Emergency MedicalTechnician – Basic Course Manual Life Support Training International This page left intentionally blank 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 This page left intentionally blank 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 This page left intentionally blank . 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. 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 . Hygiene. 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. In the Philippines. We are also the founding executive members of the Philippine Society of Emergency Medical Technicians. Life Support Training International is heavily involved with the Philippine Heart Association. Our consultants have been involved in developing Emergency Medical Services Systems (EMSS) in various parts of the world. which is a society dedicated to developing a National Emergency Medical Services System throughout The Philippines. we work closely with Emergency Medicine Consultants from the University of the Philippines. Our faculty is composed of only the most qualified and experienced instructors ranging from trained Trauma Surgeons and fully registered Emergency Medical Page 1 Emergency Medical Technician – Basic . Department of Emergency Medicine. here in The Philippines. ranging from the United Kingdom to the Middle East. being active members of both the Expanded Council on Resuscitation and the National Emergency Medical Services Council. the Western Pacific Region and. indeed. Philippines General Hospital. We must accept. however. training and maintenance of the highest standards. that any chain is only as strong as its weakest link. religious beliefs or political affiliations. Research and Development Council. Page 2 Emergency Medical Technician – Basic .WE GIVE YOU ONLY THE VERY BEST. Our National Training. internationally.Chapter 1: EMS In The Philippines Technicians and Paramedics . 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. has developed comprehensive training guidelines which clearly outline the standards required of all those seeking the implementation of truly professional standards of PreHospital Emergency Medical Care. The development of a first-class Emergency Medical Services System in The Philippines is our prime objective. cultural background. the Australasian Registry of Emergency Medical Technicians (AREMT) and the Technical Education and Skills Development Authority (TESDA). and these standards will be required of anyone seeking membership of the Society. 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 nonprofit. 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. We will help students to develop the essential knowledge. and with this in mind. irrespective of social status. the Philippine Society of Emergency Medical Technicians has recognized that excellence can only be achieved through education. non-political. 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. as this is absolutely essential in order to form an integral link in the chain of delivering quality care to the ill and injured. The AREMT is an Australian-based pre-hospital professional body. 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. the Philippine Society of Emergency Medical Technicians was. Due to this recognition. awarded direct and complete reciprocity with the Australasian Registry of Emergency Medical Technicians (AREMT). but also establishing a National Examination System to ensure that these standards are achieved and maintained.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. PSEMT Affiliations American College of Emergency Physicians Page 3 Emergency Medical Technician – Basic . due to our adherence to the highest of international standards and practice. 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. in March 2007. not only setting the Society’s Training Standards. the Filipino EMT is justifiably and proudly acknowledged as a world-standard professional. which bases its standards on both the US Department of Transport and European models of pre-hospital care. Research and Development Council. We are pleased to announce that. which is tasked with. 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 Page 4 Emergency Medical Technician – Basic . PARAMEDIC . This must be confirmed by the applicant’s Officer-In-Charge and duly approved by the Society’s National Executive Committee. INFUSION & INTUBATION TRAINED EMT (I & I) ADVANCED EMERGENCY MEDICAL TECHNICIAN .EMT (D) EMERGENCY MEDICAL TECHNICIAN. This grade is inclusive of ambulance staff and nursing personnel who can demonstrate appropriate training and experience in line with PSEMT/PBEMT published standards. Submission of a personal log of experience gained.EMT (B) EMERGENCY MEDICAL TECHNICIAN.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. with a further eight hours in Basic Life Support.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 . Completion of a minimum of 40 hours continuous medical education.EMT (B) “Certification” This is the initial entry grade for all professional pre-hospital care providers. Basic Emergency Medical Technician . 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. Successful completion of National Examinations.EMT (A) REGISTERED EMERGENCY MEDICAL TECHNICIAN. The minimum requirement will be thirty-two hours of instruction in First Aid. DEFIBRILLATOR TRAINED . Page 5 Emergency Medical Technician – Basic . Proof of a minimum of 250 hands-on patient management in the preceding twelve months. and examinations thereof. 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. with at least 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. which must include emergency response duties. Registered Emergency Medical Technician Paramedic - EMT (P) “Registration” The minimum entry criteria for Paramedic training is EMT Advanced (A). They must have successfully completed the prescribed defibrillation module. This level will only be available to those who complete a minimum of seven hundred and fifty (750) hours actual operational experience per year. in accordance with the standards set out by the PSEMT/PBEMT.Chapter 1: EMS In The Philippines The minimum age shall be 20 years. 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. which will include all the content as outlined in the Society’s National Syllabus. Page 6 Emergency Medical Technician – Basic . All applicants must have successfully completed the three hundred and sixty (360) hour Advanced Clinical Training modules. 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 . Emergency Medical Technician.EMT (A) “Registration” Entry requirement must be that of EMT (I & I) with not less than six (6) months post-certification experience. whether or not the candidate chooses to complete the course . 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. 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. Requests for exemption will be reviewed by the PSEMT National Training. Registered Emergency Medical Services Instructor . Exemptions Exemptions from some requirements may be considered based on alternative qualifications and experience. Their decision will be considered final. irrespective of the outcome thereof. Page 7 Emergency Medical Technician – Basic . all students who start the course are obliged to pay in full. Payment of Tuition Fees Training fees may be paid on an instalment basis. but must be paid in full.REMSI This level has yet to be defined. In accordance with the Philippine Heart Association (PHA).Chapter 1: EMS In The Philippines 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. Research and Development Council and the PBEMT.in other words. Page 8 Emergency Medical Technician – Basic . are applicable. The high standards of training shall not be compromised in any way. Life Support Training International reserves the right to terminate the training of any student who fails to honor the set payment schedule. and as such: Any cheating.PHP5000 (Non-refundable) Weekly payment . Students should follow the schedule diligently. All policies regarding examinations. Students must settle all outstanding accounts before the Final Examination. 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). re-sit/re-examination shall be done at a time and date designated by the PSEMT/AREMT.Chapter 1: EMS In The Philippines Reservation fee . Weekly Assessment Every Monday morning. payment of fees etc. and those involved will forfeit any chance to re-sit the exam. in the Final Examinations will be subject to immediate disqualification. All students are obliged to follow the scheduled examination date.PHP3000 (Week 2-6 inclusive) LSTI meticulously enforces the payment schedule given to students on the first day of the class. or perceived attempt to cheat. starting week 2. an assessment/examination shall be conducted to gauge the student’s performance and knowledge. Re-Sit/Re-Examination In the case of failures. Non-payment or incomplete payment of tuition fees will result in forfeiture of the student’s chance to take the examination. If a student fails to re-sit or take the Final Examination within this grace period. No EMT certification can be awarded to a candidate without successful completion of both practical and theoretical examinations in Basic Life Support. Under no circumstances will a candidate who has failed the final examinations and re-sit be accepted for retraining at LSTI. In accordance with PSEMT/AREMT policies. he/she shall forfeit their right to retake said Final Examination. Students who fail all the re-sits/re-examinations shall not be awarded any certificate of proficiency. Page 9 Emergency Medical Technician – Basic . Smoking is strictly prohibited in and around the training facility at all times.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). a maximum of three (3) sits are allowed (1 exam and 2 re-sits). repetition of the EMT-Basic Course is also not permitted. Validity of the re-sit/re-examination is limited to within one (1) year from the time the student finishes the course. Please put all your litter in the numerous garbage receptacles provided around the training facility for student use. For the Basic Life Support Written Examination. a symbol whose use is encouraged by both the American Medical Association and the Advisory Council within the Department of Health and Human Services. EMS Branch Chief at the National Highway Traffic Safety Administration (NHTSA) USA.Basic . 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. Page 10 Emergency Medical Technician . The Star of Life was designed by Leo Schwartz. the Star of Life indicates the location or access to qualified emergency care services.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. Emergency Medical Services have the ‘Star of Life’. On road maps and highway signs. and pharmacists the mortar and pestle. The staff in the center of the symbol represents medicine and healing.Chapter 2: Roles and Responsibilities of the EMT The symbol’s six-barred cross represents the six-system function of Emergency Medical Services. According to Greek mythology. truth and prophesy). Resource Management Centralized coordination of resources (i.e. who learned the art of healing. to an appropriate facility. the son of Apollo (god of light. the staff belonged to Asclepius. The Emergency Medical Services S Regulation and Policy Laws that allow the system to exist. Page 11 Sample Manual Template . hospitals) to have equal access to basic emergency care and transport by certified personnel in a licenced and equipped ambulance. rehabilitation programs. 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. reliable ambulance transportation is a critical component. Communications There must be an effective ccommunications system. Page 12 Emergency Medical Technician . data collection and means for managing and assuring the quality of the 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. Transportation Safe. Triage and transfer guidelines for trauma patients. Evaluation Program for improving the EMS system.Basic .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. Lifting and Moving Effective and safe application of patient handling procedures to avoid self-inflicted and career-ending injuries. Page 13 Sample Manual Template . 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.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. Patient Care Preparation for action or a series of actions to take that will help the patient deal with and survive illness or injury. Professional Attributes of the EMT Appearance Excellent personal grooming and a neat clean appearance to instil confidence in patients. 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. Transport A serious responsibility in ambulance operations. Must develop a rapport that will give understanding of the patient’s condition. as well as for other rescuers. Temperament and Abilities • A pleasant personality • Leadership ability • Good judgement • Good moral character • Stability and adaptability Page 14 Emergency Medical Technician . • Personal safety and security measures. • How to clean.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. • The territory and terrain within the service area. Physical Demands Good physical health and good eyesight to properly assess the patient and drive safely.Basic . disinfect and sterilize non-disposable equipment. the patient and bystanders. • How and when to assist the administration of medications approved by medical direction or protocol. • Traffic laws and ordinances concerning emergency transportation of the sick and injured. EMS systems continued to be refined in the 1980s and 1990s. The state provides laws that broadly outline what is prudent. safe and acceptable.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. Page 15 Sample Manual Template . prevention. EMS systems must be planned and operated at the local level. rehabilitation. To be effective. financing and operational and patient care protocols. including medical direction and accountability. Successful EMS systems are designed to meet the needs of the communities they serve. Medical Direction Physician input. and become involved at all levels in structuring the system. such as the enhanced 911 Page 16 Emergency Medical Technician . consumer and public safety agencies to ensure consensus in developing policies and settling disputes. The base station facility providing on-line control is required to monitor all advanced life support (ALS) communications. On-line medical direction provides EMTs with consultation in the field. protocols. more commonly. In cooperation with the local medical community. either in person or.Basic . Additional advancements have been made with enhanced systems. The council consists of representatives from the local medical. implementing. policies and procedures. the medical director is responsible for developing standards. via radio or telephone communication. The medical director assumes authority and responsibility for off-line medical direction. A governing body or council should be established to organize. develop funding mechanisms. EMS. direct and coordinate all system components. issuing credentials and providing evaluations. provide field consultations. leadership and oversight in ensuring that medical care provided is safe. effective and in accordance with accepted standards. Physicians providing on-line direction should be appropriately trained and familiar with the operations and limitations of the system. overseeing and evaluating all components of the system. 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. developing training programs. and remain protected from forces that serve the interests of only one group. and notify receiving facilities of incoming patients. The EMS system must provide equal access to all. This responsibility is delegated medical director to physicians who staff local Emergency Departments. Medical direction is characterized as either immediate (on-line) or organisational (off-line). Physicians must be empowered and imvolved in planning.Chapter 2: Roles and Responsibilities of the EMT Communities need to identify their individual needs and resources. 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. Using enhanced systems. Patients should be transported to the closest. and does not necessarily overburden the system. Consolidated Omnibus Budget Reconciliation Act [COBRA] and Emergency Medical Treatment and Active Labor Act [EMTALA] in the US). and • Triage to a lower level of care. Page 17 Emergency Medical Technician – Basic . Air transport. callers can obtain services even if they are unable to communicate with dispatch. • Patient refusal of care. may also be either BLS or ALS. such as a helicopter or airplane. and be appropriately equipped to provide basic or advanced level of care. has the approval of online medical control. Otherwise. the number of personnel and the level of certification required. Patients are transported in compliance with regional protocols and federal.g. and improve their outcome.Chapter 2: Roles and Responsibilities of the EMT system. This includes: • Decision to transport. as long as the transport meets regional point-of-entry protocols. most appropriate facility. which automatically provide the dispatcher with the caller’s address and telephone number. On-line medical direction should be obtained in all calls that result in transport. Ambulances should be constructed according to federal or national standards. Air transport is used to transport patients over greater distances. as well as the response-time criteria and the destination for each transport. Emergency medicine dispatch includes assessment of patient location and status. Operational standards are established to delineate the equipment needed. Stable patients may be transported to the hospital of their choice. Receiving facilities are required to have the capabilities to treat the patients. Legislation dictates that medically unstable patients be transferred only when the transfer is expected to have a positive effect on outcome. national or state laws (e. the provider may be perceived as practicing without a licence. stabilize their condition. and could be charged with an offence. decrease total pre-hospital time or to reach patients in poorly accessible locations. Ground vehicles provide most EMS transportation. Transportation Inter-facility transportation occurs once the patient has been examined and stabilized. as well as the provision of pre-arrival instructions. sorts patients into treatment categories. Physician involvement is essential to assure appropriate utilizations of skills and equipment. On-line medical direction is crucial in systems. acceptable approach to commonly encountered problems. Protocols Protocols are developed to deal with operational. first aid. Optimal care and medical accountability require standardized protocols. Any deviation from these standing orders must be considered a breach of duty and must result in an audit. Education is also used to reinforce proper patient care. Protocols should reflect regional and national standards. Treatment protocols describe the authority and responsibilities of providers and offer guidance for medical evaluation and care. and remedy perceived deficiencies in patient care. The EMS system also provides community education. They define a standardized. Additionally. administrative and patient care issues. requiring decision-making to provide guidance and assume some of the patient-care responsibilities. prioritization. such as public courses in CPR. triage addresses the level of provider during multiple casualty incidents to facilitate the screening. and optimizes use of field resources for treatment and transport. Most states require that candidates pass written and practical examinations prior to certification. The medical director has the responsibility to address protocols dealing with patient care. Local communities need to establish regional protocols to provide clear guidance for the transport of unstable patients to categorized facilities. Training Standards Providers must be trained to meet the expectations and requirements in programs that comply with regional and national standards. Unstable patients with special problems. Triage assesses the condition of each patient. can be transported to regionally designated hospitals. bypassing closer facilities. as well as the uniqueness and limitations of the local environment. clinical and field components. EMTs are required to receive continuing didactic and clinical education to maintain certification. Page 18 Emergency Medical Technician – Basic . treatment and transport of patients. algorithms and standing orders that outline specific actions providers can take without contacting a physician for orders. update standards and protocols. such as burns or trauma. such as triage and treatment. In addition.Chapter 2: Roles and Responsibilities of the EMT Specialized resources to care for the severely injured are not available in every hospital. Training includes didactic. child safety and EMS access. Periodic disaster drills serve to assess performance. CQI staff members must identify the problem. performance and documentation are invaluable in constructing a successful CQI process. consistent. Disaster Preparedness The EMS system is an integral part of disaster preparedness and planning. Prospective evaluation is most effective process to ensure quality in EMS. appropriate. Public support is invaluable in constructing a successful EMS system. The goal is to influence patient outcomes positively by delivering products timely. Retrospective evaluation is the least valuable and most time-consuming. Staff members observe performance. government and the medical community. Concurrent evaluation occurs on scene or on-line. The system must be scrutinized constantly to determine areas requiring refinement and improvement. because it has the potential to prevent mistakes. encourage positive behavior and correct problems before bad habits develop. Standardized protocols. Consumers need to be well informed of the benefits of having an EMS system and how to gain access to it. and is essential in establishing a regional disaster preparedness plan in coordination with public safety agencies. Quality should be monitored from within the EMS system and by an external. CQI ensures that the field staff provides the highest quality of care and that the system supports this goal. refine management and educate personnel and the community. and measure the outcome. The plan should address disaster management. communication. involvement is required to plan a system that works for everyone. policies. concurrent and retrospective. When goals and standards are not met. It plays an important role in initial response and transportation. compassionate and cost-effective systems. independent and unbiased body that involves the consumer. government and medical communities. establish and implement a corrective course of action. It includes critique sessions and reviews of patient encounter tapes and charts.Chapter 2: Roles and Responsibilities of the EMT Continuous Quality Improvement Continuous quality improvement (CQI) is the sum of all activities undertaken to assess and improve the products and services EMS provides. Quality evaluation is prospective. treatment and designation of casualties. Page 19 Emergency Medical Technician – Basic . The patient has the right to expect continuity of care. The patient has the right to expect that all communications and records pertaining to his or her care should be treated as confidential.The part of ethics that deals with the health care of human beings.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 . of moral duties and of ideal behaviour.The science of right and wrong. Patient Bill of Rights The patient has the right to considerate and respectful care. Page 20 Emergency Medical Technician – Basic . MEDICAL ETHICS . 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. Different standards may be held in different legal jurisdictions. Good Samaritan Law Protects a person from liability for acts performed in good faith. 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. Medical Direction The legal right to function as an EMT-B is contingent upon medical direction. the Patient Bill of Rights is known as Title 111: Declaration of Rights. Does not prevent one from being sued. or may pass the scene and make no attempt to call for help. although it may provide some protection against losing a lawsuit if one has performed to the standard of care for an EMT-B.Chapter 3: Medico-Legal and Ethical Issues in EMS In the Philippines. IF ON-DUTY: legally obligated may stop and help. or may pass the scene and call for help. IF OFF-DUTY: Page 21 Emergency Medical Technician – Basic . unless those acts constitute gross negligence. More than one physician may be required to verify the patient’s condition. Maintain skill mastery. Report with honesty. gender. Usually accompanied by a doctor’s written orders. Associated problems: More useful in an institutional setting. creed or status. Patient Consent and Refusal Types of Consent Expressed consent Implied consent Consent to treat a minor or mentally incompetent adult Advance Directives “Living Will”. Page 22 Emergency Medical Technician – Basic .Chapter 3: Medico-Legal and Ethical Issues in EMS Ethical Responsibilities Serve the needs of the patients with respect for human dignity. Scrutiny of an advance directive may be time consuming. Keep abreast of changes in EMS which affect patient care. Work harmoniously with others. without regard to nationality. race. 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. Critically review performances. it must be proved that: The EMT-B had a duty to act. Remember: Try to persuade the patient to accept treatment or Consult medical direction as required by local A competent adult is defined as one who is lucid and capable of making an informed decision. 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. either physically or psychologically. Before you leave. encourage the patient to seek help if certain symptoms develop. Protecting yourself: Do the following before you leave the scene: transport to a hospital. have them sign a refusal form.Chapter 3: Medico-Legal and Ethical Issues in EMS Refusal of Treatment Competency A competent adult is defined as one who is lucid and capable of making an informed decision. protocol. The EMT-B’s action or lack thereof caused or contributed to the patient’s injury. Page 23 Emergency Medical Technician – Basic . If the patient still refuses. Make sure that the patient is able to make a rational informed decision. The EMT-B violated the standard of care expected. The patient was injured. As requested by the police as part of a potential criminal investigation. As required by legal subpoena. Identify the patient as a potential donor. Provide emergency care that will maintain the vital organs. Communicate with medical direction regarding the possibility of organ donation. friends or other members of the public about details of the emergency care you provided to a patient. In other situations.Chapter 3: Medico-Legal and Ethical Issues in EMS Confidentiality Do not speak to the press. As required on a third-party billing form. To provide assistance in organ harvesting: 1. When a patient signs a release form. Special Situations Donors and Organ Harvesting A legal signed document is required. 3. Dying and Deceased Patients If the person is obviously dead. such as a signed donor care sticker affixed to a driver’s licence or an organ donor card. you may be required to arrange for transport of the body so that a physician can officially pronounce the patient dead. 2. Instances when an EMT-B is allowed to release confidential information: Another health care provider needs to know the information to continue medical care. your family. Page 24 Emergency Medical Technician – Basic . you may be required to leave the body at the scene if there is any possibility that the police will have to investigate. Releasing confidential information requires a written release form signed by the patient or a legal guardian. Page 25 Emergency Medical Technician – Basic . Move only what you need to move. Crime Scenes General guidelines . Do not cut through any knot in a rope or tie. Observe and document anything unusual at the scene. Try to avoid any item at the scene that may be considered evidence.Chapter 3: Medico-Legal and Ethical Issues in EMS Medical Identification Insignia A patient with a serious medical condition may be wearing a medical identification tag (bracelet. Do not use the phone unless authorised by the police. If possible. If you suspect a crime is in progress or a criminal is still active at a scene. change their clothing. If the crime is rape. do not cut through holes in the patient’s clothing. necklace or card). use the bathroom or take anything by mouth. Basic Guidelines for the EMT at a Crime Scene Touch only what you need to touch.a potential crime scene is any scene that may require police support. do not wash the patient or allow the patient to wash. do not attempt to provide care to any patient. Page 26 Emergency Medical Technician – Basic . The Emergency Medical Technician. as a citizen. An Emergency Medical Technician assumes responsibility in defining and upholding standards of professional practice and education. The Emergency Medical Technician does not use professional knowledge and skills in any enterprise detrimental to the public wellbeing. or status. 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. other medical professionals. As an Emergency Medical TechnicianParamedic. with respect for human dignity. to alleviate suffering. and to encourage the quality and equal availability of emergency medical care. race creed. The Emergency Medical Technician provides services based on human need. I solemnly pledge myself to the following code of professional ethics: A fundamental responsibility of the Emergency Medical Technician is to conserve life. to do no harm. 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. to promote health. color. 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.Chapter 3: Medico-Legal and Ethical Issues in EMS 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. unrestricted by consideration of nationality. as a professional. and the profession of Emergency Medical Technician. understands and upholds the law and performs the duties of citizenship. An Emergency Medical Technician has the responsibility to be aware of and participate in matters of legislation affecting the Emergency Medical Service System. or groups of Emergency Medical Technicians. The Emergency Medical Technician has an obligation to protect the public by not delegating to a person less qualified. who advertise professional service. The Emergency Medical Technician. the nurses. do so in conformity with the dignity of the profession. any service which requires the professional competence of an Emergency Medical Technician. both in dependent and independent emergency functions. The Emergency Medical Technician will work harmoniously with and sustain confidence in Emergency Medical Technician associates. The EMT Code of Ethics was written by Dr.Chapter 3: Medico-Legal and Ethical Issues in EMS The Emergency Medical Technician assumes responsibility for individual professional actions and judgment. and assumes the responsibility to expose incompetence or unethical conduct of others to the appropriate authority in a proper and professional manner. Charles Gillespie and adopted by the National Association of EMTs in 1978. and knows and upholds the laws which affect the practice of the Emergency Medical Technician. The Emergency Medical Technician refuses to participate in unethical procedures. and other members of the Emergency Medical Services health care team. the physicians. Page 27 Emergency Medical Technician – Basic . Chapter 4: Ambulance Vehicles and Equipment Chapter 4: Ambulance Vehicles 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 Page 28 Emergency Medical Technician – Basic and . Many newer ambulances look similar to older vehicles. In America. Equipment and supplies for emergency care at the scene as well as during transport. 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. Ambulances are equipped according to their role . North American Ambulance Designs Ambulance vehicle designations in the USA are governed by federal laws and standards.basic transport.Chapter 4: Ambulance Vehicles and Equipment Introduction M odern ambulances have evolved into sophisticated vehicles. with modern safety features such as ABS brakes and airbags. or Mobile Intensive Care Unit (MICU). Intermediate Life Support (ILS). Safety. with changes related to the use of new lightweight materials and increased safety features. Audible and Visual Traffic warning devices Page 29 Emergency Medical Technician – Basic . comfort. Two-way radio communication. Ambulances now are often equipped with GPS and computer dispatch systems. and avoidance of aggravation of the patient’s injury or illness. Advanced Life Support (ALS). a cab chassis furnished with a modular ambulance body. Helicopter Emergency Medical Services (HEMS) Helicopter Emergency Medical Services (HEMS) units are basically used for trauma and high-dependency transfers.Chapter 4: Ambulance Vehicles and Equipment There are three basic ambulance specifications in North America: TYPE I AMBULANCE . TYPE II AMBULANCE . HEMS are particularly useful for the pickup of patients in isolated areas where access by other forms of air.this promotes vehicle handling characteristics as well as reducing overall weight and fuel consumption. 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. sea or road transport is difficult or just not possible at all.a long wheelbase van. TYPE III AMBULANCE . with integral cab-body. European Ambulance Designs European ambulances are generally manufactured on an individual service requirement basis. 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. 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. It should be said that HEMS units are extremely costly to set up and Page 30 Emergency Medical Technician – Basic .a cutaway van with integrated modular ambulance body. Fibreglass is used extensively in the manufacture of European vehicles . Paramedic Fast Response Vehicles These vehicles are utilized to deliver Advanced Life Support quickly and efficiently at the scene of any emergency. Immobilisation / Splinting Equipment: Scoop Stretcher. Standard Ambulance Equipment Monitoring Equipment: BP Cuff / NIBP. Stethoscope. Flowmeter. Automated Transport Ventilator / Resuscitator. Airway Equipment: Oxygen Cylinder. HEMS units are usually run on a regional or national basis as opposed to local operations. Straps and harnesses. Bag Valve Mask. Head Immobilizer.Chapter 4: Ambulance Vehicles and Equipment run. Traction Splint. Others: Stretcher Carry chair Entonox Medical Bag Medical disposables according to checklist Page 31 Emergency Medical Technician – Basic . ECG Monitor Defibrillator. Extrication Device (KED). Vacuum Mattress. Pulse Oximeter. Due to the high cost factor. Combitubes. Suction unit. Vital Signs Monitor. Endotracheal Tubes. Laryngeal Mask Airway. Regulator. Extremity Splints. Thermometer. Guedal Airways. Cervical Collars. loss of power and shorten the life of the engine. automatic transmission fluid. DO NOT rev the engine immediately on or after start up. 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. direction indicators. rotators. battery water levels before starting the vehicle. Also check for leaks under the vehicle. Check lights – headlights. sirens. before the oil is circulated through the engine. radiator coolant. It is also important to remember that diesel engines with a turbo need to idle before shut down. As emergency care professionals. taillights. wear and damage. The safety of the crew also depends on any faults with the vehicle being noted and corrected. NEVER rev a turbo engine before turning off the ignition.Chapter 4: Ambulance Vehicles and Equipment 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. engine oil. 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. Check communications equipment – vehicle radio and handheld radio Check tyres for pressure. Page 32 Emergency Medical Technician – Basic . flashers. Duties of Driver Check all fluid levels – fuel. we are dealing with people’s lives each time we respond to a call. as it can cause damage to the turbo bearings. etc. etc. Make sure batteries are charged for any battery powered equipment such as ECG monitors. Make sure that you know exactly how each item of equipment works.Chapter 4: Ambulance Vehicles and Equipment Duties of Attendant Check equipment according to the checklist. both inside and out serves two purposes. as a surface which appears clean. Daily pre-run vehicle and equipment preparation Ambulance maintenance benefits: • decreases vehicle downtime Page 33 Emergency Medical Technician – Basic . and that gauges and flowmeters are working. Check medical disposables according to checklist. linen. making sure that all the equipment is complete and in good working order. equipment and supplies are clinically clean and thoroughly hygienic. It is vitally important to clean the interior surfaces with approved disinfectants. noting expiry dates. 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. etc. Cleanliness Cleanliness of the vehicle. Phases of an Ambulance Call 1. can harbour bacteria and viruses. Make sure that the patient compartment. The first is that a clean vehicle portrays a professional image. and the trouble-shooting procedures for that item of equipment. pulse oximeters. equipment. Check oxygen cylinders are full. 5. Dispatch Location of call. En route to the scene.Chapter 4: Ambulance Vehicles and Equipment • 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. 7. Any other special problems or circumstances that may be pertinent. 3. Name. En route to the receiving facility. En route to the station. At the receiving facility. Location of the patient. At the scene. Nature of call. 6. 4. The number of patients and severity of the problem. location and callback number of the caller. Page 34 Emergency Medical Technician – Basic . Turn in any direction at an intersection. Cautiously proceed through a red flashing signal. Emergency Driving Emergency Driving Privileges Exceed the posted speed limit for the area as long as you are not endangering lives or propery.Chapter 4: Ambulance Vehicles and Equipment 8. Ambulance Hygiene After every call Strip used linens from the stretcher and place them in a plastic bag or designated receptacle. Leave the ambulance standing in the middle of a street or intersection. Drive the wrong way down a one-way street or drive down the opposite side of the road. Park anywhere as long as you do not endanger lives or property. Ambulance emergency lights should be high enough to cast a beam above the traffic. Post run. Warning and Emergency Lights Warning lights must be activated at all times when responding to an emergency call. Pass other vehicles in a no-passing zones. Lights should be used even when you are not using the siren. Page 35 Emergency Medical Technician – Basic . Scrub all the interior surfaces with soap and water. Air out the ambulance with all doors and windows open for 15 minutes. dispose of all disposable equipment used for patient care.Chapter 4: Ambulance Vehicles and Equipment In an appropriate receptacle. then air out again to let everything dry. Disinfect all non-disposable equipment used for patient care. clean it up. Page 36 Emergency Medical Technician – Basic . If there is any spoilage or contamination in the ambulance. Clean the stretcher with germicidal solution. Scrub again with germicidal solution. At least once a day: Empty the ambulance of the stretcher and equipment boxes. Disinfect the oxygen humidifier and refill with clean water. toward the head Inferior Below.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 Midline Imaginary vertical line down the middle of the front surface of the body Anterior Toward the front Posterior Toward the back Superior Above. 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 Distal Farther from the point of attachment to the body (or the heart) Internal Inside External Outside Page 37 Emergency Medical Technician – Basic . Chapter 5: Medical Terminology in EMS 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 Page 38 Emergency Medical Technician – Basic . ringing noise in the ear NCAT .nosebleed Rhinorrhea . such as red eye Page 39 Emergency Medical Technician – Basic .Chapter 5: Medical Terminology in EMS Medical Terms By Body Systems HEENT – Head.runny nose or nasal discharge Otorrhea .blood vessel congestion. Eyes.intolerant of sounds Diplopia .consisting of pus Injected .intolerant of light Phonophobia . Ears.double vision Epistasis .back of the head Photophobia . atraumatic PERRL . Nose & Throat Occipital .Pupils Equal Round and Reactive to Light Erythema .discharge from the ear Tinnitus .redness Purulent .normocephalic. visible skin retractions with inspiration Tachypnea .Shortness of Breath (dyspnea) Productive cough .vomiting NBNB .Coronary (the heart) Pulm . non-bilious Hematemesis .wheezes/whistling sounds Retractions .high pitched sounds Hemoptysis .bloody emesis Hematochezia .after eating Emesis .Bright Red Blood per Rectum Melena . ronchi or wheezes SOB .crackles Ronchi .worse with deep inspiration Rales .phlegm producing Wheezing .bloody stool BRBPR .coughing up blood Pleuritic .Pulmonary (respiratory system) CTAB no rrw . no rales.Clear to auscultation bilaterally.Chapter 5: Medical Terminology in EMS Coronary & Pulmonary Cor .loss or lack of appetite Post-prandial .non-bloody.tarry black stool Page 40 Emergency Medical Technician – Basic .rapid breathing Abdomen (Abd) or Gastrointestinal (GI) Anorexia . Musculoskeletal Ext . often more so in a single quadrant Guarding .worse pain as examining hand is quickly pulled away Genitourinary (GU) Dysuria .Extremities Myalgias .muscle aches Arthralgias .raised area Sacs: Vesicle .itchy Macule .Chapter 5: Medical Terminology in EMS BS .blood in the urine Musculoskeletal & Extremities MS .joint aches Edema .painful urination Hematuria .bowel sounds (normoactive.bump 5mm or less Nodule . hypoactive.tender to palpation.fluid filled sac >5mm Page 41 Emergency Medical Technician – Basic .hard abdomen when palpated Rebound . hyperactive. absent) TTP .fluid filled sac <5mm Bulla .swelling Skin Pruritic .flat discoloration <10mm in diameter Bumps: Papule .well defined bump >5mm Plaque . Before meals ASA Aspirin AMA Against medical advice AMI Acute myocardial infarction ASHD Arteriosclerotic heart disease B b. bowel sounds.redness Common Medical Abbreviations A AED Automated External Defibrillator a.i.d.c.Chapter 5: Medical Terminology in EMS Pustule . Twice a day BP Blood pressure BS Breath sounds. or blood sugar BVM Bag-valve-mask C c/o Complaining of Ca Cancer/carcinoma cc Cubic centimeter CC Chief Complaint CHF Congestive heart failure CO Carbon monoxide Page 42 Emergency Medical Technician – Basic .sac filled with pus Erythema . For example ETA Estimated time of arrival ETOH Alcohol (ethanol) F Fx Fracture G GI Gastrointestinal GSW Gun shot wound gtt.g. chronic bronchitis) CPR Cardiopulmonary resuscitation CSF Cerebrospinal fluid CVA Cerebrovascular accident CXR Chest X-ray D d/c Discontinue DM Diabetes mellitus DOA Dead on arrival DOB Date of birth Dx Diagnosis E ECG. Drop Page 43 Emergency Medical Technician – Basic .Chapter 5: Medical Terminology in EMS COPD Chronic obstructive pulmonary disease (emphysema. EKG Electrocardiogram e. nose. hr. eyes. throat Hg Mercury h/o History of hs At bedtime HTN Hypertension Hx History I ICP Intracranial pressure ICU Intensive Care Unit IM Intramuscular IO Intraosseous J JVD Jugular venous distension K KVO Keep vein open Page 44 Emergency Medical Technician – Basic .Chapter 5: Medical Terminology in EMS GU Genitourinary GYN Gynecologic H h. Hour H/A Headache HEENT Head. ears. Chapter 5: Medical Terminology in EMS L L Left or Liter LAC Laceration LOC Level of consciousness LR Lactated Ringers solution M mcg Micrograms MS Morphine sulphate. multiple sclerosis N 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 O O2 Oxygen OB Obstetrics OD Overdose OR Operating room Page 45 Emergency Medical Technician – Basic . d. Every hour q.i. Four times a day R R Right r/o Rule out Rx or Tx Treatment S SIDS Sudden Infant Death Syndrome SOB Shortness of breath Page 46 Emergency Medical Technician – Basic .h.Chapter 5: Medical Terminology in EMS P 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 q. immediately SVT Supraventricular tachycardia T TIA Transient ischemic attack t.d. Vital signs X x Times W w/o or s without WNL Within normal limits Y y/o or y. Three times a day TKO To keep open V V. Years old Symbols Δ change + Positive .Negative Page 47 Emergency Medical Technician – Basic .o.Chapter 5: Medical Terminology in EMS stat.i.S. 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. Page 48 Emergency Medical Technician – Basic . Portal of exit from reservoir 4. 15-18 days). Method of transmission 5. influenza.Chapter 6: Infection Control and the EMT Communicable Disease Any disease that can be spread from one person to another or to a person from contaminated objects. 1-3 days. Prodromal Stage Interval from onset of nonspecific signs and symptoms (malaise. The Chain of Infection 1. mumps.. 2-3 weeks. Reservoir 3. common cold. 1-2 days. chickenpox. microorganisms grow and multiply. fatigue) to more specific symptoms (during this time. low-grade fever. Portal of entry to the susceptible host 6. Page 49 Emergency Medical Technician – Basic .g. Etiologic Agent/Causative Agent 2. Susceptible host Stages of Infection Incubation Period Interval between entrance of pathogen into body and appearance of first symptoms (e. and client may be more capable of spreading disease to others). high fever. sinus congestion.. Meningitis) The bite of an infected animal. Methods of Transmission Direct contact Contact with contaminated materials Inhalation of infected droplets (TB. mumps manifested by earache. 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) Page 50 Emergency Medical Technician – Basic . rhinitis. common cold manifested by sore throat.g.Chapter 6: Infection Control and the EMT Illness Stage Interval when client manifests signs and symptoms specific to type of infection (e. Convalescence Interval when acute symptoms of infection disappear (length of recovery depends on severity of infection and client’s general state of health. parotid and salivary gland swelling). recovery may take several days to months). done as soon as possible after suspect contact with an animal and following WHO recommendations. protected by a thick waxy coat. But people infected with TB bacilli will not necessarily become sick with the disease. The immune system “walls off” the TB bacilli which. 2004). rabies is fatal. tears. Hepatitis B Hepatitis B is the most common serious liver infection in the world. • Overall. each person with active TB disease will infect on average between 10 and 15 people every year. and is spread to people through close contact with infected saliva (via bites or scratches). the chances of becoming sick are greater. It is very common in Asia. Africa and the Middle East. • Someone in the world is newly infected with TB bacilli every second. The overall incidence of reported Hepatitis B is 2 per 10.000 individuals. The disease is present on nearly every continent of the world but most human deaths occur in Asia and Africa (more than 95%). but the true incidence may be higher. Globally. a single virus particle can cause disease. can lie dormant for years. the Philippines’ rate of TB infection is ninth among 22 high burden countries and ranks third in the Western Pacific region (WHO. one-third of the world’s population is currently infected with the TB bacillus. Rabies is widely distributed across the globe.Chapter 6: Infection Control and the EMT Rabies Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is caused by a virus. Once the signs and symptoms of rabies start to appear. It is transmitted through infected blood and other body fluids like seminal fluid. can prevent the onset of rabies in virtually 100% of exposures. saliva and open sores. Once symptoms of the disease develop. Page 51 Emergency Medical Technician – Basic . Rabies infects domestic and wild animals. Once infected with the hepatitis B virus. vaginal secretions. More than 55 000 people die of rabies each year. there is no treatment and the disease is almost always fatal. It is caused by the hepatitis B virus (HBV) that attacks the liver. About 95% of human deaths occur in Asia and Africa. because many cases do not cause symptoms and go undiagnosed and unreported. Tuberculosis Left untreated. When someone’s immune system is weakened. This disease is more infectious than AIDS because it is very easily transmitted by blood. breast milk. Wound cleansing and immunizations. approximately 10% of the people develop a chronic permanent infection. which you get when a virus enters the body through the nose or mouth and travels to the brain. but can be deadly. Exposure Control Plan A comprehensive plan that helps employees reduce their risk of exposure or acquisition of communicable diseases. There are several types of meningitis. Do not provide direct patient care when you have open and oxidative skin lesions. Meningitis can progress rapidly. Bacterial meningitis is rare. Wear a gown in situations where it is likely that droplets of blood or body fluids will be sprayed on your working clothes. Use mouthpieces. Wear gloves when in contact with blood or bodily fluids. Immediately and thoroughly wash or other skin surfaces that come into contact with blood or body fluids. It can also harm other organs. It usually starts with bacteria that cause a cold-like infection. Meningitis is more common in people whose bodies have trouble fighting infections. 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. The most common is viral meningitis. resuscitation bags or ventilation equipment when providing resuscitation. called the meninges. To prevent needle stick injuries. Page 52 Emergency Medical Technician – Basic .Chapter 6: Infection Control and the EMT Meningitis Meningitis is inflammation of the thin tissue that surrounds the brain and spinal cord. It can block blood vessels in the brain and lead to stroke and brain damage. dispose of all use needles in a puncture-resistant container with a secured lid. 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 Page 53 Emergency Medical Technician – Basic .should list the PPE and should be of good quality. Personal Protective Equipment . Changing and Disinfection Practices .should describe how to care for and maintain vehicle and equipment.this area should explain why a qualified individual has to answer questions about CD and why infection control is required Hepatitis Vaccination Program .should identify who to notify when you believe you have been exposed.outlines the immunization schedules for EMT personnel.this area should define who is at risk at comining in contact with blood or body fluids.Chapter 6: Infection Control and the EMT Determination of Exposure . Post-Exposure Management . Education and Training . mouth. breathing. urine open wound. semen. vagine. needle puncture site. talking. anus. saliva. any disruption of intact skin or Blood 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. ET tubes and tracheostomies. feces. urinary diversion. ostomies Reproductive Tract vaginal discharges. vomitus. through sneezing. drainage tubes. Gastro-Intestinal Tract mouth.Chapter 6: Infection Control and the EMT Feces Vomitus Nasal Secretions Sputum Reservoirs – Portals of Exit Respiratory Tract nose. Page 54 Emergency Medical Technician – Basic . ostomies Urinary Tract urethral meatus. urine. coughing. To reduce the number of microorganisms onto the hands. To reduce the risk of transmission of microorganisms and cross-contamination to patients Page 55 Emergency Medical Technician – Basic . Nutrition Adequate nutrition enhances the health of all body tissues. Fluid Adequate fluid intake flushes the bladder and urethra Rest and Sleep Adequate rest and sleep are essential to health and preserving energy. helps keep the skin intact and promotes the skin’s ability to repel microorganisms. 2. 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.Chapter 6: Infection Control and the EMT Immunization The immunologic system is a major defense against infection. 3. Stress Predisposes people to infection. To reduce the risk of transmission of infectious organisms to one’s self. unless splashing is likely Yes No. unless soiling is likely No No No No No No Measuring temperature No No No No Giving an injection No No No No Bleeding control with spurting blood Page 56 Emergency Medical Technician – Basic .Chapter 6: Infection Control and the EMT Recommended Use of Personal Protective Equipment by Situation Task or Activity Disposable Gloves Yes Gown Mask Yes Yes Protective Eyewear Yes Bleeding control with minimal blood Yes No No No Emergency childbirth Yes Yes Yes. manually clearing airway Handling and cleaning instruments with microbial contamination Measuring blood pressure Yes No No. unless splashing is likely No. unless splashing is likely Oral/nasal suctioning. unless splashing is likely No. if splashing is likely Blood drawing At certain times No No No Starting an IV line Yes No No No Endotracheal intubation Yes No No. if splashing is likely Yes. Chapter 7: Anatomy for EMTs 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 Page 57 Emergency Medical Technician – Basic . the production of energy takes place in the mitochondria when oxygen and pyruvate are combined.ATP) which is essential for life processes.Chapter 7: Anatomy for EMTs Anatomical Planes and Directions Metabolism Metabolism refers to the chemical and energy transformations which occur in the body. proteins and fats are oxidised to produce CO2. In the human body. At the cellular level. H2O and form available energy (adenosine triphosphate . carbohydrates. Page 58 Emergency Medical Technician – Basic . there is sufficient oxygen entering the cell to react with and convert the available pyruvate into ATP. Discs of cartilage between the vertebrae: allow limited movement prevent friction act as shock absorbers. Page 59 Emergency Medical Technician – Basic . As little as 10% of ATP is produced during anaerobic metabolism. It is a column of 33 irregular bones called vertebrae. 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. The remaining pyruvate converts into lactic acid and cellular acidosis occurs. there is no oxygen or insufficient oxygen entering the cell and little or no utilisation of pyruvate. invariably leading to cell damage or death.Chapter 7: Anatomy for EMTs Aerobic Metabolism In aerobic metabolism. Anaerobic Metabolism In anaerobic metabolism. 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 Page 60 Emergency Medical Technician – Basic .Chapter 7: Anatomy for EMTs The Skeletal System The Circulatory System The circulatory system is a closed system which transports essential food. passing down the Bundle of His and radiating throughput the heart muscle. Page 61 Emergency Medical Technician – Basic .Chapter 7: Anatomy for EMTs 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’). Diastole: Left ventricle relaxes. Can be felt where an artery passes near the skin surface and over a bone.Chapter 7: Anatomy for EMTs Physiology of the Circulatory System Pulse The wave of blood through the arteries formed when the left ventricle contracts. Perfusion Blood Vessels There are five types of blood vessels: Arteries Arterioles Page 62 Emergency Medical Technician – Basic . the patient goes into shock. Systole: Left ventricle contracts. If inadequate. Circulation of blood within an organ or tissue. Blood Pressure Amount of force exerted against walls of arteries. They are semi-permeable to permit the passage of substances between the blood and the tissues. Veins have thinner walls and are provided with valves. to stop the blood flowing in the wrong direction. Capillaries have very thin walls consisting of a single layer of cells only. 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.Chapter 7: Anatomy for EMTs Veins Venules Capillaries Arteries carry blood away from the heart. Capillaries allow for the interchange of gases and the transfer of nutrients and waste products. 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 Page 63 Emergency Medical Technician – Basic . Arterioles and venules dilate or contract to control the blood flow into and out of the capillary bed. variable Expired Air The air we breathe out contains approximately: 79% nitrogen 16% oxygen 4% carbon dioxide 1% inert gases water vapour to saturation Page 64 Emergency Medical Technician – Basic .04% carbon dioxide 1% inert gases water vapour .Chapter 7: Anatomy for EMTs 0. Pressure in the lungs increases. all dimensions of the thorax decrease. increasing the size of the thoracic cavity. Pressure in the lungs decreases. Air flows out of the lungs. Exhalation Diaphragm and intercostal muscles relax. Carbon dioxide is released from the blood into the lungs and is exhaled. Internal respiration takes place in the tissues. As the muscles relax. Page 65 Emergency Medical Technician – Basic . Air travels to the lungs. Oxygen from inhaled air is absorbed into the blood via the capillaries of the lung.Chapter 7: Anatomy for EMTs Exchange of Gases External respiration takes place in the lungs. 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. 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.controls involuntary body functions Page 66 Emergency Medical Technician – Basic . Somatic nervous system .Chapter 7: Anatomy for EMTs Normal Breathing Characteristics Normal rate and depth Regular rhythm Good breath sounds in both lungs Regular rise and fall movements in the chest Easy.regulates voluntary actions Autonomic nervous system . in the thalamus and hypothalamus regulates the central nervous system. and is pivotal in maintaining consciousness and regulating the sleep cycle. sensory centres receive sensory signals from the skin. It is divided into three main parts: Cerebrum motor centres control all the voluntary muscles. Page 67 Emergency Medical Technician – Basic . muscles. control of the autonomic nervous system is buried deep in the cerebrum. muscle coordination and muscle tone. Cerebellum responsible for the maintenance of balance. 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.Chapter 7: Anatomy for EMTs The Brain The brain is the highest level of the nervous system and is continuous with the spinal cord. bones and joints. nose. ears. Page 68 Emergency Medical Technician – Basic . Muscular System Gives the body shape Protects internal organs Provides for movement Consists of more than 600 muscles Three Types of Muscles 1. stomach. Central nerves connect areas within the brain and spinal cord. Nerves There are four types of nerves: 1.). Smooth (involuntary) muscle Carries out the automatic muscular functions of the body. mouth) to the brain. Skeletal (voluntary) muscle Attached to the bones of the body. 3. Cardiac muscle Involuntary muscle. etc. 4. Autonomic nerves connect the brain and spinal cord with the organs (heart. Cranial nerves connect the sense organs (eyes.Chapter 7: Anatomy for EMTs 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. 2. Motor nerves carry information from the central nervous system to the muscles of the body. Peripheral nerves connect the spinal cord with the limbs. intestines. 2. Sensory nerves carry information from the body to the central nervous system. 3. blood vessels. Chapter 7: Anatomy for EMTs Has own blood supply and electrical system. Body Cavities The Abdomen Page 69 Emergency Medical Technician – Basic . Can tolerate interruptions of blood supply for only very short periods. Chapter 7: Anatomy for EMTs Page 70 Emergency Medical Technician – Basic . a regular program of exercise will enhance the benefits of maintaining nutrition and adequate hydration. Exercise and relaxation . Balancing work.should be able to cope with stress at work and able to overcome unpleasant aspects of any emergencies.to perform efficiently. 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 . family and health . Physically fit . Healthy Lifestyle of an EMT Nutrition . Shift work may be required to be apart from loved ones for long periods of time. Never let the job interfere Page 71 Emergency Medical Technician – Basic . Hygiene. an EMT should eat nutritious food to fuel the body and make it run.as an EMT you will often be called to assist the sick and the injured any time of the day or night. Hygiene. Physical exertion and stress are part of an EMT‟s job and require high energy output.to promote confidence in both patients and bystanders and to reduce the possibility of contamination.Chapter 8: Health. Fitness and Safety of the EMT Chapter 8: Health. Emotionally and mentally fit .should be in good health and fit to carry out duties. The Food Pyramid for Filipino Adults Page 72 Emergency Medical Technician – Basic . Hygiene.Chapter 8: Health. Make sure that you have the time that you need to relax with family and friends. Fitness and Safety of the EMT excessively with your own needs. Find a balance between work and family. renal and gastrointestinal function. A person maintains balance as long as the line of gravity passes through the centre of gravity and the base of support. Proper movement promotes body musculoskeletal functioning. Place your feet appropriately in the direction in which the movement will occur. Apply principles of body mechanics when moving objects: Spread your feet apart to provide a wide base of support. Body Alignment (Posture) . Exercise regularly to maintain overall physical condition. Fitness and Safety of the EMT Body Mechanics The efficient coordinated and safe use of the body to produce motion and maintain balance during activity. 3. roll or slide objects rather than lifting them whenever possible. 2. reduces the energy required for a task. Hygiene.when the body is well-aligned. unless you have a pillow or other support beneath your abdomen. including exercises that strengthen the pelvic. abdominal and lumbar muscles. Guidelines for Preventing Back Injuries 1. Push. Page 73 Emergency Medical Technician – Basic . Be consciously aware of your posture and body mechanics. 4. avoid sleeping in the prone position. periodically flex one hip and knee and rest your foot on an object if possible.body mechanics involves the integrated functioning of the musculoskeletal and nervous system as well as joint mobility. Proper body alignment also enhances lung expansion and promotes efficient circulatory.good body alignment is essential to body balance. pull. Minimize lumbar lordosis as much as possible: when standing for a period of time. when sitting. keep your knees slightly higher than your hips. Balance (Stability) . muscles. 2. and maintains balance.Chapter 8: Health. balance is achieved without undue strain on the joints. tendons or ligaments. thereby reducing fatigue and decreasing the risk of injury. Coordinated Body Movement . Three Basic Elements of Body Mechanics 1. 3. Page 74 Emergency Medical Technician – Basic . Ellis L. Hygiene.365 in direct costs per occurrence. 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.Chapter 8: Health. Fitness and Safety of the EMT Avoid twisting the spine by pushing or pulling an object.5 year period. University of Pittsburgh Affiliated Residency in Emergency Medicine. distribute the weight between the large muscles of the arms and legs. stumble and turn your ankle. (Hogya PT. “Almost one in two workers(47%) have sustained a back injury while performing EMS duties.” (Mitterre D. 1990). When lifting objects.” (mytactical. The number one physical reason for leaving EMS. and low back strain was the cause of 78% of the compensation days in a 3. “Back Injuries in EMS.” EMS Magazine. directly away from or toward the body and squarely facing the direction of movement. “Back injury from improper lifting is the number one injury suffered by pre-hospital care providers.. 5. 1999).” according to New Mexico‟s EMT training manual. 2005)..” (National Association of Emergency Medical Technicians. EMS and Back Injuries “One in four EMS workers will suffer a career ending back injury within the first 4 years of service. PA. “Average cost for a „simple‟ sprain or strain of the lumbar spine is approximately US$18. EMS Back Injury Facts.com. 2007). Lifting caused just over 62% of back injuries for EMT‟s. Chapter 9: Patient Assessment 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 Page 75 Emergency Medical Technician – Basic . To provide further emergency 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 Page 76 Emergency Medical Technician – Basic . To determine further assessment and care on the scene vs immediate transport with assessment and care continuing en route. To identify and manage immediately life threatening injuries or conditions. To communicate patient information to the medical facility to ensure continuity of care. To examine the patient and gather a patient medical history. assessing and adjusting care as required. To monitor the patient’s condition.Chapter 9: Patient Assessment 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. Triage to identify severity of each patient’s condition.Chapter 9: Patient Assessment Scene Safety Park in a safe area. Request additional resources if needed to make scene safe. Assess what additional resources will be needed. Additional Resources Medical resources Additional units Advanced life support Nonmedical resources Fire suppression Rescue Page 77 Emergency Medical Technician – Basic . 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. 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. Observe the scene. Do not move without immobilization. Err on the side of caution Page 78 Emergency Medical Technician – Basic . Cervical-Spine Immobilization Consider early during assessment.Chapter 9: Patient Assessment 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. 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. Assess airway. 3. Develop a general impression.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. 6. Assess the adequacy of breathing. 5. Identify patient priority. 2.Chapter 9: Patient Assessment Initial Assessment 1. Assess circulation.to three-word dyspnea Use of accessory muscles Nasal flaring and use of accessory muscles in children Page 79 Emergency Medical Technician – Basic . 4. Assess mental status.awake and oriented V Verbal . 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 . Chapter 9: Patient Assessment 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 Page 80 Emergency Medical Technician – Basic . Chapter 9: Patient Assessment 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. Use of gurgling and accessory muscles. nasal flaring Rhythm Regular Irregular Page 81 Emergency Medical Technician – Basic . effort. wheezing. grunting noises gasping. 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 Page 82 Emergency Medical Technician – Basic .Chapter 9: Patient Assessment Effort Effortless . Abnormally cold/frozen Blood not properly saturated with oxygen Fever. A drop in blood pressure may indicate: Loss of blood Loss of vascular tone Page 83 Emergency Medical Technician – Basic . sunburn. heatstroke. high blood pressure Temperature Cold Cool Normal Shock. inadequate perfusion Hot Hyperthermia.Chapter 9: Patient Assessment Rhythm Regular Irregular Skin Color Pale/grey/waxy Blue/grey Red/flushed Poor peripheral perfusion. hypothermia Early shock. sunburn 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. poisoning. mild hypothermia. fever. Pressure of circulating blood against the walls of the arteries. 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) Systolic pressure The amount of pressure exerted against the walls of the arteries when the left ventricle contracts. Diastolic pressure The pressure exerted against the wall of the arteries when the left ventricle is at rest. Pulse pressure Systolic pressure minus diastolic pressure. BP by Auscultation BP by Palpation Page 84 Emergency Medical Technician – Basic .Chapter 9: Patient Assessment Cardiac pumping problem Blood pressure should be measured in all patients older than 3 years of age. Pupils E .Regular in size L .React to Light Abnormal pupil reaction Page 85 Emergency Medical Technician – Basic .Round R .And R .Chapter 9: Patient Assessment Level of Responsiveness A Alert .Equal A .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 . ‘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 Page 86 Emergency Medical Technician – Basic .Chapter 9: Patient Assessment Priority Patients ‘Stay and Play’ vs. 4. Apply a cervical spine immobilization collar. Maintain spinal immobilization while checking patient’s ABCs. Assess the pelvis. 7. Inspect and palpate the head and face. motor function and sensation (PMS). Page 87 Emergency Medical Technician – Basic . If the patient complains of pain or there is obvious trauma. 6. including the ears. 5. checking for stability and crepitus.BTLS Stages of the Rapid Trauma Assessment 1. including pulses. Assess the abdomen.Chapter 9: Patient Assessment During the Rapid Trauma Assessment. Roll the patient with spinal precautions. pupils. Assess all four extremities. the EMT is looking for signs of: D Deformities C Contusions A Abrasions P Punctures/Penetrations B Burns T Tenderness L Lacerations S Swelling Remember: DCAP . do not palpate. Perform a four-point auscultation of the chest to listen for breath sounds. Expose and assess the chest. 2. Assess the neck. nose and mouth. 9. 8. 3. and Cervical Spine Feel head and neck for deformity.Chapter 9: Patient Assessment Focused Physical Exam Used to evaluate patient’s chief complaint. Evaluate for tenderness and any bleeding. Look for obvious injury. bruises. Watch chest rise and fall with breathing. Feel for grating bones as patient breathes. Neck. Ask about pain or tenderness. or bleeding. Chest Abdomen Page 88 Emergency Medical Technician – Basic . tenderness. or crepitation. Performed on: • Trauma patients without significant MOI • Responsive medical patients SAMPLE History S Signs and Symptoms A Allergies M Medications P Pertinent past history L Last oral intake E Events leading to injury or illness Remember: SAMPLE Stages of the Focused Physical Exam Head. Check for bleeding. Listen to breath sounds. Pelvis Extremities Look for obvious injuries. Carefully palpate from neck to pelvis. Press gently inward and downward on pelvic bones. and open wounds. deformity. Assess PMS: Pulse Motor function Sensory function Posterior Body Feel for tenderness. Look for any signs of obvious injury. 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 Page 89 Emergency Medical Technician – Basic .Chapter 9: Patient Assessment Do not palpate too hard. or deformity. Feel for deformities. bleeding. • What is the nature of any newly identified problems? Page 90 Emergency Medical Technician – Basic .Chapter 9: Patient Assessment 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. better? Worse? • Check interventions. • Has an already identified problem gotten • Repeat focused assessment. The components of this step may be altered based on the patient’s presentation. Initial Assessment The process used to identify and treat lifethreatening problems. noting the mechanism of injury or patient’s nature of illness. rapidly assess the patient from head to toe using DCAP-BTLS. Page 91 Emergency Medical Technician – Basic . This is performed on patients with significant mechanism of injury to determine potential life threatening injuries. consider the platinum 10 minutes and the Golden Hour.Chapter 9: Patient Assessment Patient Assessment Definitions Scene Size-Up Steps taken by EMS providers when approaching the scene of an emergency call. In the conscious patient. obtain a baseline set of vital signs. determining the number of patients. determine if a Rapid Trauma Assessment or a Focused Assessment is needed. symptoms should be sought before and during the Rapid Trauma assessment. Airway. concentrating on Level of Consciousness. You will also be forming a 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. and Circulation. if any additional resources are needed including Advanced Life Support. re-consider your transport decision. Breathing. assess medical patients complaints and signs and symptoms using OPQRST. and deciding what. assess the patient’s chief complaint. determining scene safety. taking BSI precautions. and perform a SAMPLE history. and perform a SAMPLE history. reconsider Advanced Life Support. Focused History and Physical Exam Rapid Trauma Assessment In this step you will reconsider the mechanism of injury. obtain a baseline set of vital signs. You will estimate the severity of the injuries. Cervical Spinal Stabilization. able to adequately relate their Focused History and Physical Exam . that have been determined to have no life-threatening injuries. and perform a SAMPLE history. Page 92 Emergency Medical Technician – Basic . with no significant mechanism of injury. and perform a SAMPLE history This is used for patients. This is used for patients with a medical complaint who are conscious. obtain a baseline set of vital signs. This assessment would be used in place of your Rapid Medical Assessment.Medical chief complaint to you. and have no life-threatening conditions. You should focus on the patient’s chief Exam . This assessment is used Rapid Medical History to quickly identify existing or potentially lifethreatening conditions. obtain a baseline set of vital signs.Chapter 9: Patient Assessment This is performed on medical patients who are unconscious. or unable to adequately relate their chief complaint. You will perform a head to toe rapid assessment using DACP-BTLS. You should focus on the patient’s chief complaint using OPQRST. An example of a patient requiring this assessment would be a patient who has sustained a fractured arm with no other injuries and no lifethreatening conditions.Trauma complaint. This assessment Focused History would be used in place of your Rapid Trauma and Physical Assessment. confused. repeat the focused assessment. Patients who will have this assessment completed are patients with significant mechanism of injury. This assessment is used to answer the following questions: Ongoing Assessment 1. What is the nature of any newly identified problems? You will continue to reassess mental status.Chapter 9: Patient Assessment This is a more in-depth assessment that builds on the Focused Physical Exam. The Ongoing Assessment will be repeated every 15 minutes for the stable patient and every 5 minutes for the unstable patient. or unable to adequately relate their chief complaint. ABCs. Is the treatment improving the patient’s condition? 2. and continually recheck your interventions. This assessment is performed during transport on all patients. confused. This assessment will only be performed while en route to the hospital or if there is time on Detailed Physical Exam scene while waiting for an ambulance to arrive. reassess vital signs. 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. 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. unconscious. Are any known problems getting better or worse? 3. Page 93 Emergency Medical Technician – Basic . reestablish patient priorities. Chapter 9: Patient Assessment 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. Provocation The word “provocation” should trigger questions regarding what makes the symptoms better or worse. 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 Page 94 Emergency Medical Technician – Basic . This is especially true with patients presenting with suspected cardiac signs & symptoms. • 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. • 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. Chapter 9: Patient Assessment a cardiac origin whose pain is not made any better or worse with movement or palpation. The patient may need you to offer some suggestions such as. “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. Asking if they can point with one finger to where it hurts the most is a good start. “does the pain radiate anywhere else such as your back. • 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. especially with pediatric patients. Quality The word “quality” should trigger questions regarding the character of the symptoms and how they feel to the patient. jaw or shoulders”? Always give them two or three choices and allow them to select from the options that you give. it is important to ask. For instance. From there you will want to know if the pain “moves” or “radiates” anywhere from the point of origin. • 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. 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. neck. It is sometime helpful to offer the patient choices and allow them to decide which is most appropriate for their situation. Page 95 Emergency Medical Technician – Basic . • When did the symptoms first begin? • Have you ever experienced these symptoms before? If so.this is a common mistake made by many new EMTs. 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 . Identify the mechanism of injury or nature of illness. Ask the patient a few minutes later how the discomfort is and if it has changed at all since your arrival. Ensure BSI (Body Substance Isolation) procedures and & personal protective gear is being used. Page 96 Emergency Medical Technician – Basic . Often times with a little oxygen and reassurance the symptoms may subside. Observe scene for safety of crew. This question has special importance when caring for patients presenting with suspected cardiac signs and symptoms. how would you rate your level of discomfort right now? • Using the same scale.Chapter 9: Patient Assessment Severity The word “severity” should trigger questions relating to the severity of the symptoms. when? Establishing an accurate duration of the symptoms will be very helpful to the hospital staff that will be caring for the patient. • On a scale of 1 to 10. The Full Assessment SCENE SIZE-UP Steps taken when approaching the scene. You will want to follow these two checkpoints up with an additional check once the patient has received some of your care and reassurance. you must follow this up with how severe the discomfort was at onset. bystanders. This will help you establish whether the discomfort is getting better. Once you have established the level of discomfort that the patient is experiencing at that moment. Identify the number of patients involved. patient. Determine the need for additional resources including Advanced Life Support. Time The word “time” should trigger questions relating to the when the symptoms began. worse or staying the same over time. Problems with Airway.as needed Insert an OPA/NPA . Airway Is the pt. Page 97 Emergency Medical Technician – Basic . appears to be unconscious.Chapter 9: Patient Assessment Consider C-Spine stabilization INITIAL ASSESSMENT Assessment & treatment (life-threats) General Impression Mechanism of injury or nature of illness Age. Obtain a chief complaint. or Circulation Verbalize general impression of patient Mental Status If the pt. (“Hey! Are you OK”?) Evaluate mental status using AVPU. Breathing. open chest wounds. if possible.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. race Find and treat life threatening conditions (any obvious problems that may kill the patient within seconds). and bruising (trauma).head-tilt-chin-lift or jaw thrust – as needed Clear the airway – as needed Suction . sex. check for responsiveness. talking or crying? Do you hear any noise? Will the airway stay open on its own? Does anything endanger it? Open the airway . begin packaging the patient during the rapid assessment while treating life threats and transport as soon as possible.) Page 98 Emergency Medical Technician – Basic . assess for presence and quality of the carotid pulse. Circulation If the pt. If radial pulse is weak or absent. perform the appropriate focused physical exam (for the medical pt. use a BVM to maintain pulse oximetry at 94% or above. perform the focused physical exam. For the unresponsive medical patient perform the rapid medical assessment. assess the rate and quality of the radial pulse. 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. is unresponsive and breathing is inadequate. Check pulse oximetry . In addition. is responsive. If the pt. If the patient is or STABLE.if below 94% administer oxygen. can also check the conjunctiva and lips Assess capillary refill in infant or child < 6 yrs. is unresponsive.Chapter 9: Patient Assessment Quickly palpate the chest for unstable segments. crepitation (trauma). assess the brachial pulse. and equal expansion of the chest. Is there life threatening hemorrhage? Control life threatening hemorrhage Assess the patient’s perfusion by evaluating skin for color. temperature and condition (CTC). UNSTABLE or POTENTIALLY UNSTABLE . perform the rapid trauma assessment for the trauma patient if he/she has significant mechanism of injury and apply spinal immobilization as needed. for trauma patient perform the focused trauma assessment. For patients 1 year old or less. compare it to the carotid pulse. If the pt. bilateral assessment of the apices.Chapter 9: Patient Assessment FOCUSED HISTORY AND PHYSICAL EXAM . mid-clavicular line. perform a Rapid Trauma Assessment on-scene while preparing for transport and then a Detailed Assessment during transport. and at the bases ABDOMEN DCAP-BTLS Pain Firm Page 99 Emergency Medical Technician – Basic . including cerebrospinal fluid NECK DCAP-BTLS JVD (Jugular Vein Distention) Crepitation Apply CSIC (Cervical Spinal Immobilization Collar) . If there is significant mechanism of injury. 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.if not already done CHEST DCAP-BTLS Paradoxical movement Crepitation Breath sounds . If there is no significant mechanism of injury. perform the Focused Trauma Assessment.TRAUMA Re-consider the mechanism of injury. midaxillary at the nipple line. Rapid Trauma Assessment Performed on patients with significant MOI. Direct the focused trauma assessment to the patient’s chief complaint and the mechanism of injury (perform it instead of the rapid trauma assessment). Maintain c-spine stabilization. EXTREMITIES DCAP-BTLS Crepitation Distal pulses Sensory function Motor function POSTERIOR Logroll the patient.Chapter 9: Patient Assessment Soft Distended PELVIS DCAP-BTLS If no pain is noted. gently compress the pelvis to determine tenderness or unstable movement. 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 Page 100 Emergency Medical Technician – Basic . If it is irregular.Chapter 9: Patient Assessment 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. QUALITY: Normal Shallow Any unusual pattern? Labored? Deep Noisy breathing? Pulse RATE: Check the radial pulse. count for 30 seconds and multiply x 2. Page 101 Emergency Medical Technician – Basic . count for a full 60 seconds. If pulse is regular. If abnormal respirations are present count for a full 60 seconds. or constricted Page 102 Emergency Medical Technician – Basic . palpate (only the systolic reading can be obtained). In a high noise environment. Auscultate the blood pressure. also assess for size equal or unequal normal.Chapter 9: Patient Assessment 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. dilated. Pupils Use a penlight to check reactivity of the pupils. 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. FOCUSED MEDICAL ASSESSMENT Performed on the conscious. Obtain the history of the present illness Onset .change when exposed to light non-reactive .Chapter 9: Patient Assessment reactive . or unable to adequately relate their chief complaint. confused.“What does the pain/discomfort feel like?” Page 103 Emergency Medical Technician – Basic . RAPID MEDICAL ASSESSMENT Performed on patients who are unconscious.“Is there anything that makes the symptoms better or worse?” Quality . alert patient who can adequately relate their chief complaint. 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. family.do not change when exposed to light equally or unequally reactive when exposed to light FOCUSED HISTORY AND PHYSICAL EXAM . 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.“What were you doing when the symptoms started?” Provocation .MEDICAL During this phase of the patient assessment. or friends. “How bad is the pain?” “How would you rate the pain on a scale of 1-10.“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 yourself?” o Estimated weight o Threat to self or others o Medical problem o Interventions Page 104 Emergency Medical Technician – Basic . with 10 being the worst pain you’ve felt in your life?” Time .Chapter 9: Patient Assessment Radiation .“Where do you feel the pain/discomfort?” “Does the pain/discomfort travel anywhere else?” Severity . Pupils Provide Treatment Provide emergency medical care based on signs and symptoms. Not all patients will require a Detailed Physical Exam.Chapter 9: Patient Assessment 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. color/substance o Position o Pain or contraction o Bleeding or discharge o Has your water broke? o Do you want to push? o Taking birth control o Vaginal bleeding or discharge o Abnormal vital signs o Last menstrual period? o History o Blood in vomit or stool o Trauma o Incontinence o Abnormal vital signs Baseline Vital Signs Obtain a full set of vital signs including: .Blood Pressure .Level of Consciousness . It is performed in a systematic head-to-toe order. During the detailed physical exam.Respirations . you will look more closely at each area to search for findings Page 105 Emergency Medical Technician – Basic . 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.Skin . You will examine the same body areas that you examined during your rapid assessment.Pulse . During the detailed physical exam. • DCAP-BTLS • Blood & fluids from the head FACE . Do not delay transport to perform a detailed physical exam.inspect and palpate for signs of injury. • DCAP-BTLS EARS . • DCAP-BTLS • Discoloration • Unequal Pupils • Foreign Bodies • Blood in Anterior Chamber Page 106 Emergency Medical Technician – Basic . it is only performed while en route to the hospital or while waiting for transport to arrive.inspect and palpate for signs of injury. 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. It is performed in a systematic head-totoe order.Chapter 9: Patient Assessment 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. You will examine the same body areas that you examined during your rapid assessment.inspect for signs of injury.inspect and palpate for signs of injury. Not all patients will require a Detailed Physical Exam. HEAD . • DCAP-BTLS • Drainage (blood or any other fluid) EYES . 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. inspect for signs of injury.inspect and palpate for signs of injury. • DCAP-BTLS • Paradoxical movement • Crepitation • Breath sounds . and at the bases • Present • Absent • Equal Page 107 Emergency Medical Technician – Basic .inspect and palpate for signs of injury. • DCAP-BTLS • Drainage • Bleeding MOUTH . midclavicular line.Chapter 9: Patient Assessment NOSE . • DCAP-BTLS • JVD • Tracheal deviation • Crepitation CHEST .inspect and palpate for signs of injury. • DCAP-BTLS • Damaged/Missing Teeth • Obstructions • Swollen or Lacerated Tongue • Discoloration • Unusual Odors NECK . mid-axillary at the nipple line.bilateral assessment of the apices. • DCAP-BTLS • Pain/Tenderness • Firm • Soft • Distended PELVIS .Chapter 9: Patient Assessment ABDOMEN .inspect and palpate for signs of injury.inspect and palpate for signs of injury. • DCAP-BTLS Page 108 Emergency Medical Technician – Basic . • DCAP-BTLS • Crepitation • Distal pulses • Sensory function • Motor function POSTERIOR • Log roll the patient. • DCAP-BTLS • If no pain is noted. EXTREMITIES .inspect and palpate the lower and upper extremities for signs of injury. Maintain c-spine stabilization. • Inspect and palpate for injuries or signs of injury. gently compress the pelvis to determine tenderness or unstable movement. It is designed to reassess the patient for changes that may require new intervention. • Monitor skin color and temperature (CTC). Repeat Initial Assessment • Reassess mental status. • Reassess pulse for rate and quality. Page 109 Emergency Medical Technician – Basic . • Monitor breathing for rate and quality. You should be prepared to modify treatment as appropriate and begin new treatment on the basis of your findings during the On-Going Assessment. • Re-establish patient priorities.Chapter 9: Patient Assessment ON-GOING ASSESSMENT The On-Going Assessment will be performed on all patients while the patient is being transported to the hospital. • Assure adequacy of other interventions UNSTABLE PATIENTS – repeat On-Going Assessment at least every 5 minutes. and reassess earlier significant findings. Reassess and Record Vital Signs Repeat Focused Assessment Check Interventions • Assure adequacy of oxygen delivery/artificial ventilation. You will also evaluate the effectiveness of earlier interventions. • Maintain an open airway. STABLE PATIENTS – repeat On-Going Assessment at least every 15 minutes. • Assure management of bleeding. • Reporting and record keeping are essential aspects of patient care. Page 110 Emergency Medical Technician – Basic . • Adequate reporting and accurate records ensure continuity of patient care.Chapter 10: Communication and Documentation 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. Chapter 10: Communication and Documentation 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. Digital Systems • Some EMS systems use telemetry to send an ECG from the unit to the hospital. audible signals. • Immediately “on” when you lift up the receiver Mobile and Portable Radios • Mobile radios installed in vehicle . • Signals can be decoded by the hospital.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. • Telemetry is the process of converting electronic signals into coded. Page 111 Emergency Medical Technician – Basic .Range of 10 to 15 miles • Portable radios hand-held . Cellular Telephones • Low-powered portable radios that communicate through interconnected repeater stations • Cellular telephones can be easily scanned. or incident • Location of incident • Number of patients • Responses by other agencies • Special information • Time dispatched Page 112 Emergency Medical Technician – Basic . illness.Simultaneous talk-listen • MED channels .Push-to-talk communication • Duplex .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.Chapter 10: Communication and Documentation Others • Simplex . and a longer response time for non-acute calls. law enforcement and fire departments Response Times Most countries have adopted a response time of 8 to 10 minutes for the most critical cases. Toronto. B (Urgent Call). life-threatening and serious cases. and within 21 minutes in 90% of non-acute cases. AMPDS is developed and marketed by Priority Dispatch Corporation which also has similar products for police and fire. especially ALS Increased safety of response personnel in the field Increased knowledge at arrival of response personnel Increased cooperation with associated public safety systems. in the United Kingdom. unified system used to dispatch appropriate aid to medical emergencies including systematized caller interrogation and pre-arrival instructions. The output gives a main response category . calls rated as „A‟ on AMPDS are targeted with getting a responder on scene within 8 minutes. C (Routine Call). Canada Within 9 minutes in 90% of critical. interrogation and decision making Increased appropriateness of medical care through correct response Increased resource availability.Chapter 10: Communication and Documentation Advanced Medical Priority Dispatch System (AMPDS) The Advanced Medical Priority Dispatch System (AMPDS). is a medically-approved. For example.A (Immediately Life Threatening). This may well be linked to a performance targeting system such as ORCON where calls must be responded to within a given time period. 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. Page 113 Emergency Medical Technician – Basic . The Heimlich manoeuvre should be the primary treatment of infants. Dispatch Life Support An Emergency Medical Dispatcher (EMD) is trained to dispatch EMTs based on the information given during the initial emergency call. and ensure it is removed. If the caller is a third-party who cannot identify if the victim is unconscious and not breathing. BLS protocol for a choking victim should be modified to reflect EMDs recommend a specific number of thrusts. no target set for cases that are not serious or life-threatening. Page 114 Emergency Medical Technician – Basic . UK Within 8 minutes in 75% of immediately life-threatening cases. the victim should be assumed to be in cardiac arrest until proven otherwise. rather than stating a range of thrusts. Cardiac arrest in a previously healthy child should be considered to be caused by a foreign body obstructing the airway until proven otherwise. Queensland. Dispatchers should be trained to identify obvious death situations (as defined by medical control). children and adults who are choking. mobilize response accordingly and give limited pre-arrival instructions. 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. until proven otherwise. Australia Within 10 minutes in 68% of Emergency Transport cases. EMDs should assume that bystanders have inappropriately placed a pillow under the head of an unconscious victim.Chapter 10: Communication and Documentation London. no target set for nonurgent cases. Advise of arrival. Estimate the potential number of patients. .Notify hospital of incoming patient. EMT Communication with Medical Control Radio communications facilitate contact between providers and medical control. Because people calling emergency services rarely have medical training. Identify special needs of patient. Notify as early as possible. Do not blindly follow an order that does not make sense to you . Repeat all orders received. Organize your thoughts before transmitting. EMT Communication EMT Communication with Dispatch Report any problems during run. Calling Medical Control The physician bases his or her instructions on the report received from the EMT-B. Consult with medical control to: . EMDs are trained to err on the side of caution and cater for the worst case scenario.Request advice or orders.Chapter 10: Communication and Documentation Remember that Emergency Medical Dispatchers are not usually EMT-trained. Page 115 Emergency Medical Technician – Basic .ask the physician to clarify his or her orders. They are trained to ask specific questions and give basic life support advice over the telephone. Keep communications brief.Advise hospital of special circumstances. Never use codes while communicating. . Communicate scene size-up. Chapter 10: Communication and Documentation Reporting Requirements Acknowledge dispatch information. 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 Page 116 Emergency Medical Technician – Basic . Notify arrival at hospital or facility. 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. Notify arrival at scene. Notify departure from scene. It occurs both in the field and at the hospital. Notify you are clear of the incident. Notify arrival back in quarters. Tell the patient the truth. Be careful of what you say about the patient to others. Always speak slowly. and distinctly.Chapter 10: Communication and Documentation 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 are a vital link between the patient and the health care team. Components of an Oral Report Patient‟s name. 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. nature of illness. Be aware of your body language. Use the patient‟s proper name. Page 117 Emergency Medical Technician – Basic . Use language the patient can understand. clearly. chief complaint. You must be able to find out what the patient needs and then tell others. Communicating With Geriatric Patients Determine the person‟s functional age. Explain all procedures as they are being performed.Chapter 10: Communication and Documentation If the patient is hearing impaired. confident manner. If a guide dog is present. speak clearly and face him or her. Make sure you have a paper and pen. clearly and distinctly. Explain what is being done and why. Face the patient and speak slowly. anxiety. Act and speak in a calm. or impaired hearing or vision. Allow people or objects that provide comfort to remain close. Communicating With Children Children are aware of what is going on. Communicating With Hearing-Impaired Patients Always assume that the patient has normal intelligence. Allow patient ample time to respond. Do not assume that an older patient is senile or confused. Never shout! Learn simple phrases used in sign language. transport it also. Communicating With Vision-Impaired Patients Ask the patient if he or she can see at all. if possible. Allow time for the patient to answer questions. Position yourself on their level. Explain procedures to children truthfully. Page 118 Emergency Medical Technician – Basic . Watch for confusion. 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 Page 119 Emergency Medical Technician – Basic . simple questions and answers. Point to specific parts of the body as you ask questions.Chapter 10: Communication and Documentation Communicating With Non-English-Speaking Patients Use short. Learn common words and phrases in the non-English languages used in your area. 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. Spell correctly. Initial and date error. Documenting Right of Refusal Document assessment findings and care given. Remember: A PCR is a legal document. Have the patient sign the form. If error made on report then: Draw a single horizontal line through error. Have a witness sign the form. Write the correct information.don‟t write it down. including: Gunshot wounds Animal bites Page 120 Emergency Medical Technician – Basic .it didn‟t happen. Reporting Errors Do not write false statements on report. Record time with assessment findings. If you didn‟t do something . Report is considered confidential. If you don‟t write it down .Chapter 10: Communication and Documentation Types of PCR Forms Written forms Computerized versions Narrative sections of the form: Use only standard abbreviations. or substance abuse Multiple-casualty incidents (MCI) Page 121 Emergency Medical Technician – Basic .Chapter 10: Communication and Documentation Certain infectious diseases Suspected physical. sexual. Chapter 10: Communication and Documentation Page 122 Emergency Medical Technician – Basic . Chapter 11: Airway Management 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 Page 123 Emergency Medical Technician – Basic . Chapter 11: Airway Management Anatomy Review Normal Breathing Rates Adult 12-20 breaths per minute Child 15-30 breaths per minute Infant 25-50 breaths per minute Page 124 Emergency Medical Technician – Basic . Chapter 11: Airway Management 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.Not breathing Page 125 Emergency Medical Technician – Basic .Breathing inadequately . damp. pale or cyanotic skin Hypoxia • Not enough oxygen for metabolic needs • Develops when patient is: . and fear • Tachycardia • Mental status changes • Use of accessory muscles for breathing • Difficulty breathing.respirations are abnormally deep but regular. possible chest pain Different Types of Abnormal Respirations • BRADYPNEA . • HYPERVENTILATION . Similar to hyper ventilation. nonmusical and brief. • TACHYPNEA . irritability.rate of ventilation is insufficient for metabolic requirements.condition of the central nervous system which causes shallow breathing interrupted by irregular periods of apnoea. • HYPOVENTILATION .Chapter 11: Airway Management Signs of Hypoxia • Nervousness.rate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases. • CHEYNE-STOKES RESPIRATION . Crackles may be heard on inspiration or expiration.rate of breathing is abnormally slow < 10 bpm.respirations are increased in depth and rate (occurs normally with exercise).respiratory condition in which the person must sit or stand to breathe deeply and comfortably. they are intermittent. The popping sounds Page 126 Emergency Medical Technician – Basic . • APNEA . Respiratory rate is below normal and depth of ventilations is depressed. • HYPERNEA . characterised by alternating periods of apnoea and hyperventilation. • KUSSMAUL RESPIRATION . Rate and depth of respiration is increased. • ORTHOPNEA .rate of breathing is abnormally rapid > 24 bpm.respiratory rhythm is irregular.respirations cease for several seconds. Abnormal Lung Sounds Crackles Crackles (or rales) are caused by fluid in the small airways or atelectasis. Crackles are referred to as discontinuous sounds. The respiratory cycle begins with slow and shallow respiration and gradually increases to abnormal depth and rapidity. • BIOT’S RESPIRATION . they may clear somewhat with coughing. mucus. • Fine crackles are soft. • Coarse crackles are somewhat louder. • Wheezes that are lower-pitched sounds with a snoring or moaning quality may be referred to as sonorous rhonchi. They have been described as sounding like opening a Velcro fastener. Stridor Stridor refers to a high-pitched harsh sound heard during inspiration. it is important to assess: • their loudness. bronchioles. lower in pitch. Page 127 Emergency Medical Technician – Basic . Secretions in large airways. and very brief. If abnormal lungs sounds are heard. high-pitched. and last longer than fine crackles. Crackles are often associated with inflammation or infection of the small bronchi. may produce these sounds. Wheezes Wheezes are sounds that are heard continuously during inspiration or expiration. such as occurs with bronchitis. medium. They are often heard continuously through both inspiration and expiration and have a musical quality. or during both inspiration and expiration. Stridor is caused by obstruction of the upper airway. such as may occur during an acute asthmatic attack. or pus. and alveoli. • Wheezes that are relatively high pitched and have a shrill or squeaking quality may be referred to as sibilant rhonchi. is a sign of respiratory distress and thus requires immediate attention. These wheezes occur when airways are narrowed. and coarse. They are caused by air moving through airways narrowed by constriction or swelling of airway or partial airway obstruction.Chapter 11: Airway Management produced are created when air is forced through respiratory passages that are narrowed by fluid. 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). or by moistening your thumb and index finger and separating them near your ear. • Crackles are often described as fine. You can simulate this sound by rolling a strand of hair between your fingers near your ear. 4.secretions from bronchitis may cause wheezes. 3. that clear with coughing. . 2. Kneel beside patient’s head. (or rhonchi). Place tips of finger under lower jaw. • location on the chest wall. • whether or not the sounds clear after a cough or a few deep breaths: . and. Place one hand on forehead. Apply backward pressure. • persistence of the pattern from breath to breath. 5. Page 128 Emergency Medical Technician – Basic . 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.Chapter 11: Airway Management • timing in the respiratory cycle. Lift chin. 1.crackles may be heard when atelectatic alveoli pop open after a few deep breaths. Listen 3.Chapter 11: Airway Management Jaw Thrust Maneuver Used when cervical spine injury is suspected. Look 2. Kneel above patient’s head. 2. 1. Use thumbs to keep mouth open Assessment of the Airway 1. Place fingers behind angle of jaw. 3. Feel Page 129 Emergency Medical Technician – Basic . • Never suction adults for more than 15 seconds. Open the patient’s mouth. Select the proper size airway. 4. • Select and measure proper catheter to be used. Suctioning Technique • Check the unit and turn it on. • Suction as you withdraw the catheter. Page 130 Emergency Medical Technician – Basic .Chapter 11: Airway Management Suctioning Suctioning of a patient’s airway may be necessary when: • Blood. 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. Hold the airway upside down and insert it in the patient’s mouth. Rotate the airway 180° until the flange rests on the patient’s lips. 3. 2. • Open the patient’s mouth and insert tip. • A gurgling sound is heard when performing artificial ventilation. other liquids and food particles block the airway. Airway Kits A typical EMS airway kit Basic airways Advanced airways Page 131 Emergency Medical Technician – Basic . Lubricate the airway. 2. insert the airway. 4. Gently push the nostril open. With the bevel turned toward the septum. 3. Select the proper size airway.Chapter 11: Airway Management 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. 3. Pocket masks may be disposable or reusable.Chapter 11: Airway Management Ventilation Devices The EMT is equipped with a range of devices to assist ventilation. Place the mask on the patient’s face. Remove your mouth and watch for patient’s chest to fall. Three different sizes are available . but the EMT-B may be called upon to assist with the use of these devices. Kneel at patient’s head and open airway. Take a deep breath and breathe into the patient for 1 1/2 to 2 seconds. 4. Bag-valve masks can also be used in conjunction with airway adjuncts and advanced airways such as the endotracheal tube. Pocket Mask A pocket mask may be used to provide artificial ventilations when no other equipment is available. Bag-Valve Mask The bag-valve mask should be the EMTs primary method of delivering ventilations.adult. Some of these devices are not authorized for use by EMT-Bs. 2. The child and infant BVM have a pressure valve to prevent overinflation of the lungs. child and infant. Some pocket masks have a nozzle for the attachment of oxygen tubing. Supplemental oxygen may be attached to the bag-valve if needed. Page 132 Emergency Medical Technician – Basic . A pocket mask should be equipped with a one-way valve to prevent body fluids from transferring from the patient to the EMT. Ventilation Techniques Mouth to Mask Technique 1. 2. One caregiver maintains seal while the other delivers ventilations. Page 133 Emergency Medical Technician – Basic . 3. 2. Insert an oral airway. 4. Squeeze bag to deliver ventilations. Place mask on patient’s face. Squeeze bag to deliver ventilations. 3. Place mask on patient’s face. 4. 2 Person BVM Technique 1.Chapter 11: Airway Management 1 Person BVM Technique 1. Insert an oral airway. Establish and maintain an adequate seal with one hand while using the other hand to delivers ventilations. using pulse oximetry and end-tidal CO2 capnography to guide the EMT. • Takes several minutes to give an accurate reading. The chemical symbol for the element oxygen is O. research has led to the prescription of oxygen when and as needed. oxygen contains not less than 99. A pulse oximetry of 94% O2 saturation or above means the patient is receiving adequate oxygen for metabolism. odourless gas normally present in the atmosphere at concentrations of approximately 21%. • May give false readings with CO absorption because it cannot distinguish between O2 and CO.Chapter 11: Airway Management Oxygen Therapy Medical Oxygen Oxygen is a colourless. As a medicinal gas. Page 134 Emergency Medical Technician – Basic . Pulse Oximeters • Used to measure the oxygen saturation of hemoglobin. Whereas previously oxygen tended to be given to a majority of patients.0% by volume of O2. which indirectly measures cardiac output. the level of carbon dioxide released at the end of expiration) falls. 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. A properly positioned tube in the trachea guards the patient’s airway and enables the paramedic to breathe for the patient. congestive heart failure. and other conditions. and then rises when a fresh rescuer takes over. These uses include verifying and monitoring the position of an endotracheal tube. Likewise. the first indication is often a sudden rise in the ETCO2 as the rush of circulation washes untransported CO2 from the tissues. Other studies have shown when a patient experiences return of spontaneous circulation. As more clinical studies are conducted into the uses of capnography in asthma. Page 135 Emergency Medical Technician – Basic . the patient’s end-tidal CO2 (ETCO2. A misplaced tube in the esophagus can lead to death. a sudden drop in ETCO2 may indicate the patient has lost pulses and CPR may need to be initiated. can also be used to monitor the effectiveness of CPR and as an early indication of return of spontaneous circulation (ROSC). the prehospital use of capnography will greatly expand. The American Heart Association (AHA) affirmed the importance of using capnography to verify tube placement in their 2005 CPR and ECG Guidelines. acidosis. diabetes. comparing field intubations that used continuous capnography to confirm intubations versus nonuse showed zero unrecognized misplaced intubations in the monitoring group versus 23% misplaced tubes in the unmonitored group. circulatory shock. Capnography.Chapter 11: Airway Management Capnography Capnography is increasingly being used by paramedics to aid in their assessment and treatment of patients in the prehospital environment. A study in the March 2005 Annals of Emergency Medicine. 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. Studies have shown that when a person doing CPR tires. because it provides a breath by breath measurement of a patient’s ventilation. pulmonary embolus. Paramedics are also now beginning to monitor the ETCO2 status of nonintubated patients by using a special nasal cannula that collects the carbon dioxide. The AHA also notes in their new guidelines that capnography. Hold your breath. oxygen and glucose combine to produce energy. 2007 10 Things Every Paramedic Should Know About Capnography Capnography is the vital sign of ventilation. Capnogram – the wave form. Oxygen is transported to the tissues through the blood stream. Pulse oximetry measures oxygenation. capnography enables paramedics to objectively evaluate a patient’s ventilatory status (and indirectly circulatory and metabolic status). diffuses into the blood. a waste product of this process (The Krebs cycle). Carbon dioxide. Capnography will show immediate apnea. 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. Part One: The Science Definitions: Capnography – the measurement of carbon dioxide (CO2) in exhaled breath. Page 136 Emergency Medical Technician – Basic . as the medics utilize their clinical judgement to assess and treat their patients. By tracking the carbon dioxide in a patient’s exhaled breath. by Peter Canning. At the cellular level. while pulse oximetry will show a high saturation for several minutes. December 29. End Tidal CO2 (ETCO2 or PetCO2) – the level of (partial pressure of) carbon dioxide released at end of expiration. Capnometer – the numeric measurement of CO2. Oxygenation Versus Ventilation Oxygenation is how we get oxygen to the tissue. Capnography measures ventilation. Oxygen is inhaled into the lungs where gas exchange occurs at the capillary-alveolar membrane. Pulse oximetry is delayed.Chapter 11: Airway Management Article: 10 Things Every Paramedic Should Know About Capnography Adapted from an Article from JEMS (Journey of Emergency Medical Services). Capnography versus Pulse Oximetry Capnography provides an immediate picture of patient condition. EMT-P. For example. Also.Chapter 11: Airway Management Circulation and Metabolism While capnography is a direct measurement of ventilation in the lungs. Page 137 Emergency Medical Technician – Basic . Monitoring Ventilation Capnography monitors patient ventilation. Other reasons C02 may be low: cardiac arrest. Hyperventilation can be caused by many factors from anxiety to bronchospasm to pulmonary embolus. Unique nasal anatomy. some experts say 30 mm HG – 43 mm Hg can be considered normal. an increased metabolism will increase the production of carbon dioxide increasing the ETCO2. severe pulmonary edema. Cautions: Imperfect positioning of nasal cannula capnofilters may cause distorted readings. oxygen by mask may lower the reading by 10% or more. decreased cardiac output. Normal Capnography Values ETCO2 35-45 mm Hg is the normal value for capnography. 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. 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. cold. it also indirectly measures metabolism and circulation. their CO2 goes down. hypotension. providing a breath by breath trend of respirations and an early warning system of impending respiratory crisis. A decrease in cardiac output will lower the delivery of carbon dioxide to the lungs decreasing the ETCO2. Breathing out comes before breathing in. Hyperventilation When a person hyperventilates. The capnogram wave form begins before exhalation and ends with inspiration. obstructed nares and mouth breathers may skew results and/or require repositioning of cannula. However. Heroin Overdoses – Some EMS systems permit medics to administer narcan only to unresponsive patients with suspected opiate overdoses with respiratory rates less than 10. sepsis. fever. use the monitor to assist placement. pain. postictal states. Annals of Emergency Medicine. Other reasons CO2 may be high: Increased cardiac output with increased breathing. -Silverstir. in cases where it is difficult to visualize the chords. sedation. then up. head trauma. 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. May 2005 Paramedics can attach the capnography filter to the ET tube prior to intubation and. 2. intoxication. or stroke.Chapter 11: Airway Management Note: Ventilation equals tidal volume X respiratory rate. Maintaining . 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. This includes cases of nasal tracheal intubation. chronic hypercapnia. their CO2 goes up. Hypoventilation can be caused by altered mental status such as overdose. Confirming. or by a tiring CHF patient. Pay more attention to the ETCO2 trend than the actual number. Some diseases may cause the CO2 to go down. and Assisting Intubation Continuous end-tidal CO2 monitoring can confirm a tracheal intubation. but an ETCO2 of 35. Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate. A good wave form indicating the presence of CO2 ensures the ET tube is in the trachea. depressed respirations. Hypoventilation When a person hypoventilates. 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. 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. then down. Page 138 Emergency Medical Technician – Basic . severe difficulty breathing. (See asthma below). 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. Encourage them to keep the ETCO2 number up as high as possible. It is not continuous.” –Gravenstein. 2004 With the new American Heart Association Guidelines calling for quality compressions (”push hard. Kalenda “reported a decrease in ETC02 as the person performing CPR fatigued. no number.Chapter 11: Airway Management 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. maintain cardiac output may be more readily assessed by measurements of ETCO2 than palpation of arterial pulses. Capnography: Clinical Aspects. Critical Care Medicine. End-tidal CO2 will often overshoot baseline values when circulation is restored due to carbon dioxide washout from the tissues. Set the monitor up so the compressors can view the ETCO2 readings as well as the ECG wave form generated by their compressions.. rescuers should switch places every two minutes. is hard to read in dark.D. push fast. especially precordial compression. 3. push deep”). stop CPR and check for pulses. if you see the CO2 number shoot up. M. Return of Spontaneous Circulation (ROSC) ETCO2 can be the first sign of return of spontaneous circulation (ROSC). followed by an increase in ETCO2 as a new rescuer took over. presumably providing better chest compressions. Paramedics should encourage their services to equip them with continuous wave form capnography. In 1978. Cambridge Press.The extent to which resuscitation maneuvers. During a cardiac arrest. Measuring Cardiac Output During CPR Monitoring ETC02 measures cardiac output. This device has several drawbacks when compared to waveform capnography. is easily contaminated. Page 139 Emergency Medical Technician – Basic . Cardiac Output and EndTidal carbon dioxide. “Reductions in ETCO2 during CPR are associated with comparable reductions in cardiac output…. no alarms. has no waveform. and can give false readings. thus monitoring ETCO2 is a good way to measure the effectiveness of CPR.” -Max Weil. -Grmec S. patients have been successfully resuscitated with an initial ETCO2 >10 mmHg. 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.The difference between survivors and nonsurvivors in 20 minute end-tidal carbon dioxide levels is dramatic and obvious. Academic Emergency Medicine. immediately check pulses.Chapter 11: Airway Management A recent study found the ETCO2 shot up on average 13. “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. July 1997 Likewise. the odds of surviving increased by 16%. Can Cardiac Sonography and Capnography Be Used Independently and in Combination to Predict Resuscitation Outcomes?. end-tidal carbon dioxide rose to at least 18 mm Hg before the clinically detectable return of vital signs…. Kozelj A. Spindler M. The greater the initial value. Lesnik B. 2006 Dec 8 Loss of Spontaneous Circulation In a resuscitated patient.” -Levine R.Resuscitation. June 2001 Caution: While a low initial ETCO2 makes resuscitation less likely than a higher initial ETCO2. if you see the stabilized ETCO2 number significantly drop in a person with ROSC. “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.” – ibid. New England Journal of Medicine. 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. 4. “No patient who had an end-tidal carbon dioxide of level of less than 10 mm Hg survived. Cardiopulmonary resuscitation may reasonably be terminated in such patients. in all 35 patients in whom spontaneous circulation was restored. Mally S. Conversely. the likelier the chance of a successful resuscitation.” –Salen. End-tidal Carbon Dioxide and Outcome of Out-of-Hospital Cardiac Arrest. Our logistic regression model further showed that for every increase of 1 torr in ETCO2.5 mmHg with sudden ROSC before settling into a normal range . Page 140 Emergency Medical Technician – Basic .. You may have to restart CPR. Krizmaric M. 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. starting to breathe on their own. Does End-Tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices.” – -Burton. in 14 of 17 patients who suffered acute respiratory events. Bronchospasm will produce a characteristic “shark fin” wave form. In a 2006 published study of 60 patients undergoing sedation. and the effectiveness of treatment.Chapter 11: Airway Management Asphyxic Cardiac Arrest versus Primary Cardiac Arrest Capnography can also be utilized to differentiate the nature of the cardiac arrest. “End-tidal carbon dioxide monitoring of patients undergoing PSA detected many clinically significant acute respiratory events before standard ED monitoring practice did so. as the patient has to struggle to exhale.Crit Care. Page 141 Emergency Medical Technician – Basic .-Grmec S. The shape is caused by uneven alveolar emptying. 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. The majority of acute respiratory events noted in this trial occurred before changes in SP02 or observed hypoventilation and apnea. should come down within a minute. and will need additional medication to prevent them from “bucking” the tube. May 2006 Sedated. Academic Emergency Medicine. COPD. intubated patients. A small notch in the wave form indicates the patient is beginning to arouse from sedation. ETCO2 in Asthma. Lah K. These high initial readings. 6. 2003 Dec 5. The ETCO2 values of asphyxic arrest patients then become prognostic of ROSC . 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. ETCO2 monitoring flagged a problem before changes in SPO2 or observed changes in respiratory rate. creating a sloping “B-C” upstroke. Intubated Patients Capnography is also essential in sedated. Tusek-Bunc K. and CHF End-tidal CO2 monitoring on non-intubated patients is an excellent way to assess the severity of Asthma/COPD. This can help assist your clinical judgement when attempting to differentiate between obstructive airway wheezing such as COPD and the “cardiac asthma” of CHF. Capnography: Clinical Perspectives. for the most part. Gravenstein. Journal of Trauma. Ventilating Head Injured Patients Capnography can help paramedics avoid hyperventilation in intubated head injured patients. Patients with ETCO2 monitoring had lower incidence of inadvertant severe hyperventilation (5. Cambridge Press. D. Cambridge Press. “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.” – –Capnography as a Guide to Ventilation in the Field. monitoring capnography will also allow you to maintain sufficient oxygen levels in the majority of tachypneic COPDers without worry that they will hypoventilate. On the other hand. 144 had ETCO2 monitoring. alerting you to cut back on the oxygen before the patient becomes obtunded. 2004 Page 142 Emergency Medical Technician – Basic . Patients in both groups with severe hyperventilation had significantly higher mortality (56%) than those without (30%).Chapter 11: Airway Management Hypoxic Drive Capnography will show the hypoxic drive in COPD “retainers. D. 7. The Use of Quantitative End-Tidal Capnometry to Avoid Inadvertant Severe Hyperventilation in Patients with Head Injury After Paramedic Rapid Sequence Intubation. –Davis. In a study of 291 intubated head injured patients. emptying equally).6%) than those without ETCO2 monitoring (13.” ETCO2 readings will steadily rise. Davis.4%).P. Davis. Gravenstein. This underscores the importance of avoiding hyperventilation in the prehospital environment. 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. 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.P. CHF: Cardiac Asthma It has been suggested that in wheezing patients with CHF (because the alveoli are still.” –Capnography as a Guide to Ventilation in the Field. April 2004 8. Capnography: Clinical Perspectives. 2004 Hyperventilation decreases intracranial pressure by decreasing intracranial blood flow. Since it has been estimated that only 5% of COPDers have a hypoxic drive. the wave form should be upright. The decreased cerebral blood flow may result in cerebral ischemia. 2004. 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. telling them that Page 143 Emergency Medical Technician – Basic . September 2006 Anxiety. This has implications for trauma patients. 15 Second Triage Tool. rapid assessment and triage tool for critically injured patients and victims of chemical exposure. “Prehospital end-tidal carbon dioxide concentration and outcome in major trauma. in conjunction with clinical assessment. Heightman. Other Issues DKA – Patients with DKA hyperventilate to lessen their acidosis. EMS systems should consider adding capnography to their triage and patient assessment toolbox and emphasize its use during educational programs and MCI drills. Academic Emergency Medicine. The hyperventilation causes their PAC02 to go down. 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. may help discriminate between patients with and without DKA. which may cause ETCO2 to rise.Deakin CD. Hyperthermia – Metabolism is on overdrive in fever. . a rare side effect of RSI (Rapid Sequence Induction). cardiac patients – any patient at risk for shock. 9.ETCO2 is being used on an ambulatory basis to teach patients with anxiety disorders as well as asthmatics how to better control their breathing. “End-tidal C02 is linearly related to HC03 and is significantly lower in children with DKA. Coats TJ. It provides the ABCs in less than 15 seconds and identifies the common complications of chemical terrorism. Try (it may not always be possible) to get your anxious patient to focus on the monitor. JEMS.57:65-68. Sado DM. The ETCO2 will go down.25 mm Hg after 20 minutes survived to discharge. such as those that might be caused by terrorism. Davies G. respectively. “Capnography…can serve as an effective. Observing this phenomena can be live-saving in patients with malignant hyperthermia.Krauss.Chapter 11: Airway Management End tidal CO2 monitoring can provide an early warning sign of shock.75. If confirmed by larger trials. The median ETCO2 for survivors was 30.” Journal of Trauma. End-tidal carbon dioxide predicts the presence and severity of acidosis in children with diabetes. cut-points of 29 torr and 36 torr.” –Fearon. 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. Trauma – A 2004 study of blunt trauma patients requiring RSI showed that only 5 percent of patients with ETCO2 below 26.”. it provides an accurate trend or respirations. the role of capnography in prehospital medicine will continue to grow and evolve. etc. Accurate Respiratory Rate – Studies have shown that many medical professionals do a poor job of recording a patient’s respiratory rate. as well as for monitoring ventilation in sedated patients. Capnography not only provides an accurate respiratory rate. their respiratory rate number will fall and they will feel better. seafood. their ETCO2 number will rise.Chapter 11: Airway Management as they slow their breathing. 10. 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. Page 144 Emergency Medical Technician – Basic .Some patients who suffer anaphylactic reactions to food they have ingested (nuts. The Future Capnography should be the prehospital standard of care for confirmation and continuous monitoring of intubation.) may experience a second attack after initial treatment because the allergens remain in their stomach. As more research is done. The wave form may start to slope before wheezing is noticed. Anaphylaxis. it should see increasing use in the monitoring of unstable patients of many etiologies. Monitoring ETCO2 may provide early warning to a reoccurrence. Additionally. Chapter 11: Airway Management Segment II (B to C) of the wave represents exhalation upstroke where dead space gas mixes with alveolar gas. Page 145 Emergency Medical Technician – Basic . 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. Chapter 11: Airway Management 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. • 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 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. • The waves should be analyzed to see if there is any difference from the expected squaredoff wave form. Oxygen requirement = 15 LPM. Adult or Pediatric Simple Face Mask No reservoir and can only deliver up to 60% oxygen. Page 146 Emergency Medical Technician – Basic . 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.Chapter 11: Airway Management 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. Venturi Mask A low flow oxygen system that provides precise concentrations of oxygen through an entertainment valve connected to the face mask. Can provide an oxygen concentration of about 35% to 60%. Oxygen requirement = 8 LPM. 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 Page 147 Emergency Medical Technician – Basic . Never smoke or allow others to smoke in any area where oxygen cylinders are in use or on standby.28 = contents in liters G cylinder . and oxygen cylinders are under high pressure.Lbs per in2 x 2.Lbs per in2 x 0.41 = contents in liters Page 148 Emergency Medical Technician – Basic .Chapter 11: Airway Management Oxygen Cylinders In emergency medical care. Calculation of Oxygen Cylinder Contents in Liters D cylinder . 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. such as oil and grease. touch the cylinder. valves or hoses. regulator fittings. Never allow combustible materials.16 = contents in liters E cylinder .Lbs per in2 x 0. • Keep oxygen cylinders secured to prevent them from toppling over. properly fitting regulator valve. • Keep all valves closed when the cylinder is not in use. Page 149 Emergency Medical Technician – Basic . • Never use an oxygen cylinder without a safe. even if the tank is empty.Lbs per in2 x 3.56= 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.Lbs per in2 x 1.14 = contents in liters M cylinder .Chapter 11: Airway Management H cylinder . through a step-down regulator. Page 150 Emergency Medical Technician – Basic . Therapy regulator This type of regulator has two gauges. 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. 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).Chapter 11: Airway Management • When you are working with oxygen cylinders. can provide 50psi to power a flow restricted oxygen powered automatic transport ventilator (ATV). and controls the flow of oxygen from 1-15 liters per minute. one indicating the pressure in the tank and a flowmeter indicating the measured flow of oxygen being delivered to the patient (0-15 LPM). never put any body parts over the cylinder valve. html) In EMS. the injury does not occur during periods of hypoxia. formerly called retrolental fibroplasia. We had always known that high-concentration oxygen was associated with the development of retinopathy of prematurity (ROP). the better -. Bledsoe.especially low thresholds. Without ventilation.(2) Further. neonates resuscitated with room air had a lower mortality at one week compared to those resuscitated with 100% oxygen. But ventilation involves much more than oxygenation. Reperfusion injury occurs when oxygen is reintroduced to ischemic tissues.Chapter 11: Airway Management Article: The Oxygen Myth? The Oxygen Myth? An article by Bryan E. your patient cannot ventilate.com/news_and_articles/columns/Bledsoe/the_oxygen_myth. Likewise. It occurs after oxygen is restored to the affected tissues. mortality was 13% for those resuscitated with 100% oxygen and only 8% for those resuscitated with room air. They occur normally. But following a period of hypoxia. the phenomenon of reperfusion injury was noted. a large number of free radicals Page 151 Emergency Medical Technician – Basic .(1) In one study of depressed infants. We’ve always taught that a little oxygen is good and a lot of oxygen is better. Stated another way.(3) The American Heart Association now recommends starting with room air and increasing oxygen concentration as needed to maintain an adequate oxygen saturation. They’re inseparably linked. without ventilation.jems. but the body has enzyme systems that process the free radicals into less toxic substances. thus avoiding significant cellular damage. we should be emphasizing ventilation. oxygenation is impossible. to a limited degree. We adopted pulse oximeters and really only use them to document oxygen saturations -.” These chemicals have an unpaired electron in their outer shell and are very unstable. clinicians found that neonates resuscitated with high-concentration oxygen had worse outcomes than those resuscitated with room air. you cannot assess the airway. DO. The primary mechanism is thought to be the development of toxic chemicals called “reactive oxygen species” or “free radicals. in premature infants. JEMS (http://www. In reality.(4) Next. 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’ve always emphasized two things: airway and oxygenation. The closer to 100%.or so we thought. infants resuscitated with 100% oxygen have a greater delay to first cry and a greater delay to first respiration. Without an airway. For example. FACEP. Mar 5 2009. Later. It involves the elimination of carbon dioxide and toxins and plays a role in other important biological processes. the induction of free-radicals may be worse than the effects of CO. We also know that there’s no reliable evidence that hyperbaric oxygen (HBO) therapy improves outcome (although it’s still widely used). in some conditions. what does this mean to the future evolution of EMS practice? Well. The data on patients with severe strokes is less clear. airway) are of little. Thus. Alzheimer’s disease. Thus.(9) But when you think about it. Again.(8) Carbon Monoxide (CO) Poisoning: We have learned a lot about carbon monoxide poisoning in the past few years. Parkinson’s disease. and others have been linked to oxidative stress and free radical induction. We do know that virtually all current therapies for cardiac arrest (drugs.Chapter 11: Airway Management are produced that overwhelm the protective enzyme systems (antioxidants) and cellular damage occurs. Stroke: The brain is very vulnerable to the effects of oxidative stress. the evolving thought is that. the science here is in a state of flux. So. 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.(7) Post-Cardiac Arrest: Here. but there’s no evidence it’s harmful. Also. Although oxygen can displace some CO from hemoglobin. We know that the mechanism of CO poisoning is a lot more complex than once thought. benefit. there’s no evidence that giving supplemental oxygen to acute coronary syndrome patients is helpful. Page 152 Emergency Medical Technician – Basic . be detrimental. The primary therapies remain CPR (often with limited ventilation initially) and defibrillation followed by induced hypothermia. in some cases. if any. some diseases such as atherosclerosis.not hyperoxygenation. “ The effects of aging are often due to oxidative stress. high concentrations of oxygen can be harmful. 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. Thus far. 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.(5) Current research indicates that supplemental oxygen should not be routinely given to patients with stroke and can. too. This damage is called “oxidative stress .(6) Acute Coronary Syndrome: The myocardium is highly oxygen dependent and vulnerable to the effects of oxidative stress. The brain has fewer antioxidants than other tissues. the evidence is too scant to tell. there are several disease processes we must consider. the goal of treatment in CO poisoning is to eliminate CO through ventilation -. 4. Always continue to follow the direction of your medical director and local protocols. 7. Mackway-Jones K: “Oxygen in uncomplicated myocardial infarction. Yee W: “Room air resuscitation of the depressed newborn: A systematic review and meta-analysis. et al: “Consequences of neonatal resuscitation with supplemental oxygen. Gelfand SL. or both. The goal of therapy is to avoid hypoxia and hyperoxia. 2007. our physical exam skills. each technology has its limitations. Bookatz GB.” Semin Perinatol. 2004. 6. Ronning OM. Rabi D. 364:1329-1333. this is a discussion of the changing science. We should use pulse oximetry and waveform capnography. 2005. Martin RJ. et al: “Supplemental oxygen use in ischemic stroke patients: Does utilization correspond to need for oxygen therapy. Bullard MJ. et al: “Resuscitation of newborn infants with 100% oxygen or air: A systematic review and meta-analysis. Page 153 Emergency Medical Technician – Basic . 3. 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. Grulee ME. but not replace. 2. supplemental oxygen is probably not required. Guldvog B: “Should stroke victims routinely receive supplemental oxygen? A quasi-randomized controlled trial. O’Donnell CP. Stockinger ZT. 1999. If the patient is hypoxic or hypercapnic. 2004. then you must determine whether the problem can be remedied through increased ventilation. Pancioli AM. Although. Rabi Y. References 1. 8. together they provide important information about the patient. Tan A.” Emergency Medicine Journal. 169:609-612.” Lancet. Again. plan an appropriate therapy (within the scope of your protocols). 5. If the patient’s oxygen saturation and ventilation are adequate. individually. increased oxygenation. It should be used only when room air ventilation fails.” Circulation. 162:49-52. McSwain NE: “Prehospital supplemental oxygen in trauma patients: Its efficacy and implications for military medical care.” Military Medicine. 72:353-363. That said. Thus. 2002.Chapter 11: Airway Management Neonates: The science is clear in regard to supplemental oxygen in neonates. 32:355-366. and provide the needed therapy. 21:75-81.” Archives of Internal Medicine. you have to assess the problem. it’s clear that we need to use every tool possible to support. recognize and understand the pathophysiological processes involved. 2004.13:IV1-203. 30:2033-2037.” Stroke.” Resuscitation. Davis PG. 2008. That is what prehospital care is all about. et al: “Hyperbaric oxygen does not improve neurologic sequelae after carbon monoxide poisoning. Gilmer B. Kilkenny J. Page 154 Emergency Medical Technician – Basic .Chapter 11: Airway Management 9. 9:18. Tomaszewski C.” Academic Emergency Medicine. 2002. The flow of electrical current causes contractions that produce pumping of blood.Chapter 12: The Basic ECG 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. Page 155 Emergency Medical Technician – Basic . The pulse. and through the aortic valve (for the left ventricle) to the rest of the body. this doesn’t happen at exactly the same moment. The left ventricle contracts an instant before the right ventricle.Chapter 12: The Basic ECG The heart’s electrical system is made up of three main parts: The sinoatrial (SA) node. This signal causes the atria to contract. A heartbeat is a single cycle in which the heart’s chambers relax and contract to pump blood. The signal spreads across the cells of the ventricle walls. which is located in the walls of the heart’s ventricles. located in the right atrium of the heart. 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 is why the SA node is sometimes called the heart’s natural pacemaker. each beat begins with a signal from the SA node. The His-Purkinje system. the atria and ventricles of the heart relax and begin to fill with blood. The signal arrives at the AV node near the ventricles. is the number of signals the SA node produces per minute. A heartbeat is a complex series of events that take place in the heart. 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 is released and moves along a pathway called the bundle of His. the heart’s atria contract (atrial systole) and pump blood into the ventricles. Page 156 Emergency Medical Technician – Basic . located along the walls of the heart’s ventricles. This cycle includes the opening and closing of the inlet and outlet valves of the right and left ventricles of the heart. This pushes blood through the pulmonary valve (for the right ventricle) to the lungs. In a normal. Each heartbeat has two basic parts: diastole and atrial and ventricular systole. From the bundle of His. The atrioventricular (AV) node. During diastole. It slows for an instant to allow the heart’s right and left ventricles to fill with blood. located on the interatrial septum close to the tricuspid valve. However. The atria then begin to relax. and both ventricles contract. This action pushes blood through the open valves from the atria into both ventricles. Each beat of the heart is set in motion by an electrical signal from within the heart muscle. The heart’s ventricles then contract (ventricular systole) pumping blood out of the heart. healthy heart. At the end of diastole. or heart rate. The dominant pacemaker of the heart is the sinus node in the right atrium. and T waves.Chapter 12: The Basic ECG As the signal passes. Should the sinus node fail. QRS. 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. It normally fires between 60 and 100 times a minute. The P-QRS-T complex of the normal ECG represents electrical activity over one cardiac cycle. the walls of the ventricles relax and await the next signal. 3 lead ECG used for monitoring purposes.0mV/1cm. the AV node is a potential pacemaker but it only fires at 40-60 beats per minute. Most ECG recordings are obtained with paper speeds of 25mm/sec and signal calibration of 1. • Complex consists of P. Lead II shows life-threatening rhythms. 12 lead ECG used for diagnostic purposes. Page 157 Emergency Medical Technician – Basic . The ECG Complex • One complex represents one beat in the heart. Plateau phase ventricular depolarization .0.isoelectric (baseline) T Wave .0.42 seconds 8-10 small squares An In-depth Look at the ECG and Its Generation Page 158 Emergency Medical Technician – Basic .0.04-0.5mV/5mm QT Interval .33-0.Atrial depolarization .12-0.SA Node-AV Node conduction time .10 seconds .12 seconds .0.Total duration of ventricular depolarization .1-2 small squares ST Segment .3-5 small squares QRS Complex .0.04-0.Chapter 12: The Basic ECG Parts of the ECG Complex P Wave .Ventricular depolarization .20 seconds .Ventricular repolarization .1-2 small squares PR Interval . Chapter 12: The Basic ECG Page 159 Emergency Medical Technician – Basic . Chapter 12: The Basic ECG Page 160 Emergency Medical Technician – Basic Chapter 12: The Basic ECG 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 Page 161 Emergency Medical Technician – Basic Chapter 12: The Basic ECG 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 Page 162 Emergency Medical Technician – Basic Chapter 12: The Basic ECG Asystole • Complete absence of electrical cardiac activity • Patient is clinically dead. • Decision to terminate resuscitation efforts depends on local protocol. Page 163 Emergency Medical Technician – Basic 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 Page 164 Emergency Medical Technician – Basic can then be administered as needed by EMS personnel. particularly in western countries. Early Defibrillation is the only one that can re-start the heart function of a person with ventricular fibrillation (VF). public awareness of the importance of its components has increased. a trained operator should administer defibrillation as quickly as possible until EMS personnel arrive. the final link. Early CPR should be started and maintained until emergency medical services (EMS) arrive. To provide the best opportunity for survival. Early Advanced Care. If an automated external defibrillator (AED) is available. 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. 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 Page 165 Emergency Medical Technician – Basic . and that failure to defibrillate early results in a high rate of failure to resuscitate patients. where AEDs are often located readily in public places. In response to the development of the chain of survival.Chapter 13: The Automated External Defibrillator 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. 43% paramedic help within 8 minutes In certain environments.Chapter 13: The Automated External Defibrillator 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 bystander or family member) begun within 2-8% 2 minutes. but delayed defibrillation 20% CPR and defibrillation within 8 minutes CPR and defibrillation within 4 minutes. ILCOR AED Symbol Page 166 Emergency Medical Technician – Basic . survival rates can approach 80% to 100%. where the Chain is strong and when defibrillation occurs within the first few minutes of cardiac arrest. 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) Page 167 Emergency Medical Technician – Basic .Chapter 13: The Automated External Defibrillator The Purpose of Defibrillation Defibrillation does not „jump start‟ the heart. 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 shock attempts to completely depolarize the myocardium and provide an opportunity for the natural pacemaker centers of the heart to resume normal activity. The probability of successful defibrillation diminishes rapidly over time. The purpose of the shock is to produce temporary aystole. (if the patient is pulseless and unconscious) Non-Shockable Rhythms Asystole Pulseless Electrical Activity (PEA) . Efficient transmission of electricity Page 168 Emergency Medical Technician – Basic . but is not) Advantages of the AED ALS providers do not need to be on scene. Remote.Chapter 13: The Automated External Defibrillator Ventricular Tachycardia (V-Tach) .(any heart rhythm observed on the ECG that should be producing a pulse. adhesive defibrillator pads are used. Should provide review of skills every 3 to 6 months. which makes these devices more effective to restore the heart‟s regular rhythm more quickly. Should review AED usage.5 or 10 to 360J Fully or semi-automated defibrillators . Page 169 Emergency Medical Technician – Basic . The patient has no signs of circulation. and. Indications for AED Use The patient is unresponsive. and. Energy Levels of the AED Electrical current is measured in joules (J) Manual defibrillators . which means that they passed an electrical current in just one direction to try to reset the heart. Biphasic The earliest defibrillators were monophasic.preset values of 200 and 360J programmed. Should review speed of defibrillation. Biphasic defibrillators use an electrical current that flows in two directions to shock the heart. Monophasic vs. The advantage of using biphasic defibrillators is that less electrical current is needed to successfully shock the heart.Chapter 13: The Automated External Defibrillator Medical Direction Should approve protocols. The patient demonstrates no effective breathing. Do not defibrillate a patient lying in pooled water. Do not defibrillate a patient who is touching metal. AED pads for adults (left) and children (right) Page 170 Emergency Medical Technician – Basic . Remove nitroglycerin patches. The patient demonstrates response to external stimulus. Dry a soaking wet patient‟s chest first.Chapter 13: The Automated External Defibrillator 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. Shave a hairy patient‟s chest if needed. Preparing to Operate an AED Make sure the electricity injures no one. Chapter 13: The Automated External Defibrillator Using an AED – 3 Simple Steps Page 171 Emergency Medical Technician – Basic . Chapter 13: The Automated External Defibrillator AED Treatment Algorithm Page 172 Emergency Medical Technician – Basic . Chapter 13: The Automated External Defibrillator Page 173 Emergency Medical Technician – Basic . Chapter 13: The Automated External Defibrillator Page 174 Emergency Medical Technician – Basic . Turn on the machine. Stop CPR if in progress. deliver a shock then perform 5 cycles of CPR.Chapter 13: The Automated External Defibrillator Using an AED . Wait for the computer. If patient is unresponsive and not breathing adequately. Reanalyze the rhythm. If shock is not needed. Step 2 If there is a delay in obtaining an AED. make sure that no one is touching the patient. immediately resume CPR. If the machine advises a shock. Page 175 Emergency Medical Technician – Basic .Detailed Steps Step 1 Assess responsiveness. if there is one. Perform 5 cycles of CPR. State aloud. give two slow ventilations.” Step 4 Push the analyze button. start CPR. Step 3 Remove clothing from the patient‟s chest area. have your partner start or resume CPR. Stop CPR. Push the shock button Step 5 After the shock is delivered. If shock is advised. prepare the AED pads. Apply pads to the chest. If an AED is close at hand. “Clear the patient. Check breathing and pulse. If the patient has a pulse. shock advised If a patient is breathing independently: Administer oxygen if needed. or Page 176 Emergency Medical Technician – Basic . perform 1 minute of CPR. make sure no one is touching the patient. Push the analyze button again (as applicable). Continue to support the patient as needed. check breathing. Gather additional information on the arrest event. Step 8 If the patient has no pulse. After 1 minute of CPR. no shock advised No pulse. Transport and check with medical control. If the patient is breathing adequately. After AED Shocks Check pulse. but breathing is inadequate. provide oxygen via non-rebreathing mask if needed and transport. No pulse. If a patient has a pulse.Chapter 13: The Automated External Defibrillator Step 6 Check for pulse. assist ventilations. or After delivering six to nine shocks. use necessary airway adjuncts and proper positioning to open airway. Transport When patient regains pulse. Check pulse. Provide artificial ventilations with high concentration oxygen. Transport. Step 7 If the patient is not breathing adequately. Chapter 13: The Automated External Defibrillator 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. Page 177 Emergency Medical Technician – Basic Chapter 14: Environmental Emergencies 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. Page 178 Emergency Medical Technician – Basic Chapter 14: Environmental Emergencies 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. Page 179 Emergency Medical Technician – Basic Chapter 14: Environmental Emergencies 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. Page 180 Emergency Medical Technician – Basic Chapter 14: Environmental Emergencies 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. Page 181 Emergency Medical Technician – Basic 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. aching and joint pain. Emergency Care for Local Cold Injury Remove the patient from further exposure to the cold. burning. Administer oxygen if necessary. People with other illnesses and injuries are susceptible to hypothermia. Transport. Affected area feels numb. requiring amputation of the affected part. Older persons and infants are at higher risk. Stages of Hypothermia (ILCOR 2005) Stage Celsius Fahrenheit Mild 34-36 93. Never rub the area. Do not break blisters. and feels hard and cold. Handle the injured part gently. Remove any wet or restrictive clothing. When thawed.8 Moderate 30-34 86 Severe <30 Page 182 Emergency Medical Technician – Basic .Chapter 14: Environmental Emergencies 2nd Degree (Superficial Frostbite) Skin appears waxy and white. the patient may feel pain. Hypothermia Lowering of the body temperature below 35°C Weather does not have to be below freezing for hypothermia to occur.2-96. throbbing. Gangrene may set in within a few days. Underlying tissue is soft. eat. Interventions for Hypothermia Move from cold environment. check for a pulse for an extended period of 30 to 45 seconds.Chapter 14: Environmental Emergencies Signs and Symptoms of Mild Hypothermia Shivering Rapid pulse and respirations Red. Do not allow patient to walk. pale. Page 183 Emergency Medical Technician – Basic . cyanotic skin Signs and Symptoms of More Severe Hypothermia Shivering stops. Eventually. Do not massage extremities. Place dry blankets under and over patient. Handle gently. In a hypothermic patient. Muscular activity decreases. humidified oxygen. all muscle activity stops. Remove wet clothing. Fine muscle activity ceases. or smoke. Give warm. use any stimulants. Body attempts to maintain normal temperature despite ambient temperature. Cold. give water slowly. Normal or slightly elevated body temperature Treatment for Heat Exhaustion Remove extra clothing and remove from hot environment. weakness. Be prepared to transport. clammy skin Dry tongue and thirst Patients usually have normal vital signs. If patient is alert. If cramps persist. High temperature and humidity decrease effectiveness of cooling mechanisms. Heat Exhaustion Dizziness. but pulse can increase and blood pressure can decrease. Give patient oxygen if necessary. Have patient lie down and elevate legs.Chapter 14: Environmental Emergencies Exposure to Heat Heat Exposure Normal body temperature is approximately 37°C. humid. Rest the cramping muscle. Body cools itself by sweating (evaporation) and dilation of blood vessels. onset may occur while at rest in hot. or fainting Onset while working hard or exercising in hot environment In older people and young. Page 184 Emergency Medical Technician – Basic . Replace fluids by mouth. and poorly ventilated areas. transport the patient to hospital. Heat Cramps Painful muscle spasms Remove the patient from hot environment. Major Causes of Drowning Accidents Getting exhausted in water Losing control and getting swept into water that is too deep Losing support (e. sinking boat) Getting trapped or entangled while in water Using drugs or alcohol before getting into water Suffering hypothermia Suffering trauma Page 185 Emergency Medical Technician – Basic . Provide air conditioning at a high setting. Notify the hospital of patient‘s condition.Chapter 14: Environmental Emergencies Heat Stroke Hot. Aggressively fan the patient. at least temporarily. dry. Give the patient oxygen.g. Cover the patient with wet towels or sheets. Treatment for Heat Stroke Move patient out of the hot environment. Blood pressure drops. then slows. and groin. after suffocation in water. Drowning and Near Drowning Drowning • Death as a result of suffocation after submersion in water. Remove the patient‘s clothing. Near drowning • Survival. flushed skin Change in behavior leading to unresponsiveness Pulse rate is rapid. Death can occur if the patient is not treated. armpits. Immediately transport patient. Apply cold packs to the patient‘s neck. This is dry drowning (10-15% of cases) Step 2 Page 186 Emergency Medical Technician – Basic .Public 3% Lake. Rivers. Breathing ceases and metabolic acidosis occurs. Water sports and alcoholic beverages should not be mixed.Chapter 14: Environmental Emergencies Having a diving accident Preventing Drowning Accidents Children should be under constant supervision if a body of water.Private 50% . Where People Drown Type of Water Percentage of Drownings Salt water 1-2% Fresh water 96-99% Swimming Pools . Life preservers or life jackets should be worn when boating. lake or creek is nearby. such as a pool. 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 A small amount of water enters the larynx and causes laryngospasm. Chapter 14: Environmental Emergencies Step 3 The laryngeal muscles become severely hypoxic and relax. This triggers peripheral airway resistance and constriction of the pulmonary vessels resulting in ‗Stiff Lung‘. 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. where the lung ceases to be compliant. Page 187 Emergency Medical Technician – Basic . Brain damage and death occur. allowing air to enter the lungs. 6. Don‘t use the boat‘s motor close to a person in the water. Reach: Hold on to the dock or your boat and reach your hand. 3. Ensure an open airway and attempt rescue breathing. Tow: If you‘re in a boat. 3. Continue rescue breathing and remove from the water. 4. a boat oar. 4. 2. Transport.use positive pressure ventilation (PEEP) to dry the lungs. or whatever you have nearby to the person in the water 2. toss things that will float for the person to grab.Chapter 14: Environmental Emergencies Water Rescue 1. Throw: If you can‘t reach far enough. Management of Drowning 1. Page 188 Emergency Medical Technician – Basic . If given the opportunity . use to oars to move the boat closer to the person in the water or call out to a nearby boat for help. they could be injured by the propeller. Don’t Go: Don‘t go into the water unless you are trained for water rescue. begin chest compressions 5. Do not enter the water unless trained in water rescue.if absent. a fishing pole. Check pulse . superficial burns Severe: Cardiopulmonary arrest Emergency Medical Care Protect yourself. open areas. An EMT working near the coast. amnesia. anyone in large. for example. Three categories of lightning injuries Mild: Loss of consciousness. tingling.000 emergency room visits every year. Rabies is a threat in some countries. may come across a range of marine animal stings and bites.Chapter 14: Environmental Emergencies Lightning Strikes boaters. the EMT must monitor for allergic reactions and anaphylaxis. Move patient to sheltered area or stay close to ground. Infection rate of 15-20%. Cardiac arrest and tissue damage are common. In general. Page 189 Emergency Medical Technician – Basic . Transport to nearest facility. However. As venomous animals can vary from region to region. asystole (spontaneously resolves). Bites and Stings EMTs may be called to deal with a wide range of bites and stings. golfers. Approximately 10-20 deaths every year. swimmers. Bite statistics (US) Dogs Over 1 million dog bites a year Cause approximately 340. it is important for the EMT to be aware of threats in their area. most bites and stings are not fatal. Treat as for other electrical injuries. whereas an EMT working in a desert area may require awareness of scorpion stings. Use reverse triage. as well as treatment protocols. superficial burns Moderate: Seizures. due to the availability of antivenom. respiratory arrest. 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. Page 190 Emergency Medical Technician – Basic . Infection rate of 30-40%. not venom exposure. Calm the patient. Most deaths occur due to anaphylaxis. Flush the wound with water and apply a dressing. Usually an animal control officer or police officer will do this. NB: Do not kill the dog unless it is absolutely necessary to prevent a full-scale crippling attack. Immobilize injury. human bites are more infectious than most animals. tears or punctures Treatment of Animal Bites Immediately and thoroughly wash the wound with soap and water. Because the human mouth contains many potentially harmful microorganisms.Chapter 14: Environmental Emergencies Cats Less common than dog bites. Humans Approximately 70000 human bites every year. 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. Transport the patient. especially if the wound needs stitches or occurred on the face or neck. warm lump Hives Itching. tenderness. swollen. Ticks Ticks attach themselves to the skin. Bite is not painful. dizziness. Wash area gently. Monitor for signs of anaphylaxis. fever. most stings are only painful. desert climates. muscle spasms. Treatment of Arthropod Bites and Stings If stinger is present. but potential exposure to infecting organisms is dangerous. With one exception. Signs and Symptoms of Arthropod Bites and Stings Red. Many species of spiders bite. can become infected Serious allergic reactions (anaphylaxis) when symptoms spread. the Centruroides sculpturatus. Immobilize the affected limb. pain Sores from scratching. Ticks commonly carry Rocky Mountain spotted fever or Lyme disease. Page 191 Emergency Medical Technician – Basic . nausea. remove it by scraping it out with the edge of a card (Avoid tweezers as they can squeeze more venom into the wound). Remove jewellery from affected limb.Chapter 14: Environmental Emergencies Spiders Spiders are numerous and widespread in many countries. Scorpions Venom gland and stinger found in the tail end. Very few spiders deliver serious or life-threatening bites. Place injection site slightly below the level of the patient‘s heart. These can include difficulty breathing. or loss of consciousness. Mostly found in dry. Tiger Snake .North America.Southeast Asia and Indonesia. 4. 7. Australian Brown Snake .Middle East Asia. 2. 8. Page 192 Emergency Medical Technician – Basic .Australia. About 15 deaths occur each year in the US. Beaked Sea Snake .Chapter 14: Environmental Emergencies Snakes 40. Taipan . 6.South Asian waters (Arabian Sea to Coral Sea).Australia.000 reported snake bites in the US annually. Four Types of Poisonous Snakes in the US Rattlesnake (Pit Viper) Cottonmouth Copperhead Coral Snake The 10 Deadliest Snakes in the World 1. Malayan Krait .Australia. 5. 9. Saw Scaled Viper . Fierce Snake or Inland Taipan .000 bites in the US come from poisonous snakes. Coral Snake .000 to 50. 7.Australia. 3. Death from snake bites is rare. Boomslang .Africa. Treatment of Snake Bite Locate and fang marks and clean the site with soap and water.Australia and New Guinea. Progressive general weakness. Transport and monitor the patient. pain or swelling in the bite area. Death Adder . Seizures. Remove any jewellery from the affected limb.Chapter 14: Environmental Emergencies 10. Develops slowly from 30 minutes to several hours. Rapid pulse and laboured breathing. Nausea and vomiting. Page 193 Emergency Medical Technician – Basic . Signs and Symptoms of Snake Bite on the skin Discolouration. Apply light contracting band above and below the bite if all allowed by protocol. Blurring of vision. Drowsiness or unconsciousness. Keep the affected limb immobilized. nausea. hemorrhage. seizures and paralysis. Provide transport to hospital. abdominal pain. Remove any foreign material at the wound site. diarrhea. excruciating pain that lasts several hours. Patient may suffer difficulty breathing. Victim may suffer diarrhea. vomiting and diarrhea. bleeding. vomiting. Stonefish Wash the area with fresh water. Venom contains neurotoxin. muscle spasms and cramps. Remove the remaining tentacles by scraping them off. Pain can continue for up to 48 hours. vomiting. Provide transport to hospital. Stingrays Stingray venom produces immediate. Soak wound in the hottest water the patient can tolerate for 30-90 minutes.Chapter 14: Environmental Emergencies Marine Animals Jellyfish Venom delivered by barbs called nematocysts. Stonefish Venom usually delivered in spines when stepped on. Inactivate nematocysts by applying alcohol or vinegar. Sever cases may lead to skin necrosis. Page 194 Emergency Medical Technician – Basic . if instructed to do so. paralysis sets in and the body goes into respiratory arrest. Instantly painful and itchy red lesions result. Cardiorespiratory failure may result. Within 3 minutes. a drop in BP and cardiac arrhythmia Treatment for Marine Stings Jellyfish Limit further discharge by minimizing patient movement. severe pain and whitened colour at the site of the sting. Bue-Ringed Octopus Saliva contains a powerful neurotoxin. Provide transport to hospital. volume ↑ Dalton’s law: Pt = P02 + PN2 + Px Total pressure of gas mixture is sum of partial pressures of its components. Soak wound in the hottest water the patient can tolerate for 30-90 minutes. Provide ventilation support. Remove any foreign material at the wound site. Provide transport to hospital. volume ↓ As pressure ↓. if instructed to do so.Chapter 14: Environmental Emergencies Blue-Ringed Octopus Apply pressure to the wound. Barotrauma Injury caused by compression or expansion of gas in body spaces. Diving Emergencies Pressure Laws Boyle’s law: PV=K As pressure ↑. 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. Stingrays Wash the area with fresh water. vertigo/incapacitation Page 195 Emergency Medical Technician – Basic . Henry’s law: Pressure of a gas in liquid is proportional to its pressure in the atmosphere. is pumped to systemic circulation Air bubbles enter. 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. clog cerebral circulation Signs and Symptoms Alterations in consciousness—usually within 10 minutes Page 196 Emergency Medical Technician – Basic .Chapter 14: Environmental Emergencies 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. Retrieved 200906-29. Navy Diving Manual. SS521-AGPRO-010. vol.5.S. U. Page 197 Emergency Medical Technician – Basic . revision 6. http://supsalv. Naval Sea Systems Command. 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. U.S.S. 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. Navy Supervisor of Diving (2008) (PDF).pdf. 20–5.org/pdf/DiveMan_rev6.Chapter 14: Environmental Emergencies Hemiplegia Unequal pupils Cardiopulmonary failure Vertigo Visual disturbances Management ABC‘s 100% oxygen. p. 3% Shortness of breath 1. pp. 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 Page 198 Emergency Medical Technician – Basic .3% Collapse/Loss of consciousness 0.5% Source: Powell. Southend-on-Sea: Aquapress.Chapter 14: Environmental Emergencies DCS Symptoms by Frequency Symptom % of Cases Local joint pain 89% Arm symptoms 70% Leg symptoms 30% Dizziness 5.3% Paralysis 2.6% Extreme fatigue 1. 70. Deco for Divers. Mark (2008). Chapter 14: Environmental Emergencies 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? Page 199 Emergency Medical Technician – Basic . The cardiovascular system consists of three parts: Heart (pump) Blood vessels (container) Blood and body fluids (fluids) Page 200 Emergency Medical Technician – Basic .Chapter 15: Bleeding and Shock 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. Blood loss of 1 L can be dangerous in adults. and waste removal. Venous Blood is dark red and does not spurt. in children. Page 201 Emergency Medical Technician – Basic .Chapter 15: Bleeding and Shock Perfusion Circulation within tissues in adequate amounts to meet the cells’ needs for oxygen. Some tissues and organs need a constant supply of blood while others can survive on very little when at rest. Bleeding Hemorrhage = bleeding Body cannot tolerate greater than 20% blood loss. The heart demands a constant supply of blood. The brain and spinal cord can survive for 4 to 6 minutes without perfusion. loss of 100-220 mL is serious. The skeletal muscles may last up to 4 or 5 hours. nutrients. The kidneys may survive 45 minutes. Characteristics of Bleeding Arterial Blood is bright red and spurts. Chapter 15: Bleeding and Shock 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. Page 202 Emergency Medical Technician – Basic Chapter 15: Bleeding and Shock 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. Page 203 Emergency Medical Technician – Basic Chapter 15: Bleeding and Shock 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. Page 204 Emergency Medical Technician – Basic Chapter 15: Bleeding and Shock The Four Classes of Hemorrhage Class of Hemorrhage Class 1 Class 2 Class 3 Up to 15% blood loss Up to 30% blood loss Up to 40% blood loss (750ml) (750-1500ml) (1500-2000ml) Class 4 More than 40% blood loss (>2000ml) How The Body Responds Compensatory mechanisms Body compensates for blood loss by constricting blood vessels (vasoconstriction) in an effort to maintain blood pressure and delivery of oxygen to all organs of the body. Increase in diastolic pressure. Pulse pressure less than 40. become overtaxed. Vasoconstriction Vasoconstriction can continues to maintain no longer sustain BP, adequate blood which begins to fall. pressure, but with Cardiac output and some difficulty now. tissue perfusion Blood is shunted to continue to decrease, vital organs, with becoming potentially decreased flow to life-threatening. intestines, kidneys Even at this stage, the and the skin. patient can still recover with prompt treatment. Page 205 Emergency Medical Technician – Basic Compensatory vasoconstriction now becomes a complicating factor, further impairing tissue perfusion and cellular oxygenation. Anaerobic metabolism increases. Chapter 15: Bleeding and Shock 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 Shock Irreversible 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.” Page 206 Emergency Medical Technician – Basic Chapter 15: Bleeding and Shock 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 Page 207 Emergency Medical Technician – Basic . Blood in the body cannot fill the enlarged system. Content failure (hypovolemic shock) Results from fluid or blood loss Blood is lost through external and internal bleeding. The vascular system increases. Combined vessel and content failure Some patients with severe bacterial infections. toxins. Severe thermal burns cause plasma loss. Dehydration aggravates shock. Page 208 Emergency Medical Technician – Basic . Neurogenic shock occurs. or infected tissues contract septic shock.Chapter 15: Bleeding and Shock 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. Insufficient oxygen in the blood will produce shock. 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 Page 209 Emergency Medical Technician – Basic . 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. Leads to dilation of vessels and loss of plasma. causing leaking and impairing ability to contract. causing 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.Chapter 15: Bleeding and Shock Toxins damage vessel walls. 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. cyanotic skin Thready or absent pulse Dull eyes. mottled. When to Expect Shock Multiple severe fractures Abdominal or chest injuries Spinal injuries Severe infection Major heart attack Anaphylaxis Page 210 Emergency Medical Technician – Basic . irregular breathing Ashen. A transfusion of any type will not be enough to save a patient’s life. 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. dilated pupils Poor urinary output Irreversible Shock This is the terminal stage of shock.Chapter 15: Bleeding and Shock Compensated Shock Agitation Anxiety Restlessness Feeling of impending doom Altered mental status Weak pulse Clammy skin Pallor Shallow. If there are no broken bones.Chapter 15: Bleeding and Shock Treatment of Shock Make certain patient has open airway. rapid pulse or cool clammy skin . Simply stated.these are merely the signs. elevate the legs 6” to 12”. shock results from inadequate perfusion of the body’s cells with oxygenated blood. Do not give the patient anything by mouth. Place blankets under and over patient. Keep patient supine. Splint any broken bones or joint injuries. Page 211 Emergency Medical Technician – Basic . Provide oxygen if required. The definition of shock does not involve low blood pressure. Control external bleeding. Shock left untreated may be fatal. or the patient may die. It must be recognized and treated immediately. Common Types of Poisoning Poisoning in Children The most common poisons among children are: cosmetics and personal care products Page 212 Emergency Medical Technician – Basic .Chapter 16: Poisoning and Substance Abuse 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. gasoline. thermometers plants diaper care. acne preparations.Chapter 16: Poisoning and Substance Abuse cleaning substances pain medicine/fever-reducers coins. kerosene. contraceptives) hydrocarbons (lamp oil. hypnotics. vapors hydrocarbons antihistamines anticonvulsants antimicrobials stimulants and street drugs plants cough and cold preparations Page 213 Emergency Medical Technician – Basic . antiseptics cough and cold preparations pesticides vitamins gastrointestinal preparations antimicrobials arts. lighter fluid) Poisoning in Adults The most common poisons among adults are: pain medicine sedatives. crafts and office supplies antihistamines hormones and hormone antagonists (diabetes medications. antipsychotics cleaning substances antidepressants bites and envenomation alcohols food products and food poisoning cosmetics and personal care products chemicals pesticides cardiovascular drugs fumes. gases. ammonia. • Abnormal breathing. • Signs of shock Page 214 Emergency Medical Technician – Basic . Ingestion food poisoning. medications. Radiation exposure to radiation. body odour or odour from the patient’s clothing or from the scene. • Pain or swelling in the mouth or throat. • Abdominal tenderness. household and industrial chemicals. headache or dizziness. alcohol. • Burns or stains around the patient’s mouth. • Profuse sweating. bee sting.Chapter 16: Poisoning and Substance Abuse How Poisons Enter the Body Inhalation include carbon monoxide. Absorption corrosives or irritants. • Nausea and vomiting. poison ivy. • Altered mental status. petroleum products. • Seizures. Injection snake bite. • Abnormal pulse rate. pesticides. plant material. • Excessive salivation or foaming at the mouth. injected drugs. spider bite. sometimes with distention. Some Signs and Symptoms of Poisoning • Unusual breath odour. • Abdominal pain. insect sprays. 86. medicines. Most poisonings involve everyday household items such as cleaning supplies. while others are painless. Some poisons enlarge the pupils. Confusion is often seen with these symptoms. 89 percent of all poison exposures occur in the home. With poisoning. Some speed the heart. cosmetics and personal care items. Some cause hyperactivity. while others cause drowsiness. Over two million poison exposures were reported to local poison centers in 2000. while others shrink them. 92 percent of exposures involve only one poisonous substance. Some increase the breathing rate. Some cause pain. while others dry the mouth and skin.Chapter 16: Poisoning and Substance Abuse The signs and symptoms seen in poisoning are so wide and variable that there is no easy way to classify them. poison centers handle one poison exposure every 14 seconds. Poison Exposures in the United States Facts On Poison Exposures: On average. Page 215 Emergency Medical Technician – Basic . not the poison. while others slow it. remember to treat the patient.7 percent of poison exposures are unintentional. while others slow the heart. 75 percent of poison exposures involve ingestion of a poisonous substance. Some result in excessive drooling. Chapter 16: Poisoning and Substance Abuse Other causes include breathing in poison gas. While adults 60 and over account for four percent of poison exposures. guide clinical research and direct training. irritants. Page 216 Emergency Medical Technician – Basic . In children between ages 13 and 19. 84 percent of reported adolescent deaths from poison exposure were due to intentional poison exposure such as suicide or drug abuse.3%).000 cases of poison exposure were reported among teenagers in 2000. 77 percent of all exposures are treated on the site where they occurred.9%). generally the patient’s home with phone advice and assistance from local poison control experts. they represent just over two percent of poison fatalities. focus prevention education. The most common forms of poison exposure for children under the age of six are cosmetics and personal care products (13. analgesics (7. the data from the TESS have been used to identify hazards early.6%) and plants (6. and bites and stings. A full report is available on the web at www.aapcc. getting foreign substances in the eyes or on the skin. cleaning substances (10. Adults and Poison: Over 8. narcotics. and narcoticoirritants. they account for 15. which is compiled by the American Association of Poison Control Centers in cooperation with the majority of U.S.5 percent of the fatalities.org. In children under 13. Since 1983. the reverse is true. Teens and Poison: 160.000 poison exposures in 2000 occurred in pregnant women. over 56 percent of these exposures involve boys. the majority of poison exposures (55%) involve girls. Although children under the age of six are the most likely to be exposed to poison. Classifications of poisons Poisons may be classified into four main groups: corrosives. Over 60 percent of all poison fatalities occur in adults ages 20 to 49.7%). Source: Data from the 2000 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Children and Poison: 53 percent of poison exposures occur in children under the age of six. poison centers. Lead. The onset of signs and symptoms may be deferred for a few hours after ingesting the poison. If swelling occurs within the airway this may also cause asphyxia. Eventual unconsciousness and death (depending on dose). Sulphuric acid. Examples Vegetable acids and salts (eg. features of shock through loss of fluid. Signs & symptoms of irritant poisoning Vomiting.Chapter 16: Poisoning and Substance Abuse Food poisoning. Copper sulphate. Page 217 Emergency Medical Technician – Basic . resins of many plants (in larger doses). Iron Sulphate. Corrosives Corrosive poisons react in a chemical manner with body tissue. particularly the stomach and bowels. Tartaric acid). maybe accompanied by discoloration. Irritants Irritant poisons aggravate the digestive system. leaves. and animal bites and stings are considered as special cases. Eventual unconsciousness and death (depending on dose). Examples Strong acids: Hydrochloric acid. berries. roots. such that they burn and destroy the parts with which they come into contact. Zinc Chloride. abdominal discomfort or pain. Silver Nitrate. diarrhoea. Potassium Bichromate. Antimony. Potassium hydroxide Salts: Mercuric chloride Signs & symptoms of corrosive poisoning Immediate pain and swelling at the points of contact. Arsenic. Nitric acid Strong alkalis: Sodium hydroxide. chloroform. digitalis. loss of co-ordination. Eventual unconsciousness and death (depending on dose). paralysing poison). swelling. Potassium Cyanide. Carbon Monoxide (also affects the ability of red blood cells to carry oxygen). persistent nausea and vomiting. Hydrocyanic acid (very fast acting. yew leaves/berries. lethargy. interference with vision. spontaneous bleeding. convulsions. atropine. Oxalic acid. and then act as narcotics. Then delirium and/or convulsions. diarrhoea. Examples Opium and derivatives. halitosis). various fungi.Chapter 16: Poisoning and Substance Abuse Narcotics Narcotic poisons affect the brain and/or nervous system. alcohol. Signs And Symptoms Caused by Some Specific Poisons Adder Venom Early stages: Pain. Narcotico-Irritants Narcotico-irritant poisons initially have an irritant action upon the digestive system. cloudy urine. Examples Phenol (carbolic acid). abdominal pain. diarrhoea. Strychnine. ether. diarrhoea. Hydrogen Sulphide. vomiting. Eventual unconsciousness (sometimes preceded by convulsions) and death (depending on dose). laburnum pods. Chloral Hydrate. Signs & symptoms of narcotic poisoning Dizziness. causing a reduction in coordination and the level of consciousness. acute kidney failure (characterised by a much reduced urine output. and enlargement of lymph nodes around the bite. dry skin. vomiting. Signs & symptoms of narcotico-irritant poisoning Initially. Later stages: abnormal heartbeat. fainting. difficulty in breathing. hemlock. Narcotic poisons do not generally produce pain. Ammonium Sulphide. Page 218 Emergency Medical Technician – Basic . tobacco. abdominal pain. drowsiness. unreactive dilated pupils. rapid unconsciousness. shallow breathing. Hydrogen Sulphide Headache. Acute poisoning: Rapid distressed breathing. nausea. falling consciousness. nausea. confusion. gasping and wheezing. shallow breathing. pain and redness of the eyes. vomiting. deep noisy breathing. unconsciousness. weak irregular pulse. dry mouth. vomiting (maybe blood-stained). delirium. In severe cases: Confusion. excitable behaviour. weakness. lethargy. blurred vision with ‘haloes’ around lights. unconsciousness. spasm of the eyelids.maybe with blood-stained sputum. Carbon Dioxide Headache. confusion. drowsiness. Atropine (Deadly Nightshade) Hot dry skin. falling consciousness. Narcotic Drugs Dizziness. Severe cases may lead on to: Vomiting. coughing . full bounding pulse. cyanosis. slow shallow breathing. Aspirin Upper abdominal pain. tinnitus. confusion. Depressant Drugs (Tranquilizers) Lethargy. dilated pupils. constricted pupils. pale skin with cyanosis). hyperventilation. sweating. dizziness.Chapter 16: Poisoning and Substance Abuse Alcohol Early stages: Flushed moist face. convulsions. aggression. sweating. unconsciousness. noisy breathing. Page 219 Emergency Medical Technician – Basic . pulmonary oedema (characterised by extreme breathlessness. weak rapid pulse. rapid unconsciousness. delirium. incontinence. Later stages: Dry bloated face. Carbon Monoxide Long term exposure: Headache. breathlessness. diarrhoea. Parathion. vomiting. nausea. nausea. Note: Oxygen must not be given to casualties who have been poisoned by Paraquat. unconsciousness. Ammonia Coughing. Ingestion: Nausea. hallucinations. Severe cases may lead on to: Convulsions. nausea. (Spray inhalation is rarely serious). dizziness. sore throat. abdominal pain. inside mouth. maybe leading on to acute pulmonary oedema up to 36 hours after inhalation. Page 220 Emergency Medical Technician – Basic . choking. Sulphur Dioxide. diarrhoea.Chapter 16: Poisoning and Substance Abuse Organophosphorus Insecticides (eg. developing muscular weakness. Paraquat Inhaled spray: Bleeding from the nose. vomiting. Paracetamol Initial stages: Nausea. After approximately 48 hours: Painful ulcers on lips. sweating. Solvents Headache. tremors. unconsciousness. hypersalivation. After 2 to 3 days: Features of liver failure . pulmonary oedema with excessive secretions. vomiting. restlessness. hallucinations. Stimulant drugs Excitable hyper-active wild frenzied behaviour. vomiting. After a few days: Difficulty in breathing caused by proliferating inflammation of the lung tissues. constricted pupils. Chlorine. tenderness. Note: Liver damage will usually be irreversible unless an antidote is given within 12 hours of ingestion.upper abdominal pain. Malathion) Anxiety. kidney failure. vomiting. Monitor airway and breathing. it is helpful for the EMT to be able to contact a Poisons Information Center to find out how to treat a certain poison.Chapter 16: Poisoning and Substance Abuse Poisons Information Centers Because the treatment of a poison can vary significantly. It can be contacted on (02) 524 1078. Philippines General Hospital runs the National Poison Management and Control Service (NPMCC). Move to fresh air immediately.org Poison Treatment Identifying the Patient and the Poison If you suspect poisoning. containers. 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. http://www. Page 221 Emergency Medical Technician – Basic .uppoisoncenter. 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. In the Philippines. and vomitus to the hospital. All patients require immediate transport. Chapter 16: Poisoning and Substance Abuse Absorbed Poisons Many substances will damage the skin. Obtain approval from medical control. Be prepared for vomiting. Prompt transport. Charcoal is not indicated for: • Ingestion of an acid. alkali. Activated charcoal will bind to poison in stomach and carry it out of the body. Assess ABCs. Record the time you administered the activated charcoal. Do not irrigate with water if substance is reactive Injected Poisons Usually result of drug overdose. Substance should be removed from patient as rapidly as possible. Ingested Poisons Poison enters the body by mouth. Shake bottle vigorously. Ask patient to drink with a straw. ALS providers may be able to use medications such as Narcan to reverse overdose. Accounts for 80% of poisonings. or eyes. 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. reducing absorption by the body. If substance is in the eyes.5 to 25 g for paediatric patients. May be accidental or deliberate. Activated Charcoal Activated charcoal absorbs many poisonous compounds to its surface. Impossible to remove or dilute poison once injected. mucous membranes. they should be irrigated. Page 222 Emergency Medical Technician – Basic . semicomatose or severely inebriated patients. 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. especially in the case of infants and children. If given 1 hour after. ipecac should be given on the advice of a Poison Control Centre or physician.Chapter 16: Poisoning and Substance Abuse Syrup of Ipecac Ipecac induces vomiting by both gastric irritation and central stimulation of the chemoreceptor trigger zone. Indications: To induce vomiting in the early management of certain oral poisonings. include: poisoning involving strong acids or alkalis. Rarely used anymore. Ipecac should be given as soon as possible after ingestion of a toxin. • Adults: 15 to 30 mL. Page 223 Emergency Medical Technician – Basic . 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. Dose should be followed by 1 to 2 glasses of water since ipecac is ineffective when the stomach is empty. Ideally. unconscious. • Children 6 months to <1 year: 5 to 10 mL. ideally within 1 hour. If vomiting has not occurred within 15 to 20 minutes. a maximum of 30% of the toxin will be removed. patients experiencing convulsions and patients who have lost the gag reflex. • Children 1 to <12 years: 15 mL. Contraindications: Situations where emesis is contraindicated. Administration with milk can prolong the time to vomiting because it decreases the irritant action of ipecac on the stomach. the dose may be repeated once in adults and children over 12 years. abdominal pain Shock Immediate Treatment of Watusi Poisoning If ingested. Page 224 Emergency Medical Technician – Basic . 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. Transport patient to the hospital as ill-effects may not present immediately. Give 6-8 egg whites to children.Chapter 16: Poisoning and Substance Abuse EMT-Bs may administer both activated charcoal and Syrup of Ipecac. DO NOT induce vomiting. diarrhea. If there is dermal exposure. bathe the patient using alkaline soap like Perla or Ivory. 8-12 egg whites to adults. cells starve. Insulin • Hormone produced by the pancreas. Glucose One of the basic sugars in the body. it is a primary fuel for cellular metabolism. Usually due to a lack of insulin. Along with oxygen.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. • Without insulin. Page 225 Emergency Medical Technician – Basic . • Enables glucose to enter the cells. including mood. The endocrine system is an information signal system like the nervous system. and metabolism.Chapter 17: Diabetic Emergencies Hormone Chemical substance produced by a gland. Has special regulatory effects on other body organs and tissues. each of which secretes a type of hormone into the bloodstream to regulate the body. Hormones regulate many functions of an organism. The Endocrine System The endocrine system is a system of glands. tissue function. Page 226 Emergency Medical Technician – Basic . growth and development. Constant supply of glucose needed for the brain Insulin acts as the key for glucose to enter cells.Chapter 17: Diabetic Emergencies Role of Glucose and Insulin Glucose is the major source of energy for the body. Page 227 Emergency Medical Technician – Basic . Type II Diabetes Page 228 Emergency Medical Technician – Basic . Insulin injected daily. Disease may be controlled by diet or oral hypoglycemics. Patient produces inadequate amounts of insulin.Chapter 17: Diabetic Emergencies Type I and Type II Diabetes Type I Diabetes Insulin-dependent diabetes. Non-insulin-dependent diabetes . Onset usually in childhood. Patient does not produce any insulin. Chapter 17: Diabetic Emergencies Hypoglycemia vs Hyperglycemia Hyperglycemia Hypoglycemia High blood glucose . reducing the diabetic has vomited a meal that disrupts their glucose/insulin balance Signs and Symptoms • gradual onset of signs and • symptoms over a period of days • • • rapid onset of signs and symptoms over a period of minutes patient complains of dry mouth and • copious saliva and drooling intense thirst • intense hunger • dizziness abdominal pain and vomiting and headache. • perfuse perspiration acetone and is sickly-sweet • normal blood pressure warm. sighing • cold. flooding • the body with a sudden excess of overexerted carbohydrates their blood glucose level • the diabetic has suffered an infection • • the diabetic has over-exercised or themselves. • weak. rapid pulse • signs of air hunger .usually less than 70 mg/ mg/dL dL Causes • undiagnosed or untreated diabetic • condition • the diabetic has taken too much insulin the diabetic has not taken their • insulin the diabetic has not eaten enough to provide their normal sugar intake • the diabetic has overeaten. dry skin • normal eyes • sudden breath odour smells of Page 229 Emergency Medical Technician – Basic no . pale and clammy skin respirations. seizures and occasionally gradually increasing restlessness and coma confusion. followed by stupor and • full rapid pulse coma • relative normal respirations. red.deep.usually more than 120 Low blood glucose . common fainting. Chapter 17: Diabetic Emergencies • 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 Page 230 Emergency Medical Technician – Basic . Chapter 17: Diabetic Emergencies Glucometer Blood glucose monitor Normal range 80-120 mg/dL Test strips for calibration Some concerns about accuracy Page 231 Emergency Medical Technician – Basic . Chapter 17: Diabetic Emergencies Page 232 Emergency Medical Technician – Basic . Chapter 17: Diabetic Emergencies Normal range for blood glucose is 80-120 mg/dL Page 233 Emergency Medical Technician – Basic . DO NOT give glucose to a patient with the inability to swallow or who is unconscious.Hypergylcemia Administer oxygen if required.administer glucose. Transport to medical facility.Chapter 17: Diabetic Emergencies Emergency Care Emergency Care . Squeeze a generous amount onto a bite stick. Provide oxygen if required. Turn head to side or place the patient in the lateral recumbent (recovery) position. Emergency Care . Administering Oral Glucose Names: • Glutose • Insta-Glucose Dose equals one tube. Repeat. Immediately transport. Provide a sprinkle of granulated sugar under the tongue or a dab of glucose if protocols permit. Page 234 Emergency Medical Technician – Basic . Place the bite stick on the mucous membranes between the cheek and the gum with the gel side next to the cheek. Open the patient’s mouth. Arrange for ALS intercept if available. granular sugar. Unconscious patient .avoid giving liquids. Arrange for ALS intercept if available. Make sure the tube is intact and has not expired. Glucose should be given to a diabetic patient with a decreased level of consciousness. honey or a candy under the tongue or give orange juice.Hypoglycemia Conscious patient . Often a patient suffering a diabetic emergency may simply appear drunk. Page 235 Emergency Medical Technician – Basic . assume that the patient is suffering from hypoglycaemia and administer glucose. Look for medical identification medallions.such as a diabetic complication – when treating someone who appears intoxicated. 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.Chapter 17: Diabetic Emergencies Special Notes on Diabetic Emergencies When faced with a patient who may be suffering from hyperglycemia or hypoglycemia: Determine if the patient is diabetic. Always check for other underlying conditions . 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. Page 236 Emergency Medical Technician – Basic . Rash starts on the trunks and flexor surfaces spreading to the palms and soles.Chapter 18: Infectious Diseases Syphilis has three stages: Primary – characterized by a painful chancre (canker sore) with indurated borders on the penis. 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. cough and weight loss. headaches. Secondary – this stage which occurs 10 days to 10 weeks after the end of the primary stage. leading to loss of pulmonary function. Tertiary – involvement of the nervous system and CVS is characteristic of this stage which may occur 3-4 years after the initial infection. vulva or other areas of sexual contact. Pulmonary infection with symptoms can develop within 2-10 weeks. TB causes an area of scar tissue to develop in the lungs. Specific manifestations range from acute meningitis. Tuberculosis Tuberculosis is not a highly contagious disease. 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. TB can lie dormant for many years before the signs commonly associated with TB appear – night sweats. dementia and neuropathy to thoracic aneurysm. Rash and lymphadenopathy are the most common symptoms. Suspect TB with: Undiagnosed pulmonary or respiratory function Viral syndrome. usually those living in the same household. night sweats and weight loss Productive cough (green or yellow sputum) Coughing up blood Difficulty breathing Page 237 Emergency Medical Technician – Basic . Signs and symptoms Initial infection – usually minimal and most patients do not show any symptoms when first infected. 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. 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. Negribodies are the characteristic histologic findings for rabies.Chapter 18: Infectious Diseases 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. rabies manifests the same findings as seen in other forms of encephalitis (inflammation of the brain). Page 238 Emergency Medical Technician – Basic . Histologically. Transport to hospital for Human Immunoglobulin (HRIG) and Human Diploid Cell Vaccine. There are five forms of Hepatitis: 1. Hepatitis D – HDV or Delta 5. 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. The type most often involved in epidermal outbreak is caused by the meningococcous bacteria and is usually referred to as Meningococcal Meningitis.Chapter 18: Infectious Diseases Emergency Care BSI ABC Scrubbing and cleansing of the wound to remove rabies is important. Hepatitis A – HAV 2. Hepatitis C 4. Hepatitis E Page 239 Emergency Medical Technician – Basic . Meningitis Inflammation of the meninges of the brain. It is more contagious than HIV and is a major threat to Health Care Providers. Hepatitis B – HBV 3. 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. although medical tests show that about 40% of urban Americans have had hepatitis A. Introduction of infected materials into the mucous membranes (especially the mouth. Hepatitis A Most common Hepatitis infection in children Spread primarily by the fecal-oral route. Other body secretions including saliva. Hepatitis B Serum hepatitis – primarily spread through contact with infectious blood or blood products. it's possible for some people to be unaware that they have had the illness. it typically only causes short-lived illnesses and it does not cause chronic liver disease. 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. including chickenpox and cytomegalovirus (CMV). only about 5% recall being sick. Although the hepatitis A virus can cause prolonged illness up to 6 months. HBV can survive for up to 10 days in dried blood spills. 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. semen and vaginal secretions can contain the HBV. particularly in children. Page 240 Emergency Medical Technician – Basic . In fact.Chapter 18: Infectious Diseases Hepatitis can also be caused by other viruses and bacteria. scalpels and other sharp items in a punctureresistant container kept within easy reach. Air out the ambulance and send soiled linen for cleaning. In some cases. The communicable period starts weeks before the first symptoms appear and may persist for years in chronic carriers. Disinfect all equipment contaminated with blood or sputum. but once established. and the virus universally recurs after transplantation. Observe and practice universal precautions. including: Wearing gloves whenever there is a potential exposure to blood or other bodily fluids. Hepatitis C The infection is often asymptomatic. those with cirrhosis will go on to develop liver failure or other complications of cirrhosis. needles. Those who develop cirrhosis or liver cancer may require a liver transplant. Dispose of syringes. Most people have few. and advanced scarring (cirrhosis) which is generally apparent after many years. Wash your hands thoroughly after the call. peginterferon and ribavirin being the standard-of-care therapy.Chapter 18: Infectious Diseases The incubation period of HBV varies widely – usually somewhere between 45 to 180 days. chronic infection can progress to scarring of the liver (fibrosis). Page 241 Emergency Medical Technician – Basic . bend or break needles after use or manipulate them by hand. yet the virus persists in the liver in about 85% of those infected. HBV lasts several weeks although complete recovery may take 3 to 4 weeks. 51% are cured overall. remove. Never recap. Make sure you have your Hepatitis vaccination. Precautions when dealing with Hepatitis patients Handle with extreme care all needles and IV equipment used for a patient with jaundice. The hepatitis C virus is spread by blood-to-blood contact. 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. if any symptoms after the initial infection. Stay in touch with the hospital to which the patient was transported to follow up for diagnosis. Persistent infection can be treated with medication. including liver cancer or life threatening esophageal varices and gastric varices. The communicable period for AIDS is not known but is presumed to continue throughout the time that the patient is seropositive. It is estimated that approximately 33 million people are currently infected with the AIDS virus. life expectancy is reduced. viral and fungal infections. As a result. From the time of exposure to the time a person’s blood tests positive for AIDS (becomes seropositive or HIV positive). 6 months and 1 year later. AIDS is the name for the set of conditions that results when the immune system has been attacked by HIV. Page 242 Emergency Medical Technician – Basic . May be anywhere from a few weeks to a few months.e. In patients who have contracted AIDS from contaminated blood products. including 2-3 million children. even before the patient develops clinically apparent AIDS. An AIDS’ patient becomes extremely vulnerable to a whole variety of bacterial. becoming HIV positive) and the development of full-blown 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. although antiretroviral medication can extend this significantly. there are two incubation periods to consider: 1. From a variety of data. In considering the incubation period of AIDS. 3 months.Chapter 18: Infectious Diseases HIV/AIDS HIV is the virus that causes AIDS. 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. The time between the documented infection (i. 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. the mean incubation after infection has been approximately 8 years for adults and 2 years for children. 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. 2. Once AIDS has developed. Chapter 18: Infectious Diseases Transmission of AIDS 1. saliva. Assume that every patient you treat is HIV positive. blood. urine and feces. there are countless signs and symptoms. Signs and Symptoms Because AIDS can involve many organs and systems of the body. Sexual contact – involving semen. Parentally – through contaminated blood products or infected needles. 3. Restrict pregnant EMTs from contact with known AIDS patients. 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. Page 243 Emergency Medical Technician – Basic . 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. Protect the AIDS patient from acquiring infections from you or your crew. 2. Chapter 18: Infectious Diseases Lists of common antiretroviral medications Page 244 Emergency Medical Technician – Basic . The patent for AZT has expired and generic versions are available in the US.Chapter 18: Infectious Diseases 1. 2. The US Department of Health and Human Services also no longer recommend stavudine as a ‘preferred’ or ‘alternative’ component in initial treatment. Stavudine is no longer recommended for initial therapy in the UK. Page 245 Emergency Medical Technician – Basic . In the US. 4. generic forms given tentative approval are available in certain developing countries only. 12. 7.Chapter 18: Infectious Diseases 3. Raltegravir is not licensed as a starting regimen in the UK. 9.avert. 5. Delavirdine is licensed in US but not UK. 10. (Source: http://www. 6. for example informed patient choice based on likely poor adherence if alternative options are used. * Because of patent laws. but it is not the ‘preferred’ treatment option. The US Department of Health and Human Services do not recommend tipranavir for initial treatment. The manufacturer has discontinued a tablet version. Roche Pharmaceuticals have discontinued the sale and distribution of Fortovase brand saquinavir soft gel capsules in the US.org/aids-drugs-table. Maraviroc is not licensed as a starting regimen in the UK. while unboosted atazanavir is an ‘alternative’ for initial treatment.htm) Page 246 Emergency Medical Technician – Basic . The patent for ddI has expired and generic versions are available in the US. or concomitant medication needed such as for TB". ritonavir-boosted atazanavir has been approved as a ‘preferred’ initial treatment. The British HIV Association (BHIVA) recommends that Trizivir "should only be considered as a starting regimen in very occasional circumstances. Enfuvirtide is not licensed as a starting regimen in the UK. 8. Etravirine is approved in the US and the UK for treatment-experienced patients only. Tipranavir 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. Trizivir is listed as a ‘possible’ treatment option in the US. Atazanavir is not licensed as a starting regimen in the UK. 11. although many organs overlap different regions. the use of regions is more precise and should be used as a first preference. Although the use of quadrants is common in medical systems.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. Page 247 Emergency Medical Technician – Basic . which can be used to locate organs. Chapter 19: The Acute Abdomen 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 Page 248 Emergency Medical Technician – Basic . Chapter 19: The Acute Abdomen 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. Page 249 Emergency Medical Technician – Basic Chapter 19: The Acute Abdomen 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 Page 250 Emergency Medical Technician – Basic Chapter 19: The Acute Abdomen 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. Page 251 Emergency Medical Technician – Basic 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. Page 252 Emergency Medical Technician – Basic Chapter 20: Burns 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 outerlayer 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 Page 253 Emergency Medical Technician – Basic swelling and blisters. Page 254 Emergency Medical Technician – Basic . swelling and decreased blood flow in the tissue can result in the burn becoming a third-degree burn. Healing from third-degree burns is very slow due the skin tissue and structures being destroyed. pain. These burns often affect sweat glands. causing charring of skin or a translucent white color. These burn areas may be numb. 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. and hair follicles. dermis and hypodermis. This pain is usually because of second-degree burns.Chapter 20: Burns Second Degree Burns (Partial-Thickness) Second-degree burns affect both the outer-layer (epidermis) and the under lying layer of skin (dermis) causing redness. with coagulated vessels visible just below the skin surface. but the person may complain of pain. If a deep second-degree burn is not properly treated. Third-degree burns usually result in extensive scarring. thermal injury is confined to the upper airways. ligaments and muscles. They may occur from prolonged exposure to flame or electrical injury. secondary airway involvement can occur after inhalation of steam as it has a greater thermal capacity than dry air. such as tendons. Fourth degree burns can be life-threatening and may require amputation due to the severe nature of fourth degree burn injuries. Page 255 Emergency Medical Technician – Basic . bone. However. Fourth degree burns often result in permanent disability and may require lengthy rehabilitation. owing to destruction of nerve endings. When hot air enters the nose. The three types of inhalation injuries are: 1. More than a hundred known toxic substances are present in fire smoke. damage to the mucous membranes can readily transpire as the upper airway acts as a cooling chamber. These burns always require surgery or grafting to close the wounds. These burns are not painful. When inhalation injuries are combined with external burns the chance of death can increase significantly. In most cases. or have high pressure force the heat into you. Damage from Heat Inhalation: True lung burn occurs only if you directly breathe in a hot air/flame source. because the trachea usually shields the lung from thermal loads. Inhalation Injuries Fire has been associated with 3 different types of inhalation injuries.Chapter 20: Burns 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. 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. Early obstruction of the upper airway is managed with intubation. 60% to 80% of fatalities resulting from burn injuries can be attributed to smoke inhalation. Damage from Smoke Inhalation: Smoke intoxication is frequently hidden by more visible injuries such as burns as a result of fire. Page 256 Emergency Medical Technician – Basic . 3. Indications of inhalation injury usually appears within 2-48 hours after the burn occurred. eyebrows. 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. Age of Patient Infants. Damage from Systemic Toxins: Systemic Toxins affect our ability to absorb oxygen. Patients that appear apparently unharmed can collapse due to major smoke inhalation. If someone is found unconscious or acting confused in the surroundings of an enclosed fire. Which in a disaster situation can lead to not receiving the medical attention needed. Upper airway edema is commonly seen during the first 6 to 24 hours after injury. Carbon Monoxide poisoning can appear symptomless up until the point where the victim falls into a coma. An adult’s reactions to burns and complications associated with burn injury healing increase significantly after the age of 35. eyelashes have been singed Burns around the face or neck Upper airway edema is the earliest consequence of inhalation injury. due to the rescue teams taking care of the more apparent patients. Initial treatment consists of removing the patient from the gas and allowing him to breathe air or oxygen. Toxin poisoning can cause permanent damage to organs including the brain.Chapter 20: Burns 2. systemic toxins could be a possible cause. Chapter 20: Burns 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 Page 257 Emergency Medical Technician – Basic . hands. hot liquids Electrical burn Low voltage current from normal domestic outlets. and complicating factors Minor Burns Full-thickness burns of less than 2%. excluding face. feet. Arcing from high voltage currents. genitalia or respiratory tract Partial-thickness burns of 15-25% Superficial burns that involve more than 50% of the body Page 258 Emergency Medical Technician – Basic domestic . 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%. contact with hot objects Scald Steam. liquids or vapors Chemical burn Industrial chemicals Radiation burn Sunburn. exposure to radioactive sources and Classification of Burn Severity: Adults Classifications by thickness. overexposure to UV light. hands. excluding face.Chapter 20: Burns Burns and Scalds Types of Burn Cause Dry burn Flames. feet. percentage of BSA. contact with freezing materials. lightning strikes Freeze burn Frostbite. 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. are moderate should be considered critical in a person less than 5 years or greater than 55 years of age. by the above classification.Chapter 20: Burns Critical Burns All burns complicated by injuries of the respiratory tract. hands. Using this information they have divided burns into major. and minor burns based on severity of burn and the patient risk group. moderate. 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 Page 259 Emergency Medical Technician – Basic . genitalia or respiratory tract Full-thickness burns of more than 10% Partial-thickness burns of more than 25% Circumferential burns Burns by which. feet. other soft tissue injuries and bone injuries Chemical burns Electrical burns Partial or full-thickness burns involving the face. such as heart disease. 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 higherrisk group Partial-thickness burns more than 25% of the body surface area in the low-risk group Page 260 Emergency Medical Technician – Basic . face. feet. lung disease.Chapter 20: Burns Poor-Risk Patients: underlying medical conditions. 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. extent and severity. Be certain burn is thermal. If the burn is chemical.Chapter 20: Burns Patient Care Stop the burning process: - Flame – wet down. Follow local burn protocols and transport burn patients ASAP. Remove clothing and jewellery. not chemical. 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. Evaluate burns by depth. Burns to the eyes – do not open the eyelids if burned. tar. smother and remove clothing - Semi-solid (grease. 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. Allergies/medications? Specific Chemical Burn Treatment Whenever possible. to a burn center is available. Look for signs of airway injury – soot deposits. Look for signs of shock – burns seldom result in early shock so there may be another underlying injury. Do not clear debris. flush eyes for 20 minutes en route to hospital. Separate fingers or toes with sterile gauze pads. Wrap with dry sterile dressing. burnt nasal hair and facial burns. Burns to hands/feet – remove rings and jewellery that may constrict with swelling. Assess breathing. find out the exact chemical or mixture of chemicals that were involved in the incident Page 261 Emergency Medical Technician – Basic . Complete the initial assessment. Apply sterile gauze pads to both eyes to prevent sympathetic movement. Combined action can be severe and immediate. so treat all patients who have come into contact with the chemical. Page 262 Emergency Medical Technician – Basic .Chapter 20: Burns Mixed or strong acids or unidentified substances For industrial process – mixed acids. Hydrofluoric Acid Used for etching glass and in many other manufacturing processes. Pain produced from initial burn may mask pain caused by renewed burning. but it is still preferable to wash rather than leave the contaminant on the skin. Inhaled Vapors Whenever a patient is exposed to a caustic agent and may have inhaled the vapors. provide high concentration oxygen and transport immediately. Continue washing the patient even after the patient claims they are no longer in pain. 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. Burns from this acid may be delayed. Industrial sites that use chemicals should have specific facilities for washing chemicals. Sulfuric Acid Heat is produced when water is added to the concentrated sulphuric acid. even if burns are not evident. The use of prompt/feedback devices during CPR will enable immediate feedback to rescuers and is encouraged. trained or not.Appendix 1 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. The importance of gasping as sign of cardiac arrest is emphasised. and to minimise interruptions in chest compressions. In combination with unresponsiveness. absence of breathing or any abnormality of breathing should start a dispatch protocol for suspected cardiac arrest. A strong emphasis on delivering high quality chest compressions remains essential. All rescuers. to allow full chest recoil. Page a Emergency Medical Technician – Basic . 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. should provide chest compressions to victims of cardiac arrest. This information should focus on the recognition of unresponsiveness and the quality of breathing. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions min-1. Telephone-guided chest compression-only CPR is encouraged for untrained rescuers. Trained rescuers should also provide ventilations with a compression–ventilation (CV) ratio of 30:2. emergency medical services (EMS) personnel should provide good-quality CPR while a defibrillator is retrieved. but routine delivery of a pre-specified period of CPR (e. applied and charged. given the lack of convincing data either supporting or refuting this strategy. witnessed VF/VT cardiac arrest when the patient is already connected to a manual defibrillator. 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. Page b Emergency Medical Technician – Basic . but there is recognition in these guidelines that the risk of harm to a rescuer from a defibrillator is very small. Safety of the rescuer remains paramount. Much greater emphasis on minimizing the duration of the pre-shock and postshock pauses. The focus is now on a rapid safety check to minimise the preshock pause. particularly if the rescuer is wearing gloves. Immediate resumption of chest compressions following defibrillation is also emphasised. For some EMS that have already fully implemented a pre-specified period of chest compressions before defibrillation. Further development of AED programmes is encouraged – there is a need for further deployment of AEDs in both public and residential areas. it is reasonable for them to continue this practice. When treating out-of-hospital cardiac arrest.g.Appendix 1 Electrical therapies The most important changes in the 2010 ERC Guidelines for electrical therapies include: The importance of early. two or three minutes) before rhythm analysis and a shock is delivered is no longer recommended. the delivery of defibrillation should be achievable with an interruption in chest compressions of no more than 5 seconds. the continuation of compressions during charging of the defibrillator is recommended. This three shock strategy may also be considered for an initial. uninterrupted chest compressions is emphasized throughout these guidelines. in combination with continuation of compressions during defibrillator charging.. Appendix 1 Page c Emergency Medical Technician – Basic . Appendix 1 Page d Emergency Medical Technician – Basic . Appendix 1 Page e Emergency Medical Technician – Basic . Appendix 1 Page f Emergency Medical Technician – Basic .