Emergency Medical Technicians, 2005).
 “Average cost for a „simple‟ sprain or strain of the lumbar spine is approximately
US$18,365 in direct costs per occurrence,” (Mitterre D., “Back Injuries in EMS,” EMS
Magazine, 1999).
 Lifting caused just over 62% of back injuries for EMT‟s, and low back strain was the
cause of 78% of the compensation days in a 3.5 year period, (Hogya PT, Ellis L.,
University of Pittsburgh Affiliated Residency in Emergency Medicine, PA, 1990).

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Chapter 9:
Patient Assessment
Outline

 Overview
 Purpose of Patient Assessment
 Scene Size-Up
 Body Substances Isolation
 Scene Safety
 Number of Patients
 Additional Resources
 Mechanism of Injury (MOI)
 Nature of Illness (NOI)
 Cervical-Spine Immobilization
 Initial Assessment
 Baseline Vital Signs
 Priority Patients
 Transport Decisions
 Trauma Assessment
 Focused Physical Examination
 Significant Mechanism of Injury
 Patient Assessment Definitions
 OPQRST
 The Full Assessment

Overview

 Scene size-up
 Initial assessment
 Focused history and physical exam

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 Vital signs
 History
 Detailed physical exam
 Ongoing assessment

Purpose of Patient Assessment

Your total patient care and transport decisions will be based on your assessment of
the patient’s condition as follows:

 To determine whether the patient has suffered trauma or has a medical complaint.
 To identify and manage immediately life threatening injuries or conditions.
 To determine further assessment and care on the scene vs immediate transport with
assessment and care continuing en route.
 To provide further emergency care.
 To examine the patient and gather a patient medical history.
 To monitor the patient’s condition, assessing and adjusting care as required.
 To communicate patient information to the medical facility to ensure continuity of care.

Scene Size-Up

 Review dispatch information

 Inspection of scene
 Scene hazards
 Safety concerns
 Mechanism of injury
 Nature of illness/chief complaint
 Number of patients
 Additional resources needed

Body Substances Isolation

 Assumes all body fluids present a possible risk for infection

 Protective equipment:
 Latex or vinyl gloves should always be worn
 Eye protection
 Mask
 Gown

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Scene Safety

 Park in a safe area.

 Speak with law enforcement first if present.
 The safety of you and your partner comes first!
 Next concern is the safety of patient(s) and bystanders.
 Request additional resources if needed to make scene safe.

Potential hazards

 Oncoming traffic
 Unstable surfaces
 Leaking gasoline
 Downed electrical lines
 Potential for violence
 Fire or smoke
 Hazardous materials
 Other dangers at crash or rescue scenes
 Crime scenes

Number of Patients

 Determine the number of patients and their condition.

 Assess what additional resources will be needed.
 Triage to identify severity of each patient’s condition.

Additional Resources

Medical resources

 Additional units
 Advanced life support

Nonmedical resources

 Fire suppression
 Rescue

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 Law enforcement

Mechanism of Injury (MOI)

Helps determine the possible extent of injuries on trauma patients

Evaluate:

 Amount of force applied to body

 Length of time force was applied
 Area of the body involved

Nature of Illness (NOI)

Search for clues to determine the nature of illness.

Often described by the patient’s chief complaint

Gather information from the patient and people on scene.

Observe the scene.

The Importance of MOI/NOI

 Guides preparation for care of the patient

 Suggests equipment that will be needed
 Prepares for further assessment
 Fundamentals of assessment are the same whether the emergency appears to be
related to trauma or a medical cause.

Cervical-Spine Immobilization

 Consider early during assessment.

 Do not move without immobilization.
 Err on the side of caution

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Initial Assessment

1. Develop a general impression.

2. Assess mental status.
3. Assess airway.
4. Assess the adequacy of breathing.
5. Assess circulation.
6. Identify patient priority.

Forming a General Impression

 Occurs as you approach the scene and the patient

 Assessment of the environment
 Patient’s chief complaint
 Presenting signs and symptoms of patient

Assessing Mental Status/Level of Consciousness

A Alert - awake and oriented

V Verbal - responds to verbal stimuli

P Painful: responds to painful stimuli

U Unresponsive: does not respond to stimuli

Assessing the ABCs

A Airway

B Breathing

C Circulation

Airway

Look for signs of airway compromise:

 Two- to three-word dyspnea

 Use of accessory muscles
 Nasal flaring and use of accessory muscles in children

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 Labored breathing

Breathing

Look for:

 Choking
 Rate
 Depth
 Cyanosis
 Lung sounds
 Air movement

Circulation

Assessing the pulse:

 Presence
 Rate
 Rhythm
 Strength

Assessing and controlling external bleeding

 Assess after clearing the airway and stabilizing breathing

 Look for blood flow or blood on floor/clothes
 Controlling bleeding
 Direct pressure
 Elevation
 Pressure points

Assessing perfusion:

 Color
 Temperature
 Skin condition
 Capillary refill

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Baseline Vital Signs

Check:

 Breathing
 Pulse
 Skin
 Pupils
 Blood Pressure
 Pulse Oximetry

Respirations

Normal ranges for respiration:

Adult 12-20 breaths/min

Children 15-30 breaths/min

Infants 25-50 breaths/min

Breathing checklist:

Normal Shallow Laboured Noisy

Equal chest rise Shallow chest rise Increased breathing Snoring, wheezing,

effort. Use of gurgling and

accessory muscles; grunting noises

gasping, nasal flaring

Rhythm

 Regular
 Irregular

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Effort

 Effortless - Talks normally

 Difficulty breathing - Can only speak few words at a time

Depth

 Shallow
 Normal
 Deep

Pulse checklist:

Normal ranges for pulse rates:

Adult 60-100 60 – 100 beats/min

Children 80-120 80-120 beats/min

Toddlers 90-150 beats/min

Newborn 120-160 beats/min

Tachycardia >100 beats/min

Bradycardia <60 beats/min

Strength

 Weak
 Normal
 Strong

Quality

 Slow
 Normal
 Rapid

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Rhythm

 Regular
 Irregular

Skin

Color

Pale/grey/waxy Blue/grey Red/flushed

Fever, poisoning, sunburn,

Poor peripheral perfusion; Blood not properly
heatstroke, high blood
Abnormally cold/frozen saturated with oxygen
pressure

Temperature

Cold Cool Normal Hot

Early shock, mild

hypothermia, Hyperthermia, fever,
Shock, hypothermia
inadequate sunburn
perfusion

Moisture

Dry/Normal Moist Wet

Early Shock Shock

Capillary Refill in Children

CRT=2 secs Normal

CRT>2 secs Poor peripheral circulation

Blood Pressure

 Blood pressure is a vital sign.

 Pressure of circulating blood against the walls of the arteries.
 A drop in blood pressure may indicate:
 Loss of blood
 Loss of vascular tone

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 Cardiac pumping problem

 Blood pressure should be measured in all patients older than 3 years of age.

Normal ranges for blood pressure:

Adults 90 to 140 mmHg (s)

60 to 90 mmHg (d)

Children (1-8) 80 to 110 mmHg (s)

Infants (up to 1 yr) 50 to 90 mmHg (s)

The amount of pressure exerted against the walls

Systolic pressure
of the arteries when the left ventricle contracts.

The pressure exerted against the wall of the

Diastolic pressure
arteries when the left ventricle is at rest.

Pulse pressure Systolic pressure minus diastolic pressure.

BP by Auscultation BP by Palpation

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Level of Responsiveness

A Alert - awake and oriented

V Verbal - responds to verbal stimuli

P Painful: responds to painful stimuli

U Unresponsive: does not respond to stimuli

Pupil Response

P - Pupils

E - Equal

A - And

R - Round

R - Regular in size

L - React to Light

Abnormal pupil reaction

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Priority Patients

‘Stay and Play’ vs. ‘Scoop and Run’

 Difficulty breathing

 Poor general impression

 Unresponsive with no gag reflex

 Severe chest pain

 Signs of poor perfusion

 Complicated childbirth

 Uncontrolled bleeding

 Responsive but unable to follow commands

 Severe pain

 Inability to move any part of the body

Transport Decisions

 Patient condition

 Availability of advanced care

 Distance to transport

 Local protocols

Rapid Trauma Assessment

A 60-90 second head-to-toe exam that is quickly conducted on a patient who has
suffered or may have suffered severe injuries

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During the Rapid Trauma Assessment, the EMT is looking for signs of:

D Deformities

C Contusions

A Abrasions

P Punctures/Penetrations Remember:
DCAP - BTLS
B Burns

T Tenderness

L Lacerations

S Swelling

Stages of the Rapid Trauma Assessment

1. Maintain spinal immobilization while checking patient’s ABCs.

2. Inspect and palpate the head and face, including the ears, pupils, nose and mouth.

3. Assess the neck.

4. Apply a cervical spine immobilization collar.

5. Expose and assess the chest. Perform a four-point auscultation of the chest to listen
for breath sounds.

6. Assess the abdomen. If the patient complains of pain or there is obvious trauma, do
not palpate.

7. Assess the pelvis, checking for stability and crepitus.

8. Assess all four extremities, including pulses, motor function and sensation (PMS).

9. Roll the patient with spinal precautions.

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Focused Physical Exam

Used to evaluate patient’s chief complaint.

Performed on:

• Trauma patients without significant MOI

• Responsive medical patients

SAMPLE History

S Signs and Symptoms

A Allergies

M Medications Remember:
P Pertinent past history SAMPLE
L Last oral intake

E Events leading to injury or illness

Stages of the Focused Physical Exam

Head, Neck, and Cervical Spine

 Feel head and neck for deformity, tenderness, or crepitation.

 Check for bleeding.
 Ask about pain or tenderness.

Chest

 Watch chest rise and fall with breathing.

 Feel for grating bones as patient breathes.
 Listen to breath sounds.

Abdomen

 Look for obvious injury, bruises, or bleeding.

 Evaluate for tenderness and any bleeding.

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 Do not palpate too hard.

Pelvis

 Look for any signs of obvious injury, bleeding, or deformity.

 Press gently inward and downward on pelvic bones.

Extremities

 Look for obvious injuries.

 Feel for deformities.
 Assess PMS:
 Pulse
 Motor function
 Sensory function

Posterior Body

 Feel for tenderness, deformity, and open wounds.

 Carefully palpate from neck to pelvis.
 Look for obvious injuries.

Significant Mechanism of Injury

 Ejection from vehicle

 Death in passenger compartment

 Fall greater than 15’-20’

 Vehicle rollover

 High-speed collision

 Vehicle-pedestrian collision

 Motorcycle crash

 Unresponsiveness or altered mental status

 Penetrating trauma to the head, chest, or abdomen

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Assessment Summary

Assessment Steps for Significant MOI Assessment Steps for Trauma Patients
Without Significant MOI
• Rapid trauma assessment
• Focused assessment
• Baseline vital signs
• Baseline vital signs
• SAMPLE history
• SAMPLE history
• Re-evaluate transport decision
• Re-evaluate transport decision

Responsive Medical Patients Unresponsive Medical Patients

• History of illness • Rapid medical assessment

• SAMPLE history • Baseline vital signs

• Focused assessment • SAMPLE history

• Vital signs • Re-evaluate transport decision

• Re-evaluate transport decision

Ongoing Assessment Steps of the Ongoing Assessment

• Is treatment improving the patient’s • Repeat the initial assessment.

condition? • Reassess and record vital signs.

• Has an already identified problem gotten • Repeat focused assessment.

better? Worse? • Check interventions.

• What is the nature of any newly

identified problems?

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Patient Assessment Definitions

Steps taken by EMS providers when approaching the

scene of an emergency call; determining scene
safety, taking BSI precautions, noting the mechanism
Scene Size-Up of injury or patient’s nature of illness, determining
the number of patients, and deciding what, if any
additional resources are needed including Advanced
Life Support.

The process used to identify and treat life-

threatening problems, concentrating on Level of
Consciousness, Cervical Spinal Stabilization, Airway,
Breathing, and Circulation. You will also be forming a
Initial Assessment General Impression of the patient to determine the
priority of care based on your immediate assessment
and determining if the patient is a medical or trauma
patient. The components of the initial assessment
may be altered based on the patient presentation.

In this step you will reconsider the mechanism of

injury, determine if a Rapid Trauma Assessment or a
Focused History Focused Assessment is needed, assess the patient’s
chief complaint, assess medical patients complaints
and Physical
and signs and symptoms using OPQRST, obtain a
Exam baseline set of vital signs, and perform a SAMPLE
history. The components of this step may be altered
based on the patient’s presentation.

This is performed on patients with significant

mechanism of injury to determine potential life
threatening injuries. In the conscious patient,
symptoms should be sought before and during the
Rapid Trauma Rapid Trauma assessment. You will estimate the
severity of the injuries, re-consider your transport
Assessment decision, reconsider Advanced Life Support, consider
the platinum 10 minutes and the Golden Hour,
rapidly assess the patient from head to toe using
DCAP-BTLS, obtain a baseline set of vital signs, and
perform a SAMPLE history.

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This is performed on medical patients who are

unconscious, confused, or unable to adequately
relate their chief complaint. This assessment is used

Rapid Medical to quickly identify existing or potentially life-

threatening conditions. You will perform a head to
History
toe rapid assessment using DACP-BTLS, obtain a
baseline set of vital signs, and perform a SAMPLE
history

This is used for patients, with no significant

mechanism of injury, that have been determined to
have no life-threatening injuries. This assessment
Focused History would be used in place of your Rapid Trauma

and Physical Assessment. You should focus on the patient’s chief

complaint. An example of a patient requiring this
Exam - Trauma
assessment would be a patient who has sustained a
fractured arm with no other injuries and no life-
threatening conditions.

This is used for patients with a medical complaint

who are conscious, able to adequately relate their
chief complaint to you, and have no life-threatening
Focused History
conditions. This assessment would be used in place
and Physical
of your Rapid Medical Assessment. You should focus
Exam - Medical on the patient’s chief complaint using OPQRST,
obtain a baseline set of vital signs, and perform a
SAMPLE history.

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This is a more in-depth assessment that builds on the

Focused Physical Exam. Many of your patients may
not require a Detailed Physical Exam because it is
either irrelevant or there is not enough time to
complete it. This assessment will only be performed
while en route to the hospital or if there is time on
scene while waiting for an ambulance to arrive.
Detailed Physical Patients who will have this assessment completed are
patients with significant mechanism of injury,
Exam
unconscious, confused, or unable to adequately relate
their chief complaint. In the Detailed Physical Exam
you will perform a head to toe assessment using
DCAP-BTLS to find isolated and non-life-threatening
problems that were not found in the Rapid
Assessment and also to further explore what you
learned during the Rapid Assessment.

This assessment is performed during transport on all

patients.

The Ongoing Assessment will be repeated every 15

minutes for the stable patient and every 5 minutes for
the unstable patient.

This assessment is used to answer the following

questions:

Ongoing
1. Is the treatment improving the patient’s condition?
Assessment
2. Are any known problems getting better or worse?

3. What is the nature of any newly identified

problems?

You will continue to reassess mental status, ABCs, re-

establish patient priorities, reassess vital signs, repeat
the focused assessment, and continually recheck your
interventions.

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OPQRST

Used to assess a patient’s chief complaint during a medical exam.

O Onset

P Provocation

Q Quality

R Radiation/Region

S Severity

T Time

OPQRST Explained

Onset

The word “onset” should trigger questions regarding what the patient was doing just
prior to and during the onset of the specific symptom(s) or chief complaint.

• What were you doing when the symptoms started?

• Was the onset sudden or gradual?

It may be helpful to know if the patient was at rest when the symptoms began or if they
were involved in some form of activity. This is especially true with patients presenting
with suspected cardiac signs & symptoms.

Provocation

The word “provocation” should trigger questions regarding what makes the symptoms
better or worse.

• Does anything you do make the symptoms better or relieve them in any way?

• Does anything you do make the symptoms worse in any way?

This is sometimes helpful in ruling in or out a possible musculoskeletal cause. A patient

with a broken rib or pulled muscle will most likely have pain that is easily provoked by
palpation and/or movement. This is often in contrast to the patient having chest pain of

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a cardiac origin whose pain is not made any better or worse with movement or
palpation.

Quality

The word “quality” should trigger questions regarding the character of the symptoms
and how they feel to the patient.

• Can you describe the symptom (pain/discomfort) that you are having right now?

• What does it feel like?

• Is it sharp or dull?

• Is it steady or does it come and go?

• Has it changed since it began?

This if often the most difficult question for the patient to understand and to articulate.
The key here is to allow the patient to use their own words and not try to feed the
patient with suggestions that they may choose simply because you have made it easy. It
is sometime helpful to offer the patient choices and allow them to decide which is most
appropriate for their situation. For instance, “is your pain sharp or is it dull” or “is your
pain steady or does it come and go”?

Region/Radiation

The words “region and radiation” should trigger questions regarding the exact location
of the symptoms.

• Can you point with one finger where it hurts the most?

• Does the pain radiate or move anywhere else?

Although it is not always easy for a patient to identify the exact point of pain, especially
with pediatric patients, it is important to ask. Asking if they can point with one finger to
where it hurts the most is a good start. From there you will want to know if the pain
“moves” or “radiates” anywhere from the point of origin. The patient may need you to
offer some suggestions such as, “does the pain radiate anywhere else such as your back,
neck, jaw or shoulders”? Always give them two or three choices and allow them to select
from the options that you give.

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Severity

The word “severity” should trigger questions relating to the severity of the symptoms.

• On a scale of 1 to 10, how would you rate your level of discomfort right now?

• Using the same scale, how would you rate your discomfort when it first began?

It’s not always just about how bad the pain or discomfort is when you arrive - this is a
common mistake made by many new EMTs. Once you have established the level of
discomfort that the patient is experiencing at that moment, you must follow this up with
how severe the discomfort was at onset. This will help you establish whether the
discomfort is getting better, worse or staying the same over time. You will want to
follow these two checkpoints up with an additional check once the patient has received
some of your care and reassurance. Often times with a little oxygen and reassurance the
symptoms may subside. Ask the patient a few minutes later how the discomfort is and if
it has changed at all since your arrival.

Time

The word “time” should trigger questions relating to the when the symptoms began.

• When did the symptoms first begin?

• Have you ever experienced these symptoms before? If so, when?

Establishing an accurate duration of the symptoms will be very helpful to the hospital
staff that will be caring for the patient. This question has special importance when caring
for patients presenting with suspected cardiac signs and symptoms.

The Full Assessment

SCENE SIZE-UP

Steps taken when approaching the scene.

 Ensure BSI (Body Substance Isolation) procedures and & personal protective gear is
being used.
 Observe scene for safety of crew, patient, bystanders. Identify the mechanism of injury
or nature of illness.
 Identify the number of patients involved.
 Determine the need for additional resources including Advanced Life Support.

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 Consider C-Spine stabilization

INITIAL ASSESSMENT

Assessment & treatment (life-threats)

General Impression

 Mechanism of injury or nature of illness

 Age, sex, race
 Find and treat life threatening conditions (any obvious problems that may
kill the patient within seconds). Problems with Airway, Breathing, or
Circulation
 Verbalize general impression of patient

Mental Status

 If the pt. appears to be unconscious, check for responsiveness, (“Hey! Are

you OK”?)
 Evaluate mental status using AVPU.
 Obtain a chief complaint, if possible.

Airway

 Is the pt. talking or crying?

 Do you hear any noise?
 Will the airway stay open on its own?
 Does anything endanger it?
 Open the airway - head-tilt-chin-lift or jaw thrust – as needed
 Clear the airway – as needed
 Suction - as needed
 Insert an OPA/NPA - as needed

Breathing

 Do you see any signs of inadequate respirations?

 Is the rate and quality of breathing adequate to sustain life?
 Is the patient complaining of difficulty breathing?
 Quickly inspect the chest for impaled objects, open chest wounds, and
bruising (trauma).

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 Quickly palpate the chest for unstable segments, crepitation (trauma), and equal
expansion of the chest.
 Check pulse oximetry - if below 94% administer oxygen.
 If the pt. is unresponsive and breathing is inadequate, use a BVM to maintain pulse
oximetry at 94% or above.

Circulation

 If the pt. is unresponsive, assess for presence and quality of the carotid pulse.
 If the pt. is responsive, assess the rate and quality of the radial pulse.
 If radial pulse is weak or absent, compare it to the carotid pulse.
 For patients 1 year old or less, assess the brachial pulse.
 Is there life threatening hemorrhage?
 Control life threatening hemorrhage
 Assess the patient’s perfusion by evaluating skin for color, temperature and condition
(CTC);
 can also check the conjunctiva and lips
 Assess capillary refill in infant or child < 6 yrs. old
 Cover with blanket and elevate the legs as needed for shock (hypoperfusion)

Identify Priority Patients

 Is the patient:
 Critical?
 Unstable?
 Potentially Unstable?
 Stable?
 Consider the need for Advanced Life Support
 If the patient is CRITICAL, UNSTABLE or POTENTIALLY UNSTABLE , begin packaging the
patient during the rapid assessment while treating life threats and transport as soon as
possible.
 In addition, perform the rapid trauma assessment for the trauma patient if he/she has
significant mechanism of injury and apply spinal immobilization as needed.
 For the unresponsive medical patient perform the rapid medical assessment.
 If the patient is or STABLE, perform the appropriate focused physical exam (for the
medical pt. perform the focused physical exam; for trauma patient perform the focused
trauma assessment.)

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FOCUSED HISTORY AND PHYSICAL EXAM - TRAUMA

Re-consider the mechanism of injury. If there is significant mechanism of injury, perform a Rapid
Trauma Assessment on-scene while preparing for transport and then a Detailed Assessment
during transport. If there is no significant mechanism of injury, perform the Focused Trauma
Assessment. Direct the focused trauma assessment to the patient’s chief complaint and the
mechanism of injury (perform it instead of the rapid trauma assessment).

Rapid Trauma Assessment

Performed on patients with significant MOI.

 Continue spinal stabilization

 Re-consider ALS back-up

Inspect and palpate the body for injuries to the following:

HEAD

 DCAP-BTLS
 Blood & fluids from the head, including cerebrospinal fluid

NECK

 DCAP-BTLS
 JVD (Jugular Vein Distention)
 Crepitation
 Apply CSIC (Cervical Spinal Immobilization Collar) - if not already done

CHEST

 DCAP-BTLS
 Paradoxical movement
 Crepitation
 Breath sounds - bilateral assessment of the apices, mid-clavicular line;
midaxillary at the nipple line; and at the bases

ABDOMEN

 DCAP-BTLS
 Pain
 Firm

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 Soft
 Distended

PELVIS

 DCAP-BTLS
 If no pain is noted, gently compress the pelvis to determine tenderness or unstable
movement.

EXTREMITIES

 DCAP-BTLS
 Crepitation
 Distal pulses
 Sensory function
 Motor function

POSTERIOR

 Logroll the patient. Maintain c-spine stabilization.

 Inspect and palpate for injuries or signs of injury.
 DCAP-BTLS

FOCUSED TRAUMA ASSESSMENT

Performed on patients with no significant MOI.

Assess the patient’s chief complaint

 The specific injury they are complaining about – why they called EMS
 Assess and treat injuries not found during your Initial Assessment
 Reconsider your transport decision
 Consider ALS intercept

Focused Assessment

 Follow order of the Rapid Assessment

 Focus assessment on the specific area of injury or complaint

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Baseline Vital Signs

 Obtain a full set of vital signs including:

 Respirations
 Pulse
 Blood Pressure
 Level of Consciousness
 Skin
 Pupils
 Assess SAMPLE History
 Signs & Symptoms
 Pertinent Past Medical History
 Allergies
 Last oral intake
 Medications
 Events leading up to the injury/illness

Respirations

RATE:

 Watch the chest/abdomen and count for no less than 30 seconds.

 If abnormal respirations are present count for a full 60 seconds.

QUALITY:

 Normal
 Shallow
 Any unusual pattern?
 Labored?
 Deep
 Noisy breathing?

Pulse

RATE:

Check the radial pulse. If pulse is regular, count for 30 seconds and multiply x 2. If it is irregular,
count for a full 60 seconds.

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QUALITY:

 Regular
 Strong
 Irregular
 Weak

Skin (CTC)

COLOUR:

 Normal (unremarkable)
 Cyanotic
 Pale
 Flushed
 Jaundice

TEMPERATURE:

 Warm
 Hot
 Cool
 Cold

CONDITION:

 Wet
 Dry

Blood Pressure

 Blood pressure should be measured in all patients over the age of 3.

 Auscultate the blood pressure. In a high noise environment, palpate (only the systolic
reading can be obtained).

Pupils

 Use a penlight to check reactivity of the pupils; also assess for size
 equal or unequal
 normal, dilated, or constricted

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 reactive - change when exposed to light

 non-reactive - do not change when exposed to light
 equally or unequally reactive when exposed to light

FOCUSED HISTORY AND PHYSICAL EXAM - MEDICAL

During this phase of the patient assessment, the mnemonic OPQRST and SAMPLE will be used
to gather information about the chief complaint and history of the present illness. Baseline vital
signs and a focused physical exam or a rapid medical assessment will be performed. The order
in which you perform the steps of this focused history and physical exam varies depending on
whether the patient is responsive or unresponsive.

RAPID MEDICAL ASSESSMENT

Performed on patients who are unconscious, confused, or unable to adequately relate their chief
complaint.

Perform a rapid assessment using DCAP-BTLS following the order of the Rapid Trauma
Assessment:

 Assess the head

 Assess the neck
 Assess the chest
 Assess the abdomen
 Assess the pelvis
 Assess the extremities
 Assess the posterior
 Obtain baseline set of vital signs
 Position patient to protect the airway
 Obtain the SAMPLE history from bystander, family, or friends.

FOCUSED MEDICAL ASSESSMENT

Performed on the conscious, alert patient who can adequately relate their chief complaint.

 Obtain the history of the present illness

 Onset - “What were you doing when the symptoms started?”
 Provocation - “Is there anything that makes the symptoms better or worse?”
 Quality - “What does the pain/discomfort feel like?”

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 Radiation - “Where do you feel the pain/discomfort?” “Does the pain/discomfort
travel anywhere else?”
 Severity - “How bad is the pain?” “How would you rate the pain on a scale of 1-10,
with 10 being the worst pain you’ve felt in your life?”
 Time - “How long has the problem been going on?”
 Assess SAMPLE

Examples of questions to ask a conscious medical patient and assessment elements

according to the patient’s chief complaint

Altered Mental Status Allergic Reaction Cardiac/Respiratory

o Description of episode o History of allergies o Onset

o Duration o Exposed to what? o Provocation

o Onset o How exposed o Quality

o Associated symptoms o Effects o Radiation

o Evidence of trauma o Progression o Severity

o Interventions o Interventions o Time

o Seizures o Interventions

o Fever

Poisoning & OD Environmental Behavioral

o Substance o Source o How do you feel?

o When exposed/ingested o Environment o Determine if suicidal:

o Amount o Duration “Were you trying to hurt yourself?”

o Time period o Loss of consciousness “Have you been feeling that life is not
worth living?”
o Interventions o Effects-general or local
“Have you been feeling like killing
o Estimated weight yourself?”

o Threat to self or others

o Medical problem

o Interventions

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Obstetrics Acute Abdomen Loss of Consciousness

o Are you pregnant? o Location of pain o Length of time unconscious

o How long have you been pregnant? o Any vomiting? If so, o Position
color/substance
o Pain or contraction o History
o Taking birth control
o Bleeding or discharge o Blood in vomit or stool
o Vaginal bleeding or discharge
o Has your water broke? o Trauma
o Abnormal vital signs
o Do you want to push? o Incontinence

o Last menstrual period? o Abnormal vital signs

Baseline Vital Signs

Obtain a full set of vital signs including:

- Respirations

- Pulse

- Blood Pressure

- Level of Consciousness

- Skin

- Pupils

Provide Treatment

Provide emergency medical care based on signs and symptoms.

DETAILED PHYSICAL EXAM

The Detailed Physical Exam is used to gather additional information regarding the patient’s
condition only after you have provided interventions for life threats and serious conditions. Not
all patients will require a Detailed Physical Exam. It is performed in a systematic head-to-toe
order. You will examine the same body areas that you examined during your rapid assessment.

During the detailed physical exam, you will look more closely at each area to search for findings

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of lesser priority than life threats and/or signs of injury that have worsened. Do not delay
transport to perform a detailed physical exam; it is only performed while en route to the
hospital or while waiting for transport to arrive.

Detailed Physical Exam – Trauma or Medical

The Detailed Physical Exam is used to gather additional information regarding the patient’s
condition only after you have provided interventions for life threats and serious conditions.
Not all patients will require a Detailed Physical Exam. It is performed in a systematic head-to-
toe order. You will examine the same body areas that you examined during your rapid
assessment. During the detailed physical exam, you will look more closely at each area to
search for findings of lesser priority than life threats and/or signs of injury that have
worsened. Do not delay transport to perform a detailed physical exam; it is only performed
while en route to the hospital or while waiting for transport to arrive.

HEAD - inspect and palpate for signs of injury.

• DCAP-BTLS

• Blood & fluids from the head

FACE - inspect and palpate for signs of injury.

• DCAP-BTLS

EARS - inspect and palpate for signs of injury.

• DCAP-BTLS

• Drainage (blood or any other fluid)

EYES - inspect for signs of injury.

• DCAP-BTLS

• Discoloration

• Unequal Pupils

• Foreign Bodies

• Blood in Anterior Chamber

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NOSE - inspect and palpate for signs of injury.

• DCAP-BTLS

• Drainage

• Bleeding

MOUTH - inspect for signs of injury.

• DCAP-BTLS

• Damaged/Missing Teeth

• Obstructions

• Swollen or Lacerated Tongue

• Discoloration

• Unusual Odors

NECK - inspect and palpate for signs of injury.

• DCAP-BTLS

• JVD

• Tracheal deviation

• Crepitation

CHEST - inspect and palpate for signs of injury.

• DCAP-BTLS

• Paradoxical movement

• Crepitation

• Breath sounds - bilateral assessment of the apices, midclavicular line; mid-axillary at the
nipple line; and at the bases

• Present

• Absent

• Equal

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ABDOMEN - inspect and palpate for signs of injury.

• DCAP-BTLS

• Pain/Tenderness

• Firm

• Soft

• Distended

PELVIS - inspect and palpate for signs of injury.

• DCAP-BTLS

• If no pain is noted, gently compress the pelvis to determine tenderness or

unstable movement.

EXTREMITIES - inspect and palpate the lower and upper extremities for signs of injury.

• DCAP-BTLS

• Crepitation

• Distal pulses

• Sensory function

• Motor function

POSTERIOR

• Log roll the patient. Maintain c-spine stabilization.

• Inspect and palpate for injuries or signs of injury.

• DCAP-BTLS

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ON-GOING ASSESSMENT

The On-Going Assessment will be performed on all patients while the patient is being
transported to the hospital. It is designed to reassess the patient for changes that may require
new intervention. You will also evaluate the effectiveness of earlier interventions, and reassess
earlier significant findings. You should be prepared to modify treatment as appropriate and
begin new treatment on the basis of your findings during the On-Going Assessment.

Repeat Initial Assessment

• Reassess mental status.

• Maintain an open airway.

• Monitor breathing for rate and quality.

• Reassess pulse for rate and quality.

• Monitor skin color and temperature (CTC).

• Re-establish patient priorities.

Reassess and Record Vital Signs

Repeat Focused Assessment

Check Interventions

• Assure adequacy of oxygen delivery/artificial ventilation.

• Assure management of bleeding.

• Assure adequacy of other interventions

UNSTABLE PATIENTS – repeat On-Going

Assessment at least every 5 minutes.

STABLE PATIENTS – repeat On-Going

Assessment at least every 15 minutes.

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Chapter 10:
Communication and
Documentation
Outline

 Overview
 Types of Communication in EMS
 Emergency Medical Dispatch
 Response Times
 Dispatch Life Support
 EMT Communication
 Triage
 Verbal Communication
 Communicating with Patients
 Documentation
 The Pre-hospital Care Report/Patient Care Report
 Documenting Refusal
 Special Reporting Situations

Overview

Essential components of pre-hospital care:

• Verbal communications are vital.

• Adequate reporting and accurate records ensure continuity of patient care.

• Reporting and record keeping are essential aspects of patient care.

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Types of Communication in EMS

Base Station Radios

• Transmitter and receiver located in a fixed place

• Power of 100 watts or more

• A dedicated line (hot line) is always open.

• Immediately “on” when you lift up the receiver

Mobile and Portable Radios

• Mobile radios installed in vehicle

- Range of 10 to 15 miles

• Portable radios hand-held

- Operate at 1 to 5 watts of power

Repeater-Based Systems

• Receives radio messages and retransmits

• A repeater is a base station able to receive low-power signals.

Digital Systems

• Some EMS systems use telemetry to send an ECG from the unit to the hospital.

• Telemetry is the process of converting electronic signals into coded, audible signals.

• Signals can be decoded by the hospital.

Cellular Telephones

• Low-powered portable radios that communicate through interconnected repeater stations

• Cellular telephones can be easily scanned.

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Others

• Simplex

- Push-to-talk communication

• Duplex

- Simultaneous talk-listen

• MED channels

- Reserved for EMS

Emergency Medical Dispatch

Responsibilities

• Screen and assign priorities

• Select and alert appropriate units to respond

• Dispatch and direct units to the location

• Coordinate response with other agencies

• Provide pre-arrival instructions to the caller

Information Received From Dispatch

• Nature and severity of injury, illness, or incident

• Location of incident

• Number of patients

• Responses by other agencies

• Special information

• Time dispatched

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Advanced Medical Priority Dispatch System (AMPDS)

The Advanced Medical Priority Dispatch System (AMPDS), is a medically-approved,

unified system used to dispatch appropriate aid to medical emergencies including
systematized caller interrogation and pre-arrival instructions. AMPDS is developed and
marketed by Priority Dispatch Corporation which also has similar products for police and
fire.

The output gives a main response category - A (Immediately Life Threatening), B (Urgent
Call), C (Routine Call). This may well be linked to a performance targeting system such as
ORCON where calls must be responded to within a given time period. For example, in
the United Kingdom, calls rated as „A‟ on AMPDS are targeted with getting a responder
on scene within 8 minutes.

Positive Benefits of AMPDS

 Decreased EMV accidents

 Decreased burn-out of field personnel
 Decreased lights-and-siren runs
 Improved medical control at dispatch
 Improved medical dispatcher professionalism
 Improved standardization of care, interrogation and decision making
 Increased appropriateness of medical care through correct response
 Increased resource availability, especially ALS
 Increased safety of response personnel in the field
 Increased knowledge at arrival of response personnel
 Increased cooperation with associated public safety systems, law enforcement
and fire departments

Response Times

Most countries have adopted a response time of 8 to 10 minutes for the most critical
cases, and a longer response time for non-acute calls.

Toronto, Canada

Within 9 minutes in 90% of critical, life-threatening and serious cases; and within 21
minutes in 90% of non-acute cases.

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London, UK

Within 8 minutes in 75% of immediately life-threatening cases; no target set for

cases that are not serious or life-threatening.

Queensland, Australia

Within 10 minutes in 68% of Emergency Transport cases; no target set for non-
urgent cases.

Dispatch Life Support

An Emergency Medical Dispatcher (EMD) is trained to dispatch EMTs based on

the information given during the initial emergency call. They are trained to
mobilise resources based on these essential guidelines:

 A seizure or convulsion may be a sympton of the onset of cardiac arrest.

Any person 35 years or older who presents with a seizure as a chief
complaint should be assumed to be in cardiac arrest until proven
otherwise.
 Cardiac arrest in a previously healthy child should be considered to be
caused by a foreign body obstructing the airway until proven otherwise.
 Dispatchers should be trained to identify obvious death situations (as
defined by medical control), mobilize response accordingly and give
limited pre-arrival instructions.
 If the caller is a third-party who cannot identify if the victim is
unconscious and not breathing, the victim should be assumed to be in
cardiac arrest until proven otherwise.
 EMDs should assume that bystanders have inappropriately placed a pillow
under the head of an unconscious victim, until proven otherwise, and
ensure it is removed.
 BLS protocol for a choking victim should be modified to reflect EMDs
recommend a specific number of thrusts, rather than stating a range of
thrusts.
 The Heimlich manoeuvre should be the primary treatment of infants,
children and adults who are choking.

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Remember that Emergency Medical Dispatchers are not usually EMT-trained.

They are trained to ask specific questions and give basic life support advice over
the telephone. Because people calling emergency services rarely have medical
training, EMDs are trained to err on the side of caution and cater for the worst
case scenario.

EMT Communication

EMT Communication with Dispatch

 Report any problems during run.

 Advise of arrival.
 Communicate scene size-up.
 Keep communications brief.

EMT Communication with Medical Control

 Radio communications facilitate contact between providers and medical

control.
 Consult with medical control to:

- Notify hospital of incoming patient.

- Request advice or orders.

- Advise hospital of special circumstances.

 Organize your thoughts before transmitting.

Calling Medical Control

 The physician bases his or her instructions on the report received from the
EMT-B.
 Never use codes while communicating.
 Repeat all orders received.
 Do not blindly follow an order that does not make sense to you - ask the
physician to clarify his or her orders.
 Notify as early as possible.
 Estimate the potential number of patients.
 Identify special needs of patient.

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Reporting Requirements

 Acknowledge dispatch information.

 Notify arrival at scene.
 Notify departure from scene.
 Notify arrival at hospital or facility.
 Notify you are clear of the incident.
 Notify arrival back in quarters.

Patient Report

 Identification and level of services

 Receiving hospital and ETA
 Patient‟s age and gender
 Chief complaint
 History of current problem
 Other medical history
 Physical findings
 Summary of care given and patient response

Triage

Triage Priorities

Triage is the sorting of patients according to the urgency of their need for care.
It occurs both in the field and at the hospital.

Priority One (Highest)

 Airway or breathing difficulties

 Uncontrolled or severe bleeding
 Decreased or altered mental status
 Severe medical problems
 Signs and symptoms of shock
 Severe burns with airway compromise

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Priority Two

 Burns without airway compromise

 Multiple or major bone or joint injuries
 Back injuries with or without spinal cord damage

Priority 3 (Lowest)

 Minor bone or joint injuries

 Minor soft-tissue injuries
 Prolonged cardiac arrest
 Cardiopulmonary arrest
 Death

Verbal Communication

 Essential part of quality patient care.

 You must be able to find out what the patient needs and then tell others.
 You are a vital link between the patient and the health care team.

Components of an Oral Report

 Patient‟s name, chief complaint, nature of illness, mechanism of injury

 Summary of information from radio report
 Any important history not given earlier
 Patient‟s response to treatment
 The vital signs assessed
 Any other helpful information

Communicating with Patients

 Make and keep eye contact.

 Use the patient‟s proper name.
 Tell the patient the truth.
 Use language the patient can understand.
 Be careful of what you say about the patient to others.
 Be aware of your body language.
 Always speak slowly, clearly, and distinctly.

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 If the patient is hearing impaired, speak clearly and face him or her.
 Allow time for the patient to answer questions.
 Act and speak in a calm, confident manner.

Communicating With Geriatric Patients

 Determine the person‟s functional age.

 Do not assume that an older patient is senile or confused.
 Allow patient ample time to respond.
 Watch for confusion, anxiety, or impaired hearing or vision.
 Explain what is being done and why.

Communicating With Hearing-Impaired Patients

 Always assume that the patient has normal intelligence.

 Make sure you have a paper and pen.
 Face the patient and speak slowly, clearly and distinctly.
 Never shout!
 Learn simple phrases used in sign language.

Communicating With Children

 Children are aware of what is going on.

 Allow people or objects that provide comfort to remain close.
 Explain procedures to children truthfully.
 Position yourself on their level.

Communicating With Vision-Impaired Patients

 Ask the patient if he or she can see at all.

 Explain all procedures as they are being performed.
 If a guide dog is present, transport it also, if possible.

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Communicating With Non-English-Speaking Patients

 Use short, simple questions and answers.

 Point to specific parts of the body as you ask questions.
 Learn common words and phrases in the non-English languages
used in your area.

Documentation

Minimum Data Set for Written Documentation

 Patient information:
 Chief complaint
 Mental status
 Systolic BP (patients older than 3 years)
 Capillary refill (patients younger than 6 years)
 Skin color and temperature
 Pulse
 Respirations and effort
 Time incident was reported
 Time that EMS unit was notified
 Time EMS unit arrived on scene
 Time EMS unit left scene
 Time EMS unit arrived at facility
 Time that patient care was transferred

The Pre-hospital Care Report (PCR)

The Pre-hospital Care Report (or Patient Care Report) serves six functions:

 Continuity of care
 Legal documentation
 Education
 Administrative
 Research
 Evaluation and quality improvement

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Types of PCR Forms

 Written forms
 Computerized versions
 Narrative sections of the form:
 Use only standard abbreviations.
 Spell correctly.
 Record time with assessment findings.
 Report is considered confidential.

Reporting Errors

 Do not write false statements on report.

 If error made on report then:
 Draw a single horizontal line through error.
 Initial and date error.
 Write the correct information.

Remember:

 A PCR is a legal document.

 If you didn‟t do something - don‟t write it down.
 If you don‟t write it down - it didn‟t happen.

Documenting Right of Refusal

 Document assessment findings and care given.

 Have the patient sign the form.
 Have a witness sign the form.
 Include a statement that you explained the possible consequences of
refusing care to the patient

Special Reporting Situations

Be familiar with required reporting in your jurisdiction, including:

 Gunshot wounds
 Animal bites

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 Certain infectious diseases

 Suspected physical, sexual, or substance abuse
 Multiple-casualty incidents (MCI)

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Chapter 11:
Airway Management
Outline

 Anatomy Review
 Normal Breathing Rates
 Recognizing Adequate Breathing
 The Patent Airway
 Recognizing Inadequate Breathing
 Hypoxia
 Different Types of Abnormal Respirations
 Abnormal Lung Sounds
 Conditions Resulting in Hypoxia
 Opening the Airway
 Assessing the Airway
 Suctioning
 Basic Airway Adjuncts
 Ventilation Devices
 Oxygen Therapy
 Article: 10 Things Every Paramedic Should Know About
Capnography
 Reading a Capnograph Wave
 Oxygen Delivery Equipment
 Pressure Regulation Devices
 Article: The Oxygen Myth

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Anatomy Review

Normal Breathing Rates

Adult 12-20 breaths per minute

Child 15-30 breaths per minute

Infant 25-50 breaths per minute

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Recognizing Adequate Breathing

• Normal rate and depth

• Regular pattern
• Regular and equal chest rise and fall
• Adequate depth

The Patent Airway

0-1 minute without oxygen Cardiac irritability

0-4 minutes without oxygen Brain damage not likely

4-6 minutes without oxygen Brain damage possible

6-10 minutes without oxygen Brain damage very likely

More than 10 minutes without oxygen Irreversible brain damage

Recognizing Inadequate Breathing

• Fast or slow rate

• Irregular rhythm
• Abnormal lung sounds
• Reduced tidal volumes
• Use of accessory muscles
• Cool, damp, pale or cyanotic skin

Hypoxia

• Not enough oxygen for metabolic needs

• Develops when patient is:

- Breathing inadequately

- Not breathing

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Signs of Hypoxia

• Nervousness, irritability, and fear

• Tachycardia
• Mental status changes
• Use of accessory muscles for breathing
• Difficulty breathing, possible chest pain

Different Types of Abnormal Respirations

• BRADYPNEA - rate of breathing is abnormally slow < 10 bpm.

• TACHYPNEA - rate of breathing is abnormally rapid > 24 bpm.
• HYPERNEA - respirations are increased in depth and rate (occurs normally with
exercise).
• APNEA - respirations cease for several seconds.
• HYPERVENTILATION - rate of ventilation exceeds normal metabolic requirements
for exchange of respiratory gases. Rate and depth of respiration is increased.
• HYPOVENTILATION - rate of ventilation is insufficient for metabolic requirements.
Respiratory rate is below normal and depth of ventilations is depressed.
• CHEYNE-STOKES RESPIRATION - respiratory rhythm is irregular, characterised by
alternating periods of apnoea and hyperventilation. The respiratory cycle begins
with slow and shallow respiration and gradually increases to abnormal depth and
rapidity.
• KUSSMAUL RESPIRATION - respirations are abnormally deep but regular. Similar
to hyper ventilation.
• ORTHOPNEA - respiratory condition in which the person must sit or stand to
breathe deeply and comfortably.
• BIOT’S RESPIRATION - condition of the central nervous system which causes
shallow breathing interrupted by irregular periods of apnoea.

Abnormal Lung Sounds

Crackles

Crackles (or rales) are caused by fluid in the small airways or atelectasis. Crackles
are referred to as discontinuous sounds; they are intermittent, nonmusical and
brief. Crackles may be heard on inspiration or expiration. The popping sounds

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produced are created when air is forced through respiratory passages that are
narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation
or infection of the small bronchi, bronchioles, and alveoli. Crackles that don’t clear
after a cough may indicate pulmonary edema or fluid in the alveoli due to heart
failure or adult respiratory distress syndrome (ARDS).

• Crackles are often described as fine, medium, and coarse.

• Fine crackles are soft, high-pitched, and very brief. You can simulate this
sound by rolling a strand of hair between your fingers near your ear, or by
moistening your thumb and index finger and separating them near your
ear.
• Coarse crackles are somewhat louder, lower in pitch, and last longer than
fine crackles. They have been described as sounding like opening a Velcro
fastener.

Wheezes

Wheezes are sounds that are heard continuously during inspiration or expiration,
or during both inspiration and expiration. They are caused by air moving through
airways narrowed by constriction or swelling of airway or partial airway
obstruction.

• Wheezes that are relatively high pitched and have a shrill or squeaking
quality may be referred to as sibilant rhonchi. They are often heard
continuously through both inspiration and expiration and have a musical
quality. These wheezes occur when airways are narrowed, such as may
occur during an acute asthmatic attack.
• Wheezes that are lower-pitched sounds with a snoring or moaning quality
may be referred to as sonorous rhonchi. Secretions in large airways, such
as occurs with bronchitis, may produce these sounds; they may clear
somewhat with coughing.

Stridor

Stridor refers to a high-pitched harsh sound heard during inspiration. Stridor is

caused by obstruction of the upper airway, is a sign of respiratory distress and
thus requires immediate attention.

If abnormal lungs sounds are heard, it is important to assess:

• their loudness.

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• timing in the respiratory cycle.

• location on the chest wall.

• persistence of the pattern from breath to breath, and.

• whether or not the sounds clear after a cough or a few deep breaths:

- secretions from bronchitis may cause wheezes, (or rhonchi), that clear with
coughing.

- crackles may be heard when atelectatic alveoli pop open after a few deep
breaths.

Conditions Resulting In Hypoxia

• Myocardial infarction
• Pulmonary edema
• Acute narcotic overdose
• Smoke inhalation
• Stroke
• Chest injury
• Shock
• Lung disease
• Asthma
• Premature birth

Opening the Airway

Head Tilt-Chin Lift Method

Used when cervical spine injury is not suspected.

1. Kneel beside patient’s head.

2. Place one hand on forehead.
3. Apply backward pressure.
4. Place tips of finger under lower jaw.
5. Lift chin.

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Jaw Thrust Maneuver

Used when cervical spine injury is suspected.

1. Kneel above patient’s head.

2. Place fingers behind angle of jaw.
3. Use thumbs to keep mouth open

Assessment of the Airway

1. Look
2. Listen
3. Feel

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Suctioning

Suctioning of a patient’s airway may be necessary when:

• Blood, other liquids and food particles block the airway.

• A gurgling sound is heard when performing artificial ventilation.

Suctioning Technique

• Check the unit and turn it on.

• Select and measure proper catheter to be used.

• Open the patient’s mouth and insert tip.

• Suction as you withdraw the catheter.

• Never suction adults for more than 15 seconds.

Basic Airway Adjuncts

Oropharyngeal airways

• Keep the tongue from blocking the upper airway

• Allow for easier suctioning of the airway

• Used in conjunction with BVM device

• Used on unconscious patients without a gag reflex

Inserting an oropharyngeal airway

1. Select the proper size airway.

2. Open the patient’s mouth.
3. Hold the airway upside down and insert it in the patient’s mouth.
4. Rotate the airway 180° until the flange rests on the patient’s lips.

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Nasopharyngeal Airways

• Used on conscious patients who cannot maintain airway

• Can be used with intact gag reflex

• Should not be used with head injuries or nosebleeds

Inserting a nasopharyngeal airway

1. Select the proper size airway.

2. Lubricate the airway.
3. Gently push the nostril open.
4. With the bevel turned toward the septum, insert the airway.

Airway Kits

A typical EMS airway kit

Basic airways Advanced airways

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Ventilation Devices

The EMT is equipped with a range of devices to assist ventilation. Some of these
devices are not authorized for use by EMT-Bs, but the EMT-B may be called upon to
assist with the use of these devices.

Pocket Mask

A pocket mask may be used to provide artificial ventilations when no other equipment
is available. Pocket masks may be disposable or reusable. Some pocket masks have a
nozzle for the attachment of oxygen tubing. A pocket mask should be equipped with a
one-way valve to prevent body fluids from transferring from the patient to the EMT.

Bag-Valve Mask

The bag-valve mask should be the EMTs primary method of delivering ventilations.
Supplemental oxygen may be attached to the bag-valve if needed. Bag-valve masks
can also be used in conjunction with airway adjuncts and advanced airways such as the
endotracheal tube. Three different sizes are available - adult, child and infant. The child
and infant BVM have a pressure valve to prevent overinflation of the lungs.

Ventilation Techniques

Mouth to Mask Technique

1. Kneel at patient’s head and open airway.

2. Place the mask on the patient’s face.
3. Take a deep breath and breathe into the patient for 1 1/2 to 2 seconds.
4. Remove your mouth and watch for patient’s chest to fall.

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1 Person BVM Technique

1. Insert an oral airway.

2. Establish and maintain an adequate seal with one hand while using the other
hand to delivers ventilations.
3. Place mask on patient’s face.
4. Squeeze bag to deliver ventilations.

2 Person BVM Technique

1. Insert an oral airway.

2. One caregiver maintains seal while the other delivers ventilations.
3. Place mask on patient’s face.
4. Squeeze bag to deliver ventilations.

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Oxygen Therapy

Medical Oxygen

Oxygen is a colourless, odourless gas normally present in the atmosphere at

concentrations of approximately 21%.

The chemical symbol for the element oxygen is O. As a medicinal gas, oxygen contains
not less than 99.0% by volume of O2.

Whereas previously oxygen tended to be given to a majority of patients, research has led
to the prescription of oxygen when and as needed, using pulse oximetry and end-tidal
CO2 capnography to guide the EMT.

Pulse Oximeters

• Used to measure the oxygen saturation of hemoglobin.

• May give false readings with CO absorption because it cannot distinguish between
O2 and CO.
• Takes several minutes to give an accurate reading.

A pulse oximetry of 94% O2 saturation or

above means the patient is receiving
adequate oxygen for metabolism.

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Capnography

Capnography is increasingly being used by paramedics to aid in their assessment and

treatment of patients in the prehospital environment. These uses include verifying and
monitoring the position of an endotracheal tube. A properly positioned tube in the trachea
guards the patient’s airway and enables the paramedic to breathe for the patient. A
misplaced tube in the esophagus can lead to death.

A study in the March 2005 Annals of Emergency Medicine, comparing field intubations that
used continuous capnography to confirm intubations versus non-
use showed zero unrecognized misplaced intubations in the
monitoring group versus 23% misplaced tubes in the
unmonitored group. The American Heart Association (AHA)
affirmed the importance of using capnography to verify tube
placement in their 2005 CPR and ECG Guidelines.

The AHA also notes in their new guidelines that capnography,

which indirectly measures cardiac output, can also be used to
monitor the effectiveness of CPR and as an early indication of
return of spontaneous circulation (ROSC). Studies have shown
that when a person doing CPR tires, the patient’s end-tidal CO2
(ETCO2, the level of carbon dioxide released at the end of
expiration) falls, and then rises when a fresh rescuer takes over.
Other studies have shown when a patient experiences return of
spontaneous circulation, the first indication is often a sudden rise in the ETCO2 as the rush
of circulation washes untransported CO2 from the tissues. Likewise, a sudden drop in
ETCO2 may indicate the patient has lost pulses and CPR may need to be initiated.

Paramedics are also now beginning to monitor the ETCO2 status of nonintubated patients
by using a special nasal cannula that collects the carbon dioxide. A high ETCO2 reading in a
patient with altered mental status or severe difficulty breathing may indicate
hypoventilation and a possible need for the patient to be intubated.

Capnography, because it provides a breath by breath measurement of a patient’s

ventilation, can quickly reveal a worsening trend in a patient’s condition by providing
paramedics with an early warning system into a patient’s respiratory status. As more clinical
studies are conducted into the uses of capnography in asthma, congestive heart failure,
diabetes, circulatory shock, pulmonary embolus, acidosis, and other conditions, the
prehospital use of capnography will greatly expand.

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Article: 10 Things Every Paramedic Should Know About Capnography

Adapted from an Article from JEMS (Journey of Emergency Medical Services), by Peter Canning,
EMT-P, December 29, 2007

10 Things Every Paramedic Should Know About Capnography

Capnography is the vital sign of ventilation.

By tracking the carbon dioxide in a patient’s exhaled breath, capnography enables paramedics
to objectively evaluate a patient’s ventilatory status (and indirectly circulatory and metabolic
status), as the medics utilize their clinical judgement to assess and treat their patients.

Part One: The Science

Definitions:

Capnography – the measurement of carbon dioxide (CO2) in exhaled breath.

Capnometer – the numeric measurement of CO2.

Capnogram – the wave form.

End Tidal CO2 (ETCO2 or PetCO2) – the level of (partial pressure of) carbon dioxide released at
end of expiration.

Oxygenation Versus Ventilation

Oxygenation is how we get oxygen to the tissue. Oxygen is inhaled into the lungs where gas
exchange occurs at the capillary-alveolar membrane. Oxygen is transported to the tissues
through the blood stream. Pulse oximetry measures oxygenation.

At the cellular level, oxygen and glucose combine to produce energy. Carbon dioxide, a waste
product of this process (The Krebs cycle), diffuses into the blood.

Ventilation (the movement of air) is how we get rid of carbon dioxide. Carbon dioxide is carried
back through the blood and exhaled by the lungs through the alveoli. Capnography measures
ventilation.

Capnography versus Pulse Oximetry

Capnography provides an immediate picture of patient condition. Pulse oximetry is delayed.

Hold your breath. Capnography will show immediate apnea, while pulse oximetry will show a
high saturation for several minutes.

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Circulation and Metabolism

While capnography is a direct measurement of ventilation in the lungs, it also indirectly

measures metabolism and circulation. For example, an increased metabolism will
increase the production of carbon dioxide increasing the ETCO2. A decrease in cardiac
output will lower the delivery of carbon dioxide to the lungs decreasing the ETCO2.

Normal Capnography Values

ETCO2 35-45 mm Hg is the normal value for capnography. However, some experts say
30 mm HG – 43 mm Hg can be considered normal.

Cautions: Imperfect positioning of nasal cannula capnofilters may cause distorted

readings. Unique nasal anatomy, obstructed nares and mouth breathers may skew
results and/or require repositioning of cannula. Also, oxygen by mask may lower the
reading by 10% or more.

Capnography Wave Form

The normal wave form appears as straight boxes on the monitor screen but the wave
form appears more drawn out on the print out because the monitor screen is
compressed time while the print out is in real time.

The capnogram wave form begins before exhalation and ends with inspiration. Breathing
out comes before breathing in.

Abnormal Values and Wave Forms

ETCO2 Less Than 35 mmHg = “Hyperventilation/Hypocapnia”

ETC02 Greater Than 45 mmHg = “Hypoventilation/Hypercapnia”

Part Two: Clinical Uses of Capnography

1. Monitoring Ventilation

Capnography monitors patient ventilation, providing a breath by breath trend of

respirations and an early warning system of impending respiratory crisis.

Hyperventilation

When a person hyperventilates, their CO2 goes down.

Hyperventilation can be caused by many factors from anxiety to bronchospasm to

pulmonary embolus. Other reasons C02 may be low: cardiac arrest, decreased cardiac
output, hypotension, cold, severe pulmonary edema.

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Note: Ventilation equals tidal volume X respiratory rate. A patient taking in a large tidal
volume can still hyperventilate with a normal respiratory rate just as a person with a small
tidal volume can hypoventilate with a normal respiratory rate.

Hypoventilation

When a person hypoventilates, their CO2 goes up.

Hypoventilation can be caused by altered mental status such as overdose, sedation,

intoxication, postictal states, head trauma, or stroke, or by a tiring CHF patient. Other
reasons CO2 may be high: Increased cardiac output with increased breathing, fever, sepsis,
pain, severe difficulty breathing, depressed respirations, chronic hypercapnia.

Some diseases may cause the CO2 to go down, then up, then down. (See asthma below).

Pay more attention to the ETCO2 trend than the actual number.

A steadily rising ETCO2 (as the patient begins to hypoventilate) can help a paramedic
anticipate when a patient may soon require assisted ventilations or intubation.

Heroin Overdoses – Some EMS systems permit medics to administer narcan only to
unresponsive patients with suspected opiate overdoses with respiratory rates less than 10.
Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate.
ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow
ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a
respiratory rate of 8, but an ETCO2 of 35.

2. Confirming, Maintaining , and Assisting Intubation

Continuous end-tidal CO2 monitoring can confirm a tracheal intubation. A good wave
form indicating the presence of CO2 ensures the ET tube is in the trachea.

A 2005 study comparing field intubations that used continuous capnography to confirm
intubations versus non-use showed zero unrecognized misplaced intubations in the
monitoring group versus 23% misplaced tubes in the unmonitored group. -Silverstir,
Annals of Emergency Medicine, May 2005

Paramedics can attach the capnography filter to the ET tube prior to intubation and, in
cases where it is difficult to visualize the chords, use the monitor to assist placement. This
includes cases of nasal tracheal intubation.

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Continuous Wave Form Capnography Versus Colorimetric Capnography

In colorimetric capnography a filter attached to an ET tube changes color from purple

to yellow when it detects carbon dioxide. This device has several drawbacks when
compared to waveform capnography. It is not continuous, has no waveform, no
number, no alarms, is easily contaminated, is hard to read in dark, and can give false
readings.

Paramedics should encourage their services to equip them with continuous wave form
capnography.

3. Measuring Cardiac Output During CPR

Monitoring ETC02 measures cardiac output, thus monitoring ETCO2 is a good way to
measure the effectiveness of CPR.

In 1978, Kalenda “reported a decrease in ETC02 as the person performing CPR

fatigued, followed by an increase in ETCO2 as a new rescuer took over, presumably
providing better chest compressions.” –Gravenstein, Capnography: Clinical Aspects,
Cambridge Press, 2004

With the new American Heart Association Guidelines calling for quality compressions
(”push hard, push fast, push deep”), rescuers should switch places every two minutes.
Set the monitor up so the compressors can view the ETCO2 readings as well as the ECG
wave form generated by their compressions. Encourage them to keep the ETCO2
number up as high as possible.

“Reductions in ETCO2 during CPR are associated with comparable reductions in cardiac
output….The extent to which resuscitation maneuvers, especially precordial
compression, maintain cardiac output may be more readily assessed by measurements
of ETCO2 than palpation of arterial pulses.” -Max Weil, M.D., Cardiac Output and End-
Tidal carbon dioxide, Critical Care Medicine, November 1985

Note: Patients with extended down times may have ETCO2 readings so low that quality
of compressions will show little difference in the number.

Return of Spontaneous Circulation (ROSC)

ETCO2 can be the first sign of return of spontaneous circulation (ROSC). During a
cardiac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses.

End-tidal CO2 will often overshoot baseline values when circulation is restored due to
carbon dioxide washout from the tissues.

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A recent study found the ETCO2 shot up on average 13.5 mmHg with sudden ROSC before
settling into a normal range

.-Grmec S, Krizmaric M, Mally S, Kozelj A, Spindler M, Lesnik B.,Resuscitation. 2006 Dec 8

Loss of Spontaneous Circulation

In a resuscitated patient, if you see the stabilized ETCO2 number significantly drop in a
person with ROSC, immediately check pulses. You may have to restart CPR.

4. End Tidal CO2 As Predictor of Resuscitation Outcome

End tidal CO2 monitoring can confirm the futility of resuscitation as well as forecast the
likelihood of resuscitation.

“An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the
initiation of advanced cardiac life support accurately predicts death in patients with cardiac
arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may
reasonably be terminated in such patients.” -Levine R, End-tidal Carbon Dioxide and
Outcome of Out-of-Hospital Cardiac Arrest, New England Journal of Medicine, July 1997

Likewise, case studies have shown that patients with a high initial end tidal CO2 reading
were more likely to be resuscitated than those who didn’t. The greater the initial value, the
likelier the chance of a successful resuscitation.

“No patient who had an end-tidal carbon dioxide of level of less than 10 mm Hg survived.
Conversely, in all 35 patients in whom spontaneous circulation was restored, end-tidal
carbon dioxide rose to at least 18 mm Hg before the clinically detectable return of vital
signs….The difference between survivors and nonsurvivors in 20 minute end-tidal carbon
dioxide levels is dramatic and obvious.” – ibid.

“An ETCO2 value of 16 torr or less successfully discriminated between the survivors and
the nonsurvivors in our study because no patient survived with an ETCO2 less than 16 torr.
Our logistic regression model further showed that for every increase of 1 torr in ETCO2,
the odds of surviving increased by 16%.” –Salen, Can Cardiac Sonography and
Capnography Be Used Independently and in Combination to Predict Resuscitation
Outcomes?, Academic Emergency Medicine, June 2001

Caution: While a low initial ETCO2 makes resuscitation less likely than a higher initial
ETCO2, patients have been successfully resuscitated with an initial ETCO2 >10 mmHg.

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Asphyxic Cardiac Arrest versus Primary Cardiac Arrest

Capnography can also be utilized to differentiate the nature of the cardiac arrest.

A 2003 study found that patients suffering from asphyxic arrest as opposed to primary
cardiac arrest had significantly increased initial ETCO2 reading that came down within a
minute. These high initial readings, caused by the buildup of carbon dioxide in the lungs
while the nonbreathing/nonventilating patient’s heart continued pump carbon dioxide to
the lungs before the heart bradyed down to asystole, should come down within a minute.
The ETCO2 values of asphyxic arrest patients then become prognostic of ROSC

.-Grmec S, Lah K, Tusek-Bunc K,Crit Care. 2003 Dec

5. Monitoring Sedated Patients

Capnography should be used to monitor any patients receiving pain management or

sedation (enough to alter their mental status) for evidence of hypoventilation and/or
apnea.

In a 2006 published study of 60 patients undergoing sedation, in 14 of 17 patients who

suffered acute respiratory events, ETCO2 monitoring flagged a problem before changes in
SPO2 or observed changes in respiratory rate.

“End-tidal carbon dioxide monitoring of patients undergoing PSA detected many clinically
significant acute respiratory events before standard ED monitoring practice did so. The
majority of acute respiratory events noted in this trial occurred before changes in SP02 or
observed hypoventilation and apnea.” – -Burton, Does End-Tidal Carbon Dioxide
Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices,
Academic Emergency Medicine, May 2006

Sedated, Intubated Patients

Capnography is also essential in sedated, intubated patients. A small notch in the wave
form indicates the patient is beginning to arouse from sedation, starting to breathe on
their own, and will need additional medication to prevent them from “bucking” the tube.

6. ETCO2 in Asthma, COPD, and CHF

End-tidal CO2 monitoring on non-intubated patients is an excellent way to assess the

severity of Asthma/COPD, and the effectiveness of treatment. Bronchospasm will produce
a characteristic “shark fin” wave form, as the patient has to struggle to exhale, creating a
sloping “B-C” upstroke. The shape is caused by uneven alveolar emptying.

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Hypoxic Drive

Capnography will show the hypoxic drive in COPD “retainers.” ETCO2 readings will steadily
rise, alerting you to cut back on the oxygen before the patient becomes obtunded. Since it
has been estimated that only 5% of COPDers have a hypoxic drive, monitoring capnography
will also allow you to maintain sufficient oxygen levels in the majority of tachypneic COPDers
without worry that they will hypoventilate.

CHF: Cardiac Asthma

It has been suggested that in wheezing patients with CHF (because the alveoli are still, for
the most part, emptying equally), the wave form should be upright. This can help assist your
clinical judgement when attempting to differentiate between obstructive airway wheezing
such as COPD and the “cardiac asthma” of CHF.

7. Ventilating Head Injured Patients

Capnography can help paramedics avoid hyperventilation in intubated head injured patients.

“Recent evidence suggests hyperventilation leads to ischemia almost immediately…current

models of both ischemic and TBI suggest an immediate period during which the brain is
especially vulnerable to secondary insults. This underscores the importance of avoiding
hyperventilation in the prehospital environment.” –Capnography as a Guide to Ventilation in
the Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004

Hyperventilation decreases intracranial pressure by decreasing intracranial blood flow. The

decreased cerebral blood flow may result in cerebral ischemia.

In a study of 291 intubated head injured patients, 144 had ETCO2 monitoring. Patients with
ETCO2 monitoring had lower incidence of inadvertant severe hyperventilation (5.6%) than
those without ETCO2 monitoring (13.4%). Patients in both groups with severe
hyperventilation had significantly higher mortality (56%) than those without (30%). –Davis,
The Use of Quantitative End-Tidal Capnometry to Avoid Inadvertant Severe Hyperventilation
in Patients with Head Injury After Paramedic Rapid Sequence Intubation, Journal of Trauma,
April 2004

8. Perfusion Warning Sign

“A target value of 35 mmHg is recommended…The propensity of prehospital personnel to

use excessively high respiratory rates suggests that the number of breaths per minute
should be decreased. On the other hand, the mounting evidence against tidal volumes in
excessive of 10cc/kg especially in the absence of peep, would suggest the hypocapnia be
addressed by lower volume ventilation.” – –Capnography as a Guide to Ventilation in the
Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004

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End tidal CO2 monitoring can provide an early warning sign of shock. A patient with a
sudden drop in cardiac output will show a drop in ETCO2 numbers that may be regardless
of any change in breathing. This has implications for trauma patients, cardiac patients –
any patient at risk for shock.

9. Other Issues

DKA – Patients with DKA hyperventilate to lessen their acidosis. The hyperventilation
causes their PAC02 to go down.

“End-tidal C02 is linearly related to HC03 and is significantly lower in children with DKA. If
confirmed by larger trials, cut-points of 29 torr and 36 torr, in conjunction with clinical
assessment, may help discriminate between patients with and without DKA, respectively.”
–Fearon, End-tidal carbon dioxide predicts the presence and severity of acidosis in
children with diabetes, Academic Emergency Medicine, December 2002

Pulmonary Embolus – Pulmonary embolus will cause an increase in the dead space in the
lungs decreasing the alveoli available to offload carbon dioxide. The ETCO2 will go down.

Hyperthermia – Metabolism is on overdrive in fever, which may cause ETCO2 to rise.

Observing this phenomena can be live-saving in patients with malignant hyperthermia, a
rare side effect of RSI (Rapid Sequence Induction).

Trauma – A 2004 study of blunt trauma patients requiring RSI showed that only 5 percent
of patients with ETCO2 below 26.25 mm Hg after 20 minutes survived to discharge. The
median ETCO2 for survivors was 30.75. - Deakin CD, Sado DM, Coats TJ, Davies G.
“Prehospital end-tidal carbon dioxide concentration and outcome in major trauma.”
Journal of Trauma. 2004;57:65-68.

Field Disaster Triage – It has been suggested that capnography is an excellent triage tool
to assess respiratory status in patients in mass casualty chemical incidents, such as those
that might be caused by terrorism.

“Capnography…can serve as an effective, rapid assessment and triage tool for critically
injured patients and victims of chemical exposure. It provides the ABCs in less than 15
seconds and identifies the common complications of chemical terrorism. EMS systems
should consider adding capnography to their triage and patient assessment toolbox and
emphasize its use during educational programs and MCI drills.”- Krauss, Heightman, 15
Second Triage Tool, JEMS, September 2006

Anxiety- ETCO2 is being used on an ambulatory basis to teach patients with anxiety
disorders as well as asthmatics how to better control their breathing. Try (it may not
always be possible) to get your anxious patient to focus on the monitor, telling them that

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as they slow their breathing, their ETCO2 number will rise, their respiratory rate number will fall
and they will feel better.

Anaphylaxis- Some patients who suffer anaphylactic reactions to food they have ingested (nuts,
seafood, etc.) may experience a second attack after initial treatment because the allergens
remain in their stomach. Monitoring ETCO2 may provide early warning to a reoccurrence. The
wave form may start to slope before wheezing is noticed.

Accurate Respiratory Rate – Studies have shown that many medical professionals do a poor job
of recording a patient’s respiratory rate. Capnography not only provides an accurate respiratory
rate, it provides an accurate trend or respirations.

10. The Future

Capnography should be the prehospital standard of care for confirmation and continuous
monitoring of intubation, as well as for monitoring ventilation in sedated patients. Additionally,
it should see increasing use in the monitoring of unstable patients of many etiologies. As more
research is done, the role of capnography in prehospital medicine will continue to grow and
evolve.

The normal range for exhaled CO2 is 35-45mmHg

Reading a Capnograph Wave

Segment I (A to B) of the wave represents post inspiration / dead space expiration.

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Segment II (B to C) of the wave represents exhalation upstroke where dead space gas
mixes with alveolar gas.

Segment III (C to D) of the wave represents a continuance of exhalation and is also called
the plateau.

Segment IV (D to E) of the wave represents inspiration washout.

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The height of the wave should be compared to the scale on the page/screen to determine
ETCO2 levels.

• The number of wave forms per minute can be counted to get an accurate respiratory rate.
• The waves should be analyzed to see if there is any difference from the expected squared-
off wave form.
• Changes in the height of the waves during monitoring should also be evaluated.

Oxygen Delivery Devices

Nasal Cannula

An oxygen tube that provides only a very limited oxygen concentration.

Adult or Pediatric Simple Face Mask

No reservoir and can only deliver up to 60% oxygen.

Adult Nonrebreather Mask

Has an oxygen reservoir bag attached to the mask with a one-way valve between them that
prevents the patient’s exhaled air from mixing with the oxygen in the reservoir bag. Oxygen
requirement = 15 LPM.

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Pediatric Nonrebreather Mask

Has an oxygen reservoir bag attached to the mask with a one-way valve between them
that prevents the patient’s exhaled air from mixing with the oxygen in the reservoir bag.
Oxygen requirement = 8 LPM.

Partial Rebreather Mask

Similar to a nonrebreather mask but is equipped with a two-way valve that allows the
patient to rebreathe about 1/3 of their exhaled air. Can provide an oxygen concentration
of about 35% to 60%.

Venturi Mask

A low flow oxygen system that provides precise concentrations of oxygen through an
entertainment valve connected to the face mask.

Ventilatory Devices and Oxygen Concentration

Device Liter Flow (LPM) Oxygen Delivered

Nasal Cannulae 1-6 24-26%

Mouth-to-Mask 10 50%

Simple face mask 8-10 40-60%

BVM without reservoir 8-10 40-60%

Partial rebreather mask 6 60%

Simple mask with reservoir 6 60%

BVM with reservoir 15 100%

Nonrebreathing mask with 15 90-100%

reservoir

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Oxygen Cylinders

In emergency medical care, the following sizes of

oxygen cylinders are commonly used:

D cylinder 350 liters

E Cylinder 625 liters

M Cylinder 3000 liters

G cylinder 5300 liters

H cylinder 6900 liters

Safety Precautions

Oxygen is a gas that acts as an accelerant for combustion, and oxygen cylinders are under
high pressure.

Never allow combustible materials, such as oil and grease, touch the cylinder, regulator
fittings, valves or hoses.

Never smoke or allow others to smoke in any area where oxygen cylinders are in use or on
standby.

Calculation of Oxygen Cylinder Contents in Liters

D cylinder - Lbs per in2 x 0.16 = contents in liters

E cylinder - Lbs per in2 x 0.28 = contents in liters

G cylinder - Lbs per in2 x 2.41 = contents in liters

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H cylinder - Lbs per in2 x 3.14 = contents in liters

M cylinder - Lbs per in2 x 1.56= contents in liters

Calculation of Oxygen Required for Transport

Breaths per minute x tidal volume x travel time = ɵ

ɵ + ɵ/2 = total requirement of oxygen for transport

(Note: 50% of the estimated need is added in order to cater for emergencies or unforeseen
circumstances)

Minimum Volume Requirements for Pediatrics

Age in Years Minimum Volume Required

1 120ml

2 156ml

3-4 170ml

5-6 200ml

7-10 270ml

11-12 380ml

13-14 420ml

15 as adult

Safety with Oxygen Cylinders

• Store cylinders below 50 degrees Celsius.

• Never use an oxygen cylinder without a safe, properly fitting
regulator valve.
• Keep all valves closed when the cylinder is not in use, even if the
tank is empty.
• Keep oxygen cylinders secured to prevent them from toppling
over.

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• When you are working with oxygen cylinders, never put any body parts over
the cylinder valve.

Pressure Regulators

Pressure regulators are devices that control gas flow and reduce the high pressure in the
cylinder to a safe range (from 2000psi to around 50psi), and controls the flow of oxygen
from 1-15 liters per minute.

There are two types of regulators:

High-pressure regulator

This type of regulator has one gauge that registers the content of the cylinder and that,
through a step-down regulator, can provide 50psi to power a flow restricted oxygen
powered automatic transport ventilator (ATV).

Therapy regulator

This type of regulator has two gauges, one indicating the pressure in the tank and a
flowmeter indicating the measured flow of oxygen being delivered to the patient (0-15
LPM).

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Article: The Oxygen Myth?

The Oxygen Myth?

An article by Bryan E. Bledsoe, DO, FACEP, Mar 5 2009, JEMS

(http://www.jems.com/news_and_articles/columns/Bledsoe/the_oxygen_myth.html)

In EMS, we’ve always emphasized two things: airway and oxygenation. In reality, we should
be emphasizing ventilation. Without an airway, your patient cannot ventilate. Without
ventilation, you cannot assess the airway. They’re inseparably linked.

Likewise, without ventilation, oxygenation is impossible. But ventilation involves much more
than oxygenation. It involves the elimination of carbon dioxide and toxins and plays a role in
other important biological processes.

We’ve always taught that a little oxygen is good and a lot of oxygen is better. We adopted
pulse oximeters and really only use them to document oxygen saturations -- especially low
thresholds. The closer to 100%, the better -- or so we thought. But is doing this in the best
interest of the patients?

Several years ago we saw a change in practice in the neonatology community to limit
supplemental oxygenation given to newborns and neonates. We had always known that
high-concentration oxygen was associated with the development of retinopathy of
prematurity (ROP), formerly called retrolental fibroplasia, in premature infants. Later,
clinicians found that neonates resuscitated with high-concentration oxygen had worse
outcomes than those resuscitated with room air. For example, infants resuscitated with 100%
oxygen have a greater delay to first cry and a greater delay to first respiration.(1) In one
study of depressed infants, mortality was 13% for those resuscitated with 100% oxygen and
only 8% for those resuscitated with room air.(2) Further, neonates resuscitated with room air
had a lower mortality at one week compared to those resuscitated with 100% oxygen.(3) The
American Heart Association now recommends starting with room air and increasing oxygen
concentration as needed to maintain an adequate oxygen saturation.(4)

Next, the phenomenon of reperfusion injury was noted. Reperfusion injury occurs when
oxygen is reintroduced to ischemic tissues. Stated another way, the injury does not occur
during periods of hypoxia. It occurs after oxygen is restored to the affected tissues.

The primary mechanism is thought to be the development of toxic chemicals called “reactive
oxygen species” or “free radicals.” These chemicals have an unpaired electron in their outer
shell and are very unstable. They occur normally, to a limited degree, but the body has
enzyme systems that process the free radicals into less toxic substances, thus avoiding
significant cellular damage. But following a period of hypoxia, a large number of free radicals

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are produced that overwhelm the protective enzyme systems (antioxidants) and cellular
damage occurs. This damage is called “oxidative stress . “

The effects of aging are often due to oxidative stress. Also, some diseases such as
atherosclerosis, Alzheimer’s disease, Parkinson’s disease, and others have been linked to
oxidative stress and free radical induction. Thus, the evolving thought is that, in some
conditions, high concentrations of oxygen can be harmful.

So, what does this mean to the future evolution of EMS practice? Well, there are several
disease processes we must consider.

Stroke: The brain is very vulnerable to the effects of oxidative stress. The brain has fewer
antioxidants than other tissues. Thus, should we give oxygen to non-hypoxic stroke patients?
Studies have shown that patients with mild-moderate strokes have improved mortality when
they receive room air instead of high-concentration oxygen.

The data on patients with severe strokes is less clear.(5) Current research indicates that
supplemental oxygen should not be routinely given to patients with stroke and can, in some
cases, be detrimental.(6)

Acute Coronary Syndrome: The myocardium is highly oxygen dependent and vulnerable to
the effects of oxidative stress. Thus far, there’s no evidence that giving supplemental oxygen
to acute coronary syndrome patients is helpful, but there’s no evidence it’s harmful.(7)

Post-Cardiac Arrest: Here, too, the evidence is too scant to tell. We do know that virtually all
current therapies for cardiac arrest (drugs, airway) are of little, if any, benefit. The primary
therapies remain CPR (often with limited ventilation initially) and defibrillation followed by
induced hypothermia. The whole purpose of induced hypothermia is to prevent the
detrimental effects of oxidative stress and the other harmful effects of reperfusion injury.

Trauma: What role should oxygen play in non-hypoxic trauma patients? Little research exists,
but an interesting study out of New Orleans demonstrated that there was no survival benefit
to the use of supplemental oxygen in the prehospital setting in traumatized patients who do
not require mechanical ventilation or airway protection.(8)

Carbon Monoxide (CO) Poisoning: We have learned a lot about carbon monoxide poisoning
in the past few years. We know that the mechanism of CO poisoning is a lot more complex
than once thought. We also know that there’s no reliable evidence that hyperbaric oxygen
(HBO) therapy improves outcome (although it’s still widely used).(9) But when you think
about it, the goal of treatment in CO poisoning is to eliminate CO through ventilation -- not
hyperoxygenation. Although oxygen can displace some CO from hemoglobin, the induction
of free-radicals may be worse than the effects of CO. Again, the science here is in a state of
flux.

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Neonates: The science is clear in regard to supplemental oxygen in neonates. It should be

used only when room air ventilation fails.

Again, this is a discussion of the changing science. Always continue to follow the direction of
your medical director and local protocols. That said, it’s clear that we need to use every tool
possible to support, but not replace, our physical exam skills. We should use pulse oximetry
and waveform capnography. Although, individually, each technology has its limitations,
together they provide important information about the patient.

The goal of therapy is to avoid hypoxia and hyperoxia. If the patient’s oxygen saturation and
ventilation are adequate, supplemental oxygen is probably not required. If the patient is
hypoxic or hypercapnic, then you must determine whether the problem can be remedied
through increased ventilation, increased oxygenation, or both. Thus, you have to assess the
problem, recognize and understand the pathophysiological processes involved, plan an
appropriate therapy (within the scope of your protocols), and provide the needed therapy.
That is what prehospital care is all about.

References

1. Martin RJ, Bookatz GB, Gelfand SL, et al: “Consequences of neonatal resuscitation with
supplemental oxygen.” Semin Perinatol. 32:355-366, 2008.

2. Davis PG, Tan A, O’Donnell CP, et al: “Resuscitation of newborn infants with 100% oxygen
or air: A systematic review and meta-analysis.” Lancet. 364:1329-1333, 2004.

3. Rabi Y, Rabi D, Yee W: “Room air resuscitation of the depressed newborn: A systematic
review and meta-analysis.” Resuscitation. 72:353-363, 2007.

4. American Heart Association: “2005 American Heart Association guidelines for

cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric
and neonatal patients: Pediatric basic life support.” Circulation.13:IV1-203, 2005.

5. Ronning OM, Guldvog B: “Should stroke victims routinely receive supplemental oxygen? A
quasi-randomized controlled trial.” Stroke. 30:2033-2037, 1999.

6. Pancioli AM, Bullard MJ, Grulee ME, et al: “Supplemental oxygen use in ischemic stroke
patients: Does utilization correspond to need for oxygen therapy.” Archives of Internal
Medicine. 162:49-52, 2002.

7. Mackway-Jones K: “Oxygen in uncomplicated myocardial infarction.” Emergency Medicine

Journal. 21:75-81, 2004.

8. Stockinger ZT, McSwain NE: “Prehospital supplemental oxygen in trauma patients: Its
efficacy and implications for military medical care.” Military Medicine. 169:609-612, 2004.

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9. Gilmer B, Kilkenny J, Tomaszewski C, et al: “Hyperbaric oxygen does not improve

neurologic sequelae after carbon monoxide poisoning.” Academic Emergency Medicine. 9:1-
8, 2002.

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Chapter 12:
The Basic ECG
Outline

 Electrical Conduction System of the Heart

 The Electrocardiogram
 The ECG Complex
 An In-depth Look at the ECG and Its Generation
 ECG Rhythm Interpretation

Electrical Conduction System of the Heart

 A network of specialized tissue in the heart.

 Conducts electrical current throughout the heart.
 The flow of electrical current causes contractions that produce pumping of
blood.

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The heart’s electrical system is made up of three main parts:

 The sinoatrial (SA) node, located in the right atrium of the heart.
 The atrioventricular (AV) node, located on the interatrial septum close to the tricuspid
valve.
 The His-Purkinje system, located along the walls of the heart’s ventricles.

A heartbeat is a complex series of events that take place in the heart. A heartbeat is a single
cycle in which the heart’s chambers relax and contract to pump blood. This cycle includes
the opening and closing of the inlet and outlet valves of the right and left ventricles of the
heart.

Each heartbeat has two basic parts: diastole and atrial and ventricular systole. During
diastole, the atria and ventricles of the heart relax and begin to fill with blood.

At the end of diastole, the heart’s atria contract (atrial systole) and pump blood into the
ventricles. The atria then begin to relax. The heart’s ventricles then contract (ventricular
systole) pumping blood out of the heart.

Each beat of the heart is set in motion by an electrical signal from within the heart muscle. In
a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA
node is sometimes called the heart’s natural pacemaker. The pulse, or heart rate, is the
number of signals the SA node produces per minute. The signal is generated as the two vena
cavae fill the heart’s right atrium with blood from other parts of the body. The signal spreads
across the cells of the heart’s right and left atria. This signal causes the atria to contract. This
action pushes blood through the open valves from the atria into both ventricles.

The signal arrives at the AV node near the ventricles. It slows for an instant to allow the
heart’s right and left ventricles to fill with blood. The signal is released and moves along a
pathway called the bundle of His, which is located in the walls of the heart’s ventricles.

From the bundle of His, the signal fibers divide into left and right bundle branches through
the Purkinje fibers that connect directly to the cells in the walls of the heart’s left and right
ventricles. The signal spreads across the cells of the ventricle walls, and both ventricles
contract. However, this doesn’t happen at exactly the same moment. The left ventricle
contracts an instant before the right ventricle. This pushes blood through the pulmonary
valve (for the right ventricle) to the lungs, and through the aortic valve (for the left ventricle)
to the rest of the body.

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As the signal passes, the walls of the ventricles relax and await the next signal. This process
continues over and over as the atria refill with blood and other electrical signals come from
the SA node.

The Electrocardiogram

 Records potential (voltage) differences between a ‘neutral’ ground and recording

electrodes.
 3 lead ECG used for monitoring purposes.
 12 lead ECG used for diagnostic purposes.
 Lead II shows life-threatening rhythms.
 Most ECG recordings are obtained with paper speeds of 25mm/sec and signal
calibration of 1.0mV/1cm.
 The P-QRS-T complex of the normal ECG represents electrical activity over one cardiac
cycle.
 The dominant pacemaker of the heart is the sinus node in the right atrium. It normally
fires between 60 and 100 times a minute. Should the sinus node fail, the AV node is a
potential pacemaker but it only fires at 40-60 beats per minute.

The ECG Complex

• One complex represents one beat in the heart.

• Complex consists of P, QRS, and T waves.

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Parts of the ECG Complex

 P Wave - Atrial depolarization - 0.04-0.12 seconds - 1-2 small squares

 PR Interval - SA Node-AV Node conduction time - 0.12-0.20 seconds - 3-5
small squares
 QRS Complex - Ventricular depolarization - 0.04-0.10 seconds - 1-2 small
squares
 ST Segment - Plateau phase ventricular depolarization - isoelectric (baseline)
 T Wave - Ventricular repolarization - 0.5mV/5mm
 QT Interval - Total duration of ventricular depolarization - 0.33-0.42 seconds -
8-10 small squares

An In-depth Look at the ECG and Its Generation

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ECG Rhythm Interpretation

Normal Sinus Rhythm

• Consistent P waves
• Consistent P-R interval
• 60–100 beats/min

Sinus Bradycardia

• Consistent P waves
• Consistent P-R interval
• Less than 60 beats/min

Sinus Tachycardia

• Consistent P waves
• Consistent P-R interval
• More than 100 beats/min

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Remember - A sinus rhythm is a rhythm that has

a P Wave present.

Ventricular Tachycardia

• Three or more ventricular complexes in a row

• More than 100 beats/min

Ventricular Fibrillation

• Rapid, completely disorganized rhythm

• Deadly arrhythmia that requires immediate treatment

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Asystole

• Complete absence of electrical cardiac activity

• Patient is clinically dead.
• Decision to terminate resuscitation efforts depends on local protocol.

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Chapter 13: The Automated External Defibrillator

Chapter 13:
The Automated External
Defibrillator
Outline

 The Chain of Survival

 The Purpose of Defibrillation
 The Importance of Early Defibrillation
 Types of Defibrillators
 Shockable Rhythms
 Non-Shockable Rhythms
 Advantages of the AED
 Medical Direction
 Energy Levels for AEDs
 Monophasic vs. Biphasic
 Indications for AED Use
 Contraindications for AED Use
 Preparing to Operate an AED
 Using an AED - 3 Simple Steps
 AED Treatment Algorithm
 Using an AED – Detailed Steps
 After AED shocks
 Transport
 Cardiac Arrest During Transport

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The Chain of Survival

The Chain of Survival was developed by the American Heart Association in 1990 in
recognition of the fact that the vast majority of sudden cardiac arrests (SCA) occur outside of
hospitals, and that failure to defibrillate early results in a high rate of failure to resuscitate
patients. In response to the development of the chain of survival, public awareness of the
importance of its components has increased, particularly in western countries, where AEDs
are often located readily in public places. To provide the best opportunity for survival, each
of these four links must be put into motion within the first few minutes of SCA onset:
 Early Access to Emergency Care must be provided by calling 911 (US) or a
universal access number.
 Early CPR should be started and maintained until emergency medical services
(EMS) arrive.
 Early Defibrillation is the only one that can re-start the heart function of a
person with ventricular fibrillation (VF). If an automated external defibrillator
(AED) is available, a trained operator should administer defibrillation as quickly
as possible until EMS personnel arrive.
 Early Advanced Care, the final link, can then be administered as needed by
EMS personnel.

Time After the Onset of Attack Survival Chances

With every minute Chances are reduced by 7-10%

Within 4-6 minutes Brain damage and permanent death

start to occur

After 10 minutes Few attempts at resuscitation succeed

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Type of Care for SCA Victims Chance of Survival

after Collapse

0%
No care after collapse

No CPR and delayed defibrillation (after 10 0-2%

minutes)

CPR from a non-medical person (such as a

2-8%
bystander or family member) begun within
2 minutes, but delayed defibrillation

20%
CPR and defibrillation within 8 minutes

CPR and defibrillation within 4 minutes; 43%

paramedic help within 8 minutes

In certain environments, where the Chain is strong and when defibrillation occurs within the
first few minutes of cardiac arrest, survival rates can approach 80% to 100%.

ILCOR AED Symbol

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The Purpose of Defibrillation

Defibrillation does not „jump start‟ the heart. The purpose of the shock is to produce
temporary aystole. The shock attempts to completely depolarize the myocardium and
provide an opportunity for the natural pacemaker centers of the heart to resume normal
activity.

The Importance of Early Defibrillation

Defibrillation is the single most important factor in determining the survival from cardiac
arrest.

Rationale for Early Defibrillation

 The most common initial rhythm in witnessed sudden cardiac arrest is ventricular
fibrillation.
 The most effective treatment for ventricular fibrillation is electrical defibrillation.
 The probability of successful defibrillation diminishes rapidly over time.
 VF tends to convert to asystole within a few minutes.

Types of Defibrillators

 Manual defibrillators
 Automated internal defibrillators
 Automated external defibrillators
 fully automated
 semi-automated

Shockable Rhythms

Ventricular fibrillation (VF)

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Ventricular Tachycardia (V-Tach) - (if the patient is pulseless and unconscious)

Non-Shockable Rhythms

Asystole

Pulseless Electrical Activity (PEA) - (any heart rhythm observed on the ECG that
should be producing a pulse, but is not)

Advantages of the AED

 ALS providers do not need to be on scene.

 Remote, adhesive defibrillator pads are used.
 Efficient transmission of electricity

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Medical Direction

 Should approve protocols.

 Should review AED usage.
 Should review speed of defibrillation.
 Should provide review of skills every 3 to 6 months.

Energy Levels of the AED

 Electrical current is measured in joules (J)

 Manual defibrillators - 5 or 10 to 360J
 Fully or semi-automated defibrillators - preset values of 200 and 360J
programmed.

Monophasic vs. Biphasic

The earliest defibrillators were monophasic, which means that they passed an electrical
current in just one direction to try to reset the heart. Biphasic defibrillators use an
electrical current that flows in two directions to shock the heart. The advantage of using
biphasic defibrillators is that less electrical current is needed to successfully shock the
heart, which makes these devices more effective to restore the heart‟s regular rhythm
more quickly.

Indications for AED Use

 The patient is unresponsive, and;

 The patient demonstrates no effective breathing, and;
 The patient has no signs of circulation.

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Contraindications for AED Use

 The patient is under 1 year old;

 The patient suffered cardiac arrest as a result of trauma (except electrocution);
 The patient has a detectable pulse or respirations;
 The patient demonstrates response to external stimulus.

Preparing to Operate an AED

 Make sure the electricity injures no one.

 Do not defibrillate a patient lying in pooled water.
 Dry a soaking wet patient‟s chest first.
 Do not defibrillate a patient who is touching metal.
 Remove nitroglycerin patches.
 Shave a hairy patient‟s chest if needed.

AED pads for adults (left) and children (right)

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Using an AED – 3 Simple Steps

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AED Treatment Algorithm

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Using an AED - Detailed Steps

Step 1

 Assess responsiveness.
 Stop CPR if in progress.
 Check breathing and pulse.
 If patient is unresponsive and not breathing adequately, give two slow
ventilations.

Step 2

 If there is a delay in obtaining an AED, have your partner start or resume CPR.
 If an AED is close at hand, prepare the AED pads.
 Turn on the machine.

Step 3

 Remove clothing from the patient‟s chest area. Apply pads to the chest.
 Stop CPR.
 State aloud, “Clear the patient.”

Step 4

 Push the analyze button, if there is one.

 Wait for the computer.
 If shock is not needed, start CPR.
 If shock is advised, make sure that no one is touching the patient.
 Push the shock button

Step 5

 After the shock is delivered, immediately resume CPR. Perform 5 cycles of CPR.
 Reanalyze the rhythm.
 If the machine advises a shock, deliver a shock then perform 5 cycles of CPR.

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Step 6

 Check for pulse.

 If the patient has a pulse, check breathing.
 If the patient is breathing adequately, provide oxygen via non-rebreathing mask if
needed and transport.

Step 7

 If the patient is not breathing adequately, use necessary airway adjuncts and proper
positioning to open airway.
 Provide artificial ventilations with high concentration oxygen.
 Transport.

Step 8

 If the patient has no pulse, perform 1 minute of CPR.

 Gather additional information on the arrest event.
 After 1 minute of CPR, make sure no one is touching the patient.
 Push the analyze button again (as applicable).
 Transport and check with medical control.
 Continue to support the patient as needed.

After AED Shocks

 Check pulse.
 No pulse, no shock advised
 No pulse, shock advised
 If a patient is breathing independently:
 Administer oxygen if needed.
 Check pulse.
 If a patient has a pulse, but breathing is inadequate, assist ventilations.

Transport

 When patient regains pulse; or

 After delivering six to nine shocks; or

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 After receiving three consecutive “no shock advised” messages.

 Keep AED attached.
 Check pulse frequently.
 Stop ambulance to use an AED.

Cardiac Arrest During Transport

 Check unconscious patient‟s pulse every 30 seconds.

 If pulse is not present:
 Stop the vehicle.
 Perform CPR until AED is available.
 Analyze rhythm.
 Deliver shock(s).
 Continue resuscitation according to local protocol
 If patient becomes unconscious during transport:
 Check pulse.
 Stop the vehicle.
 Perform CPR until AED is available.
 Analyze rhythm.
 Deliver up to three shocks.
 Continue resuscitation according to local protocol.

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Chapter 14:
Environmental
Emergencies
Outline

 Body Temperature
 How The Body Keeps Warm
 How The Body Loses Heat
 Mechanisms of Heat Loss from the Body
 Factors Affecting Exposure
 Exposure to Cold
 Emergency Care for Local Cold Injury
 Hypothermia
 Exposure to Heat
 Drowning and Near-Drowning
 Pathophysiology of Drowning
 Water Rescue
 Management of Drowning
 Lightning
 Bites and Stings
 Diving Emergencies

Body Temperature

To keep the body temperature within a safe range of 36-38 degrees Celsius, the
body must maintain a constant balance between heat gain and heat loss. This is
known as thermoregulation.

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In humans, body temperature is controlled by the thermoregulatory centre in the hypothalamus.

It receives input from two sets of thermoreceptors: receptors in the hypothalamus itself monitor
the temperature of the blood as it passes through the brain (the core temperature), and
receptors in the skin (especially on the trunk) monitor the external temperature. Both sets of
information are needed so that the body can make appropriate adjustments.

How the body keeps warm

Heat is generated in the tissues by:

 the conversion of food to energy in the cells
 muscle activity, either voluntary (exercise) or, in cold conditions, involuntary (shivering)
Heat is absorbed from outside sources - the sun, fire, hot air, hot food and drinks, or any hot
object in contact with the skin.
In cold conditions, the body conserves heat by:
 constricting blood vessels at the body surface to keep warm blood at the core.
 reducing sweating.
 erecting body hairs to ‗trap‘ warm air at the skin.

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How the body loses heat

Heat may be lost to:

 cool surrounding air - by radiating from the skin and in the breath.
 cool objects in contact with skin, which provides a ‗pathway‘ by which heat escapes.
In hot conditions, the body reacts to heat loss by:
 the blood vessels in or near the skin dilating in order to lose blood heat.
 sweat glands become active. Heat is lost as the sweat evaporates in cooler air.
 The rate and depth of breathing will increase - warm air is expelled, and cool air
drawn in to replace it, cooling the blood in the vessels of the lungs.

Mechanisms of Heat Loss from the Body

 Conduction – heat loss from direct contact between a warm body and a cold one, e.g.
sitting on the ground.
 Convection – heat loss to moving air or water, e.g. the wind strips heat from you
 Radiation – heat loss via infrared radiation – Just as how you feel heat radiate from a
hot stove so too do you radiate heat.

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 Evaporation – heat loss via the evaporation of water from your skin and also from the
process of breathing in cold dry air and exhaling it as warm moist air.
 Respiration - heat loss through breathing warm air out.

Factors Affecting Exposure

 Physical condition
 Age
 Nutrition and hydration
 Environmental conditions

Exposure to Cold

Local Cold Injury

1st Degree (Frostnip)

Victim is usually unaware of injury unless they see themselves in the mirror. Patient has an
unusual pallor which returns to normal when warmed, usually accompanied by some
redness and tingling.

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2nd Degree (Superficial Frostbite)

Skin appears waxy and white. Underlying tissue is soft. Affected area feels numb. As
thawing occurs, the injured area turns a mottled blue and patient experiences a stinging
sensation. Within a few hours there is also usually edema and blisters.

3rd-4th Degree (Deep Frostbite)

Skin appears white or mottled blue and white, and feels hard and cold. When thawed,
the patient may feel pain, burning, throbbing, aching and joint pain. Gangrene may set in
within a few days, requiring amputation of the affected part.

Emergency Care for Local Cold Injury

 Remove the patient from further exposure to the cold.

 Handle the injured part gently.
 Administer oxygen if necessary.
 Remove any wet or restrictive clothing.
 Never rub the area.
 Do not break blisters.
 Transport.

Hypothermia

 Lowering of the body temperature below 35°C

 Weather does not have to be below freezing for hypothermia to occur.
 Older persons and infants are at higher risk.
 People with other illnesses and injuries are susceptible to hypothermia.

Stages of Hypothermia (ILCOR 2005)

Stage Celsius Fahrenheit

Mild 34-36 93.2-96.8

Moderate 30-34 86

Severe <30

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Signs and Symptoms of Mild Hypothermia

 Shivering
 Rapid pulse and respirations
 Red, pale, cyanotic skin

Signs and Symptoms of More Severe Hypothermia

 Shivering stops.

 Muscular activity decreases.

 Fine muscle activity ceases.

 Eventually, all muscle activity stops.

Interventions for Hypothermia

 Move from cold environment.

 Do not allow patient to walk, eat, use any stimulants, or smoke.

 Remove wet clothing.

 Place dry blankets under and over patient.

 Handle gently.

 Do not massage extremities.

 Give warm, humidified oxygen.

In a hypothermic patient, check for a pulse for an extended

period of 30 to 45 seconds.

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Exposure to Heat

Heat Exposure

 Normal body temperature is approximately 37°C.

 Body attempts to maintain normal temperature despite ambient temperature.
 Body cools itself by sweating (evaporation) and dilation of blood vessels.
 High temperature and humidity decrease effectiveness of cooling mechanisms.

Heat Cramps

 Painful muscle spasms

 Remove the patient from hot environment.
 Rest the cramping muscle.
 Replace fluids by mouth.
 If cramps persist, transport the patient to hospital.

Heat Exhaustion

 Dizziness, weakness, or fainting

 Onset while working hard or exercising in hot environment
 In older people and young, onset may occur while at rest in hot, humid, and
poorly ventilated areas.
 Cold, clammy skin
 Dry tongue and thirst
 Patients usually have normal vital signs, but pulse can increase and blood pressure
can decrease.
 Normal or slightly elevated body temperature

Treatment for Heat Exhaustion

 Remove extra clothing and remove from hot environment.
 Give patient oxygen if necessary.
 Have patient lie down and elevate legs.
 If patient is alert, give water slowly.
 Be prepared to transport.

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Heat Stroke

 Hot, dry, flushed skin

 Change in behavior leading to unresponsiveness
 Pulse rate is rapid, then slows.
 Blood pressure drops.
 Death can occur if the patient is not treated.

Treatment for Heat Stroke

 Move patient out of the hot environment.
 Provide air conditioning at a high setting.
 Remove the patient‘s clothing.
 Give the patient oxygen.
 Apply cold packs to the patient‘s neck, armpits, and groin.
 Cover the patient with wet towels or sheets.
 Aggressively fan the patient.
 Immediately transport patient.
 Notify the hospital of patient‘s condition.

Drowning and Near Drowning

Drowning

• Death as a result of suffocation after submersion in water.

Near drowning

• Survival, at least temporarily, after suffocation in water.

Major Causes of Drowning Accidents

 Getting exhausted in water

 Losing control and getting swept into water that is too deep
 Losing support (e.g. sinking boat)
 Getting trapped or entangled while in water
 Using drugs or alcohol before getting into water
 Suffering hypothermia
 Suffering trauma

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 Having a diving accident

Preventing Drowning Accidents

 Children should be under constant supervision if a body of water, such as a pool,

lake or creek is nearby.
 Water sports and alcoholic beverages should not be mixed.
 Life preservers or life jackets should be worn when boating.

Where People Drown

Type of Water Percentage of Drownings

Salt water 1-2%
Fresh water 96-99%
Swimming Pools
- Private 50%
- Public 3%
Lake, Rivers, Streams 20%
Bath Tubs 15%
Buckets of Water 4%
Fish ponds or Tanks 4%
Toilets 4%
Washing Machines 1%

Pathophysiology of Drowning

Step 1
 Victim goes under water
 Water enters the airway
 Coughing and gasping starts and victim swallows water
Step 2
 A small amount of water enters the larynx and causes laryngospasm.
 Breathing ceases and metabolic acidosis occurs.
 This is dry drowning (10-15% of cases)

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Step 3
 The laryngeal muscles become severely hypoxic and relax, allowing
air to enter the lungs.
 This triggers peripheral airway resistance and constriction of the
pulmonary vessels resulting in ‗Stiff Lung‘, where the lung ceases
to be compliant.
Step 4
 Victim‘s hypercarbic/hypoxic drive further stimulates inhalation of
water which mixes with air and chemical residue in the lungs to
form a froth.
 Brain damage and death occur.

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Water Rescue

1. Reach: Hold on to the dock or your boat and reach your hand, a boat oar, a fishing pole, or
whatever you have nearby to the person in the water
2. Throw: If you can‘t reach far enough, toss things that will float for the person to grab.
3. Tow: If you‘re in a boat, use to oars to move the boat closer to the person in the water or
call out to a nearby boat for help. Don‘t use the boat‘s motor close to a person in the water,
they could be injured by the propeller.
4. Don’t Go: Don‘t go into the water unless you are trained for water rescue.

Management of Drowning

1. Do not enter the water unless trained in water rescue.

2. Ensure an open airway and attempt rescue breathing.
3. Continue rescue breathing and remove from the water.
4. Check pulse - if absent, begin chest compressions
5. Transport.
6. If given the opportunity - use positive pressure ventilation (PEEP) to dry
the lungs.

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Lightning

 Strikes boaters, swimmers, golfers, anyone in large, open areas.

 Cardiac arrest and tissue damage are common.
 Three categories of lightning injuries
 Mild: Loss of consciousness, amnesia, tingling, superficial burns
 Moderate: Seizures, respiratory arrest, asystole (spontaneously
resolves), superficial burns
 Severe: Cardiopulmonary arrest
Emergency Medical Care
 Protect yourself.
 Move patient to sheltered area or stay close to ground.
 Use reverse triage.
 Treat as for other electrical injuries.
 Transport to nearest facility.

Bites and Stings

EMTs may be called to deal with a wide range of bites and stings. As venomous
animals can vary from region to region, it is important for the EMT to be aware of
threats in their area, as well as treatment protocols. An EMT working near the coast, for
example, may come across a range of marine animal stings and bites, whereas an EMT
working in a desert area may require awareness of scorpion stings.

In general, most bites and stings are not fatal, due to the availability of antivenom.
However, the EMT must monitor for allergic reactions and anaphylaxis.

Bite statistics (US)

Dogs
 Over 1 million dog bites a year
 Cause approximately 340,000 emergency room visits every year.
 Approximately 10-20 deaths every year.
 Infection rate of 15-20%.
 Rabies is a threat in some countries.

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Cats
 Less common than dog bites.
 Infection rate of 30-40%.
Humans
 Approximately 70000 human bites every year.
 Because the human mouth contains many potentially harmful microorganisms,
human bites are more infectious than most animals.

Signs and Symptoms of Animal Bites

 Redness at or around the bite site

 Swelling
 Pus (thick) drainage from the wound
 Increasing pain
 Localized warmth at the bite site
 Red streaks leading away from the bite site
 Fever
 Lacerations, tears or punctures

Treatment of Animal Bites

 Immediately and thoroughly wash the wound with soap and water.
 Flush the wound with water and apply a dressing.
 Transport the patient, especially if the wound needs stitches or occurred on the
face or neck.
 Immobilize injury.
 Calm the patient.

NB: Do not kill the dog unless it is absolutely necessary to prevent a full-scale crippling
attack. Usually an animal control officer or police officer will do this. If the dog is killed, call
animal control to request for a rabies examination of the corpse.

Arthropods

Insects
 Common insect bites include bees and wasps.
 Most deaths occur due to anaphylaxis, not venom exposure.

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Spiders
 Spiders are numerous and widespread in many countries.
 Many species of spiders bite.
 Very few spiders deliver serious or life-threatening bites.
Scorpions
 Venom gland and stinger found in the tail end.
 Mostly found in dry, desert climates.
 With one exception, the Centruroides sculpturatus, most stings are only painful.
Ticks
 Ticks attach themselves to the skin.
 Bite is not painful, but potential exposure to infecting organisms is
dangerous.
 Ticks commonly carry Rocky Mountain spotted fever or Lyme disease.

Signs and Symptoms of Arthropod Bites and Stings

 Red, swollen, warm lump

 Hives
 Itching, tenderness, pain
 Sores from scratching; can become infected
 Serious allergic reactions (anaphylaxis) when symptoms spread. These can
include difficulty breathing, dizziness, nausea, fever, muscle spasms, or loss of
consciousness.

Treatment of Arthropod Bites and Stings

 If stinger is present, remove it by scraping it out with the edge of a card (Avoid
tweezers as they can squeeze more venom into the wound).
 Wash area gently.
 Remove jewellery from affected limb.
 Place injection site slightly below the level of the patient‘s heart.
 Immobilize the affected limb.
 Monitor for signs of anaphylaxis.

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Snakes

 40,000 to 50,000 reported snake bites in the US annually.

 7,000 bites in the US come from poisonous snakes.
 Death from snake bites is rare.
 About 15 deaths occur each year in the US.
Four Types of Poisonous Snakes in the US
 Rattlesnake (Pit Viper)
 Cottonmouth
 Copperhead
 Coral Snake
The 10 Deadliest Snakes in the World
1. Fierce Snake or Inland Taipan - Australia.
2. Australian Brown Snake - Australia.
3. Malayan Krait - Southeast Asia and Indonesia.
4. Taipan - Australia.
5. Tiger Snake - Australia.
6. Beaked Sea Snake - South Asian waters (Arabian Sea to Coral Sea).
7. Saw Scaled Viper - Middle East Asia.
8. Coral Snake - North America.
9. Boomslang - Africa.

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10. Death Adder - Australia and New Guinea.

Signs and Symptoms of Snake

 Bite on the skin

 Discolouration, pain or swelling in the bite area. Develops slowly from 30 minutes
to several hours.
 Rapid pulse and laboured breathing.
 Progressive general weakness.
 Blurring of vision.
 Nausea and vomiting.
 Seizures.
 Drowsiness or unconsciousness.

Treatment of Snake Bite

 Locate and fang marks and clean the site with soap and water.
 Remove any jewellery from the affected limb.
 Keep the affected limb immobilized.
 Apply light contracting band above and below the bite if all allowed by protocol.
 Transport and monitor the patient.

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Marine Animals

Jellyfish
 Venom delivered by barbs called nematocysts.
 Instantly painful and itchy red lesions result.
 Pain can continue for up to 48 hours.
 Sever cases may lead to skin necrosis, muscle spasms and cramps, vomiting and
diarrhea.
 Cardiorespiratory failure may result.
Stonefish
 Venom usually delivered in spines when stepped on.
 Venom contains neurotoxin.
 Patient may suffer difficulty breathing, bleeding, severe pain and whitened colour at
the site of the sting, abdominal pain, diarrhea, nausea, vomiting, seizures and
paralysis.
Bue-Ringed Octopus
 Saliva contains a powerful neurotoxin.
 Within 3 minutes, paralysis sets in and the body goes into respiratory arrest.
Stingrays
 Stingray venom produces immediate, excruciating pain that lasts several hours.
 Victim may suffer diarrhea, vomiting, hemorrhage, a drop in BP and cardiac
arrhythmia

Treatment for Marine Stings

Jellyfish
 Limit further discharge by minimizing patient movement.
 Inactivate nematocysts by applying alcohol or vinegar.
 Remove the remaining tentacles by scraping them off.
 Provide transport to hospital.
Stonefish
 Wash the area with fresh water.
 Remove any foreign material at the wound site.
 Soak wound in the hottest water the patient can tolerate for 30-90 minutes, if
instructed to do so.
 Provide transport to hospital.

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Blue-Ringed Octopus
 Apply pressure to the wound.
 Provide ventilation support.
 Provide transport to hospital.
Stingrays
 Wash the area with fresh water.
 Remove any foreign material at the wound site.
 Soak wound in the hottest water the patient can tolerate for 30-90
minutes, if instructed to do so.
 Provide transport to hospital.

Diving Emergencies

Pressure Laws

Boyle’s law: PV=K

 As pressure ↑, volume ↓
 As pressure ↓, volume ↑
Dalton’s law: Pt = P02 + PN2 + Px
 Total pressure of gas mixture is sum of partial pressures of its components.
Henry’s law:
 Pressure of a gas in liquid is proportional to its pressure in the atmosphere.

Barotrauma

Injury caused by compression or expansion of gas in body spaces.

 Ear squeeze
 Sinus squeeze
 Lung trauma (Pulmonary Overpressure Syndrome)
 Arterial air embolism

Ear Squeeze
 Pressure does not equalize in middle ear through Eustachian tube
 Common when diving with URI
 Severe pain
 Potential for ear drum rupture
 Water enters middle ear; vertigo/incapacitation

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Sinus Squeeze
 Pressure does not equalize in frontal or maxillary sinus
 Common when diving with URI
 Severe pain

Lung Trauma

 Pulmonary Overpressure Syndrome (POPS)

 Breath-holding during ascent
 Compressed air in lungs expands
 Lung tissue ruptures, resulting in:
 Pneumothorax/tension pneumothorax
 Pneumomediastinum
 Subcutaneous emphysema
 Arterial air embolism
 May occur in shallow depths

Signs/Symptoms

 Respiratory distress
 Substernal chest pain
 Diminished breath sounds

Treatment

 Rest
 Oxygen
 Treat pneumothorax

Arterial Air Embolism

 Caused by breath-holding during ascent

 Lung tissue tears/air enters pulmonary circulation
 Air enters left heart, is pumped to systemic circulation
 Air bubbles enter, clog cerebral circulation

Signs and Symptoms

 Alterations in consciousness—usually within 10 minutes

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 Hemiplegia
 Unequal pupils
 Cardiopulmonary failure
 Vertigo
 Visual disturbances

Management

 ABC‘s
 100% oxygen, assist ventilations as needed
 Supine (Left side 300 head down)
 Transport to decompression chamber

Decompression Sickness (The Bends)

 Diver breathes compressed air

 Nitrogen dissolves in blood
 Diver does not surface at correct rate to allow nitrogen to escape from blood
 Nitrogen bubbles form in tissue, small blood vessels
 Occludes circulation in small vessels

Onset of DCS symptoms

Time to the onset of first symptoms Percentage of cases

Within 1 hour 42%

Within 3 hours 60%

Within 8 hours 83%

Within 24 hours 98%

Within 48 hours 100%

Source: U.S. Navy Supervisor of Diving (2008) (PDF). U.S. Navy Diving Manual. SS521-AGPRO-010, revision 6.
vol.5. U.S. Naval Sea Systems Command. p. 20–5. http://supsalv.org/pdf/DiveMan_rev6.pdf. Retrieved 2009-
06-29.

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DCS Symptoms by Frequency

Symptom % of Cases

Local joint pain 89%

Arm symptoms 70%

Leg symptoms 30%

Dizziness 5.3%

Paralysis 2.3%

Shortness of breath 1.6%

Extreme fatigue 1.3%

Collapse/Loss of consciousness 0.5%

Source: Powell, Mark (2008). Deco for Divers. Southend-on-Sea: Aquapress. pp. 70. ISBN 1905492073.

Treatment of DCS

 ABC‘s
 100% Oxygen if required
 IV with LR if ALS available
 Lateral recumbent position if air embolism suspected
 Transport to recompression chamber
 Steroids on Medical Control orders

Nitrogen Narcosis

 ―Rapture of the Deep‖

 Pressurized nitrogen toxic effects on CNS
 Anesthetic effect due to lipid solubility of N2
 Result is intoxication
 Other injury may result from impaired judgment
 Affects most divers to some degree
 Usually on dives 20-30 metres

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Signs and Symptoms

 Euphoria
 Confusion
 Disorientation
 Slowed motor response

Treatment

 Surfacing corrects problem

 Consider possibility of CO toxicity

Diving Incident Assessment

 When was last dive?

 How many dives that day?
 What depths?
 Did diver ascend quickly? Why?
 Did diver make decompression stops during ascent?
 Symptoms? Onset of symptoms?
 Diver‘s appearance immediately after dive?

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Chapter 15:
Bleeding and Shock
Outline
 Anatomy of the Cardiovascular System
 Perfusion
 Bleeding
 Control of External Bleeding
 Internal Bleeding
 Signs and Symptoms of Internal Bleeding
 Emergency Management of Internal Bleeding
 Epistaxis (Nosebleed)
 Bleeding from Skull Fractures
 The Four Classes of Hemorrhage
 What is Shock?
 Types of Shock
 Cardiovascular Causes of Shock
 Non-cardiovascular Causes of Shock
 Stages of Shock

Anatomy of the Cardiovascular System

The cardiovascular system is responsible for supplying and maintaining adequate blood supply
flow.

The cardiovascular system consists of three parts:

 Heart (pump)
 Blood vessels (container)
 Blood and body fluids (fluids)

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Perfusion

 Circulation within tissues in adequate amounts to meet the cells’ needs

for oxygen, nutrients, and waste removal.
 Some tissues and organs need a constant supply of blood while others
can survive on very little when at rest.
 The heart demands a constant supply of blood.
 The brain and spinal cord can survive for 4 to 6 minutes without
perfusion.
 The kidneys may survive 45 minutes.
 The skeletal muscles may last up to 4 or 5 hours.

Bleeding

 Hemorrhage = bleeding
 Body cannot tolerate greater than 20% blood loss.
 Blood loss of 1 L can be dangerous in adults; in children, loss of 100-220
mL is serious.

Characteristics of Bleeding

Arterial

Blood is bright red and spurts.

Venous

Blood is dark red and does not spurt.

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Capillary

Blood oozes out and is controlled

easily.

Control of External Bleeding

Direct Pressure

Direct pressure is the most common and effective

way to control bleeding.
Apply pressure with gloved finger or hand.

Elevation

Elevating a bleeding extremity often stops venous

bleeding.
Use both direct pressure and elevation whenever
possible.

Pressure Points

If bleeding continues, apply pressure on pressure

point.

 Splinting can help prevent movement which may increase bleeding.

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 Tourniquets are a last resort when all other methods have failed.

Internal Bleeding

Internal bleeding may result from a variety of causes, including:

 blunt or penetrating trauma
 abnormal clotting
 rupture of a blood vessel or vascular structure
 vessel damage due to nearby fracture

Signs and Symptoms of Internal Bleeding

 Pain, tenderness, swelling or discolouration of suspected injury site.

 Bleeding from the mouth, rectum, vagina or other orifice.
 Vomiting bright red blood or blood the colour of dark coffee grounds.
 Dark tarry stools (melena) or stools with bright red blood.
 Tender, rigid, and/or distended abdomen.

Late signs and symptoms, indicating hypoperfusion, include:

 Anxiety, restlessness, combativeness or altered mental status.
 Weakness, faintness or dizziness.
 Thirst.
 Shallow, rapid breathing.
 Rapid, weak pulse.
 Pale, cool clammy skin.

Emergency Medical Care of Internal Bleeding

Because it is very difficult to diagnose the extent of internal bleeding without exploratory
surgery, an EMT must be able to recognise the signs and symptoms of hypoperfusion and
internal bleeding to prioritise transport.
 Take BSI precautions.
 Maintain open airway and adequate breathing.
 Provide O2 if necessary.
 Provide immediate transport to patients with signs and symptoms of shock.
 Provide care for shock.
 Stabilise fractures.
 Control any external bleeding.

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Epistaxis (Nosebleed)

 Follow BSI precautions.

 Help the patient sit and lean forward.
 Apply direct pressure by pinching the patient’s nostrils (Or place a piece of
gauze bandage under the patient’s upper lip and gum).
 Apply ice over the nose.
 Provide transport.

Bleeding from Skull Fractures

 Do not attempt to stop the blood flow.

 Loosely cover bleeding site with sterile gauze.
 If cerebrospinal fluid is present, a target (or halo) sign will be apparent.

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The Four Classes of Hemorrhage

Class of Hemorrhage

Class 4
Class 1 Class 2 Class 3
More than 40%
Up to 15% blood loss Up to 30% blood loss Up to 40% blood loss
blood
(750ml) (750-1500ml) (1500-2000ml)
loss (>2000ml)

How The Body Responds

Compensatory
mechanisms
Body compensates for
become overtaxed.
blood loss by Compensatory
Vasoconstriction Vasoconstriction can
constricting blood vasoconstriction now
continues to maintain no longer sustain BP,
vessels becomes
adequate blood which begins to fall.
(vasoconstriction) in a complicating
pressure, but with Cardiac output and
an effort to maintain factor, further
some difficulty now. tissue perfusion
blood pressure and impairing tissue
Blood is shunted to continue to decrease,
delivery of oxygen to perfusion and
vital organs, with becoming potentially
all organs of the body. cellular oxygenation.
decreased flow to life-threatening.
Increase in diastolic Anaerobic
intestines, kidneys Even at this stage, the
pressure. metabolism
and the skin. patient can still
Pulse pressure less increases.
recover
than 40.
with prompt
treatment.

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Effects on the Patient

Patient remains Patient may become Patient becomes Patient becomes

alert. restless and more confused, lethargic, drowsy or
BP stays within confused. restless and anxious. stuporous.
normal limits. Skin turns pale, cool Classic signs of Signs of shock
Pulse stays within and dry because of shock appear: become more
normal limits or shunting of blood to • rapid heart rate pronounced.
increases slightly; vital organs. • decreased BP BP continues to fall.
pulse quality Diastolic pressure • rapid respirations Lack of blood flow
remains strong. may rise and fall. • rapid, weak pulse to the brain and
Respiratory rate and More likely to rise • cool, clammy skin. other vital organs
depth, skin color because of leads to organ
and temperature all vasoconstriction. failure and death.
remain normal. Pulse pressure
narrows.
Heart rate becomes
rapid and pulse
quality weakens.
Respiratory rate
increases.

Pulse Pressure is primary assessment BP replaces pulse pressure as primary

indicator indicator

Decompensated
Compensated Shock Irreversible Shock
Shock

What is shock?

 Also known as hypoperfusion

 State of collapse and failure of the cardiovascular system.
 Leads to inadequate circulation.
 Without adequate blood flow, cells cannot get rid of metabolic wastes.
 The result of hypoperfusion to cells that causes the organ, then organ
systems, to fail.
 “a rude unhinging of the machinery of life.”

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Perfusion

The cardiovascular system’s circulation of blood and oxygen to all the cells
in different tissues and organs of the body.

Types of Shock

Hypovolemic
 Hemorrhage
 Burns
 Diarrhea
 Vomiting
 Peritonitis

Cardiogenic
 Cardiomyopathy
 Pulmonary Embolism

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 Heart Disease
 Myocardial Infarction
 Arrhythmia
 Aortic Aneurysm
 Cardiac Contusion
 Cardiac Tamponade

Vasogenic
 Psychogenic
 Septic
 Anaphylactic

Cardiovascular Causes of Shock

Pump failure (cardiogenic shock)

 Inadequate function of the heart or pump failure
 Causes a backup of blood into the lungs
 Results in pulmonary edema
 Pulmonary edema leads to impaired ventilation

Poor vessel function (neurogenic shock)

 Damage to the cervical spine may affect control of the size and muscular
tone of blood vessels.
 The vascular system increases.
 Blood in the body cannot fill the enlarged system.
 Neurogenic shock occurs.

Content failure (hypovolemic shock)

 Results from fluid or blood loss
 Blood is lost through external and internal bleeding.
 Severe thermal burns cause plasma loss.
 Dehydration aggravates shock.

Combined vessel and content failure

 Some patients with severe bacterial infections, toxins, or infected tissues
contract septic shock.

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 Toxins damage vessel walls, causing leaking and impairing ability to

contract.
 Leads to dilation of vessels and loss of plasma, causing shock.

Non-Cardiovascular Causes of Shock

Respiratory insufficiency
 Patient with a severe chest injury or airway obstruction may be unable to
breathe adequate amounts of oxygen.
 Insufficient oxygen in the blood will produce shock.

Anaphylactic shock
 Occurs when a person reacts violently to a substance.
 Four categories of common causes:
 Injections
 Stings
 Ingestion
 Inhalation

Psychogenic shock
 Caused by sudden reaction of the nervous system that produces a
temporary, generalized vascular dilation
 Commonly referred to as fainting or syncope
 Can be brought on by serious causes: irregular heartbeat, brain aneurysm
 Can be brought on by fear, bad news, unpleasant sights

Stages of Shock

Compensated shock
When the body compensates for blood loss

Decompensated shock
The late stage of shock when blood pressure is falling

Irreversible shock
The terminal stage

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Compensated Shock
 Agitation
 Anxiety
 Restlessness
 Feeling of impending doom
 Altered mental status
 Weak pulse
 Clammy skin
 Pallor
 Shallow, rapid breathing
 Shortness of breath
 Nausea or vomiting
 Delayed capillary refill
 Marked thirst

Decompensated Shock
 Falling blood pressure (<90 mm Hg in an adult)
 Labored, irregular breathing
 Ashen, mottled, cyanotic skin
 Thready or absent pulse
 Dull eyes, dilated pupils
 Poor urinary output

Irreversible Shock
 This is the terminal stage of shock.
 A transfusion of any type will not be enough to save a patient’s life.

When to Expect Shock

 Multiple severe fractures
 Abdominal or chest injuries
 Spinal injuries
 Severe infection
 Major heart attack
 Anaphylaxis

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Treatment of Shock

 Make certain patient has open airway.

 Keep patient supine.
 Control external bleeding.
 Splint any broken bones or joint injuries.
 Provide oxygen if required.
 Place blankets under and over patient.
 If there are no broken bones, elevate the legs 6” to 12”.
 Do not give the patient anything by mouth.

Shock left untreated may be fatal. It must be recognized and treated

immediately, or the patient may die.

The definition of shock does not involve low blood pressure, rapid
pulse or cool clammy skin - these are merely the signs.

Simply stated, shock results from inadequate perfusion of the body’s

cells with oxygenated blood.

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Chapter 16:
Poisoning and Substance
Abuse
Outline
 Definitions
 Common Types of Poisoning
 How Poisons Enter The Body
 Signs and Symptoms of Poisoning
 Poison Exposure in the US
 Classifications of Poisons
 Signs and Symptoms of Some Specific Poisons
 Poison Information Centers
 Treatment
 Watusi Poisoning in the Philippines

Definitions

Poison
Any substance whose chemical action can damage body structures or impair body functions.

Substance Abuse
The knowing misuse of any substance to produce a desired effect.

Common Types of Poisoning

Poisoning in Children

The most common poisons among children are:

 cosmetics and personal care products

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 cleaning substances
 pain medicine/fever-reducers
 coins, thermometers
 plants
 diaper care, acne preparations, antiseptics
 cough and cold preparations
 pesticides
 vitamins
 gastrointestinal preparations
 antimicrobials
 arts, crafts and office supplies
 antihistamines
 hormones and hormone antagonists (diabetes medications, contraceptives)
 hydrocarbons (lamp oil, kerosene, gasoline, lighter fluid)

Poisoning in Adults

The most common poisons among adults are:

 pain medicine
 sedatives, hypnotics, antipsychotics
 cleaning substances
 antidepressants
 bites and envenomation
 alcohols
 food products and food poisoning
 cosmetics and personal care products
 chemicals
 pesticides
 cardiovascular drugs
 fumes, gases, vapors
 hydrocarbons
 antihistamines
 anticonvulsants
 antimicrobials
 stimulants and street drugs
 plants
 cough and cold preparations

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How Poisons Enter the Body

Inhalation
include carbon monoxide, ammonia, insect sprays.

Ingestion
food poisoning, alcohol, household and industrial chemicals, medications, plant material, petroleum
products, pesticides.

Injection
snake bite, spider bite, bee sting, injected drugs.

Absorption
corrosives or irritants, poison ivy.

Radiation
exposure to radiation.

Some Signs and Symptoms of Poisoning

• Unusual breath odour, body odour or odour from the patient’s clothing or from the scene.
• Burns or stains around the patient’s mouth.
• Abnormal breathing.
• Abnormal pulse rate.
• Profuse sweating, headache or dizziness.
• Excessive salivation or foaming at the mouth.
• Pain or swelling in the mouth or throat.
• Abdominal pain.
• Abdominal tenderness, sometimes with distention.
• Nausea and vomiting.
• Seizures.
• Altered mental status.
• Signs of shock

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The signs and symptoms seen in poisoning are so wide and variable that there is no easy way
to classify them.

 Some poisons enlarge the pupils, while others shrink them.

 Some result in excessive drooling, while others dry the mouth and skin.
 Some speed the heart, while others slow the heart.
 Some increase the breathing rate, while others slow it.
 Some cause pain, while others are painless.
 Some cause hyperactivity, while others cause drowsiness. Confusion is often seen
with these symptoms.

With poisoning, remember to treat the patient, not the

poison.

Poison Exposures in the United States

Facts On Poison Exposures:

 On average, poison centers handle one poison exposure every 14 seconds.
 Over two million poison exposures were reported to local poison centers in 2000.
 Most poisonings involve everyday household items such as cleaning supplies,
medicines, cosmetics and personal care items.
 89 percent of all poison exposures occur in the home.
 92 percent of exposures involve only one poisonous substance.
 86.7 percent of poison exposures are unintentional.
 75 percent of poison exposures involve ingestion of a poisonous substance.

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 Other causes include breathing in poison gas, getting foreign substances in the eyes
or on the skin, and bites and stings.
 77 percent of all exposures are treated on the site where they occurred, generally
the patient’s home with phone advice and assistance from local poison control
experts.

Children and Poison:

 53 percent of poison exposures occur in children under the age of six.
 The most common forms of poison exposure for children under the age of six are
cosmetics and personal care products (13.3%), cleaning substances (10.7%),
analgesics (7.6%) and plants (6.9%).
 Although children under the age of six are the most likely to be exposed to poison,
they represent just over two percent of poison fatalities.

Teens and Poison:

 160,000 cases of poison exposure were reported among teenagers in 2000.
 In children between ages 13 and 19, the majority of poison exposures (55%) involve
girls. In children under 13, the reverse is true; over 56 percent of these exposures
involve boys.
 84 percent of reported adolescent deaths from poison exposure were due to
intentional poison exposure such as suicide or drug abuse.

Adults and Poison:

 Over 8,000 poison exposures in 2000 occurred in pregnant women.
 Over 60 percent of all poison fatalities occur in adults ages 20 to 49.
 While adults 60 and over account for four percent of poison exposures, they
account for 15.5 percent of the fatalities.

Source: Data from the 2000 Annual Report of the American Association of Poison Control Centers Toxic Exposure
Surveillance System, which is compiled by the American Association of Poison Control Centers in cooperation with
the majority of U.S. poison centers. Since 1983, the data from the TESS have been used to identify hazards early,
focus prevention education, guide clinical research and direct training. A full report is available on the web at
www.aapcc.org.

Classifications of poisons

Poisons may be classified into four main groups: corrosives, irritants, narcotics, and
narcoticoirritants.

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Food poisoning, and animal bites and stings are considered as special cases.

Corrosives

Corrosive poisons react in a chemical manner with body tissue, such that they burn and
destroy the parts with which they come into contact.

Examples

Strong acids: Hydrochloric acid, Sulphuric acid, Nitric acid

Strong alkalis: Sodium hydroxide, Potassium hydroxide

Salts: Mercuric chloride

Signs & symptoms of corrosive poisoning

Immediate pain and swelling at the points of contact, maybe accompanied by

discoloration.

Eventual unconsciousness and death (depending on dose). If swelling occurs within the
airway this may also cause asphyxia.

Irritants

Irritant poisons aggravate the digestive system, particularly the stomach and bowels.

Examples

Vegetable acids and salts (eg. Tartaric acid), Arsenic, Lead, Antimony, Copper sulphate,
Zinc

Chloride, Silver Nitrate, Potassium Bichromate, Iron Sulphate, leaves, roots, berries, resins
of many plants (in larger doses).

Signs & symptoms of irritant poisoning

Vomiting, diarrhoea, abdominal discomfort or pain, features of shock through loss of

fluid. Eventual unconsciousness and death (depending on dose).

The onset of signs and symptoms may be deferred for a few hours after ingesting the
poison.

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Narcotics

Narcotic poisons affect the brain and/or nervous system, causing a reduction in co-
ordination and the level of consciousness.

Examples

Opium and derivatives, Potassium Cyanide, Hydrocyanic acid (very fast acting, paralysing
poison), alcohol, ether, Chloral Hydrate, chloroform, Carbon Monoxide (also affects the
ability of red blood cells to carry oxygen), Hydrogen Sulphide, Ammonium Sulphide.

Signs & symptoms of narcotic poisoning

Dizziness, loss of co-ordination, interference with vision. Eventual unconsciousness

(sometimes preceded by convulsions) and death (depending on dose). Narcotic poisons do
not generally produce pain.

Narcotico-Irritants

Narcotico-irritant poisons initially have an irritant action upon the digestive system, and
then act as narcotics.

Examples

Phenol (carbolic acid), Oxalic acid, Strychnine, atropine, tobacco, hemlock, yew
leaves/berries, laburnum pods, digitalis, various fungi.

Signs & symptoms of narcotico-irritant poisoning

Initially, vomiting, diarrhoea, abdominal pain. Then delirium and/or convulsions. Eventual
unconsciousness and death (depending on dose).

Signs And Symptoms Caused by Some Specific Poisons

Adder Venom
Early stages: Pain, swelling, and enlargement of lymph nodes around the bite, fainting,
abdominal pain, vomiting, diarrhoea.
Later stages: abnormal heartbeat, spontaneous bleeding, difficulty in breathing, acute kidney
failure (characterised by a much reduced urine output, cloudy urine, persistent nausea and
vomiting, diarrhoea, dry skin, convulsions, lethargy, drowsiness, halitosis).

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Alcohol
Early stages: Flushed moist face, full bounding pulse, deep noisy breathing, unconsciousness.
Later stages: Dry bloated face, unreactive dilated pupils, weak rapid pulse, shallow breathing,
unconsciousness.

Aspirin
Upper abdominal pain, nausea, vomiting (maybe blood-stained), sweating, tinnitus,
hyperventilation, confusion, delirium.

Atropine (Deadly Nightshade)

Hot dry skin, dry mouth, dilated pupils, excitable behaviour, noisy breathing.
Severe cases may lead on to: Vomiting, weakness, delirium, unconsciousness.

Carbon Dioxide
Headache, dizziness, breathlessness, rapid unconsciousness.

Carbon Monoxide
Long term exposure: Headache, nausea, vomiting, confusion, aggression, incontinence.
Acute poisoning: Rapid distressed breathing, cyanosis, rapid unconsciousness.

Depressant Drugs (Tranquilizers)

Lethargy, drowsiness, weak irregular pulse, shallow breathing, falling consciousness.

Hydrogen Sulphide
Headache, spasm of the eyelids, pain and redness of the eyes, blurred vision with ‘haloes’
around lights.
In severe cases: Confusion, convulsions, pulmonary oedema (characterised by extreme
breathlessness, gasping and wheezing, coughing - maybe with blood-stained sputum,
sweating, pale skin with cyanosis).

Narcotic Drugs
Dizziness, confusion, lethargy, constricted pupils, slow shallow breathing, falling
consciousness.

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Organophosphorus Insecticides (eg. Parathion, Malathion)

Anxiety, restlessness, dizziness, constricted pupils, hypersalivation, nausea, vomiting,
diarrhoea, abdominal pain, developing muscular weakness.
Severe cases may lead on to: Convulsions, pulmonary oedema with excessive secretions,
unconsciousness.

Paracetamol
Initial stages: Nausea, vomiting.
After 2 to 3 days: Features of liver failure - upper abdominal pain, tenderness, nausea,
vomiting.
Note: Liver damage will usually be irreversible unless an antidote is given within 12
hours of ingestion.

Paraquat
Inhaled spray: Bleeding from the nose, sore throat. (Spray inhalation is rarely serious).
Ingestion: Nausea, vomiting, diarrhoea.
After approximately 48 hours: Painful ulcers on lips, inside mouth, kidney failure.
After a few days: Difficulty in breathing caused by proliferating inflammation of the lung
tissues.
Note: Oxygen must not be given to casualties who have been poisoned by
Paraquat.

Solvents
Headache, nausea, vomiting, hallucinations, unconsciousness.

Stimulant drugs
Excitable hyper-active wild frenzied behaviour, hallucinations, sweating, tremors.

Sulphur Dioxide, Chlorine, Ammonia

Coughing, choking, maybe leading on to acute pulmonary oedema up to 36 hours after
inhalation.

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Poisons Information Centers

Because the treatment of a poison can vary significantly, it is helpful for the EMT to be
able to contact a Poisons Information Center to find out how to treat a certain poison.

In the Philippines, Philippines General Hospital runs the National Poison Management
and Control Service (NPMCC). It can be contacted on (02) 524 1078.

http://www.uppoisoncenter.org

Poison Treatment

Identifying the Patient and the Poison

If you suspect poisoning, ask the patient the following questions:
 What substance did you take?
 When did you take it or (become exposed to it)?
 How much did you ingest?
 What actions have been taken?
 How much do you weigh?

Determining the Nature of the Poison

Take suspicious materials, containers, and vomitus to the hospital.
Provides key information on:
 Name and concentration of the drug
 Specific ingredients
 Number of pills originally in bottle
 Name of manufacturer
 Dose that was prescribed

Inhaled Poisons
 Wide range of effects
 Some inhaled agents cause progressive lung damage.
 Move to fresh air immediately.
 Monitor airway and breathing.
 All patients require immediate transport.

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Absorbed Poisons
 Many substances will damage the skin, mucous membranes, or eyes.
 Substance should be removed from patient as rapidly as possible.
 If substance is in the eyes, they should be irrigated.
 Do not irrigate with water if substance is reactive

Injected Poisons
 Usually result of drug overdose.
 Impossible to remove or dilute poison once injected.
 Prompt transport.
 ALS providers may be able to use medications such as Narcan to reverse overdose.

Ingested Poisons
 Poison enters the body by mouth.
 Accounts for 80% of poisonings.
 May be accidental or deliberate.
 Activated charcoal will bind to poison in stomach and carry it out of the body.
 Assess ABCs.

Activated Charcoal

Activated charcoal absorbs many poisonous compounds to its surface, reducing

absorption by the body.

Charcoal is not indicated for:

• Ingestion of an acid, alkali, or petroleum
• Patients with decreased level of consciousness
• Patients who are unable to swallow

Usual dosage is 25 to 50 g for adults and 12.5 to 25 g for

paediatric patients.
Obtain approval from medical control.
Shake bottle vigorously.
Ask patient to drink with a straw.
Record the time you administered the activated charcoal.
Be prepared for vomiting.

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Syrup of Ipecac

Ipecac induces vomiting by both gastric irritation and central stimulation of the
chemoreceptor trigger zone.
Approximately 95% of patients vomit within 15 to 30 minutes of administration of a
therapeutic dose and vomiting usually persists for 30 minutes to 2 hours.
Approximately 28 to 60% of an ingested toxin will be removed by emesis if ipecac is
given within 5 minutes following ingestion of the toxin. If given 1 hour after, a
maximum of 30% of the toxin will be removed.
Indications: To induce vomiting in the early management of certain oral poisonings.
Ideally, ipecac should be given on the advice of a Poison Control Centre or physician,
especially in the case of infants and children.
Contraindications: Situations where emesis is contraindicated, include: poisoning
involving strong acids or alkalis, unconscious, semicomatose or severely inebriated
patients, patients experiencing convulsions and patients who have lost the gag reflex.

Ipecac should be given as soon as possible after ingestion of a toxin, ideally within 1
hour.
Dose should be followed by 1 to 2 glasses of water since ipecac is ineffective when
the stomach is empty. Administration with milk can prolong the time to vomiting
because it decreases the irritant action of ipecac on the stomach.
• Adults: 15 to 30 mL.
• Children 1 to <12 years: 15 mL.
• Children 6 months to <1 year: 5 to 10 mL.
If vomiting has not occurred within 15 to 20 minutes, the dose may be repeated once
in adults and children over 12 years.
Rarely used anymore.

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EMT-Bs may administer both activated charcoal and Syrup

of Ipecac, but first require the authorisation of medical
control.

Poisoning in The Philippines - Watusi Firecracker

Signs and Symptoms of Watusi Poisoning

 Burns
 Burning pain in the throat
 Garlic odour from breath
 Nausea, vomiting, diarrhea, abdominal pain
 Shock

Immediate Treatment of Watusi Poisoning

 If ingested, DO NOT induce vomiting.
 Give 6-8 egg whites to children, 8-12 egg whites to adults.
 If there is dermal exposure, bathe the patient using alkaline soap like Perla or Ivory.
 Transport patient to the hospital as ill-effects may not present immediately.

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 Chapter 17: Diabetic Emergencies

Chapter 17:
Diabetic Emergencies
Outline
 Definitions
 The Endocrine System
 Role of Glucose and Insulin
 Type I and Type II Diabetes
 Hypoglycemia vs Hyperglycemia
 Glucometers
 Emergency Care
 Administering Oral Glucose
 Special Notes on Diabetic Emergencies

Definitions

Diabetes mellitus
 Metabolic disorder in which the body cannot metabolize glucose.
 Usually due to a lack of insulin.

Glucose
 One of the basic sugars in the body.
 Along with oxygen, it is a primary fuel for cellular metabolism.

Insulin
• Hormone produced by the pancreas.
• Enables glucose to enter the cells.
• Without insulin, cells starve.

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Hormone
 Chemical substance produced by a gland.
 Has special regulatory effects on other body organs and tissues.

The Endocrine System

The endocrine system is a system of glands, each of which secretes a type of hormone
into the bloodstream to regulate the body. The endocrine system is an information signal
system like the nervous system. Hormones regulate many functions of an organism,
including mood, growth and development, tissue function, and metabolism.

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Role of Glucose and Insulin

 Glucose is the major source of energy for the body.

 Constant supply of glucose needed for the brain
 Insulin acts as the key for glucose to enter cells.

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Type I and Type II Diabetes

Type I Diabetes
 Insulin-dependent diabetes.
 Patient does not produce any insulin.
 Insulin injected daily.
 Onset usually in childhood.

Type II Diabetes
 Non-insulin-dependent diabetes .
 Patient produces inadequate amounts of insulin.
 Disease may be controlled by diet or oral hypoglycemics.

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Hypoglycemia vs Hyperglycemia

Hyperglycemia Hypoglycemia

High blood glucose - usually more than 120 Low blood glucose - usually less than 70 mg/

mg/dL dL

Causes
• undiagnosed or untreated diabetic • the diabetic has taken too much
condition insulin
• the diabetic has not taken their • the diabetic has not eaten enough to
insulin provide their normal sugar intake
• the diabetic has overeaten, flooding • the diabetic has over-exercised or
• the body with a sudden excess of overexerted themselves, reducing
carbohydrates their blood glucose level
• the diabetic has suffered an infection • the diabetic has vomited a meal
that disrupts their glucose/insulin
balance

Signs and Symptoms

• gradual onset of signs and • rapid onset of signs and symptoms

symptoms over a period of days over a period of minutes
• patient complains of dry mouth and • copious saliva and drooling
intense thirst • intense hunger
• abdominal pain and vomiting • dizziness and headache, sudden
common fainting, seizures and occasionally
• gradually increasing restlessness and coma
confusion, followed by stupor and • full rapid pulse
coma • relative normal respirations, no
• weak, rapid pulse odour
• signs of air hunger - deep, sighing • cold, pale and clammy skin
respirations, breath smells of • perfuse perspiration
acetone and is sickly-sweet • normal blood pressure
• warm, red, dry skin • normal eyes

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• normal or slightly low blood • abnormally hostile or aggressive

pressure behaviour, which may appear to
• sunken eyes be acute alcohol intoxication
• no hostile or aggressive
behaviour

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Glucometer

 Blood glucose monitor

 Normal range 80-120 mg/dL
 Test strips for calibration
 Some concerns about accuracy

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Normal range for blood glucose is 80-120 mg/dL

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Emergency Care

Emergency Care - Hypergylcemia

 Administer oxygen if required.
 Immediately transport.
 Arrange for ALS intercept if available.

Emergency Care - Hypoglycemia

 Conscious patient - administer glucose, granular sugar, honey or a candy under the
tongue or give orange juice.
 Unconscious patient - avoid giving liquids.
 Provide a sprinkle of granulated sugar under the tongue or a dab of glucose if
protocols permit.
 Turn head to side or place the patient in the lateral recumbent (recovery) position.
 Provide oxygen if required.
 Transport to medical facility.
 Arrange for ALS intercept if available.

Administering Oral Glucose

 Names:
• Glutose
• Insta-Glucose
 Dose equals one tube.
 Glucose should be given to a diabetic patient with a decreased level of consciousness.
 DO NOT give glucose to a patient with the inability to swallow or who is unconscious.
 Make sure the tube is intact and has not expired.
 Squeeze a generous amount onto a bite stick.
 Open the patient’s mouth.
 Place the bite stick on the mucous
membranes between the cheek and the gum
with the gel side next to the cheek.
 Repeat.

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Special Notes on Diabetic Emergencies

When faced with a patient who may be suffering from hyperglycemia or hypoglycemia:
 Determine if the patient is diabetic. Look for medical identification medallions, insulin
in the refrigerator or information cards.
 Interview patient and family members.
 If the patient is a known diabetic and hypoglycemia cannot be ruled out, assume that
the patient is suffering from hypoglycaemia and administer glucose.
 Often a patient suffering a diabetic emergency may simply appear drunk. Always
check for other underlying conditions - such as a diabetic complication – when
treating someone who appears intoxicated.

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Chapter 18: Infectious Diseases

Chapter 18:
Infectious Diseases
Outline

 Transmission
 Syphilis
 Tuberculosis
 Rabies
 Meningitis
 Hepatitis
 HIV/AIDS

Transmission

 Blood-born
 Other Bodily Fluids
 Synovial fluid
 Cerebrospinal fluid (CSF)
 Amniotic fluid
 Saliva
 Semen
 Vaginal secretions
 Saliva
 Organs or tissues
 Airborne
 Fecal-Oral

Syphilis

An acute and chronic disease caused by the spiral shaped bacterium – Treponema
pallidum.

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Syphilis has three stages:

 Primary – characterized by a painful chancre (canker sore) with indurated

borders on the penis, vulva or other areas of sexual contact.
 Secondary – this stage which occurs 10 days to 10 weeks after the end of the
primary stage. Rash and lymphadenopathy are the most common symptoms.
Rash starts on the trunks and flexor surfaces spreading to the palms and soles.
 Tertiary – involvement of the nervous system and CVS is characteristic of this
stage which may occur 3-4 years after the initial infection. Specific
manifestations range from acute meningitis, dementia and neuropathy to
thoracic aneurysm.

Tuberculosis

Tuberculosis is not a highly contagious disease. Transmission of the bacteria

Myobacterium tuberculosis that causes TB usually occurs by droplet spread from a
person with active disease and intimate exposure to the infected individual, usually
those living in the same household. The communicable period lasts as long as
infective tuberculi bacilli are being discharged in the sputum – usually 24-48 hours
after antibiotic treatment has been started.

Signs and symptoms

 Initial infection – usually minimal and most patients do not show any
symptoms when first infected.
 TB can lie dormant for many years before the signs commonly associated with
TB appear – night sweats, headaches, cough and weight loss.
 Pulmonary infection with symptoms can develop within 2-10 weeks.
 TB causes an area of scar tissue to develop in the lungs, leading to loss of
pulmonary function.

Suspect TB with:

 Undiagnosed pulmonary or respiratory function

 Viral syndrome, night sweats and weight loss
 Productive cough (green or yellow sputum)
 Coughing up blood
 Difficulty breathing

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 Respiratory failure

Rabies

Rabies is caused by a RNA containing Rhabdovirus and is transmitted by inoculation with

infectious saliva from an animal or by salivary contact with a break in the skin or mucous
membrane.

Incubation period – 12-700 days

The virus spreads across the motor end plate and ascends and replicate along the peripheral
nervous axoplasm to the dorsal root ganglia in the spinal cord and the CNS.

Histologically, rabies manifests the same findings as seen in other forms of encephalitis
(inflammation of the brain). Negribodies are the characteristic histologic findings for rabies.

Signs and Symptoms

Early Stage

 Fever
 Malaise
 Anorexia
 Sore throat
 Cough
 Pruritus and paresthesia on bite site

Late Stage

 Restlessness
 Agitation
 Altered mental status
 Painful bulbar and peripheral muscular spasm
 Opisthotonus (neck pain/stiffness)
 Hypersensitivity to sensory stimuli and hydrophobia resulting from bulbar spasm that occurs
with swallowing – patient won’t want to swallow because of the spasming.

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Emergency Care

 BSI
 ABC
 Scrubbing and cleansing of the wound to remove rabies is important.
 Transport to hospital for Human Immunoglobulin (HRIG) and Human Diploid Cell
Vaccine.

Meningitis

Inflammation of the meninges of the brain. The type most often involved in epidermal
outbreak is caused by the meningococcous bacteria and is usually referred to as
Meningococcal Meningitis.

Signs and Symptoms

 Usually appear 2-10 days after exposure

 Fever
 Severe headache
 Some changes in state of consciousness
 Vomiting
 Blotchy or blue rash (sometimes)
 Stiff neck (late sign)
 Local rigidity

Patient requires lumbar tap for CSF to confirm diagnosis.

Hepatitis

An infectious disease that causes an inflammation of the liver. It is more contagious than
HIV and is a major threat to Health Care Providers.

There are five forms of Hepatitis:

1. Hepatitis A – HAV
2. Hepatitis B – HBV
3. Hepatitis C
4. Hepatitis D – HDV or Delta
5. Hepatitis E

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Hepatitis can also be caused by other viruses and bacteria, including chickenpox and
cytomegalovirus (CMV).

Hepatitis A

 Most common Hepatitis infection in children

 Spread primarily by the fecal-oral route. HAV is excreted in large quantities in the
feces two weeks before and one week after onset of symptoms
 Conditions that facilitate the spread of HAV include crowding and poor hygiene.
Food-borne outbreaks have occurred in restaurants due to an infectious food
handler who unknowingly contaminates food or water.
 Because hepatitis A can be a mild infection, particularly in children, it's possible for
some people to be unaware that they have had the illness. In fact, although medical
tests show that about 40% of urban Americans have had hepatitis A, only about 5%
recall being sick. Although the hepatitis A virus can cause prolonged illness up to 6
months, it typically only causes short-lived illnesses and it does not cause chronic
liver disease.

Hepatitis B

 Serum hepatitis – primarily spread through contact with infectious blood or blood
products.
 Other body secretions including saliva, semen and vaginal secretions can contain the
HBV.
 HBV can survive for up to 10 days in dried blood spills.
 Introduction of infected materials into the mucous membranes (especially the mouth,
eyes and broken skin) has led to the transmission of HBV.
 Signs and symptoms include:
- Fatigue
- Loss of appetite
- Abdominal pain
- Headache
- Fever
- Jaundice
- Dark urine
- Swelling
 Some carriers may have no symptoms at all – chronic carrier state.

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 The incubation period of HBV varies widely – usually somewhere between 45 to

180 days.
 The communicable period starts weeks before the first symptoms appear and may
persist for years in chronic carriers.
 HBV lasts several weeks although complete recovery may take 3 to 4 weeks. A
significant proportion of patients develop a chronic infections that may last a
lifetime and predisposes them to serious illnesses such as carcinoma of the liver.

Hepatitis C

The infection is often asymptomatic, but once established, chronic infection can progress
to scarring of the liver (fibrosis), and advanced scarring (cirrhosis) which is generally
apparent after many years. In some cases, those with cirrhosis will go on to develop liver
failure or other complications of cirrhosis, including liver cancer or life threatening
esophageal varices and gastric varices.

The hepatitis C virus is spread by blood-to-blood contact. Most people have few, if any
symptoms after the initial infection, yet the virus persists in the liver in about 85% of
those infected. Persistent infection can be treated with medication, peginterferon and
ribavirin being the standard-of-care therapy. 51% are cured overall. Those who develop
cirrhosis or liver cancer may require a liver transplant, and the virus universally recurs after
transplantation.

Precautions when dealing with Hepatitis patients

 Handle with extreme care all needles and IV equipment used for a patient with
jaundice.
 Observe and practice universal precautions, including:
 Wearing gloves whenever there is a potential exposure to blood or other
bodily fluids.
 Never recap, remove, bend or break needles after use or manipulate them
by hand.
 Dispose of syringes, needles, scalpels and other sharp items in a puncture-
resistant container kept within easy reach.
 Wash your hands thoroughly after the call.
 Disinfect all equipment contaminated with blood or sputum. Air out the
ambulance and send soiled linen for cleaning.
 Stay in touch with the hospital to which the patient was transported to
follow up for diagnosis.
 Make sure you have your Hepatitis vaccination.

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HIV/AIDS

HIV is the virus that causes AIDS. AIDS is the name for the set of conditions that results
when the immune system has been attacked by HIV. The AIDS virus does its damage by
attacking a person’s immune system and impairing the ability to fight off infections and
other illnesses that depend on an intact immune response. An AIDS’ patient becomes
extremely vulnerable to a whole variety of bacterial, viral and fungal infections.

It is estimated that approximately 33 million people are currently infected with the AIDS
virus, including 2-3 million children.

In considering the incubation period of AIDS, it is important to distinguish between

patients who are infected with the HIV virus but are still asymptomatic and those who
have developed the clinical signs of the disease. As a result, there are two incubation
periods to consider:

1. From the time of exposure to the time a person’s blood tests positive for AIDS
(becomes seropositive or HIV positive). May be anywhere from a few weeks to a
few months. A person who has had an accidental exposure to AIDS should be
tested within 2 to 3 weeks after exposure and then again at 6 weeks, 3 months, 6
months and 1 year later.
2. The time between the documented infection (i.e. becoming HIV positive) and the
development of full-blown AIDS. In patients who have contracted AIDS from
contaminated blood products, the mean incubation after infection has been
approximately 8 years for adults and 2 years for children.

From a variety of data, it has been calculated that about half of seropositive patients will
develop AIDS within 9 years and nearly all seropositive patients will develop AIDS within
15 years.

Once AIDS has developed, life expectancy is reduced, although antiretroviral medication
can extend this significantly.

The communicable period for AIDS is not known but is presumed to continue throughout
the time that the patient is seropositive, even before the patient develops clinically
apparent AIDS.

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Transmission of AIDS

1. Sexual contact – involving semen, saliva, blood, urine and feces.

2. Parentally – through contaminated blood products or infected needles.
3. Across the placenta – mother-child transmission which occurs when an infected
mother passes the virus to her child, sometimes as early as the 20th week of
gestation.

Signs and Symptoms

Because AIDS can involve many organs and systems of the body, there are countless signs
and symptoms.

Common signs and symptoms can include:

 Persistent low grade fever

 Night sweats
 Swollen lymph glands
 Loss of appetite
 Nausea
 Persistent diarrhea
 Headache
 Sore throat
 Fatigue
 Weight loss
 Shortness of breath
 Muscle and joint aches
 Rashes
 Various opportunistic infections

Precautions when dealing with HIV/AIDS patients

 As for Hepatitis – universal precautions.

 Restrict pregnant EMTs from contact with known AIDS patients.
 Protect the AIDS patient from acquiring infections from you or your crew.
 Assume that every patient you treat is HIV positive.

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Lists of common antiretroviral medications

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1. The patent for AZT has expired and generic versions are available in the US.
2. Stavudine is no longer recommended for initial therapy in the UK. The US Department of Health and
Human Services also no longer recommend stavudine as a ‘preferred’ or ‘alternative’ component in
initial treatment.

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3. The patent for ddI has expired and generic versions are available in the US. The manufacturer has discontinued a tablet
version.
4. The British HIV Association (BHIVA) recommends that Trizivir "should only be considered as a starting regimen in very
occasional circumstances, for example informed patient choice based on likely poor adherence if alternative options are
used, or concomitant medication needed such as for TB". Trizivir is listed as a ‘possible’ treatment option in the US, but it
is not the ‘preferred’ treatment option.
5. Delavirdine is licensed in US but not UK.
6. Etravirine is approved in the US and the UK for treatment-experienced patients only.
7. Atazanavir is not licensed as a starting regimen in the UK. In the US, ritonavir-boosted atazanavir has been approved as a
‘preferred’ initial treatment, while unboosted atazanavir is an ‘alternative’ for initial treatment.
8. Roche Pharmaceuticals have discontinued the sale and distribution of Fortovase brand saquinavir soft gel capsules in the
US.
9. Tipranavir is not licensed as a starting regimen in the UK. The US Department of Health and Human Services do not
recommend tipranavir for initial treatment.
10. Enfuvirtide is not licensed as a starting regimen in the UK. The US Department of Health and Human Services do not
recommend enfuvirtide for initial treatment.
11. Maraviroc is not licensed as a starting regimen in the UK.
12. Raltegravir is not licensed as a starting regimen in the UK.

* Because of patent laws, generic forms given tentative approval are available in certain developing countries only.

(Source: http://www.avert.org/aids-drugs-table.htm)

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 Chapter 19: The Acute Abdomen

Chapter 19:
The Acute Abdomen
Outline

 Anatomy
 Conditions That May Cause Acute Abdomen
 Signs and Symptoms
 Assessment
 Emergency Medical Care
 Urinary Colic

Anatomy

The abdominal cavity can be divided into four quadrants or nine regions, which can be
used to locate organs, although many organs overlap different regions.

Although the use of quadrants is common in medical systems, the use of regions is more
precise and should be used as a first preference.

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Conditions That May Cause Acute Abdomen

 Appendicitis

 Pancreatitis

 Cholecystitis

 Intestinal obstruction

 Hernia

 Ulcer

 Esophageal varices

 Abdominal aortic aneurysm

 Trauma

 Internal bleeding

Signs and Symptoms

 Pain or tenderness

 Anxiety and fear

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 Position – Guarded position

 Rapid and shallow breathing

 Rapid pulse

 Nausea, vomiting and/or diarrhea

 Rigid or tense abdomen

 Signs of internal bleeding:

 Vomiting blood (bright red or coffee ground)

 Blood in stool (bright red or dark and tarry)

Assessment

Initial Assessment

Focused History:

 OPQRST

 SAMPLE

Guidelines in performing assessment

 Determine if the patient is restless, quiet and whether pain is

increased upon movement.

 Gently palpate the abdomen using quadrants or regions as landmarks.

 Assess is the abdomen feels soft or rigid.

 Assess if the abdomen is tender or non-tender.

 Assess if there is any abdominal mass.

 Ask if the patient has any other pain in the body.

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 Document the quadrant or region where the pain is located.

Emergency Medical Care

 BSI and safety

 ABC – administer O2 if necessary

 Keep airway patent and be alert for vomiting

 Place the patient in a position of comfort

 Do not give anything by mouth

 Calm and reassure the patient

 Have an increased alertness for shock and provide care for shock as necessary

 Initiate a quick and efficient transport, protecting the patient from abrupt handling

Urinary Colic

Nephrolithiasis – formation of stones (calculi) in the kidney.

Pathophysiology – occurs at any age but common in people between the ages of 20 and 55,
with men affected more often than women. Most common in developed countries.

Factors promoting stone formation

 Supersaturation of the urine

 Presence of nidus

 Stasis

 pH of solution

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Signs and symptoms

 Pain in the back or side – intensity depends on the size of the stone

 Renal colic

 Blood in your urine

 Fever and chills

 Vomiting

 Urine that smells bad or looks cloudy

 A burning feeling when urinating

Emergency Medical Care

 If conscious and alert advise to increase fluid intake over 4000ml/24hours.

 Administer analgesic/antispasmodic if allowed by local protocol.

 Transport to hospital.

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Chapter 20: Burns

Chapter 20:
Burns
Outline

 What Is A Burn?
 The Skin
 Evaluation and Classification of Burns
 Rule of Nines and Rule of Palm/Rule of Seven
 Types of Burns
 Classification of Burn Severity: Adults
 Classification of Burn Severity: Children
 Patient Care

What Is A Burn?

A burn occurs when the body or a body part receives more energy than it can absorb
without injury.

Burns are among the most painful and serious of all injuries.

The Skin

Functions

 Protection – to keep out microorganisms, debris and unwanted chemicals.

 Water balance – helps prevent water loss and stops environmental water from entering
the body.
 Temperature regulation – the sweat glands in the skin produce perspiration, which will
evaporate and help cool the body.
 Excretion – salts and excess water can be released through the skin.
 Shock absorption – skin and its layers of fat help protect underlying organs from minor
impacts and pressure.

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 Sensation

Evaluation and Classification of Burns

First Degree Burns (Superficial)

First-degree burns are red and very sensitive to touch, and the skin will appear
blanched when light pressure is applied. First-degree burns involve minimal tissue
damage and they involve the epidermis (skin surface). These burns affect the outer-
layer of skin causing pain, redness and swelling. Sunburn is a good example of a
first-degree burn.

Symptoms of first degree burns include:

 Skin redness
 Skin pain
 Skin tenderness
 Mild skin swelling
 No blisters form on the skin surface

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Second Degree Burns (Partial-Thickness)

Second-degree burns affect both the outer-layer (epidermis) and the under lying layer of skin
(dermis) causing redness, pain, swelling and blisters. These burns often affect sweat glands, and
hair follicles.

If a deep second-degree burn is not properly treated, swelling and decreased blood flow in the
tissue can result in the burn becoming a third-degree burn.

Symptoms of second degree burns include:

 Skin redness
 Skin pain
 Skin tenderness
 Skin swelling
 Blisters are common

Third Degree Burns (Full-Thickness)

Third-degree burns affect the epidermis, dermis and hypodermis, causing charring of skin or a
translucent white color, with coagulated vessels visible just below the skin surface. These burn
areas may be numb, but the person may complain of pain. This pain is usually because of
second-degree burns. Healing from third-degree burns is very slow due the skin tissue and
structures being destroyed. Third-degree burns usually result in extensive scarring.

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Symptoms of third degree burns include:

 Charring of the skin

 Burned skin may appear white or dark
 No skin redness
 No skin pain or tenderness: Nerves are damaged in the skin
 Second degree burns may surround the third degree burn

Fourth Degree Burns

Fourth degree burns (full thickness burns) affect all layers of the skin and also structures
below the skin, such as tendons, bone, ligaments and muscles. These burns are not painful,
owing to destruction of nerve endings. They may occur from prolonged exposure to flame
or electrical injury. These burns always require surgery or grafting to close the wounds.
Fourth degree burns often result in permanent disability and may require lengthy
rehabilitation. Fourth degree burns can be life-threatening and may require amputation due
to the severe nature of fourth degree burn injuries.

Inhalation Injuries

Fire has been associated with 3 different types of inhalation injuries. More than a hundred
known toxic substances are present in fire smoke. When inhalation injuries are combined
with external burns the chance of death can increase significantly. The three types of
inhalation injuries are:

1. Damage from Heat Inhalation:

True lung burn occurs only if you directly breathe in a hot air/flame source, or have
high pressure force the heat into you. In most cases, thermal injury is confined to
the upper airways, because the trachea usually shields the lung from thermal loads.
However, secondary airway involvement can occur after inhalation of steam as it has
a greater thermal capacity than dry air. When hot air enters the nose, damage to the
mucous membranes can readily transpire as the upper airway acts as a cooling
chamber.

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2. Damage from Systemic Toxins:

Systemic Toxins affect our ability to absorb oxygen. If someone is found unconscious or
acting confused in the surroundings of an enclosed fire, systemic toxins could be a possible
cause. Toxin poisoning can cause permanent damage to organs including the brain. Carbon
Monoxide poisoning can appear symptomless up until the point where the victim falls into a
coma.

3. Damage from Smoke Inhalation:

Smoke intoxication is frequently hidden by more visible injuries such as burns as a result of
fire. Which in a disaster situation can lead to not receiving the medical attention needed, due
to the rescue teams taking care of the more apparent patients. Patients that appear
apparently unharmed can collapse due to major smoke inhalation, 60% to 80% of fatalities
resulting from burn injuries can be attributed to smoke inhalation.

Indications of inhalation injury usually appears within 2-48 hours after the burn occurred.

Indications may include:

 The patient faints

 Fire or smoke present in a closed area
 Evidence of respiratory distress or upper airway obstruction
 Soot around the mouth or nose
 Nasal hairs, eyebrows, eyelashes have been singed
 Burns around the face or neck

Upper airway edema is the earliest consequence of inhalation injury. Upper airway edema is
commonly seen during the first 6 to 24 hours after injury. Early obstruction of the upper
airway is managed with intubation. Initial treatment consists of removing the patient from the
gas and allowing him to breathe air or oxygen.

Age of Patient

Infants, children under 5 and adults over the age of 55 have the most severe responses to
burns and the greatest risks of death because of their anatomy and physiology.

An adult’s reactions to burns and complications associated with burn injury healing increase
significantly after the age of 35.

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Children

 Thin skin
 Larger surface area to volume ration
 Poor immune response
 Small airways
 Consider abuse

Geriatrics

 Thin skin
 Poor circulation
 Underlying diseases
- Pulmonary
- Peripheral vascular
 Decreased cardiac reserve
 Decreased immune response

Percent mortality of geriatrics for burns = Age + %BSA burned

Rule of Nines and Rule of Palm/Rule of Seven

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Burns and Scalds

Types of Burn Cause

Dry burn Flames, contact with hot objects

Scald Steam, hot liquids

Electrical burn Low voltage current from normal

domestic outlets. Arcing from
high voltage currents, lightning
strikes

Freeze burn Frostbite, contact with freezing

materials, liquids or vapors

Chemical burn Industrial and domestic

chemicals

Radiation burn Sunburn, overexposure to UV

light, exposure to radioactive
sources

Classification of Burn Severity: Adults

Classifications by thickness, percentage of BSA, and complicating factors

Minor Burns

 Full-thickness burns of less than 2%, excluding face, hands, feet, genitalia or respiratory tract
 Partial-thickness burns of less than 15%
 Superficial burns of 50% or less

Moderate Burns

 Full-thickness burns of 2%-10%, excluding face, hands, feet, genitalia or respiratory tract
 Partial-thickness burns of 15-25%
 Superficial burns that involve more than 50% of the body

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Critical Burns

 All burns complicated by injuries of the respiratory tract, other soft tissue injuries and bone injuries
 Chemical burns
 Electrical burns
 Partial or full-thickness burns involving the face, hands, feet, genitalia or respiratory tract
 Full-thickness burns of more than 10%
 Partial-thickness burns of more than 25%
 Circumferential burns

Burns by which, by the above classification, are moderate should be considered critical in a person
less than 5 years or greater than 55 years of age.

Classification of Burns by Severity: Children Less Than 5

Classifications by thickness and percentage of BSA

Minor Burns

 Partial-thickness burns of less than 10% BSA

Moderate Burns

 Partial-thickness burns of 10-20% BSA

Critical Burns

 Full-thickness burns or partial-thickness burns of more than 20%BSA

American Burn Association Classifications

The American Burn Association has identified three risk groups of burn patients. Using this
information they have divided burns into major, moderate, and minor burns based on
severity of burn and the patient risk group.

Risk groups by age and health include:

 Low-Risk Patients: between the ages of 10 and 50 years

 Higher-Risk Patients: under 10 years of age or over 50 years

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 Poor-Risk Patients: underlying medical conditions, such as heart disease,

lung disease, and diabetes

Minor Burns

Minor burns must be:

 Less than 15% body surface area in the low-risk group

 Less than 10% body surface area in the higher-risk group
 Full-thickness burns that are less than 2% body surface area in others

Moderate Burns

These include:

 Partial-thickness burns of 15 to 25% body surface area in the low-risk

group
 Partial-thickness burns of 10-20% body surface area in the higher-risk
group
 Full-thickness burns of at least 10% body surface area or less in others

Major Burns

Major burns are:

 Any burns in infants or the elderly

 Any burns involving the hands, face, feet, or perineum
 Burns complicated by fractures or other trauma
 Burns complicated by inhalation injury
 Burns crossing major joints
 Burns extending completely around the circumference of a limb
 Electrical burns
 Full-thickness burns of greater than 10% body surface area in any risk
group
 Partial-thickness burns more than 20% body surface area in the higher-
risk group
 Partial-thickness burns more than 25% of the body surface area in the
low-risk group

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Patient Care

 Stop the burning process:

- Flame – wet down, smother and remove clothing
- Semi-solid (grease, tar, wax) – cool with water but do not remove
substance or clothes that are stuck to the burn (cut around clothing)
- Remove the patient from source of injury if necessary
 Ensure an open airway. Assess breathing.
 Look for signs of airway injury – soot deposits, burnt nasal hair and facial burns.
 Complete the initial assessment.
 Look for signs of shock – burns seldom result in early shock so there may be another
underlying injury.
 Evaluate burns by depth, extent and severity.
 Do not clear debris. Remove clothing and jewellery.
 Wrap with dry sterile dressing.
 Burns to hands/feet – remove rings and jewellery that may constrict with swelling.
Separate fingers or toes with sterile gauze pads.
 Burns to the eyes – do not open the eyelids if burned. Be certain burn is thermal, not
chemical. Apply sterile gauze pads to both eyes to prevent sympathetic movement. If
the burn is chemical, flush eyes for 20 minutes en route to hospital.
 Follow local burn protocols and transport burn patients ASAP, to a burn center is
available.

History

 How long ago did burn occur?

 What caused the burns?
 Was there loss of consciousness?
 Did the burn occur in an enclosed space?
 What has been done to treat the burn?
 Past medical history.
 Allergies/medications?

Specific Chemical Burn Treatment

 Whenever possible, find out the exact chemical or mixture of chemicals

that were involved in the incident

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Mixed or strong acids or unidentified substances

For industrial process – mixed acids. Combined action can be severe and immediate. Pain
produced from initial burn may mask pain caused by renewed burning.

Continue washing the patient even after the patient claims they are no longer in pain.

Industrial sites that use chemicals should have specific facilities for washing chemicals.

Dry Lime

Brush dry lime from the patient’s skin. Do not wash the burn site as water can mix with the dry
lime to create a corrosive liquid.

Sulfuric Acid

Heat is produced when water is added to the concentrated sulphuric acid, but it is still
preferable to wash rather than leave the contaminant on the skin.

Hydrofluoric Acid

Used for etching glass and in many other manufacturing processes. Burns from this acid may
be delayed, so treat all patients who have come into contact with the chemical, even if burns
are not evident.

Inhaled Vapors

Whenever a patient is exposed to a caustic agent and may have inhaled the vapors, provide
high concentration oxygen and transport immediately.

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Appendix 1:
Updated 2010 European
Resuscitation Council
Guidelines

Basic life support

Changes in basic life support (BLS) since the 2005 guidelines include:

 Dispatchers should be trained to interrogate callers with strict protocols to elicit

information. This information should focus on the recognition of unresponsiveness
and the quality of breathing. In combination with unresponsiveness, absence of
breathing or any abnormality of breathing should start a dispatch protocol for
suspected cardiac arrest. The importance of gasping as sign of cardiac arrest is
emphasised.
 All rescuers, trained or not, should provide chest compressions to victims of cardiac
arrest. A strong emphasis on delivering high quality chest compressions remains
essential. The aim should be to push to a depth of at least 5 cm at a rate of at least
100 compressions min-1, to allow full chest recoil, and to minimise interruptions in
chest compressions. Trained rescuers should also provide ventilations with a
compression–ventilation (CV) ratio of 30:2. Telephone-guided chest compression-only
CPR is encouraged for untrained rescuers.
 The use of prompt/feedback devices during CPR will enable immediate feedback to
rescuers and is encouraged. The data stored in rescue equipment can be used to
monitor and improve the quality of CPR performance and provide feedback to
professional rescuers during debriefing sessions.

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Electrical therapies

The most important changes in the 2010 ERC Guidelines for electrical therapies include:

 The importance of early, uninterrupted chest compressions is emphasized

throughout these guidelines.
 Much greater emphasis on minimizing the duration of the pre-shock and post-
shock pauses; the continuation of compressions during charging of the defibrillator
is recommended.
 Immediate resumption of chest compressions following defibrillation is also
emphasised; in combination with continuation of compressions during defibrillator
charging, the delivery of defibrillation should be achievable with an interruption in
chest compressions of no more than 5 seconds.
 Safety of the rescuer remains paramount, but there is recognition in these
guidelines that the risk of harm to a rescuer from a defibrillator is very small,
particularly if the rescuer is wearing gloves. The focus is now on a rapid safety
check to minimise the preshock pause.
 When treating out-of-hospital cardiac arrest, emergency medical services (EMS)
personnel should provide good-quality CPR while a defibrillator is retrieved,
applied and charged, but routine delivery of a pre-specified period of CPR (e.g.,
two or three minutes) before rhythm analysis and a shock is delivered is no longer
recommended. For some EMS that have already fully implemented a pre-specified
period of chest compressions before defibrillation, given the lack of convincing
data either supporting or refuting this strategy, it is reasonable for them to
continue this practice.
 The use of up to three-stacked shocks may be considered if VF/VT occurs during
cardiac catheterization or in the early post-operative period following cardiac
surgery. This three shock strategy may also be considered for an initial, witnessed
VF/VT cardiac arrest when the patient is already connected to a manual
defibrillator.
 Further development of AED programmes is encouraged – there is a need for
further deployment of AEDs in both public and residential areas.

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