Professional Documents
Culture Documents
Lsti Emt B Manual
Lsti Emt B Manual
Lsti Emt B Manual
Technician Basic
Course Manual
Life Support Training International
Editors 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.
Contents
Chapter
Page
10
20
28
37
48
57
71
Patient Assessment
75
10
110
11
Airway Management
123
12
155
13
164
14
Environmental Emergencies
178
15
200
16
212
17
Diabetic Emergencies
225
18
Infectious Diseases
236
19
247
20
Burns
252
Appendices
Appendix 1
Chapter 1:
EMS In The Philippines
Outline
medical emergencies.
Our consultants have been involved in developing Emergency Medical Services
Systems (EMSS) in various parts of the world, ranging from the United Kingdom
to the Middle East, the Western Pacific Region and, indeed, here in The
Philippines. In the Philippines, we work closely with Emergency Medicine
Consultants from the University of the Philippines, Philippines General Hospital,
Department of Emergency Medicine. Life Support Training International is
heavily involved with the Philippine Heart Association, being active members of
both the Expanded Council on Resuscitation and the National Emergency
Medical Services Council. We are also the founding executive members of the
Philippine Society of Emergency Medical Technicians, which is a society
dedicated to developing a National Emergency Medical Services System
throughout The Philippines.
Our faculty is composed of only the most qualified and experienced instructors
ranging from trained Trauma Surgeons and fully registered Emergency Medical
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Emergency Medical Technician Basic
Technicians and Paramedics - WE GIVE YOU ONLY THE VERY BEST. Our
standards of training meet with the highest of international standards and
great care is taken to mould the courses to meet your specific requirements.
We will help students to develop the essential knowledge, skills and
confidence in order to be able to provide essential Emergency Life Support in
times of crisis.
Life Support Training International is currently The Philippines only fully
certified training and assessment center for the Philippine Society of
Emergency Medical Technicians and, internationally, the Australasian Registry
of Emergency Medical Technicians (AREMT) and the Technical Education and
Skills Development Authority (TESDA).
WHEN THEY DEPEND ON YOU
YOU CAN ALWAYS DEPEND ON US!
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Emergency Medical Technician Basic
PSEMT Affiliations
Page 3
Emergency Medical Technician Basic
Australasian Registry of
Emergency Medical Technicians
Page 4
Emergency Medical Technician Basic
ASSOCIATE MEMBER
Associate Membership
This level will allow entry to all that hold current First Aid and Basic Life Support
Provider certificates from a Recognized Training Agency. The minimum requirement
will be thirty-two hours of instruction in First Aid, with a further eight hours in Basic
Life Support.
Basic Emergency Medical Technician - EMT (B) Certification
This is the initial entry grade for all professional pre-hospital care providers. This
grade is inclusive of ambulance staff and nursing personnel who can demonstrate
appropriate training and experience in line with PSEMT/PBEMT published standards.
Entry may be afforded to applicants who are outside the full time professional
sector on achievement of the following requirements:
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Emergency Medical Technician Basic
Emergency
Medical
Technician
Paramedic
EMT (P)
Registration
The minimum entry criteria for Paramedic training is EMT Advanced (A), in
accordance with the standards set out by the PSEMT/PBEMT, with at least six
(6) months post-certification experience. All applicants must have successfully
completed the three hundred and sixty (360) hour Advanced Clinical Training
modules. This level will only be available to those who complete a minimum of
seven hundred and fifty (750) hours actual operational experience per year.
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Emergency Medical Technician Basic
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Emergency Medical Technician Basic
For the EMT Final Written Examination PSEMT/AREMT policy allows for a
maximum of two (2) sits only (1 exam and 1 re-sit).
For the Basic Life Support Written Examination, a maximum of three (3) sits are
allowed (1 exam and 2 re-sits). No EMT certification can be awarded to a
candidate without successful completion of both practical and theoretical
examinations in Basic Life Support.
Validity of the re-sit/re-examination is limited to within one (1) year from the
time the student finishes the course. If a student fails to re-sit or take the Final
Examination within this grace period, he/she shall forfeit their right to retake
said Final Examination.
Under no circumstances will a candidate who has failed the final examinations
and re-sit be accepted for retraining at LSTI.
Students who fail all the re-sits/re-examinations shall not be awarded any
certificate of proficiency.
In accordance with PSEMT/AREMT policies, repetition of the EMT-Basic Course
is also not permitted.
Smoking is strictly
prohibited in and
around the
training facility at
all times.
Please put all your litter in the
numerous garbage receptacles
provided around the training
facility for student use.
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Emergency Medical Technician Basic
C h a p te r 2 :
Roles and
Responsibilities of the
E MT
Outline
ust as physicians have the caduceus, and pharmacists the mortar and
pestle, Emergency Medical Services have the Star of Life, a symbol
whose use is encouraged by both the American Medical Association
and the Advisory Council within the Department of Health and Human
Services. On road maps and highway signs, the Star of Life indicates the
location or access to qualified emergency care services.
The Star of Life was designed by Leo Schwartz, EMS Branch Chief at the
National Highway Traffic Safety Administration (NHTSA) USA. The star of life
was created in 1973 as a common symbol to be used by US emergency
medical services (EMS) and medical goods pertaining to EMS.
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Emergency Medical Technician - Basic
Page 11
Sample Manual Template
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Emergency Medical Technician - Basic
Personal Safety
An EMT is no good if he or she becomes another victim.
Patient Assessment
Finding out what is wrong with your patient to be able to undertake
emergency medical care.
Patient Care
Preparation for action or a series of actions to take that will help the
patient deal with and survive illness or injury.
Transport
A serious responsibility in ambulance operations, even more so with a
patient on board.
Patient Advocacy
Moral responsibility to speak on behalf of the patients need of attention
for a particular cause. Must develop a rapport that will give understanding
of the patients condition.
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Sample Manual Template
Traffic
laws
and
ordinances
concerning
emergency
A pleasant personality
Leadership ability
Good judgement
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Emergency Medical Technician - Basic
Communication
Training
Manpower
Mutual Aid
Transportation
Accessibility
Facilities
Transfer of Care
Consumer Participation
Public Education
Disaster Linkages
The above design has proved proficient in many aspects, including medical direction and
accountability, prevention, rehabilitation, financing and operational and patient care
protocols. EMS systems continued to be refined in the 1980s and 1990s.
Successful EMS systems are designed to meet the needs of the communities they serve.
The state provides laws that broadly outline what is prudent, safe and acceptable. To be
effective, EMS systems must be planned and operated at the local level.
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Sample Manual Template
Communities need to identify their individual needs and resources, develop funding
mechanisms, and become involved at all levels in structuring the system. A governing
body or council should be established to organize, direct and coordinate all system
components. The council consists of representatives from the local medical, EMS,
consumer and public safety agencies to ensure consensus in developing policies and
settling disputes. The EMS system must provide equal access to all, and remain
protected from forces that serve the interests of only one group.
Medical Direction
Physician input, leadership and oversight in ensuring that medical care provided is safe,
effective and in accordance with accepted standards. Physicians must be empowered and
imvolved in planning, implementing, overseeing and evaluating all components of the
system. Medical direction is characterized as either immediate (on-line) or organisational
(off-line).
On-line medical direction provides EMTs with consultation in the field, either in person or,
more commonly, via radio or telephone communication. This responsibility is delegated
medical director to physicians who staff local Emergency Departments. The base station
facility providing on-line control is required to monitor all advanced life support (ALS)
communications, provide field consultations, and notify receiving facilities of incoming
patients. Physicians providing on-line direction should be appropriately trained and
familiar with the operations and limitations of the system.
The medical director assumes authority and responsibility for off-line medical direction. In
cooperation with the local medical community, the medical director is responsible for
developing standards, protocols, policies and procedures; developing training programs;
issuing credentials and providing evaluations; and implementing a process for continuous
quality improvement.
Communications
A comprehensive communications plan is essential to provide the community access to
system dispatch and to provide the EMT access to medical direction and additional
resources. The establishment of a universal access number (911 in the US and Canada or
999 in the UK for example) has greatly improved the systems accessibility. Additional
advancements have been made with enhanced systems, such as the enhanced 911
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Emergency Medical Technician - Basic
system, which automatically provide the dispatcher with the callers address and
telephone number. Using enhanced systems, callers can obtain services even if they are
unable to communicate with dispatch. Emergency medicine dispatch includes assessment
of patient location and status, as well as the provision of pre-arrival instructions.
Ground vehicles provide most EMS transportation. Ambulances should be constructed
according to federal or national standards, and be appropriately equipped to provide
basic or advanced level of care. Air transport, such as a helicopter or airplane, may also be
either BLS or ALS. Air transport is used to transport patients over greater distances,
decrease total pre-hospital time or to reach patients in poorly accessible locations.
Operational standards are established to delineate the equipment needed, the number of
personnel and the level of certification required, as well as the response-time criteria and
the destination for each transport.
On-line medical direction should be obtained in all calls that result in transport. This
includes:
Decision to transport;
Otherwise, the provider may be perceived as practicing without a licence, and could be
charged with an offence.
Transportation
Inter-facility transportation occurs once the patient has been examined and stabilized.
Patients are transported in compliance with regional protocols and federal, national or
state laws (e.g. Consolidated Omnibus Budget Reconciliation Act [COBRA] and Emergency
Medical Treatment and Active Labor Act [EMTALA] in the US). Legislation dictates that
medically unstable patients be transferred only when the transfer is expected to have a
positive effect on outcome.
Patients should be transported to the closest, most appropriate facility. Receiving facilities
are required to have the capabilities to treat the patients, stabilize their condition, and
improve their outcome. Stable patients may be transported to the hospital of their choice,
as long as the transport meets regional point-of-entry protocols, has the approval of online medical control, and does not necessarily overburden the system.
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Emergency Medical Technician Basic
Specialized resources to care for the severely injured are not available in every hospital.
Local communities need to establish regional protocols to provide clear guidance for the
transport of unstable patients to categorized facilities. Unstable patients with special
problems, such as burns or trauma, can be transported to regionally designated hospitals,
bypassing closer facilities.
Training Standards
Providers must be trained to meet the expectations and requirements in programs that
comply with regional and national standards. Training includes didactic, clinical and field
components. Most states require that candidates pass written and practical examinations
prior to certification. Additionally, EMTs are required to receive continuing didactic and
clinical education to maintain certification.
Education is also used to reinforce proper patient care, update standards and protocols,
and remedy perceived deficiencies in patient care. Physician involvement is essential to
assure appropriate utilizations of skills and equipment. The EMS system also provides
community education, such as public courses in CPR, first aid, child safety and EMS access.
Protocols
Protocols are developed to deal with operational, administrative and patient care issues.
They define a standardized, acceptable approach to commonly encountered problems.
Protocols should reflect regional and national standards, as well as the uniqueness and
limitations of the local environment. The medical director has the responsibility to address
protocols dealing with patient care, such as triage and treatment.
Triage assesses the condition of each patient, sorts patients into treatment categories, and
optimizes use of field resources for treatment and transport. In addition, triage addresses
the level of provider during multiple casualty incidents to facilitate the screening,
prioritization, treatment and transport of patients.
Treatment protocols describe the authority and responsibilities of providers and offer
guidance for medical evaluation and care. Optimal care and medical accountability require
standardized protocols, algorithms and standing orders that outline specific actions
providers can take without contacting a physician for orders. Any deviation from these
standing orders must be considered a breach of duty and must result in an audit. On-line
medical direction is crucial in systems, requiring decision-making to provide guidance and
assume some of the patient-care responsibilities.
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Emergency Medical Technician Basic
Continuous quality improvement (CQI) is the sum of all activities undertaken to assess
and improve the products and services EMS provides. The goal is to influence patient
outcomes
positively
by
delivering
products
timely,
consistent,
appropriate,
compassionate and cost-effective systems. CQI ensures that the field staff provides the
highest quality of care and that the system supports this goal. Quality should be
monitored from within the EMS system and by an external, independent and unbiased
body that involves the consumer, government and medical communities. Standardized
protocols, policies, performance and documentation are invaluable in constructing a
successful CQI process.
Quality evaluation is prospective, concurrent and retrospective. Prospective evaluation
is most effective process to ensure quality in EMS, because it has the potential to
prevent mistakes. The system must be scrutinized constantly to determine areas
requiring refinement and improvement. When goals and standards are not met, CQI
staff members must identify the problem, establish and implement a corrective course
of action, and measure the outcome. Concurrent evaluation occurs on scene or on-line.
Staff members observe performance, encourage positive behavior and correct
problems before bad habits develop. Retrospective evaluation is the least valuable and
most time-consuming. It includes critique sessions and reviews of patient encounter
tapes and charts.
Disaster Preparedness
The EMS system is an integral part of disaster preparedness and planning. It plays an
important role in initial response and transportation, and is essential in establishing a
regional disaster preparedness plan in coordination with public safety agencies,
government and the medical community. The plan should address disaster
management, communication, treatment and designation of casualties. Periodic
disaster drills serve to assess performance, refine management and educate personnel
and the community.
Public support is invaluable in constructing a successful EMS system; involvement is
required to plan a system that works for everyone. Consumers need to be well
informed of the benefits of having an EMS system and how to gain access to it.
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Emergency Medical Technician Basic
Chapter 3:
Medico-Legal and Ethical
Issues in EMS
Outline
Definitions
Patient Bill of Rights
Ethical Implications
Right of Refusal
Legal Aspects
Crime Scenes
EMS Code of Ethics
Definitions
ETHICS - The science of right and wrong, of moral duties and of ideal behaviour.
MEDICAL ETHICS - The part of ethics that deals with the health care of human
beings.
The patient has the right to expect that all communications and records
pertaining to his or her care should be treated as confidential.
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Emergency Medical Technician Basic
In the Philippines, the Patient Bill of Rights is known as Title 111: Declaration of Rights.
Protects a person from liability for acts performed in good faith, unless those
acts constitute gross negligence.
Does not prevent one from being sued, although it may provide some
protection against losing a lawsuit if one has performed to the standard of
care for an EMT-B.
Medical Direction
The legal right to function as an EMT-B is contingent upon medical direction.
The EMT-B must:
Duty to Act
The obligation to provide care. May be implied or formal.
IF ON-DUTY:
legally obligated
may pass the scene and make no attempt to call for help.
IF OFF-DUTY:
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Emergency Medical Technician Basic
Ethical Responsibilities
Serve the needs of the patients with respect for human dignity, without
regard to nationality, race, gender, creed or status.
Expressed consent
Implied consent
Consent to treat a minor or mentally incompetent adult
Advance Directives
Associated problems:
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Emergency Medical Technician Basic
Refusal of Treatment
Competency
A competent adult is defined as one who is lucid and capable of making
an informed decision.
Protecting yourself:
Do the following before you leave the scene:
transport to a hospital.
Remember:
A competent adult is
defined as one who is lucid
and capable of making an
informed decision.
protocol.
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
Confidentiality
Do not speak to the press, your family, friends or other members of the public about
details of the emergency care you provided to a patient.
Releasing confidential information requires a written release form signed by the
patient or a legal guardian.
Instances when an EMT-B is allowed to release confidential information:
Another health care provider needs to know the information to continue medical
care;
Special Situations
Donors and Organ Harvesting
A legal signed document is required, such as a signed donor care sticker affixed to a
drivers licence or an organ donor card.
To provide assistance in organ harvesting:
1. Identify the patient as a potential donor.
2. Communicate with medical direction regarding the possibility of organ
donation.
3. Provide emergency care that will maintain the vital organs.
Dying and Deceased Patients
If the person is obviously dead, you may be required to leave the body at the scene if
there is any possibility that the police will have to investigate.
In other situations, you may be required to arrange for transport of the body so that a
physician can officially pronounce the patient dead.
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Emergency Medical Technician Basic
Crime Scenes
General guidelines - a potential crime scene is any scene that may require police
support.
If you suspect a crime is in progress or a criminal is still active at a scene, do not
attempt to provide care to any patient. Try to avoid any item at the scene that may
be considered evidence.
Basic Guidelines for the EMT at a Crime Scene
If the crime is rape, do not wash the patient or allow the patient to wash,
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Emergency Medical Technician Basic
The EMT Code of Ethics was written by Dr. Charles Gillespie and adopted by the
National Association of EMTs in 1978.
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Emergency Medical Technician Basic
Chapter 4:
Ambulance
Vehicles
Equipment
Outline
Introduction
Cleanliness
Emergency Driving
Ambulance Hygiene
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Emergency Medical Technician Basic
and
Introduction
lightweight materials and increased safety features. Ambulances now are often
equipped with GPS and computer dispatch systems. Ambulances are equipped
according to their role - basic transport, Intermediate Life Support (ILS), Advanced Life
Support (ALS), or Mobile Intensive Care Unit (MICU).
Ambulance vehicle designations in the USA are governed by federal laws and
standards.
A drivers compartment.
Equipment and supplies for emergency care at the scene as well as during
transport.
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Emergency Medical Technician Basic
TYPE III AMBULANCE - a cutaway van with integrated modular ambulance body.
run. Due to the high cost factor, HEMS units are usually run on a regional or national
basis as opposed to local operations.
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Emergency Medical Technician Basic
Duties of Driver
Check all fluid levels fuel, engine oil, radiator coolant, automatic transmission fluid,
battery water levels before starting the vehicle. Also check for leaks under the vehicle.
Check lights headlights, taillights, direction indicators, rotators, flashers, sirens, etc.
When checking the vehicle it is important to remember that the most engine wear occurs
during the first 30 seconds after start up, before the oil is circulated through the engine. DO
NOT rev the engine immediately on or after start up.
It is also important to remember that diesel engines with a turbo need to idle before shut
down. NEVER rev a turbo engine before turning off the ignition, as it can cause damage to
the turbo bearings, loss of power and shorten the life of the engine.
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Emergency Medical Technician Basic
Duties of Attendant
Check equipment according to the checklist, making sure that all the equipment is
complete and in good working order.
Check oxygen cylinders are full, and that gauges and flowmeters are working.
Make sure batteries are charged for any battery powered equipment such as ECG
monitors, pulse oximeters, etc.
Make sure that the patient compartment, equipment and supplies are clinically
clean and thoroughly hygienic.
Make sure that you know exactly how each item of equipment works, and the
trouble-shooting procedures for that item of equipment.
Cleanliness
Cleanliness of the vehicle, both inside and out serves two purposes. The first is that a
clean vehicle portrays a professional image. The second and more important function is
to ensure that both the crew and patients are protected from the transmission of
infection and communicable diseases by contaminated surfaces, linen, equipment, etc. It
is vitally important to clean the interior surfaces with approved disinfectants, as a surface
which appears clean, can harbour bacteria and viruses.
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Emergency Medical Technician Basic
Ambulance equipment
Personnel
2. Dispatch
Location of call.
Nature of call.
4. At the scene.
8. Post run.
Emergency Driving
Emergency Driving Privileges
Exceed the posted speed limit for the area as long as you are not
endangering lives or propery.
Drive the wrong way down a one-way street or drive down the opposite side
of the road.
Lights should be used even when you are not using the siren.
Ambulance emergency lights should be high enough to cast a beam above the
traffic.
Ambulance Hygiene
After every call
Strip used linens from the stretcher and place them in a plastic bag or designated
receptacle.
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Emergency Medical Technician Basic
Air out the ambulance with all doors and windows open for 15 minutes.
Scrub again with germicidal solution, then air out again to let everything dry.
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Emergency Medical Technician Basic
Chapter 5:
Medical Terminology in
EMS
Outline
Anterior
Posterior
Superior
Inferior
Medial
Lateral
Proximal
Distal
Internal
Inside
External
Outside
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Emergency Medical Technician Basic
Superficial
Deep
Standing upright
Recumbent
Lying down
Supine
Lying face up
Prone
Lateral
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Emergency Medical Technician Basic
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Emergency Medical Technician Basic
GU Genitourinary
GYN Gynecologic
H
h, hr. Hour
H/A Headache
HEENT Head, ears, eyes, nose, throat
Hg Mercury
h/o History of
hs At bedtime
HTN Hypertension
Hx History
I
ICP Intracranial pressure
ICU Intensive Care Unit
IM Intramuscular
IO Intraosseous
J
JVD Jugular venous distension
K
KVO Keep vein open
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Emergency Medical Technician Basic
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
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Emergency Medical Technician Basic
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.h. Every hour
q.i.d. 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
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Emergency Medical Technician Basic
stat. immediately
SVT Supraventricular tachycardia
T
TIA Transient ischemic attack
t.i.d. Three times a day
TKO To keep open
V
V.S. Vital signs
X
x Times
W
w/o or s without
WNL Within normal limits
Y
y/o or y.o. Years old
Symbols
change
+ Positive
- Negative
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Emergency Medical Technician Basic
Chapter 6:
Infection Control and the
EMT
Outline
Overview
The Chain of Infection
Stages of Infection
Methods of Transmission
Defenses against Infection
Diseases That Pose A Threat To EMS Workers
Body Substances Isolation (BSI)
Exposure Control Plan
Reservoirs Portals of Exit
Susceptible Defenses of a Susceptible Host
Hand Washing
Recommended Use of Personal Protective Equipment by Situation
Overview
Infection Control
Procedures to reduce infection in patients and health care personnel.
Infection
The growth of an organism in a susceptible host with or without signs and
symptoms of illness.
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Emergency Medical Technician Basic
Communicable Disease
Any disease that can be spread from one person to another or to a person
from contaminated objects.
Stages of Infection
Incubation Period
Interval between entrance of pathogen into body and appearance of first symptoms (e.g.,
chickenpox, 2-3 weeks; common cold, 1-2 days; influenza, 1-3 days; mumps, 15-18 days).
Prodromal Stage
Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to
more specific symptoms (during this time, microorganisms grow and multiply, and client may
be more capable of spreading disease to others).
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Emergency Medical Technician Basic
Illness Stage
Interval when client manifests signs and symptoms specific to type of infection (e.g., common
cold manifested by sore throat, sinus congestion, rhinitis; mumps manifested by earache, high
fever, parotid and salivary gland swelling).
Convalescence
Interval when acute symptoms of infection disappear (length of recovery depends on severity of
infection and clients general state of health; recovery may take several days to months).
Methods of Transmission
Direct contact
Normal flora
Inflammation
HIV
Hepatitis B and C
Tuberculosis
Syphilis
Meningitis
Rabies (Philippines)
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Emergency Medical Technician Basic
Rabies
Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is
caused by a virus. Rabies infects domestic and wild animals, and is spread to people through
close contact with infected saliva (via bites or scratches). The disease is present on nearly every
continent of the world but most human deaths occur in Asia and Africa (more than 95%). Once
symptoms of the disease develop, rabies is fatal.
Rabies is widely distributed across the globe. More than 55 000 people die of rabies each year.
About 95% of human deaths occur in Asia and Africa.
Wound cleansing and immunizations, done as soon as possible after suspect contact with an
animal and following WHO recommendations, can prevent the onset of rabies in virtually 100%
of exposures. Once the signs and symptoms of rabies start to appear, there is no treatment and
the disease is almost always fatal.
Hepatitis B
Hepatitis B is the most common serious liver infection in the world. It is caused by the hepatitis
B virus (HBV) that attacks the liver. This disease is more infectious than AIDS because it is very
easily transmitted by blood, a single virus particle can cause disease. It is transmitted through
infected blood and other body fluids like seminal fluid, vaginal secretions, breast milk, tears,
saliva and open sores. Once infected with the hepatitis B virus, approximately 10% of the people
develop a chronic permanent infection. It is very common in Asia, Africa and the Middle East.
The overall incidence of reported Hepatitis B is 2 per 10,000 individuals, but the true incidence
may be higher, because many cases do not cause symptoms and go undiagnosed and
unreported.
Tuberculosis
Left untreated, each person with active TB disease will infect on average between 10 and 15
people every year. But people infected with TB bacilli will not necessarily become sick with the
disease. The immune system walls off the TB bacilli which, protected by a thick waxy coat, can
lie dormant for years. When someones immune system is weakened, the chances of becoming
sick are greater.
Someone in the world is newly infected with TB bacilli every second.
Overall, one-third of the worlds population is currently infected with the TB bacillus.
Globally, the Philippines rate of TB infection is ninth among 22 high burden countries and ranks
third in the Western Pacific region (WHO, 2004).
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Emergency Medical Technician Basic
Meningitis
Meningitis is inflammation of the thin tissue that surrounds the brain and spinal cord, called
the meninges. There are several types of meningitis. The most common is viral meningitis,
which you get when a virus enters the body through the nose or mouth and travels to the
brain. Bacterial meningitis is rare, but can be deadly. It usually starts with bacteria that cause a
cold-like infection. It can block blood vessels in the brain and lead to stroke and brain
damage. It can also harm other organs.
Meningitis is more common in people whose bodies have trouble fighting infections.
Meningitis can progress rapidly. Symptoms include:
sudden fever
severe headache
stiff neck
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Emergency Medical Technician Basic
Determination of Exposure - this area should define who is at risk at comining in contact with
blood or body fluids.
Education and Training - this area should explain why a qualified individual has to answer
questions about CD and why infection control is required
Hepatitis Vaccination Program - outlines the immunization schedules for EMT personnel.
Personal Protective Equipment - should list the PPE and should be of good quality.
Changing and Disinfection Practices - should describe how to care for and maintain vehicle
and equipment.
Post-Exposure Management - should identify who to notify when you believe you have been
exposed.
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Feces
Vomitus
Nasal Secretions
Sputum
Gastro-Intestinal Tract
Urinary Tract
Reproductive Tract
Blood
mucous membrane
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Immunization
The immunologic system is a major defense against infection.
Nutrition
Adequate nutrition enhances the health of all body tissues, helps keep the skin intact
and promotes the skins ability to repel microorganisms.
Fluid
Adequate fluid intake flushes the bladder and urethra
Rest and Sleep
Adequate rest and sleep are essential to health and preserving energy.
Stress
Predisposes people to infection.
Protective eyewear
Cover gown
Ventilatory equipment
Handwashing
Purposes:
1. To reduce the number of microorganisms onto the hands.
2. To reduce the risk of transmission of infectious organisms to ones self.
3. To reduce the risk of transmission of microorganisms and cross-contamination
to patients
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Disposable
Gloves
Yes
Gown
Mask
Yes
Yes
Protective
Eyewear
Yes
Bleeding control
with minimal
blood
Yes
No
No
No
Emergency
childbirth
Yes
Yes
Yes, if splashing
is likely
Yes, 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, unless
splashing is
likely
No, unless
splashing is
likely
Oral/nasal
suctioning,
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
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
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Chapter 7:
Anatomy for EMTs
Outline
Body Organization
Anatomical Planes and Directions
Metabolism
Skeletal System
Circulatory System
Respiratory System
Nervous System
Muscular System
Body Cavities
The Abdomen
Body Organization
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Metabolism
Metabolism refers to the chemical and energy transformations which occur in the body.
In the human body, carbohydrates, proteins and fats are oxidised to produce CO2, H2O
and form available energy (adenosine triphosphate - ATP) which is essential for life
processes.
At the cellular level, the production of energy takes place in the mitochondria when
oxygen and pyruvate are combined.
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Aerobic Metabolism
In aerobic metabolism, there is sufficient oxygen entering the cell to react with and convert the
available pyruvate into ATP.
Anaerobic Metabolism
In anaerobic metabolism, there is no oxygen or insufficient oxygen entering the cell and little or
no utilisation of pyruvate. The remaining pyruvate converts into lactic acid and cellular acidosis
occurs, invariably leading to cell damage or death. As little as 10% of ATP is produced during
anaerobic metabolism.
Skeletal System
The skeletal system can be divided into two parts: the axial skeleton and the
appendicular skeleton
The Spine
The spine supports the skull and gives attachment to the ribs. It is a column of 33 irregular
bones called vertebrae.
Discs of cartilage between the vertebrae:
prevent friction
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The heart
Blood vessels
Blood
Pump
Pipes
Fluid
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60 to 100 bpm
Children
70 to 150 bpm
Infants
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The wave of blood through the arteries formed when the left ventricle contracts.
Can be felt where an artery passes near the skin surface and over a bone.
Blood Pressure
Perfusion
Blood Vessels
There are five types of blood vessels:
Arteries
Arterioles
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Veins
Venules
Capillaries
Arteries carry blood away from the heart. The blood is moved along by the heartbeat and
the artery walls. Arteries have a strong outer wall and a thick muscle layer to withstand
high pressure.
Veins carry blood to the heart by the action of the surrounding muscles and by the suction
of the heart. Veins have thinner walls and are provided with valves, to stop the blood
flowing in the wrong direction.
Arterioles and venules dilate or contract to control the blood flow into and out of the
capillary bed.
Capillaries allow for the interchange of gases and the transfer of nutrients and waste
products. Capillaries have very thin walls consisting of a single layer of cells only. They are
semi-permeable to permit the passage of substances between the blood and the tissues.
Respiratory System
Extracts oxygen from the atmosphere and transfer it to the bloodstream in the lungs
Adults
12 to 20 breaths/min
Children
15 to 30 breaths/min
Infants
25 to 50 breaths/min
Inspired Air
The air we breathe in contains approximately:
79% nitrogen
20% oxygen
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1% inert gases
Expired Air
The air we breathe out contains approximately:
79% nitrogen
16% oxygen
4% carbon dioxide
1% inert gases
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Exchange of Gases
External respiration
takes place in the lungs. Oxygen from inhaled air is absorbed into the blood via the
capillaries of the lung. Carbon dioxide is released from the blood into the lungs and
is exhaled.
Internal respiration
The Diaphragm
Dome-shaped muscle
Mechanisms of Breathing
Inhalation
Diaphragm and intercostal muscles contract, increasing the size of the thoracic
cavity.
Exhalation
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Airway smaller
The Brain
The brain is the highest level of the nervous system and is continuous with the spinal
cord. It is divided into three main parts:
Cerebrum
sensory centres receive sensory signals from the skin, muscles, bones and joints.
control of the autonomic nervous system is buried deep in the cerebrum, in the
thalamus and hypothalamus
Cerebellum
responsible for the maintenance of balance, muscle coordination and muscle tone.
Brainstem
the nerve connections of the motor and sensory systems from the main part of the
brain to the rest of the body pass through the brain stem.
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Sensory nerves carry information from the body to the central nervous system.
Motor nerves carry information from the central nervous system to the muscles of
the body.
Nerves
There are four types of nerves:
1. Cranial nerves connect the sense organs (eyes, ears, nose, mouth) to the brain.
2. Central nerves connect areas within the brain and spinal cord.
3. Peripheral nerves connect the spinal cord with the limbs.
4. Autonomic nerves connect the brain and spinal cord with the organs (heart, stomach, intestines,
blood vessels, etc.).
Muscular System
3. Cardiac muscle
Involuntary muscle.
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Can tolerate interruptions of blood supply for only very short periods.
Body Cavities
The Abdomen
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Chapter 8:
Health, Hygiene, Fitness
and Safety of the EMT
Outline
Physically fit - should be in good health and fit to carry out duties.
Nutrition - to perform efficiently, an EMT should eat nutritious food to fuel the
body and make it run. Physical exertion and stress are part of an EMTs job and
require high energy output.
Exercise and relaxation - a regular program of exercise will enhance the benefits of
maintaining nutrition and adequate hydration.
Balancing work, family and health - as an EMT you will often be called to assist the
sick and the injured any time of the day or night. Shift work may be required to be
apart from loved ones for long periods of time. Never let the job interfere
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excessively with your own needs. Find a balance between work and family. Make sure that you
have the time that you need to relax with family and friends.
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Body Mechanics
The efficient coordinated and safe use of the body to produce motion and maintain
balance during activity.
Proper movement promotes body musculoskeletal functioning, reduces the energy
required for a task, and maintains balance, thereby reducing fatigue and decreasing the
risk of injury.
Three Basic Elements of Body Mechanics
1. Body Alignment (Posture) - when the body is well-aligned, balance is achieved
without undue strain on the joints, muscles, tendons or ligaments. Proper body
alignment also enhances lung expansion and promotes efficient circulatory,
renal and gastrointestinal function.
2. Balance (Stability) - good body alignment is essential to body balance. A person
maintains balance as long as the line of gravity passes through the centre of
gravity and the base of support.
3. Coordinated Body Movement - body mechanics involves the integrated
functioning of the musculoskeletal and nervous system as well as joint mobility.
when sitting, keep your knees slightly higher than your hips.
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Avoid twisting the spine by pushing or pulling an object, directly away from or
toward the body and squarely facing the direction of movement.
When lifting objects, distribute the weight between the large muscles of the
arms and legs.
5. Wear clothing that allows you to use good body mechanics and wear comfortable
low-heeled shoes that provide good foot support and will not cause you to slip,
stumble and turn your ankle.
One in four EMS workers will suffer a career ending back injury within the first 4
years of service. The number one physical reason for leaving EMS, (mytactical.com,
EMS Back Injury Facts, 2007).
Back injury from improper lifting is the number one injury suffered by pre-hospital
care providers, according to New Mexicos EMT training manual.
Almost one in two workers(47%) have sustained a back injury while performing
EMS duties, (National Association of Emergency Medical Technicians, 2005).
Average cost for a simple sprain or strain of the lumbar spine is approximately
US$18,365 in direct costs per occurrence, (Mitterre D., Back Injuries in EMS, EMS
Magazine, 1999).
Lifting caused just over 62% of back injuries for EMTs, and low back strain was the
cause of 78% of the compensation days in a 3.5 year period, (Hogya PT, Ellis L.,
University of Pittsburgh Affiliated Residency in Emergency Medicine, PA, 1990).
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Chapter 9:
Patient Assessment
Outline
Overview
Purpose of Patient Assessment
Scene Size-Up
Body Substances Isolation
Scene Safety
Number of Patients
Additional Resources
Mechanism of Injury (MOI)
Nature of Illness (NOI)
Cervical-Spine Immobilization
Initial Assessment
Baseline Vital Signs
Priority Patients
Transport Decisions
Trauma Assessment
Focused Physical Examination
Significant Mechanism of Injury
Patient Assessment Definitions
OPQRST
The Full Assessment
Overview
Scene size-up
Initial assessment
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Vital signs
History
Ongoing assessment
To determine whether the patient has suffered trauma or has a medical complaint.
To determine further assessment and care on the scene vs immediate transport with
assessment and care continuing en route.
Scene Size-Up
Inspection of scene
Scene hazards
Safety concerns
Mechanism of injury
Number of patients
Protective equipment:
Eye protection
Mask
Gown
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Scene Safety
Potential hazards
Oncoming traffic
Unstable surfaces
Leaking gasoline
Fire or smoke
Hazardous materials
Crime scenes
Number of Patients
Additional Resources
Medical resources
Additional units
Nonmedical resources
Fire suppression
Rescue
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Law enforcement
Cervical-Spine Immobilization
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Initial Assessment
1. Develop a general impression.
2. Assess mental status.
3. Assess airway.
4. Assess the adequacy of breathing.
5. Assess circulation.
6. Identify patient priority.
Forming a General Impression
Airway
Breathing
Circulation
Airway
Look for signs of airway compromise:
Labored breathing
Breathing
Look for:
Choking
Rate
Depth
Cyanosis
Lung sounds
Air movement
Circulation
Assessing the pulse:
Presence
Rate
Rhythm
Strength
Controlling bleeding
Direct pressure
Elevation
Pressure points
Assessing perfusion:
Color
Temperature
Skin condition
Capillary refill
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12-20 breaths/min
Children
15-30 breaths/min
Infants
25-50 breaths/min
Breathing checklist:
Normal
Shallow
Laboured
Noisy
Increased breathing
Snoring, wheezing,
effort. Use of
gurgling and
accessory muscles;
grunting noises
Regular
Irregular
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Effort
Depth
Shallow
Normal
Deep
Pulse checklist:
Normal ranges for pulse rates:
Adult
Children
Toddlers
90-150 beats/min
Newborn
120-160 beats/min
Weak
Normal
Strong
Quality
Slow
Normal
Rapid
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Rhythm
Regular
Irregular
Skin
Color
Pale/grey/waxy
Blue/grey
Red/flushed
Temperature
Cold
Cool
Normal
Shock, hypothermia
Hot
Hyperthermia, fever,
sunburn
Moisture
Dry/Normal
Moist
Wet
Early Shock
Shock
Normal
CRT>2 secs
Blood Pressure
Loss of blood
Blood pressure should be measured in all patients older than 3 years of age.
Children (1-8)
50 to 90 mmHg (s)
Systolic pressure
Diastolic pressure
Pulse pressure
BP by Auscultation
BP by Palpation
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Level of Responsiveness
A
Pupil Response
P - Pupils
E - Equal
A - And
R - Round
R - Regular in size
L - React to Light
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Priority Patients
Stay and Play vs. Scoop and Run
Difficulty breathing
Complicated childbirth
Uncontrolled bleeding
Severe pain
Transport Decisions
Patient condition
Distance to transport
Local protocols
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During the Rapid Trauma Assessment, the EMT is looking for signs of:
D
Deformities
Contusions
Abrasions
Punctures/Penetrations
Burns
Tenderness
Lacerations
Swelling
Remember:
DCAP - BTLS
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Allergies
Medications
Remember:
SAMPLE
Chest
Abdomen
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Pelvis
Extremities
Assess PMS:
Pulse
Motor function
Sensory function
Posterior Body
Vehicle rollover
High-speed collision
Vehicle-pedestrian collision
Motorcycle crash
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Assessment Summary
Assessment Steps for Significant MOI
Focused assessment
SAMPLE history
SAMPLE history
History of illness
SAMPLE history
Focused assessment
SAMPLE history
Vital signs
Ongoing Assessment
condition?
better? Worse?
Check interventions.
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Scene Size-Up
Initial Assessment
The process used to identify and treat lifethreatening problems, concentrating on Level of
Consciousness, Cervical Spinal Stabilization, Airway,
Breathing, and Circulation. 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.
Focused History
and Physical
Exam
Rapid Trauma
Assessment
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to quickly identify existing or potentially lifethreatening conditions. You will perform a head to
toe rapid assessment using DACP-BTLS, obtain a
baseline set of vital signs, and perform a SAMPLE
history
This is used for patients, with no significant
mechanism of injury, that have been determined to
have no life-threatening injuries. This assessment
Focused History
and Physical
Exam - Trauma
Focused History
and Physical
Exam - Medical
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with
significant
mechanism
of
injury,
Ongoing
Assessment
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OPQRST
Used to assess a patients chief complaint during a medical exam.
O
Onset
Provocation
Quality
Radiation/Region
Severity
Time
OPQRST Explained
Onset
The word onset should trigger questions regarding what the patient was doing just
prior to and during the onset of the specific symptom(s) or chief complaint.
What were you doing when the symptoms started?
Was the onset sudden or gradual?
It may be helpful to know if the patient was at rest when the symptoms began or if they
were involved in some form of activity. This is especially true with patients presenting
with suspected cardiac signs & symptoms.
Provocation
The word provocation should trigger questions regarding what makes the symptoms
better or worse.
Does anything you do make the symptoms better or relieve them in any way?
Does anything you do make the symptoms worse in any way?
This is sometimes helpful in ruling in or out a possible musculoskeletal cause. A patient
with a broken rib or pulled muscle will most likely have pain that is easily provoked by
palpation and/or movement. This is often in contrast to the patient having chest pain of
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a cardiac origin whose pain is not made any better or worse with movement or
palpation.
Quality
The word quality should trigger questions regarding the character of the symptoms
and how they feel to the patient.
Can you describe the symptom (pain/discomfort) that you are having right now?
What does it feel like?
Is it sharp or dull?
Is it steady or does it come and go?
Has it changed since it began?
This if often the most difficult question for the patient to understand and to articulate.
The key here is to allow the patient to use their own words and not try to feed the
patient with suggestions that they may choose simply because you have made it easy. It
is sometime helpful to offer the patient choices and allow them to decide which is most
appropriate for their situation. For instance, is your pain sharp or is it dull or is your
pain steady or does it come and go?
Region/Radiation
The words region and radiation should trigger questions regarding the exact location
of the symptoms.
Can you point with one finger where it hurts the most?
Does the pain radiate or move anywhere else?
Although it is not always easy for a patient to identify the exact point of pain, especially
with pediatric patients, it is important to ask. Asking if they can point with one finger to
where it hurts the most is a good start. From there you will want to know if the pain
moves or radiates anywhere from the point of origin. The patient may need you to
offer some suggestions such as, does the pain radiate anywhere else such as your back,
neck, jaw or shoulders? Always give them two or three choices and allow them to select
from the options that you give.
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Severity
The word severity should trigger questions relating to the severity of the symptoms.
On a scale of 1 to 10, how would you rate your level of discomfort right now?
Using the same scale, how would you rate your discomfort when it first began?
Its not always just about how bad the pain or discomfort is when you arrive - this is a
common mistake made by many new EMTs. Once you have established the level of
discomfort that the patient is experiencing at that moment, you must follow this up with
how severe the discomfort was at onset. This will help you establish whether the
discomfort is getting better, worse or staying the same over time. You will want to
follow these two checkpoints up with an additional check once the patient has received
some of your care and reassurance. Often times with a little oxygen and reassurance the
symptoms may subside. Ask the patient a few minutes later how the discomfort is and if
it has changed at all since your arrival.
Time
The word time should trigger questions relating to the when the symptoms began.
When did the symptoms first begin?
Have you ever experienced these symptoms before? If so, when?
Establishing an accurate duration of the symptoms will be very helpful to the hospital
staff that will be caring for the patient. This question has special importance when caring
for patients presenting with suspected cardiac signs and symptoms.
Ensure BSI (Body Substance Isolation) procedures and & personal protective gear is
being used.
Observe scene for safety of crew, patient, bystanders. Identify the mechanism of injury
or nature of illness.
Determine the need for additional resources including Advanced Life Support.
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INITIAL ASSESSMENT
Assessment & treatment (life-threats)
General Impression
Find and treat life threatening conditions (any obvious problems that may
kill the patient within seconds). Problems with Airway, Breathing, or
Circulation
Mental Status
Airway
Suction - as needed
Breathing
Quickly inspect the chest for impaled objects, open chest wounds, and
bruising (trauma).
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Quickly palpate the chest for unstable segments, crepitation (trauma), and equal
expansion of the chest.
If the pt. is unresponsive and breathing is inadequate, use a BVM to maintain pulse
oximetry at 94% or above.
Circulation
If the pt. is unresponsive, assess for presence and quality of the carotid pulse.
If the pt. is responsive, assess the rate and quality of the radial pulse.
Assess the patients perfusion by evaluating skin for color, temperature and condition
(CTC);
Cover with blanket and elevate the legs as needed for shock (hypoperfusion)
Is the patient:
Critical?
Unstable?
Potentially Unstable?
Stable?
In addition, perform the rapid trauma assessment for the trauma patient if he/she has
significant mechanism of injury and apply spinal immobilization as needed.
For the unresponsive medical patient perform the rapid medical assessment.
If the patient is or STABLE, perform the appropriate focused physical exam (for the
medical pt. perform the focused physical exam; for trauma patient perform the focused
trauma assessment.)
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DCAP-BTLS
NECK
DCAP-BTLS
Crepitation
CHEST
DCAP-BTLS
Paradoxical movement
Crepitation
ABDOMEN
DCAP-BTLS
Pain
Firm
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Soft
Distended
PELVIS
DCAP-BTLS
EXTREMITIES
DCAP-BTLS
Crepitation
Distal pulses
Sensory function
Motor function
POSTERIOR
DCAP-BTLS
The specific injury they are complaining about why they called EMS
Assess and treat injuries not found during your Initial Assessment
Focused Assessment
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Respirations
Pulse
Blood Pressure
Level of Consciousness
Skin
Pupils
Allergies
Medications
Respirations
RATE:
QUALITY:
Normal
Shallow
Labored?
Deep
Noisy breathing?
Pulse
RATE:
Check the radial pulse. If pulse is regular, count for 30 seconds and multiply x 2. If it is irregular,
count for a full 60 seconds.
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QUALITY:
Regular
Strong
Irregular
Weak
Skin (CTC)
COLOUR:
Normal (unremarkable)
Cyanotic
Pale
Flushed
Jaundice
TEMPERATURE:
Warm
Hot
Cool
Cold
CONDITION:
Wet
Dry
Blood Pressure
Auscultate the blood pressure. In a high noise environment, palpate (only the systolic
reading can be obtained).
Pupils
Use a penlight to check reactivity of the pupils; also assess for size
equal or unequal
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Severity - How bad is the pain? How would you rate the pain on a scale of 1-10,
with 10 being the worst pain youve felt in your life?
Assess SAMPLE
Examples of questions to ask a conscious medical patient and assessment elements
according to the patients chief complaint
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 When exposed/ingested
o Environment
o Determine if suicidal:
o Amount
o Duration
o Time period
o Loss of consciousness
o Interventions
o Effects-general or local
Have you been feeling like killing
yourself?
o Estimated weight
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Obstetrics
Acute Abdomen
Loss of Consciousness
o Location of pain
o Position
o Pain or contraction
o Bleeding or discharge
o Has your water broke?
o Do you want to push?
o History
o Blood in vomit or stool
o Trauma
o Incontinence
o Abnormal vital signs
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of lesser priority than life threats and/or signs of injury that have worsened. Do not delay
transport to perform a detailed physical exam; it is only performed while en route to the
hospital or while waiting for transport to arrive.
Detailed Physical Exam Trauma or Medical
The Detailed Physical Exam is used to gather additional information regarding the patients
condition only after you have provided interventions for life threats and serious conditions.
Not all patients will require a Detailed Physical Exam. It is performed in a systematic head-totoe order. You will examine the same body areas that you examined during your rapid
assessment. During the detailed physical exam, you will look more closely at each area to
search for findings of lesser priority than life threats and/or signs of injury that have
worsened. Do not delay transport to perform a detailed physical exam; it is only performed
while en route to the hospital or while waiting for transport to arrive.
HEAD - inspect and palpate for signs of injury.
DCAP-BTLS
Blood & fluids from the head
FACE - inspect and palpate for signs of injury.
DCAP-BTLS
EARS - inspect and palpate for signs of injury.
DCAP-BTLS
Drainage (blood or any other fluid)
EYES - inspect for signs of injury.
DCAP-BTLS
Discoloration
Unequal Pupils
Foreign Bodies
Blood in Anterior Chamber
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ON-GOING ASSESSMENT
The On-Going Assessment will be performed on all patients while the patient is being
transported to the hospital. It is designed to reassess the patient for changes that may require
new intervention. You will also evaluate the effectiveness of earlier interventions, and reassess
earlier significant findings. You should be prepared to modify treatment as appropriate and
begin new treatment on the basis of your findings during the On-Going Assessment.
Repeat Initial Assessment
Reassess mental status.
Maintain an open airway.
Monitor breathing for rate and quality.
Reassess pulse for rate and quality.
Monitor skin color and temperature (CTC).
Re-establish patient priorities.
Reassess and Record Vital Signs
Repeat Focused Assessment
Check Interventions
Assure adequacy of oxygen delivery/artificial ventilation.
Assure management of bleeding.
Assure adequacy of other interventions
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Chapter 10:
Communication and
Documentation
Outline
Overview
Types of Communication in EMS
Emergency Medical Dispatch
Response Times
Dispatch Life Support
EMT Communication
Triage
Verbal Communication
Communicating with Patients
Documentation
The Pre-hospital Care Report/Patient Care Report
Documenting Refusal
Special Reporting Situations
Overview
Essential components of pre-hospital care:
Verbal communications are vital.
Adequate reporting and accurate records ensure continuity of patient care.
Reporting and record keeping are essential aspects of patient care.
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Others
Simplex
- Push-to-talk communication
Duplex
- Simultaneous talk-listen
MED channels
- Reserved for EMS
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Response Times
Most countries have adopted a response time of 8 to 10 minutes for the most critical
cases, and a longer response time for non-acute calls.
Toronto, Canada
Within 9 minutes in 90% of critical, life-threatening and serious cases; and within 21
minutes in 90% of non-acute cases.
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London, UK
Within 8 minutes in 75% of immediately life-threatening cases; no target set for
cases that are not serious or life-threatening.
Queensland, Australia
Within 10 minutes in 68% of Emergency Transport cases; no target set for nonurgent cases.
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EMT Communication
EMT Communication with Dispatch
Advise of arrival.
The physician bases his or her instructions on the report received from the
EMT-B.
Do not blindly follow an order that does not make sense to you - ask the
physician to clarify his or her orders.
Reporting Requirements
Patient Report
Chief complaint
Physical findings
Triage
Triage Priorities
Triage is the sorting of patients according to the urgency of their need for care.
It occurs both in the field and at the hospital.
Priority One (Highest)
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Priority Two
Priority 3 (Lowest)
Verbal Communication
You must be able to find out what the patient needs and then tell others.
You are a vital link between the patient and the health care team.
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If the patient is hearing impaired, speak clearly and face him or her.
Allow time for the patient to answer questions.
Act and speak in a calm, confident manner.
Never shout!
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Documentation
Minimum Data Set for Written Documentation
Patient information:
Chief complaint
Mental status
Pulse
Continuity of care
Legal documentation
Education
Administrative
Research
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Written forms
Computerized versions
Spell correctly.
Reporting Errors
Remember:
Gunshot wounds
Animal bites
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Chapter 11:
Airway Management
Outline
Anatomy Review
Normal Breathing Rates
Recognizing Adequate Breathing
The Patent Airway
Recognizing Inadequate Breathing
Hypoxia
Different Types of Abnormal Respirations
Abnormal Lung Sounds
Conditions Resulting in Hypoxia
Opening the Airway
Assessing the Airway
Suctioning
Basic Airway Adjuncts
Ventilation Devices
Oxygen Therapy
Article: 10 Things Every Paramedic Should Know About
Capnography
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Anatomy Review
Child
Infant
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Regular pattern
Adequate depth
Cardiac irritability
Irregular rhythm
Hypoxia
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Signs of Hypoxia
Tachycardia
HYPERNEA - respirations are increased in depth and rate (occurs normally with
exercise).
produced are created when air is forced through respiratory passages that are
narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation
or infection of the small bronchi, bronchioles, and alveoli. Crackles that dont clear
after a cough may indicate pulmonary edema or fluid in the alveoli due to heart
failure or adult respiratory distress syndrome (ARDS).
Fine crackles are soft, high-pitched, and very brief. You can simulate this
sound by rolling a strand of hair between your fingers near your ear, or by
moistening your thumb and index finger and separating them near your
ear.
Coarse crackles are somewhat louder, lower in pitch, and last longer than
fine crackles. They have been described as sounding like opening a Velcro
fastener.
Wheezes
Wheezes are sounds that are heard continuously during inspiration or expiration,
or during both inspiration and expiration. They are caused by air moving through
airways narrowed by constriction or swelling of airway or partial airway
obstruction.
Wheezes that are relatively high pitched and have a shrill or squeaking
quality may be referred to as sibilant rhonchi. They are often heard
continuously through both inspiration and expiration and have a musical
quality. These wheezes occur when airways are narrowed, such as may
occur during an acute asthmatic attack.
Stridor
Stridor refers to a high-pitched harsh sound heard during inspiration. Stridor is
caused by obstruction of the upper airway, is a sign of respiratory distress and
thus requires immediate attention.
If abnormal lungs sounds are heard, it is important to assess:
their loudness.
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Myocardial infarction
Pulmonary edema
Smoke inhalation
Stroke
Chest injury
Shock
Lung disease
Asthma
Premature birth
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1. Look
2. Listen
3. Feel
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Suctioning
Suctioning of a patients airway may be necessary when:
Suctioning Technique
Check the unit and turn it on.
Select and measure proper catheter to be used.
Open the patients mouth and insert tip.
Suction as you withdraw the catheter.
Never suction adults for more than 15 seconds.
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Nasopharyngeal Airways
Used on conscious patients who cannot maintain airway
Can be used with intact gag reflex
Should not be used with head injuries or nosebleeds
Inserting a nasopharyngeal airway
1. Select the proper size airway.
2. Lubricate the airway.
3. Gently push the nostril open.
4. With the bevel turned toward the septum, insert the airway.
Airway Kits
Basic airways
Advanced airways
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Ventilation Devices
The EMT is equipped with a range of devices to assist ventilation. Some of these
devices are not authorized for use by EMT-Bs, but the EMT-B may be called upon to
assist with the use of these devices.
Pocket Mask
A pocket mask may be used to provide artificial ventilations when no other equipment
is available. Pocket masks may be disposable or reusable. Some pocket masks have a
nozzle for the attachment of oxygen tubing. A pocket mask should be equipped with a
one-way valve to prevent body fluids from transferring from the patient to the EMT.
Bag-Valve Mask
The bag-valve mask should be the EMTs primary method of delivering ventilations.
Supplemental oxygen may be attached to the bag-valve if needed. Bag-valve masks
can also be used in conjunction with airway adjuncts and advanced airways such as the
endotracheal tube. Three different sizes are available - adult, child and infant. The child
and infant BVM have a pressure valve to prevent overinflation of the lungs.
Ventilation Techniques
Mouth to Mask Technique
1. Kneel at patients head and open airway.
2. Place the mask on the patients face.
3. Take a deep breath and breathe into the patient for 1 1/2 to 2 seconds.
4. Remove your mouth and watch for patients chest to fall.
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Oxygen Therapy
Medical Oxygen
Oxygen is a colourless, odourless gas normally present in the atmosphere at
concentrations of approximately 21%.
The chemical symbol for the element oxygen is O. As a medicinal gas, oxygen contains
not less than 99.0% by volume of O2.
Whereas previously oxygen tended to be given to a majority of patients, research has led
to the prescription of oxygen when and as needed, using pulse oximetry and end-tidal
CO2 capnography to guide the EMT.
Pulse Oximeters
May give false readings with CO absorption because it cannot distinguish between
O2 and CO.
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Capnography
Capnography is increasingly being used by paramedics to aid in their assessment and
treatment of patients in the prehospital environment. These uses include verifying and
monitoring the position of an endotracheal tube. A properly positioned tube in the trachea
guards the patients airway and enables the paramedic to breathe for the patient. A
misplaced tube in the esophagus can lead to death.
A study in the March 2005 Annals of Emergency Medicine, comparing field intubations that
used continuous capnography to confirm intubations versus nonuse showed zero unrecognized misplaced intubations in the
monitoring group versus 23% misplaced tubes in the
unmonitored group. The American Heart Association (AHA)
affirmed the importance of using capnography to verify tube
placement in their 2005 CPR and ECG Guidelines.
The AHA also notes in their new guidelines that capnography,
which indirectly measures cardiac output, can also be used to
monitor the effectiveness of CPR and as an early indication of
return of spontaneous circulation (ROSC). Studies have shown
that when a person doing CPR tires, the patients end-tidal CO2
(ETCO2, the level of carbon dioxide released at the end of
expiration) falls, and then rises when a fresh rescuer takes over.
Other studies have shown when a patient experiences return of
spontaneous circulation, the first indication is often a sudden rise in the ETCO2 as the rush
of circulation washes untransported CO2 from the tissues. Likewise, a sudden drop in
ETCO2 may indicate the patient has lost pulses and CPR may need to be initiated.
Paramedics are also now beginning to monitor the ETCO2 status of nonintubated patients
by using a special nasal cannula that collects the carbon dioxide. A high ETCO2 reading in a
patient with altered mental status or severe difficulty breathing may indicate
hypoventilation and a possible need for the patient to be intubated.
Capnography, because it provides a breath by breath measurement of a patients
ventilation, can quickly reveal a worsening trend in a patients condition by providing
paramedics with an early warning system into a patients respiratory status. As more clinical
studies are conducted into the uses of capnography in asthma, congestive heart failure,
diabetes, circulatory shock, pulmonary embolus, acidosis, and other conditions, the
prehospital use of capnography will greatly expand.
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Note: Ventilation equals tidal volume X respiratory rate. A patient taking in a large tidal
volume can still hyperventilate with a normal respiratory rate just as a person with a small
tidal volume can hypoventilate with a normal respiratory rate.
Hypoventilation
When a person hypoventilates, their CO2 goes up.
Hypoventilation can be caused by altered mental status such as overdose, sedation,
intoxication, postictal states, head trauma, or stroke, or by a tiring CHF patient. Other
reasons CO2 may be high: Increased cardiac output with increased breathing, fever, sepsis,
pain, severe difficulty breathing, depressed respirations, chronic hypercapnia.
Some diseases may cause the CO2 to go down, then up, then down. (See asthma below).
Pay more attention to the ETCO2 trend than the actual number.
A steadily rising ETCO2 (as the patient begins to hypoventilate) can help a paramedic
anticipate when a patient may soon require assisted ventilations or intubation.
Heroin Overdoses Some EMS systems permit medics to administer narcan only to
unresponsive patients with suspected opiate overdoses with respiratory rates less than 10.
Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate.
ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow
ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a
respiratory rate of 8, but an ETCO2 of 35.
2. Confirming, Maintaining , and Assisting Intubation
Continuous end-tidal CO2 monitoring can confirm a tracheal intubation. A good wave
form indicating the presence of CO2 ensures the ET tube is in the trachea.
A 2005 study comparing field intubations that used continuous capnography to confirm
intubations versus non-use showed zero unrecognized misplaced intubations in the
monitoring group versus 23% misplaced tubes in the unmonitored group. -Silverstir,
Annals of Emergency Medicine, May 2005
Paramedics can attach the capnography filter to the ET tube prior to intubation and, in
cases where it is difficult to visualize the chords, use the monitor to assist placement. This
includes cases of nasal tracheal intubation.
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A recent study found the ETCO2 shot up on average 13.5 mmHg with sudden ROSC before
settling into a normal range
.-Grmec S, Krizmaric M, Mally S, Kozelj A, Spindler M, Lesnik B.,Resuscitation. 2006 Dec 8
Loss of Spontaneous Circulation
In a resuscitated patient, if you see the stabilized ETCO2 number significantly drop in a
person with ROSC, immediately check pulses. You may have to restart CPR.
4. End Tidal CO2 As Predictor of Resuscitation Outcome
End tidal CO2 monitoring can confirm the futility of resuscitation as well as forecast the
likelihood of resuscitation.
An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the
initiation of advanced cardiac life support accurately predicts death in patients with cardiac
arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may
reasonably be terminated in such patients. -Levine R, End-tidal Carbon Dioxide and
Outcome of Out-of-Hospital Cardiac Arrest, New England Journal of Medicine, July 1997
Likewise, case studies have shown that patients with a high initial end tidal CO2 reading
were more likely to be resuscitated than those who didnt. The greater the initial value, the
likelier the chance of a successful resuscitation.
No patient who had an end-tidal carbon dioxide of level of less than 10 mm Hg survived.
Conversely, in all 35 patients in whom spontaneous circulation was restored, end-tidal
carbon dioxide rose to at least 18 mm Hg before the clinically detectable return of vital
signs.The difference between survivors and nonsurvivors in 20 minute end-tidal carbon
dioxide levels is dramatic and obvious. ibid.
An ETCO2 value of 16 torr or less successfully discriminated between the survivors and
the nonsurvivors in our study because no patient survived with an ETCO2 less than 16 torr.
Our logistic regression model further showed that for every increase of 1 torr in ETCO2,
the odds of surviving increased by 16%. Salen, Can Cardiac Sonography and
Capnography Be Used Independently and in Combination to Predict Resuscitation
Outcomes?, Academic Emergency Medicine, June 2001
Caution: While a low initial ETCO2 makes resuscitation less likely than a higher initial
ETCO2, patients have been successfully resuscitated with an initial ETCO2 >10 mmHg.
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Hypoxic Drive
Capnography will show the hypoxic drive in COPD retainers. ETCO2 readings will steadily
rise, alerting you to cut back on the oxygen before the patient becomes obtunded. Since it
has been estimated that only 5% of COPDers have a hypoxic drive, monitoring capnography
will also allow you to maintain sufficient oxygen levels in the majority of tachypneic COPDers
without worry that they will hypoventilate.
CHF: Cardiac Asthma
It has been suggested that in wheezing patients with CHF (because the alveoli are still, for
the most part, emptying equally), the wave form should be upright. This can help assist your
clinical judgement when attempting to differentiate between obstructive airway wheezing
such as COPD and the cardiac asthma of CHF.
7. Ventilating Head Injured Patients
Capnography can help paramedics avoid hyperventilation in intubated head injured patients.
Recent evidence suggests hyperventilation leads to ischemia almost immediatelycurrent
models of both ischemic and TBI suggest an immediate period during which the brain is
especially vulnerable to secondary insults. This underscores the importance of avoiding
hyperventilation in the prehospital environment. Capnography as a Guide to Ventilation in
the Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004
Hyperventilation decreases intracranial pressure by decreasing intracranial blood flow. The
decreased cerebral blood flow may result in cerebral ischemia.
In a study of 291 intubated head injured patients, 144 had ETCO2 monitoring. Patients with
ETCO2 monitoring had lower incidence of inadvertant severe hyperventilation (5.6%) than
those without ETCO2 monitoring (13.4%). Patients in both groups with severe
hyperventilation had significantly higher mortality (56%) than those without (30%). Davis,
The Use of Quantitative End-Tidal Capnometry to Avoid Inadvertant Severe Hyperventilation
in Patients with Head Injury After Paramedic Rapid Sequence Intubation, Journal of Trauma,
April 2004
8. Perfusion Warning Sign
A target value of 35 mmHg is recommendedThe propensity of prehospital personnel to
use excessively high respiratory rates suggests that the number of breaths per minute
should be decreased. On the other hand, the mounting evidence against tidal volumes in
excessive of 10cc/kg especially in the absence of peep, would suggest the hypocapnia be
addressed by lower volume ventilation. Capnography as a Guide to Ventilation in the
Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004
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End tidal CO2 monitoring can provide an early warning sign of shock. A patient with a
sudden drop in cardiac output will show a drop in ETCO2 numbers that may be regardless
of any change in breathing. This has implications for trauma patients, cardiac patients
any patient at risk for shock.
9. Other Issues
DKA Patients with DKA hyperventilate to lessen their acidosis. The hyperventilation
causes their PAC02 to go down.
End-tidal C02 is linearly related to HC03 and is significantly lower in children with DKA. If
confirmed by larger trials, cut-points of 29 torr and 36 torr, in conjunction with clinical
assessment, may help discriminate between patients with and without DKA, respectively.
Fearon, End-tidal carbon dioxide predicts the presence and severity of acidosis in
children with diabetes, Academic Emergency Medicine, December 2002
Pulmonary Embolus Pulmonary embolus will cause an increase in the dead space in the
lungs decreasing the alveoli available to offload carbon dioxide. The ETCO2 will go down.
Hyperthermia Metabolism is on overdrive in fever, which may cause ETCO2 to rise.
Observing this phenomena can be live-saving in patients with malignant hyperthermia, a
rare side effect of RSI (Rapid Sequence Induction).
Trauma A 2004 study of blunt trauma patients requiring RSI showed that only 5 percent
of patients with ETCO2 below 26.25 mm Hg after 20 minutes survived to discharge. The
median ETCO2 for survivors was 30.75. - Deakin CD, Sado DM, Coats TJ, Davies G.
Prehospital end-tidal carbon dioxide concentration and outcome in major trauma.
Journal of Trauma. 2004;57:65-68.
Field Disaster Triage It has been suggested that capnography is an excellent triage tool
to assess respiratory status in patients in mass casualty chemical incidents, such as those
that might be caused by terrorism.
Capnographycan serve as an effective, rapid assessment and triage tool for critically
injured patients and victims of chemical exposure. It provides the ABCs in less than 15
seconds and identifies the common complications of chemical terrorism. EMS systems
should consider adding capnography to their triage and patient assessment toolbox and
emphasize its use during educational programs and MCI drills.- Krauss, Heightman, 15
Second Triage Tool, JEMS, September 2006
Anxiety- ETCO2 is being used on an ambulatory basis to teach patients with anxiety
disorders as well as asthmatics how to better control their breathing. Try (it may not
always be possible) to get your anxious patient to focus on the monitor, telling them that
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as they slow their breathing, their ETCO2 number will rise, their respiratory rate number will fall
and they will feel better.
Anaphylaxis- Some patients who suffer anaphylactic reactions to food they have ingested (nuts,
seafood, etc.) may experience a second attack after initial treatment because the allergens
remain in their stomach. Monitoring ETCO2 may provide early warning to a reoccurrence. The
wave form may start to slope before wheezing is noticed.
Accurate Respiratory Rate Studies have shown that many medical professionals do a poor job
of recording a patients respiratory rate. Capnography not only provides an accurate respiratory
rate, it provides an accurate trend or respirations.
10. The Future
Capnography should be the prehospital standard of care for confirmation and continuous
monitoring of intubation, as well as for monitoring ventilation in sedated patients. Additionally,
it should see increasing use in the monitoring of unstable patients of many etiologies. As more
research is done, the role of capnography in prehospital medicine will continue to grow and
evolve.
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Segment II (B to C) of the wave represents exhalation upstroke where dead space gas
mixes with alveolar gas.
Segment III (C to D) of the wave represents a continuance of exhalation and is also called
the plateau.
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The height of the wave should be compared to the scale on the page/screen to determine
ETCO2 levels.
The number of wave forms per minute can be counted to get an accurate respiratory rate.
The waves should be analyzed to see if there is any difference from the expected squaredoff wave form.
Changes in the height of the waves during monitoring should also be evaluated.
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Oxygen Delivered
Nasal Cannulae
1-6
24-26%
Mouth-to-Mask
10
50%
8-10
40-60%
8-10
40-60%
60%
60%
15
100%
15
90-100%
reservoir
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Oxygen Cylinders
In emergency medical care, the following sizes of
oxygen cylinders are commonly used:
D cylinder 350 liters
E Cylinder 625 liters
M Cylinder 3000 liters
G cylinder 5300 liters
H cylinder 6900 liters
Safety Precautions
Oxygen is a gas that acts as an accelerant for combustion, and oxygen cylinders are under
high pressure.
Never allow combustible materials, such as oil and grease, touch the cylinder, regulator
fittings, valves or hoses.
Never smoke or allow others to smoke in any area where oxygen cylinders are in use or on
standby.
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120ml
156ml
3-4
170ml
5-6
200ml
7-10
270ml
11-12
380ml
13-14
420ml
15
as adult
Keep all valves closed when the cylinder is not in use, even if the
tank is empty.
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When you are working with oxygen cylinders, never put any body parts over
the cylinder valve.
Pressure Regulators
Pressure regulators are devices that control gas flow and reduce the high pressure in the
cylinder to a safe range (from 2000psi to around 50psi), and controls the flow of oxygen
from 1-15 liters per minute.
There are two types of regulators:
High-pressure regulator
This type of regulator has one gauge that registers the content of the cylinder and that,
through a step-down regulator, can provide 50psi to power a flow restricted oxygen
powered automatic transport ventilator (ATV).
Therapy regulator
This type of regulator has two gauges, one indicating the pressure in the tank and a
flowmeter indicating the measured flow of oxygen being delivered to the patient (0-15
LPM).
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are produced that overwhelm the protective enzyme systems (antioxidants) and cellular
damage occurs. This damage is called oxidative stress .
The effects of aging are often due to oxidative stress. Also, some diseases such as
atherosclerosis, Alzheimers disease, Parkinsons disease, and others have been linked to
oxidative stress and free radical induction. Thus, the evolving thought is that, in some
conditions, high concentrations of oxygen can be harmful.
So, what does this mean to the future evolution of EMS practice? Well, there are several
disease processes we must consider.
Stroke: The brain is very vulnerable to the effects of oxidative stress. The brain has fewer
antioxidants than other tissues. Thus, should we give oxygen to non-hypoxic stroke patients?
Studies have shown that patients with mild-moderate strokes have improved mortality when
they receive room air instead of high-concentration oxygen.
The data on patients with severe strokes is less clear.(5) Current research indicates that
supplemental oxygen should not be routinely given to patients with stroke and can, in some
cases, be detrimental.(6)
Acute Coronary Syndrome: The myocardium is highly oxygen dependent and vulnerable to
the effects of oxidative stress. Thus far, theres no evidence that giving supplemental oxygen
to acute coronary syndrome patients is helpful, but theres no evidence its harmful.(7)
Post-Cardiac Arrest: Here, too, the evidence is too scant to tell. We do know that virtually all
current therapies for cardiac arrest (drugs, airway) are of little, if any, benefit. The primary
therapies remain CPR (often with limited ventilation initially) and defibrillation followed by
induced hypothermia. The whole purpose of induced hypothermia is to prevent the
detrimental effects of oxidative stress and the other harmful effects of reperfusion injury.
Trauma: What role should oxygen play in non-hypoxic trauma patients? Little research exists,
but an interesting study out of New Orleans demonstrated that there was no survival benefit
to the use of supplemental oxygen in the prehospital setting in traumatized patients who do
not require mechanical ventilation or airway protection.(8)
Carbon Monoxide (CO) Poisoning: We have learned a lot about carbon monoxide poisoning
in the past few years. We know that the mechanism of CO poisoning is a lot more complex
than once thought. We also know that theres no reliable evidence that hyperbaric oxygen
(HBO) therapy improves outcome (although its still widely used).(9) But when you think
about it, the goal of treatment in CO poisoning is to eliminate CO through ventilation -- not
hyperoxygenation. Although oxygen can displace some CO from hemoglobin, the induction
of free-radicals may be worse than the effects of CO. Again, the science here is in a state of
flux.
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Chapter 12:
The Basic ECG
Outline
The sinoatrial (SA) node, located in the right atrium of the heart.
The atrioventricular (AV) node, located on the interatrial septum close to the tricuspid
valve.
The His-Purkinje system, located along the walls of the hearts ventricles.
A heartbeat is a complex series of events that take place in the heart. A heartbeat is a single
cycle in which the hearts chambers relax and contract to pump blood. This cycle includes
the opening and closing of the inlet and outlet valves of the right and left ventricles of the
heart.
Each heartbeat has two basic parts: diastole and atrial and ventricular systole. During
diastole, the atria and ventricles of the heart relax and begin to fill with blood.
At the end of diastole, the hearts atria contract (atrial systole) and pump blood into the
ventricles. The atria then begin to relax. The hearts ventricles then contract (ventricular
systole) pumping blood out of the heart.
Each beat of the heart is set in motion by an electrical signal from within the heart muscle. In
a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA
node is sometimes called the hearts natural pacemaker. The pulse, or heart rate, is the
number of signals the SA node produces per minute. The signal is generated as the two vena
cavae fill the hearts right atrium with blood from other parts of the body. The signal spreads
across the cells of the hearts right and left atria. This signal causes the atria to contract. This
action pushes blood through the open valves from the atria into both ventricles.
The signal arrives at the AV node near the ventricles. It slows for an instant to allow the
hearts right and left ventricles to fill with blood. The signal is released and moves along a
pathway called the bundle of His, which is located in the walls of the hearts ventricles.
From the bundle of His, the signal fibers divide into left and right bundle branches through
the Purkinje fibers that connect directly to the cells in the walls of the hearts left and right
ventricles. The signal spreads across the cells of the ventricle walls, and both ventricles
contract. However, this doesnt happen at exactly the same moment. The left ventricle
contracts an instant before the right ventricle. This pushes blood through the pulmonary
valve (for the right ventricle) to the lungs, and through the aortic valve (for the left ventricle)
to the rest of the body.
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As the signal passes, the walls of the ventricles relax and await the next signal. This process
continues over and over as the atria refill with blood and other electrical signals come from
the SA node.
The Electrocardiogram
Most ECG recordings are obtained with paper speeds of 25mm/sec and signal
calibration of 1.0mV/1cm.
The P-QRS-T complex of the normal ECG represents electrical activity over one cardiac
cycle.
The dominant pacemaker of the heart is the sinus node in the right atrium. It normally
fires between 60 and 100 times a minute. Should the sinus node fail, the AV node is a
potential pacemaker but it only fires at 40-60 beats per minute.
QT Interval - Total duration of ventricular depolarization - 0.33-0.42 seconds 8-10 small squares
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Consistent P waves
60100 beats/min
Sinus Bradycardia
Consistent P waves
Sinus Tachycardia
Consistent P waves
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Ventricular Fibrillation
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Asystole
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Chapter 13:
The Automated External
Defibrillator
Outline
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The Chain of Survival was developed by the American Heart Association in 1990 in
recognition of the fact that the vast majority of sudden cardiac arrests (SCA) occur outside of
hospitals, and that failure to defibrillate early results in a high rate of failure to resuscitate
patients. In response to the development of the chain of survival, public awareness of the
importance of its components has increased, particularly in western countries, where AEDs
are often located readily in public places. To provide the best opportunity for survival, each
of these four links must be put into motion within the first few minutes of SCA onset:
Early CPR should be started and maintained until emergency medical services
(EMS) arrive.
Early Defibrillation is the only one that can re-start the heart function of a
person with ventricular fibrillation (VF). If an automated external defibrillator
(AED) is available, a trained operator should administer defibrillation as quickly
as possible until EMS personnel arrive.
Early Advanced Care, the final link, can then be administered as needed by
EMS personnel.
Time After the Onset of Attack
Survival Chances
After 10 minutes
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Chance of Survival
after Collapse
0%
0-2%
minutes)
CPR from a non-medical person (such as a
bystander or family member) begun within
2-8%
43%
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The most common initial rhythm in witnessed sudden cardiac arrest is ventricular
fibrillation.
Types of Defibrillators
Manual defibrillators
fully automated
semi-automated
Shockable Rhythms
Non-Shockable Rhythms
Asystole
Pulseless Electrical Activity (PEA) - (any heart rhythm observed on the ECG that
should be producing a pulse, but is not)
Medical Direction
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Assess responsiveness.
Step 2
If there is a delay in obtaining an AED, have your partner start or resume CPR.
Step 3
Remove clothing from the patients chest area. Apply pads to the chest.
Stop CPR.
Step 4
Step 5
After the shock is delivered, immediately resume CPR. Perform 5 cycles of CPR.
If the machine advises a shock, deliver a shock then perform 5 cycles of CPR.
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Step 6
Step 7
If the patient is not breathing adequately, use necessary airway adjuncts and proper
Transport.
Step 8
Check pulse.
Check pulse.
Transport
Analyze rhythm.
Deliver shock(s).
Check pulse.
Analyze rhythm.
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Chapter 14:
Environmental
Emergencies
Outline
Body Temperature
How The Body Keeps Warm
How The Body Loses Heat
Mechanisms of Heat Loss from the Body
Factors Affecting Exposure
Exposure to Cold
Emergency Care for Local Cold Injury
Hypothermia
Exposure to Heat
Drowning and Near-Drowning
Pathophysiology of Drowning
Water Rescue
Management of Drowning
Lightning
Bites and Stings
Diving Emergencies
Body Temperature
To keep the body temperature within a safe range of 36-38 degrees Celsius, the
body must maintain a constant balance between heat gain and heat loss. This is
known as thermoregulation.
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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.
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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.
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.
Conduction heat loss from direct contact between a warm body and a cold one, e.g.
sitting on the ground.
Convection heat loss to moving air or water, e.g. the wind strips heat from you
Radiation heat loss via infrared radiation Just as how you feel heat radiate from a
hot stove so too do you radiate heat.
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Evaporation heat loss via the evaporation of water from your skin and also from the
process of breathing in cold dry air and exhaling it as warm moist air.
Physical condition
Age
Environmental conditions
Exposure to Cold
Local Cold Injury
1st Degree (Frostnip)
Victim is usually unaware of injury unless they see themselves in the mirror. Patient has an
unusual pallor which returns to normal when warmed, usually accompanied by some
redness and tingling.
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Transport.
Hypothermia
Celsius
Fahrenheit
Mild
34-36
93.2-96.8
Moderate
30-34
86
Severe
<30
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Shivering
Shivering stops.
Handle gently.
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Exposure to Heat
Heat Exposure
Heat Cramps
Heat Exhaustion
In older people and young, onset may occur while at rest in hot, humid, and
poorly ventilated areas.
Patients usually have normal vital signs, but pulse can increase and blood pressure
can decrease.
Be prepared to transport.
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Heat Stroke
Losing control and getting swept into water that is too deep
Suffering hypothermia
Suffering trauma
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Percentage of Drownings
Salt water
1-2%
Fresh water
96-99%
Swimming Pools
- Private
50%
- Public
3%
20%
Bath Tubs
15%
Buckets of Water
4%
4%
Toilets
4%
Washing Machines
1%
Pathophysiology of Drowning
Step 1
Step 2
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Step 3
Step 4
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Water Rescue
1. Reach: Hold on to the dock or your boat and reach your hand, a boat oar, a fishing pole, or
whatever you have nearby to the person in the water
2. Throw: If you cant reach far enough, toss things that will float for the person to grab.
3. Tow: If youre in a boat, use to oars to move the boat closer to the person in the water or
call out to a nearby boat for help. Dont use the boats motor close to a person in the water,
they could be injured by the propeller.
4. Dont Go: Dont go into the water unless you are trained for water rescue.
Management of Drowning
1. Do not enter the water unless trained in water rescue.
2. Ensure an open airway and attempt rescue breathing.
3. Continue rescue breathing and remove from the water.
4. Check pulse - if absent, begin chest compressions
5. Transport.
6. If given the opportunity - use positive pressure ventilation (PEEP) to dry
the lungs.
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Lightning
Protect yourself.
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Cats
Humans
Swelling
Increasing pain
Fever
Immediately and thoroughly wash the wound with soap and water.
Transport the patient, especially if the wound needs stitches or occurred on the
face or neck.
Immobilize injury.
NB: Do not kill the dog unless it is absolutely necessary to prevent a full-scale crippling
attack. Usually an animal control officer or police officer will do this. If the dog is killed, call
animal control to request for a rabies examination of the corpse.
Arthropods
Insects
Spiders
Scorpions
With one exception, the Centruroides sculpturatus, most stings are only painful.
Ticks
Hives
If stinger is present, remove it by scraping it out with the edge of a card (Avoid
tweezers as they can squeeze more venom into the wound).
Place injection site slightly below the level of the patients heart.
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Snakes
Cottonmouth
Copperhead
Coral Snake
Discolouration, pain or swelling in the bite area. Develops slowly from 30 minutes
to several hours.
Blurring of vision.
Seizures.
Drowsiness or unconsciousness.
Locate and fang marks and clean the site with soap and water.
Apply light contracting band above and below the bite if all allowed by protocol.
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Marine Animals
Jellyfish
Sever cases may lead to skin necrosis, muscle spasms and cramps, vomiting and
diarrhea.
Stonefish
Patient may suffer difficulty breathing, bleeding, severe pain and whitened colour at
the site of the sting, abdominal pain, diarrhea, nausea, vomiting, seizures and
paralysis.
Bue-Ringed Octopus
Within 3 minutes, paralysis sets in and the body goes into respiratory arrest.
Stingrays
Stingray venom produces immediate, excruciating pain that lasts several hours.
Stonefish
Soak wound in the hottest water the patient can tolerate for 30-90 minutes, if
instructed to do so.
Blue-Ringed Octopus
Stingrays
Soak wound in the hottest water the patient can tolerate for 30-90
minutes, if instructed to do so.
Diving Emergencies
Pressure Laws
Boyles law: PV=K
As pressure , volume
As pressure , volume
Henrys law:
Barotrauma
Injury caused by compression or expansion of gas in body spaces.
Ear squeeze
Sinus squeeze
Ear Squeeze
Severe pain
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Sinus Squeeze
Severe pain
Lung Trauma
Pneumothorax/tension pneumothorax
Pneumomediastinum
Subcutaneous emphysema
Signs/Symptoms
Respiratory distress
Treatment
Rest
Oxygen
Treat pneumothorax
Hemiplegia
Unequal pupils
Cardiopulmonary failure
Vertigo
Visual disturbances
Management
ABCs
Diver does not surface at correct rate to allow nitrogen to escape from blood
Percentage of cases
Within 1 hour
42%
Within 3 hours
60%
Within 8 hours
83%
Within 24 hours
98%
Within 48 hours
100%
Source: U.S. Navy Supervisor of Diving (2008) (PDF). U.S. Navy Diving Manual. SS521-AGPRO-010, revision 6.
vol.5. U.S. Naval Sea Systems Command. p. 205. http://supsalv.org/pdf/DiveMan_rev6.pdf. Retrieved 200906-29.
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% of Cases
89%
Arm symptoms
70%
Leg symptoms
30%
Dizziness
5.3%
Paralysis
2.3%
Shortness of breath
1.6%
Extreme fatigue
1.3%
Collapse/Loss of consciousness
0.5%
Source: Powell, Mark (2008). Deco for Divers. Southend-on-Sea: Aquapress. pp. 70. ISBN 1905492073.
Treatment of DCS
ABCs
Nitrogen Narcosis
Result is intoxication
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Euphoria
Confusion
Disorientation
Treatment
What depths?
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Chapter 15:
Bleeding and Shock
Outline
Anatomy of the Cardiovascular System
Perfusion
Bleeding
Control of External Bleeding
Internal Bleeding
Signs and Symptoms of Internal Bleeding
Emergency Management of Internal Bleeding
Epistaxis (Nosebleed)
Bleeding from Skull Fractures
The Four Classes of Hemorrhage
What is Shock?
Types of Shock
Cardiovascular Causes of Shock
Non-cardiovascular Causes of Shock
Stages of Shock
Anatomy of the Cardiovascular System
The cardiovascular system is responsible for supplying and maintaining adequate blood supply
flow.
The cardiovascular system consists of three parts:
Heart (pump)
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Perfusion
Some tissues and organs need a constant supply of blood while others
can survive on very little when at rest.
The brain and spinal cord can survive for 4 to 6 minutes without
perfusion.
Hemorrhage = bleeding
Characteristics of Bleeding
Arterial
Blood is bright red and spurts.
Venous
Blood is dark red and does not spurt.
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Capillary
Blood oozes out and is controlled
easily.
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.
Tourniquets are a last resort when all other methods have failed.
Internal Bleeding
abnormal clotting
Vomiting bright red blood or blood the colour of dark coffee grounds.
Thirst.
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.
Provide O2 if necessary.
Stabilise fractures.
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Epistaxis (Nosebleed)
Apply direct pressure by pinching the patients nostrils (Or place a piece of
gauze bandage under the patients upper lip and gum).
Provide transport.
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Class of Hemorrhage
Class 1
Class 2
Class 3
(750ml)
(750-1500ml)
(1500-2000ml)
Class 4
More than 40%
blood
loss (>2000ml)
Compensatory
mechanisms
become overtaxed.
Vasoconstriction
Vasoconstriction can
continues to maintain
adequate blood
tissue perfusion
Blood is shunted to
continue to decrease,
becoming potentially
decreased flow to
life-threatening.
intestines, kidneys
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Compensatory
vasoconstriction now
becomes
a complicating
factor, further
impairing tissue
perfusion and
cellular oxygenation.
Anaerobic
metabolism
increases.
Patient becomes
Patient becomes
alert.
restless and
more confused,
lethargic, drowsy or
BP stays within
confused.
stuporous.
normal limits.
Classic signs of
Signs of shock
shock appear:
become more
normal limits or
shunting of blood to
pronounced.
increases slightly;
vital organs.
decreased BP
BP continues to fall.
pulse quality
Diastolic pressure
rapid respirations
remains strong.
because of
leads to organ
vasoconstriction.
remain normal.
Pulse pressure
narrows.
Heart rate becomes
rapid and pulse
quality weakens.
Respiratory rate
increases.
indicator
indicator
Decompensated
Compensated Shock
Shock
Irreversible Shock
What is shock?
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.
Perfusion
The cardiovascular systems circulation of blood and oxygen to all the cells
in different tissues and organs of the body.
Types of Shock
Hypovolemic
Hemorrhage
Burns
Diarrhea
Vomiting
Peritonitis
Cardiogenic
Cardiomyopathy
Pulmonary Embolism
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Heart Disease
Myocardial Infarction
Arrhythmia
Aortic Aneurysm
Cardiac Contusion
Cardiac Tamponade
Vasogenic
Psychogenic
Septic
Anaphylactic
Cardiovascular Causes of Shock
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Respiratory insufficiency
Patient with a severe chest injury or airway obstruction may be unable to
breathe adequate amounts of oxygen.
Anaphylactic shock
Occurs when a person reacts violently to a substance.
Injections
Stings
Ingestion
Inhalation
Psychogenic shock
Caused by sudden reaction of the nervous system that produces a
temporary, generalized vascular dilation
Stages of Shock
Compensated shock
When the body compensates for blood loss
Decompensated shock
The late stage of shock when blood pressure is falling
Irreversible shock
The terminal stage
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Compensated Shock
Agitation
Anxiety
Restlessness
Weak pulse
Clammy skin
Pallor
Shortness of breath
Nausea or vomiting
Marked thirst
Decompensated Shock
Irreversible Shock
Spinal injuries
Severe infection
Anaphylaxis
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Treatment of Shock
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Chapter 16:
Poisoning and Substance
Abuse
Outline
Definitions
Poison
Any substance whose chemical action can damage body structures or impair body functions.
Substance Abuse
The knowing misuse of any substance to produce a desired effect.
Common Types of Poisoning
Poisoning in Children
The most common poisons among children are:
cleaning substances
pain medicine/fever-reducers
coins, thermometers
plants
pesticides
vitamins
gastrointestinal preparations
antimicrobials
antihistamines
Poisoning in Adults
The most common poisons among adults are:
pain medicine
cleaning substances
antidepressants
alcohols
chemicals
pesticides
cardiovascular drugs
hydrocarbons
antihistamines
anticonvulsants
antimicrobials
plants
Unusual breath odour, body odour or odour from the patients clothing or from the scene.
Abnormal breathing.
Abdominal pain.
Seizures.
Signs of shock
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The signs and symptoms seen in poisoning are so wide and variable that there is no easy way
to classify them.
Some result in excessive drooling, while others dry the mouth and skin.
Some cause hyperactivity, while others cause drowsiness. Confusion is often seen
with these symptoms.
Over two million poison exposures were reported to local poison centers in 2000.
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Other causes include breathing in poison gas, getting foreign substances in the eyes
or on the skin, and bites and stings.
77 percent of all exposures are treated on the site where they occurred, generally
the patients home with phone advice and assistance from local poison control
experts.
The most common forms of poison exposure for children under the age of six are
cosmetics and personal care products (13.3%), cleaning substances (10.7%),
analgesics (7.6%) and plants (6.9%).
Although children under the age of six are the most likely to be exposed to poison,
they represent just over two percent of poison fatalities.
In children between ages 13 and 19, the majority of poison exposures (55%) involve
girls. In children under 13, the reverse is true; over 56 percent of these exposures
involve boys.
While adults 60 and over account for four percent of poison exposures, they
account for 15.5 percent of the fatalities.
Source: Data from the 2000 Annual Report of the American Association of Poison Control Centers Toxic Exposure
Surveillance System, which is compiled by the American Association of Poison Control Centers in cooperation with
the majority of U.S. poison centers. Since 1983, the data from the TESS have been used to identify hazards early,
focus prevention education, guide clinical research and direct training. A full report is available on the web at
www.aapcc.org.
Classifications of poisons
Poisons may be classified into four main groups: corrosives, irritants, narcotics, and
narcoticoirritants.
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Food poisoning, and animal bites and stings are considered as special cases.
Corrosives
Corrosive poisons react in a chemical manner with body tissue, such that they burn and
destroy the parts with which they come into contact.
Examples
Strong acids: Hydrochloric acid, Sulphuric acid, Nitric acid
Strong alkalis: Sodium hydroxide, Potassium hydroxide
Salts: Mercuric chloride
Signs & symptoms of corrosive poisoning
Immediate pain and swelling at the points of contact, maybe accompanied by
discoloration.
Eventual unconsciousness and death (depending on dose). If swelling occurs within the
airway this may also cause asphyxia.
Irritants
Irritant poisons aggravate the digestive system, particularly the stomach and bowels.
Examples
Vegetable acids and salts (eg. Tartaric acid), Arsenic, Lead, Antimony, Copper sulphate,
Zinc
Chloride, Silver Nitrate, Potassium Bichromate, Iron Sulphate, leaves, roots, berries, resins
of many plants (in larger doses).
Signs & symptoms of irritant poisoning
Vomiting, diarrhoea, abdominal discomfort or pain, features of shock through loss of
fluid. Eventual unconsciousness and death (depending on dose).
The onset of signs and symptoms may be deferred for a few hours after ingesting the
poison.
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Narcotics
Narcotic poisons affect the brain and/or nervous system, causing a reduction in coordination and the level of consciousness.
Examples
Opium and derivatives, Potassium Cyanide, Hydrocyanic acid (very fast acting, paralysing
poison), alcohol, ether, Chloral Hydrate, chloroform, Carbon Monoxide (also affects the
ability of red blood cells to carry oxygen), Hydrogen Sulphide, Ammonium Sulphide.
Signs & symptoms of narcotic poisoning
Dizziness, loss of co-ordination, interference with vision. Eventual unconsciousness
(sometimes preceded by convulsions) and death (depending on dose). Narcotic poisons do
not generally produce pain.
Narcotico-Irritants
Narcotico-irritant poisons initially have an irritant action upon the digestive system, and
then act as narcotics.
Examples
Phenol (carbolic acid), Oxalic acid, Strychnine, atropine, tobacco, hemlock, yew
leaves/berries, laburnum pods, digitalis, various fungi.
Signs & symptoms of narcotico-irritant poisoning
Initially, vomiting, diarrhoea, abdominal pain. Then delirium and/or convulsions. Eventual
unconsciousness and death (depending on dose).
Alcohol
Early stages: Flushed moist face, full bounding pulse, deep noisy breathing, unconsciousness.
Later stages: Dry bloated face, unreactive dilated pupils, weak rapid pulse, shallow breathing,
unconsciousness.
Aspirin
Upper abdominal pain, nausea, vomiting (maybe blood-stained), sweating, tinnitus,
hyperventilation, confusion, delirium.
Atropine (Deadly Nightshade)
Hot dry skin, dry mouth, dilated pupils, excitable behaviour, noisy breathing.
Severe cases may lead on to: Vomiting, weakness, delirium, unconsciousness.
Carbon Dioxide
Headache, dizziness, breathlessness, rapid unconsciousness.
Carbon Monoxide
Long term exposure: Headache, nausea, vomiting, confusion, aggression, incontinence.
Acute poisoning: Rapid distressed breathing, cyanosis, rapid unconsciousness.
Depressant Drugs (Tranquilizers)
Lethargy, drowsiness, weak irregular pulse, shallow breathing, falling consciousness.
Hydrogen Sulphide
Headache, spasm of the eyelids, pain and redness of the eyes, blurred vision with haloes
around lights.
In severe cases: Confusion, convulsions, pulmonary oedema (characterised by extreme
breathlessness, gasping and wheezing, coughing - maybe with blood-stained sputum,
sweating, pale skin with cyanosis).
Narcotic Drugs
Dizziness, confusion, lethargy, constricted pupils, slow shallow breathing, falling
consciousness.
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Specific ingredients
Name of manufacturer
Inhaled Poisons
Wide range of effects
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Absorbed Poisons
Many substances will damage the skin, mucous membranes, or eyes.
Injected Poisons
Usually result of drug overdose.
Prompt transport.
ALS providers may be able to use medications such as Narcan to reverse overdose.
Ingested Poisons
Poison enters the body by mouth.
Activated charcoal will bind to poison in stomach and carry it out of the body.
Assess ABCs.
Activated Charcoal
Syrup of Ipecac
Ipecac induces vomiting by both gastric irritation and central stimulation of the
chemoreceptor trigger zone.
Approximately 95% of patients vomit within 15 to 30 minutes of administration of a
therapeutic dose and vomiting usually persists for 30 minutes to 2 hours.
Approximately 28 to 60% of an ingested toxin will be removed by emesis if ipecac is
given within 5 minutes following ingestion of the toxin. If given 1 hour after, a
maximum of 30% of the toxin will be removed.
Indications: To induce vomiting in the early management of certain oral poisonings.
Ideally, ipecac should be given on the advice of a Poison Control Centre or physician,
especially in the case of infants and children.
Contraindications: Situations where emesis is contraindicated, include: poisoning
involving strong acids or alkalis, unconscious, semicomatose or severely inebriated
patients, patients experiencing convulsions and patients who have lost the gag reflex.
Ipecac should be given as soon as possible after ingestion of a toxin, ideally within 1
hour.
Dose should be followed by 1 to 2 glasses of water since ipecac is ineffective when
the stomach is empty. Administration with milk can prolong the time to vomiting
because it decreases the irritant action of ipecac on the stomach.
Adults: 15 to 30 mL.
Children 1 to <12 years: 15 mL.
Children 6 months to <1 year: 5 to 10 mL.
If vomiting has not occurred within 15 to 20 minutes, the dose may be repeated once
in adults and children over 12 years.
Rarely used anymore.
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Shock
If there is dermal exposure, bathe the patient using alkaline soap like Perla or Ivory.
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Chapter 17:
Diabetic Emergencies
Outline
Definitions
Diabetes mellitus
Metabolic disorder in which the body cannot metabolize glucose.
Glucose
One of the basic sugars in the body.
Insulin
Hormone produced by the pancreas.
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Hormone
Chemical substance produced by a gland.
The endocrine system is a system of glands, each of which secretes a type of hormone
into the bloodstream to regulate the body. The endocrine system is an information signal
system like the nervous system. Hormones regulate many functions of an organism,
including mood, growth and development, tissue function, and metabolism.
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Insulin-dependent diabetes.
Non-insulin-dependent diabetes .
Type II Diabetes
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Hypoglycemia vs Hyperglycemia
Hyperglycemia
Hypoglycemia
mg/dL
dL
Causes
condition
insulin
overexerted
carbohydrates
reducing
gradual
onset
of
signs
and
intense thirst
intense hunger
dizziness
abdominal
pain
and
vomiting
and
headache,
common
coma
coma
relative
normal
respirations,
respirations,
perfuse perspiration
normal eyes
sudden
breath
odour
smells
of
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no
pressure
sunken eyes
no
hostile
or
aggressive
behaviour
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Glucometer
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Emergency Care
Emergency Care - Hypergylcemia
Administer oxygen if required.
Immediately transport.
Turn head to side or place the patient in the lateral recumbent (recovery) position.
Names:
Glutose
Insta-Glucose
DO NOT give glucose to a patient with the inability to swallow or who is unconscious.
Place
the
bite
stick
on
the
mucous
Repeat.
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If the patient is a known diabetic and hypoglycemia cannot be ruled out, assume that
the patient is suffering from hypoglycaemia and administer glucose.
Often a patient suffering a diabetic emergency may simply appear drunk. Always
check for other underlying conditions - such as a diabetic complication when
treating someone who appears intoxicated.
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Chapter 18:
Infectious Diseases
Outline
Transmission
Syphilis
Tuberculosis
Rabies
Meningitis
Hepatitis
HIV/AIDS
Transmission
Blood-born
Synovial fluid
Amniotic fluid
Saliva
Semen
Vaginal secretions
Saliva
Organs or tissues
Airborne
Fecal-Oral
Syphilis
An acute and chronic disease caused by the spiral shaped bacterium Treponema
pallidum.
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primary stage. Rash and lymphadenopathy are the most common symptoms.
Rash starts on the trunks and flexor surfaces spreading to the palms and soles.
Tertiary involvement of the nervous system and CVS is characteristic of this
stage which may occur 3-4 years after the initial infection. Specific
manifestations range from acute meningitis, dementia and neuropathy to
thoracic aneurysm.
Tuberculosis
Tuberculosis is not a highly contagious disease. Transmission of the bacteria
Myobacterium tuberculosis that causes TB usually occurs by droplet spread from a
person with active disease and intimate exposure to the infected individual, usually
those living in the same household. The communicable period lasts as long as
infective tuberculi bacilli are being discharged in the sputum usually 24-48 hours
after antibiotic treatment has been started.
Signs and symptoms
Initial infection usually minimal and most patients do not show any
symptoms when first infected.
TB can lie dormant for many years before the signs commonly associated with
TB appear night sweats, headaches, cough and weight loss.
Suspect TB with:
Coughing up blood
Difficulty breathing
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Respiratory failure
Rabies
Rabies is caused by a RNA containing Rhabdovirus and is transmitted by inoculation with
infectious saliva from an animal or by salivary contact with a break in the skin or mucous
membrane.
Incubation period 12-700 days
The virus spreads across the motor end plate and ascends and replicate along the peripheral
nervous axoplasm to the dorsal root ganglia in the spinal cord and the CNS.
Histologically, rabies manifests the same findings as seen in other forms of encephalitis
(inflammation of the brain). Negribodies are the characteristic histologic findings for rabies.
Signs and Symptoms
Early Stage
Fever
Malaise
Anorexia
Sore throat
Cough
Late Stage
Restlessness
Agitation
Hypersensitivity to sensory stimuli and hydrophobia resulting from bulbar spasm that occurs
with swallowing patient wont want to swallow because of the spasming.
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Emergency Care
BSI
ABC
Transport to hospital for Human Immunoglobulin (HRIG) and Human Diploid Cell
Vaccine.
Meningitis
Inflammation of the meninges of the brain. The type most often involved in epidermal
outbreak is caused by the meningococcous bacteria and is usually referred to as
Meningococcal Meningitis.
Signs and Symptoms
Fever
Severe headache
Vomiting
Local rigidity
Hepatitis
An infectious disease that causes an inflammation of the liver. It is more contagious than
HIV and is a major threat to Health Care Providers.
There are five forms of Hepatitis:
1. Hepatitis A HAV
2. Hepatitis B HBV
3. Hepatitis C
4. Hepatitis D HDV or Delta
5. Hepatitis E
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Hepatitis can also be caused by other viruses and bacteria, including chickenpox and
cytomegalovirus (CMV).
Hepatitis A
Spread primarily by the fecal-oral route. HAV is excreted in large quantities in the
feces two weeks before and one week after onset of symptoms
Conditions that facilitate the spread of HAV include crowding and poor hygiene.
Food-borne outbreaks have occurred in restaurants due to an infectious food
handler who unknowingly contaminates food or water.
Because hepatitis A can be a mild infection, particularly in children, it's possible for
some people to be unaware that they have had the illness. In fact, although medical
tests show that about 40% of urban Americans have had hepatitis A, only about 5%
recall being sick. Although the hepatitis A virus can cause prolonged illness up to 6
months, it typically only causes short-lived illnesses and it does not cause chronic
liver disease.
Hepatitis B
Serum hepatitis primarily spread through contact with infectious blood or blood
products.
Other body secretions including saliva, semen and vaginal secretions can contain the
HBV.
Introduction of infected materials into the mucous membranes (especially the mouth,
eyes and broken skin) has led to the transmission of HBV.
Fatigue
Loss of appetite
Abdominal pain
Headache
Fever
Jaundice
Dark urine
Swelling
The communicable period starts weeks before the first symptoms appear and may
persist for years in chronic carriers.
HBV lasts several weeks although complete recovery may take 3 to 4 weeks. A
significant proportion of patients develop a chronic infections that may last a
lifetime and predisposes them to serious illnesses such as carcinoma of the liver.
Hepatitis C
The infection is often asymptomatic, but once established, chronic infection can progress
to scarring of the liver (fibrosis), and advanced scarring (cirrhosis) which is generally
apparent after many years. In some cases, those with cirrhosis will go on to develop liver
failure or other complications of cirrhosis, including liver cancer or life threatening
esophageal varices and gastric varices.
The hepatitis C virus is spread by blood-to-blood contact. Most people have few, if any
symptoms after the initial infection, yet the virus persists in the liver in about 85% of
those infected. Persistent infection can be treated with medication, peginterferon and
ribavirin being the standard-of-care therapy. 51% are cured overall. Those who develop
cirrhosis or liver cancer may require a liver transplant, and the virus universally recurs after
transplantation.
Precautions when dealing with Hepatitis patients
Handle with extreme care all needles and IV equipment used for a patient with
jaundice.
Never recap, remove, bend or break needles after use or manipulate them
by hand.
Dispose of syringes, needles, scalpels and other sharp items in a punctureresistant container kept within easy reach.
Disinfect all equipment contaminated with blood or sputum. Air out the
ambulance and send soiled linen for cleaning.
Stay in touch with the hospital to which the patient was transported to
follow up for diagnosis.
HIV/AIDS
HIV is the virus that causes AIDS. AIDS is the name for the set of conditions that results
when the immune system has been attacked by HIV. The AIDS virus does its damage by
attacking a persons immune system and impairing the ability to fight off infections and
other illnesses that depend on an intact immune response. An AIDS patient becomes
extremely vulnerable to a whole variety of bacterial, viral and fungal infections.
It is estimated that approximately 33 million people are currently infected with the AIDS
virus, including 2-3 million children.
In considering the incubation period of AIDS, it is important to distinguish between
patients who are infected with the HIV virus but are still asymptomatic and those who
have developed the clinical signs of the disease. As a result, there are two incubation
periods to consider:
1. From the time of exposure to the time a persons blood tests positive for AIDS
(becomes seropositive or HIV positive). May be anywhere from a few weeks to a
few months. A person who has had an accidental exposure to AIDS should be
tested within 2 to 3 weeks after exposure and then again at 6 weeks, 3 months, 6
months and 1 year later.
2. The time between the documented infection (i.e. becoming HIV positive) and the
development of full-blown AIDS. In patients who have contracted AIDS from
contaminated blood products, the mean incubation after infection has been
approximately 8 years for adults and 2 years for children.
From a variety of data, it has been calculated that about half of seropositive patients will
develop AIDS within 9 years and nearly all seropositive patients will develop AIDS within
15 years.
Once AIDS has developed, life expectancy is reduced, although antiretroviral medication
can extend this significantly.
The communicable period for AIDS is not known but is presumed to continue throughout
the time that the patient is seropositive, even before the patient develops clinically
apparent AIDS.
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Transmission of AIDS
1. Sexual contact involving semen, saliva, blood, urine and feces.
2. Parentally through contaminated blood products or infected needles.
3. Across the placenta mother-child transmission which occurs when an infected
mother passes the virus to her child, sometimes as early as the 20th week of
gestation.
Signs and Symptoms
Because AIDS can involve many organs and systems of the body, there are countless signs
and symptoms.
Common signs and symptoms can include:
Night sweats
Loss of appetite
Nausea
Persistent diarrhea
Headache
Sore throat
Fatigue
Weight loss
Shortness of breath
Rashes
Protect the AIDS patient from acquiring infections from you or your crew.
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1.
The patent for AZT has expired and generic versions are available in the US.
2.
Stavudine is no longer recommended for initial therapy in the UK. The US Department of Health and
Human Services also no longer recommend stavudine as a preferred or alternative component in
initial treatment.
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3.
The patent for ddI has expired and generic versions are available in the US. The manufacturer has discontinued a tablet
version.
4.
The British HIV Association (BHIVA) recommends that Trizivir "should only be considered as a starting regimen in very
occasional circumstances, for example informed patient choice based on likely poor adherence if alternative options are
used, or concomitant medication needed such as for TB". Trizivir is listed as a possible treatment option in the US, but it
is not the preferred treatment option.
5.
6.
7.
Atazanavir is not licensed as a starting regimen in the UK. In the US, ritonavir-boosted atazanavir has been approved as a
preferred initial treatment, while unboosted atazanavir is an alternative for initial treatment.
8.
Roche Pharmaceuticals have discontinued the sale and distribution of Fortovase brand saquinavir soft gel capsules in the
US.
9.
Tipranavir is not licensed as a starting regimen in the UK. The US Department of Health and Human Services do not
recommend tipranavir for initial treatment.
10. Enfuvirtide is not licensed as a starting regimen in the UK. The US Department of Health and Human Services do not
recommend enfuvirtide for initial treatment.
11. Maraviroc is not licensed as a starting regimen in the UK.
12. Raltegravir is not licensed as a starting regimen in the UK.
* Because of patent laws, generic forms given tentative approval are available in certain developing countries only.
(Source: http://www.avert.org/aids-drugs-table.htm)
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Chapter 19:
The Acute Abdomen
Outline
Anatomy
Conditions That May Cause Acute Abdomen
Signs and Symptoms
Assessment
Emergency Medical Care
Urinary Colic
Anatomy
The abdominal cavity can be divided into four quadrants or nine regions, which can be
used to locate organs, although many organs overlap different regions.
Although the use of quadrants is common in medical systems, the use of regions is more
precise and should be used as a first preference.
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Appendicitis
Pancreatitis
Cholecystitis
Intestinal obstruction
Hernia
Ulcer
Esophageal varices
Trauma
Internal bleeding
Pain or tenderness
Rapid pulse
Assessment
Initial Assessment
Focused History:
OPQRST
SAMPLE
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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
Presence of nidus
Stasis
pH of solution
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Pain in the back or side intensity depends on the size of the stone
Renal colic
Vomiting
Transport to hospital.
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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
Water balance helps prevent water loss and stops environmental water from entering
the body.
Temperature regulation the sweat glands in the skin produce perspiration, which will
evaporate and help cool the body.
Excretion salts and excess water can be released through the skin.
Shock absorption skin and its layers of fat help protect underlying organs from minor
impacts and pressure.
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Sensation
Skin redness
Skin pain
Skin tenderness
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Skin redness
Skin pain
Skin tenderness
Skin swelling
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No skin redness
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2.
Systemic Toxins affect our ability to absorb oxygen. If someone is found unconscious or
acting confused in the surroundings of an enclosed fire, systemic toxins could be a possible
cause. Toxin poisoning can cause permanent damage to organs including the brain. Carbon
Monoxide poisoning can appear symptomless up until the point where the victim falls into a
coma.
3.
Smoke intoxication is frequently hidden by more visible injuries such as burns as a result of
fire. Which in a disaster situation can lead to not receiving the medical attention needed, due
to the rescue teams taking care of the more apparent patients. Patients that appear
apparently unharmed can collapse due to major smoke inhalation, 60% to 80% of fatalities
resulting from burn injuries can be attributed to smoke inhalation.
Indications of inhalation injury usually appears within 2-48 hours after the burn occurred.
Indications may include:
Upper airway edema is the earliest consequence of inhalation injury. Upper airway edema is
commonly seen during the first 6 to 24 hours after injury. Early obstruction of the upper
airway is managed with intubation. Initial treatment consists of removing the patient from the
gas and allowing him to breathe air or oxygen.
Age of Patient
Infants, children under 5 and adults over the age of 55 have the most severe responses to
burns and the greatest risks of death because of their anatomy and physiology.
An adults reactions to burns and complications associated with burn injury healing increase
significantly after the age of 35.
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Children
Thin skin
Small airways
Consider abuse
Geriatrics
Thin skin
Poor circulation
Underlying diseases
-
Pulmonary
Peripheral vascular
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Cause
Dry burn
Scald
Electrical burn
Freeze burn
Chemical burn
Industrial
chemicals
Radiation burn
Sunburn, overexposure to UV
light, exposure to radioactive
sources
and
Full-thickness burns of less than 2%, excluding face, hands, feet, genitalia or respiratory tract
Full-thickness burns of 2%-10%, excluding face, hands, feet, genitalia or respiratory tract
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domestic
Critical Burns
All burns complicated by injuries of the respiratory tract, other soft tissue injuries and bone injuries
Chemical burns
Electrical burns
Partial or full-thickness burns involving the face, hands, feet, genitalia or respiratory tract
Circumferential burns
Burns by which, by the above classification, are moderate should be considered critical in a person
less than 5 years or greater than 55 years of age.
Full-thickness burns that are less than 2% body surface area in others
Moderate Burns
These include:
Major Burns
Major burns are:
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
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Patient Care
Semi-solid (grease, tar, wax) cool with water but do not remove
substance or clothes that are stuck to the burn (cut around clothing)
Look for signs of airway injury soot deposits, burnt nasal hair and facial burns.
Look for signs of shock burns seldom result in early shock so there may be another
underlying injury.
Burns to hands/feet remove rings and jewellery that may constrict with swelling.
Separate fingers or toes with sterile gauze pads.
Burns to the eyes do not open the eyelids if burned. Be certain burn is thermal, not
chemical. Apply sterile gauze pads to both eyes to prevent sympathetic movement. If
the burn is chemical, flush eyes for 20 minutes en route to hospital.
Follow local burn protocols and transport burn patients ASAP, to a burn center is
available.
History
Allergies/medications?
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Appendix 1
Appendix 1:
Updated 2010 European
Resuscitation Council
Guidelines
Basic life support
Changes in basic life support (BLS) since the 2005 guidelines include:
All rescuers, trained or not, should provide chest compressions to victims of cardiac
arrest. A strong emphasis on delivering high quality chest compressions remains
essential. The aim should be to push to a depth of at least 5 cm at a rate of at least
100 compressions min-1, to allow full chest recoil, and to minimise interruptions in
chest compressions. Trained rescuers should also provide ventilations with a
compressionventilation (CV) ratio of 30:2. Telephone-guided chest compression-only
CPR is encouraged for untrained rescuers.
The use of prompt/feedback devices during CPR will enable immediate feedback to
rescuers and is encouraged. The data stored in rescue equipment can be used to
monitor and improve the quality of CPR performance and provide feedback to
professional rescuers during debriefing sessions.
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Appendix 1
Electrical therapies
The most important changes in the 2010 ERC Guidelines for electrical therapies include:
Much greater emphasis on minimizing the duration of the pre-shock and postshock pauses; the continuation of compressions during charging of the defibrillator
is recommended.
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Appendix 1
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Appendix 1
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Appendix 1
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Appendix 1
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