ROTATION ASSIGNMENTS: jschatzel@northwell.edu
Sinnott- 516-273-0959
Klein- 516-404-6731
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14 components
Communications, independence, clinical care, human resources, medical direction
Medical director-offline-standing orders, training, supervision,
o online- physician directions over phone or radio
o if no connection, only operate under standing orders
whistling sound, upper airway issue
CUPS Status
o Critical
o Unstable
o Stable but potentially unstable
o Stable
AVPU
o Alert
o Verbal- can answer, may not be correct, just respond to voice
o Only responsive to pain
o Unresponsive
o Alert if: know who they are, where they are, what time it is, event(what happened)
Airway- open, clear, patent
Glasgow Coma Scale
o Rate patient not alert, find severity and gives parameters
 Score 13-15- mild, 9-12- moderate, 8 or less- severe
PCR Lung sounds
o Clear-good
o Absent-bad
o Wet
o Wheezing
Pulse
o Presence
o Rate
o Rhythm
o Quality- strong, bounding, weak, thread etc.
Golden Period
o Platinum 10- assess, stabilize, package, begin transport
Secondary Assessment
o History taking- date, age, gender, race, medical history, current health status
 SAMPLE-signs/symptoms, allergies, medication, pertinent medical history, last
food or drink, events leading to incident
 OPQRST- Onset, Provocation/palliation, quality, region/radiation, severity,
timing
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History taking
o Demographic
 Date of incident
 Times of assessments and interventions
 Age, sex, past medical history, etc.
 Open ended questions
 Be polite- Mr./Mrs./Ms.- - last name
 Investigate chief complaint
o Don’t have to match call type and chief complaint
 Have consent
 OPQRST
o If patient unresponsive
 Family members present
 Witness to situation
 Medical alert jewelry
 SAMPLE-Signs/Symptoms, Allergies, medications, pertinent past medical history,
last oral intake, events leading up to injury/illness
 All go in PCR
 I feel… for allergies ask how they know, what happens
 Ask what medications, when how they took it, including illicit
 Questions different between medical and trauma patient-signs/symptoms
 OPQRST-Onset, provocation/palliation, quality, region/radiation, severity,
timing
o Document pertinent negatives
 Negative findings that warrant no care or intervention
o Taking history on sensitive topics
 Alcohol/drugs
 Signs may be hidden/disguised
 History may be unreliable
 Physical abuse or violence
 Report all physical abuse or domestic violence to appropriate
authorities
o Follow local protocols
o Do not accuse, immediately involve LE
 Sexual history
 Consider all female patients of childbearing age who report lower
abdominal pain to be pregnant
 Inquire about urinary symptoms with male patients
 Ask all patients about the potential for sexually transmitted diseases
 Special Challenges
 Silence- be patient
o Use close ended questions- be careful about religion, gender
o Consider whether silence is a clue to chief complaint.
 Overly talkative
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o Nervous
o Excessive caffeine
o May be on cocaine, crack, meth
Multiple symptoms
o Expect multiple symptoms in geriatric group
o Prioritize complaints as you would in triage
o Start with most serious and end with least serious
Anxiety
o Expect anxious patients to show signs of psychological shock
 Pallor, diaphoresis, shortness of breath, etc.
Anger/hostility
o Friends, family, bystanders may direct anger and rage towards
you.
o Remain calm, reassuring, gentle
o If scene not safe or secured-get it secured
Intoxication
o Do not put an intoxicated patient in apposition where he or she
feels threatened
o High potential for violence/physical confrontation
o Alcohol dulls a patient’s sense
Crying
o May be sad, in pain, emotionally overwhelmed
o Remain calm, patient, reassuring, confidant
Depression
Confusing behavior or history
o Conditions such as hypoxia, stroke, diabetes, trauma,
medications could alter an explanation of events.
o Geriatric patients could have dementia, delirium, or Alzheimer’s
Limited cognitive abilities
o Patients considered developmentally handicapped
o Keep questions simple, limit use of medical terms
o Rely on presence of family, caregivers, friends to supply answers
Language barriers
o Find interpreter if possible
o If not, determine if patient understand who you are
o Keep questions straightforward and brief
o Hand gestures
o Be aware of language diversity in your community
Hearing problems
o Use stethoscope as hearing aid
o Speak slowly and clearly
o Etc.
Visual impairment
o Identify self verbally
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Heart
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o Return any moved items to original positions
Secondary Assessment
 DCAP-BTLS
 Deformities, contusions, abrasions, puncture/penetration, burns,
tenderness, lacerations, swelling
Assess vital signs
 Use appropriate monitoring devices etc.
 End tidal CO2
 Full body scan
 Focused assessment
 Specific area of complaint
 Based on chief complaint
 Focus attention on immediate problem
 Focus on body system related to issue
Dyspnea
 Difficulty breathing
 Upper or lower airway infection
 Acute pulmonary edema
 COPD
 Asthma, hay fever, CO poisoning
 Infectious diseases, anaphylaxis, spontaneous pneumothorax (collapsing lung
w/o chest trauma), pleural effusion, prolonged seizures, obstruction of airway,
pulmonary embolism, hyperventilation, environmental/industrial exposure
Cardiac muscles called myocardium
SA node electrically control heart rate
SA to AV(causes contraction)
Autonomic nervous system(ANS)
 Control involuntary activity
 Sympathetic- fight or flight
 Parasympathetic- slow bodily functions
Myocardium must have continuous supply of O2
Stroke volume- volume of blood ejected with each contraction
 Coronary arteries supply blood to heart muscle
Arterioles, capillaries smaller
 Venules small veins
 Superior vena cava- bring blood back to heart from head, arms
 Inferior- abdomen, kidneys, legs
Blood
 Red blood cells- carry O2
 White- fight infection
 Platelets-clot
 Plasma- fluid cells float in
Blood pressure
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 Systolic- top # max generated by left ventricle
 Diastolic- pressure while left ventricle is at rest
Pulse
 Felt in extremities
 Central pulses felt in body’s trunk- blood passes through artery during systole
Cardiac output- volume of blood that passes through heart in 1min
 Heart rate*stroke volume
 Perfusion-constant flow of blood to tissue
Good perfusion
 Well-functioning heart
 Adequate volume of blood
 Appropriately constricted blood vessels
Chest pain
 Stems from ischemia- decreased blood flow causes
 Ischemic heart disease- decreased blood flow to one or more part of
heart
 Blood flow not restored, tissue dies
 Coronary artery disease leading cause of death in US
Atherosclerosis
 Buildup of calcium
 Can occlude artery
 Fatty material accumulates with age
Thrombo-embolism
 Blood clot floating in blood vessel
 If it lodges is coronary artery, acute myocardial infarction(AMI) results
Acute coronary syndrome (ACS)
 Caused by myocardial ischemia
 Angina pectoris- condition marked by severe pain in chest can also
spread to shoulders, arms, neck, caused by inadequate blood supply to
heart
 Acute myocardial infarction- when diminished blood supply to heart for
extended period results in irreversible myocardial cell damage or death
Controllable AMI risk factors
 Cigarette smoking, high blood pressure, high cholesterol, high blood glucose
level, lack of exercise, stress
 Uncontrollable – older age, family history, being male
Angina Pectoris
 Heart’s need for O exceeds supply
 Crushing or squeezing pain
 Not usually lead to death of permanent heart damage
 Serious warning sign
Unstable angina
 Sudden, gets worse over short period
 May be if:
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 Starts to feel different
 Lasts longer than 15-20 min
 Occurs w/o cause
 Doesn’t respond well to Nitro
 Occurs with drop in BP
 Warning sign of heart attack my happen soon
Stable Angina
 Chest pain or other symptoms occur with a certain amount of activity and
stress- doesn’t change- treat like AMI patients
AMI
 Pain signals actual death of cells in heart muscle
 Once dead, cells cannot be revived
 Clot-busting(thrombolytic) drugs or angioplasty within 1hr prevent
damage
 Immediate transport essential
 Pain differe from angina pain
o Not always due to exertion
o Lasts 30min to several hours
o Not always relieved by rest of nitro
o AMI patients may not realize they are experiencing a heart
attack
o Physical findings
o Serious consequences
 Sudden death
 Cardiogenic shock, CHF(congestive heart failure)
 Defibrillation
o Restores cardiac rhythms
 Can save lives
 Initiate CPR until a defibrillator is available.
o Asystole- no heart electrical activity
 Reflects a long period of ischemia
 Nearly all patients die
 Cardiogenic shock
 Congestive heart failure- occurs few days after heart attack
o Increased heart rate, lungs become congested w/ fluid
o May cause dependent edema
Hypertensive emergencies
 Systolic pressure greater than 160mm Hg
 Common symptoms
 Sudden severe headache, strong bounding pulse, etc
 If untreated, can lead to stroke or dissecting aortic aneurysm
 Transport quickly and safely
Aortic aneurysm
 Weakness in wall of aorta
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Can rupture
 Sudden chest pain
 Comes on full force different blood pressures
 Transport quickly and safely
 Interventions
 O2, assist breathing, aspirin etc
o Hear surgeries and pacemakers
o CABG-coronary artery bypass graft
 Chest or leg blood vessel is sewn from aorta to coronary artery beyond point of
obstruction
 Long chest scar
o PTCA- percutaneous transluminal coronary angioplasty
 Tiny balloon inflated inside narrowed coronary artery
o Pacemakers
 Maintain regular rhythm and rate
 Deliver impulse through wires in direct contact with the myocardium
 Implanted under heavy muscle or fold of skin in upper left portion of chest
 Reliable
 Malfunction can cause syncope, dizziness, weakness due to slow heart ratetransport prompt and safe
o ACID
o LVAD
o Cardiac arrest
o AED
o NYS Protocol M-5
o Chest pain present, nitro prescribe with systolic pressure of 120mm Hg, no erectile
dysfunction meds in last 72 hrs, EMT may assist in self administration of nitro-CONFIRM
120mm Hg
 Question on last dose
 If pax hasn’t take aspirin, no allergy and no recent gastro bleeding, administer
324 mg aspirin
Neurological emergencies
o Stroke-3rd or 5th leading cause of death in US
 Common in geriatric patients
 More men than women
 More fatal in women
o Contributing factors
 Family history, race
 Rapid transport vital
o Seizures and altered mental status
 Occur as result of
 Recent/old head injury, brain tumor, metabolic problem, genetic
disposition
 Possible cause of AMS
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Intoxication, head injury, hypoxia, stroke, metabolic
disturbances
Brain-body computer
 Cerebrum largest part
 Left and right hemispheres
o each control activities on the opposite side of body
o front controls emotions, thought
o middle- touch, movement
o back- sight
o most people speech is controlled on left side
o 12 cranial nerves
 Brain stem controls most basic functions
 Breathing, blood pressure, swallowing, pupil constriction
 Cerebellum controls muscle and body coordination
 Nerves
 Touch, feel
 Pathophysiology
 Different disorder cause brain dysfunctions
o Affect level of consciousness
o Voluntary muscle control
o Brain sensitive to changes in O2, glucose, temp
 General rule
o Issue with heart/lungs- brain affected
 Stroke common, potentially treatable
o Other brain disorders- infection, tumor
 Cause seizures, AMS, headaches
 Headache
o Common complaint
o Can be symptom of other condition or a condition on its own
o Most are harmless and do not require emergency care
 Sudden, severe headaches require assessment and transport
 If more than one patient reports headache-CO poisoning
 Tension headaches, migraines, sinus headaches most common
o Not medical emergencies
 Tension headaches
o Most common
o Caused b
 Migraines
o 2nd most common
 Sinus headaches
o Caused by pressure as result of fluid accumulation in sinus
cavities
 Be concerned if patient complains of sudden onset, severe, or has
associated systems
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Hemorrhagic stroke, brain tumors, meningitis
Stroke
 Cerebrovascular accident-CVA
o Interrupt blood flow to brain- cells die
 Prompt restoration of flow- preserve/ restore function
 Ischemic stroke-80%
o Embolism, thrombosis
o Symptoms go from nothing to complete paralysis
o Atherosclerosis in blood vessels often the cause- plaque in
blood vessels, restricts flow- no o2 to brain
 Hemorrhagic stroke-20%
o Bleeding inside brain
o High risk- high stress/ exertion
o Highest risk- high blood pressure
o Often fatal
o Aneurysm
 Swelling/enlargement of artery due to weakening
arterial wall
 Symptom- sudden, severe headache
 If occurs in healthy young person
 Berry aneurysm
 Surgical repair possible is care immediately
sought
o Transient Ischemic attack- TIA
 Normal process in body break up a blood clot in brain
 Blood flow restored
 Patient regains use of affected body part
 Often indicates serious medical condition that may
prove fatal
 Prone to stroke
 Symptoms go away of 24 hours
 Always emergency
 Could warn of larger stroke to come
o Signs/symptoms of stroke
 Cincinnati stroke scale
 Left hemisphere
 Inability to produce/understand speech
 Paralysis to right side of body
 Right hemisphere’
paralysis of left side
 Understand language- slurred words
 Oblivious to problem (neglect)
 Bleeding in Brain
 Mimi Stroke
o Hypoglycemia
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Seizure
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Postictal state
Subdural of epidural bleeding
Convulsion or temporary alteration in consciousness
Account for up to 30% of EMS calls
4 million people w/ epilepsy in US
Generalized Seizure
 Grand mal
Endocrine Emergencies
o Complex message/control system
o Glands secrete hormones
 Hormones chemical messengers
 Maintain homeostasis
o Pathophysiology
 Diabetes
 Affects body’s ability to use glucose for fuel
 9.3% of population-increasing
 Complications- blindness, cardiovascular disease, kidney failure
 Lack of ineffective action of insulin
 Type 1
o Childhood
o Do not produce insulin
o Needs daily injections
o Patient more likely to have
 Type 2
o Lifestyle
o Produce inadequate amt or normal amt that does not function
effectively
o Appears later in lift
o Treatment- diet, exercise, oral medications, insulin
o Adult onset diabetes
 Long term management
 Affect many tissues and functions
 Role of glues, insulin
o Glucose- major source of energy
o Insulin needed to allow glucose to enter cells
o Pancreas produces insulin
o 3 P’s Polyuria- frequent, plentiful urination
 Polydipsia- frequent drinking
 Polyphagia- excessive eating
o Glucose unavailable
 Other energy sources
 Fat most abundant
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 Buildup of ketones
o Diabetic Ketoacidosis (DKA)
 Hypoglycemic condition
 W/o insul, certain acids accumulate
 Most common in type 1
 Signs, symptoms
 Weakness, Nausea, weak, rapid pulse, Kussmaul
respirations(fast, deep), sweet breath(acetone)
 Can progress to coma and death
Hyperosmolar Hyperglycemic Nonketotic Syndrome( HHNS)
o More often caused by type 2 diabetes
o Hyperglycemic
o Slower, more gradual onset than DKA
o No sweet smelling breath
o Excessive urination results in dehydration
Blood Glucose monitoring (BGL)- only if patient has history of diabetes
o Many brands of glucometers
o Determines amt of glucose in blood
 Normal 80-120 mg/dl
 Hypoglycemia is BGL <60
 Hyper BGL >120
o Test blood
 Equipment etc
 Done in lab
o Hyper vs Hypo
 Hypo
 Both lead to crisis
 Diabetic coma
 Taken too much insulin, didn’t eat enough
 Vigorous activity
 Vomited a meal after taking glucose
 Insufficient glucose supply to brain
 Unconsciousness, death
 Hyperglycemic crisis
 Not under medical treatment
 Insufficient insulin, overeating, under stress
 Result in death in untreated
o Questions to ask diabetic patient
 Medication to lower blood sugar
 Insulin dose to day
 Eaten normally today
 Any illness, stress etc. today
o Oral glucose
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Gel-put on tongue depressor inside check and suck on it
to absorb rapidly
Contraindications- inability to swallow,
unconsciousness
Seizures
 Rarely life threatening
 Underlying condition
 Trauma, hypoglycemia as causes
 Clear airway
 On side
Hematologic emergencies
o Blood Cells
o Sickle Cell disease
 Inherted, affects red blood cells
 African American, Mediterranean descent
 Sickle shaped re cells- poor oxygen carriers live for only 16 days hemoglobin S
 Normal life 120 days
 4 main types of crisis
 vaso-occlusive
 Aplastic
 Hemolytic
 Splenic sequestrian
 Complications
o CVA, gallstone, jaundice, ulcer, infection, pain, opiate tolerance
o Clotting disorders
 Thrombosis
 Thrombophilia
 Hemophilia
 A most common- lack factor 8
 B second most common – lack factor 9
Gastrological/Urological
o Abdominal Pian
 Common complaint
 Don’t need to determine exact cause
 Should be able to recognize a life threatening problem
o Abdominal cavity
 Contains
 Gastrointestinal system
 Genital system
 Urinary system
 Solid and hollow organs
 Solid
o Liver, spleen, pancreas, kidneys, ovaries
 Shock and bleeding
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Hollow
o Gallbladder, stomach, small intestine, large intestine, urinary
bladder
 Breach into and contents leak and contaminate
abdominal cavity
Gastrointestinal system
 Responsible for digestion
 Begins when food is chewed
o Saliva starts
o Food swallowed – to stomach
o Stomach main digestive organ
 Liver assists in digestion
o Secretes bile
 Aid in fat digestion
o Filter toxic substances
o Creates glucose stores
o Gallbladder reservoir for bile
 Small Intestine
o Duodenum
 Digestive juices from pancreas and liver mix
 Pancreas secrets enzymes breaking down
starches, fats, proteins
 Pancreas produces bicarbonate, insulin
o Jejunum
 Colon
o Food that isn’t used comes here
o Movement called peristalsis moves waste through intestines
o Water absorbed
o Stool formed
 Spleen
o In abdomen
o No digestive function
o Part of llymph system
 Assists in filtering blood
 Develops red cells
 Blood reservoir
 Produces antibodies
 Male Reproductive system
 Female Reproductive system
Urinary system
 Controls discharge of waste material filtered from blood by kidneys
 Body has one on each side
o On posterior wall
o Regulate acidity, blood pressure
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o Rid body of toxic waste
o Blood flow high in kidneys
Ureters
o Join kidney to bladder
o Bladder located behind pubic symphysis
o Bladder empties urine outside body through urethra
o 1.5-2L per day
o Pathophysiology
o Abdominal cavity lined with peritoneum
 Also covers abdominal organs
 Parietal and visceral
o Foreign material; blood, pus, bile can irritate
 Peritonitis
Acute abdomen
o Refers to sudden onset of abdominal pain
 Often associated with severe progressive problems
Peritonitis
o Causes ileus
o Ileus
 Paralysis of muscular contractions
 Retained gas and feces cause distention
o Diverticulitis
 Inflammation of abnormal pockets at weak areas in
lining of colon
o Cholecystitis
 Inflammation of the gallbladder
Two types of nerves supply peritoneum
o Perceive pain, touch, pressure, heat, cold
o Visceral peritoneum supplied by autonomic nervous system
 Produces referred pain
Ulcers
o Protective layer of mucus lining erodes, allowing acid to eat into
organ
o May lead to gastric bleeding
o Some heal w/o intervention
o Pain upper mid abdomen/upper back
Gallstones
o Gallbladder stores digestive juices, waste from liver
o Gallstone may block cause pain
Pancreatitis
o Inflammation of pancreas
 Caused by obstruction gallstone, alcohol abuse, or other
diseases
o Signs, symptoms
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Upper abdomen pain(both sides)- referred back pain,
nausea, vomiting, abdominal distention
o Sepsis or hemorrhage may occur
 Appendicitis
o Infect, inflame appendix
o Nausea, vomiting, fever, chills
o Right lower quadrant pain- referred around navel
 Gastrointestinal
 Esophagitis
 Esophageal varices
 Mallory-Weiss syndrome
 Junction between esophagus and stomach tears apart- severe bleeding
 Vomiting principal symptom
 Gastroenteritis
 Infection from bacterial or viral organisms in contaminated food or
water
 Diarrhea
 Diverticulitis
 Fecal matter caught in colon walls- inflame and infection
 Hemorrhoids
 Swelling, inflammation of blood vessels surrounding rectum
 Bright red blood during defecation
Urologic emergencies
 Cystitis
 UTI
 Bacterial infection
 Serious if spreads to kidneys
 Urgency and frequency of urination
Kidneys
 Major role
 Eliminate waster
 When fail, uremia results
 Urea still in blood
 Kidney stones from over time and cause blockage
Acute kidney failure
 Sudden decrease in kidney function
Chronic kidney failure
Female reproductive organs
 Gynecologic problems cause of acute abdominal pain
 Lower quadrant pain
Other organ systems
 Aorta- lies immediately behind peritoneum
 Weak areas result in abdominal aortic aneurysm(AAA)
 Tearing sensation
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Pneumonia
Hernias
 Protrusion of organ through an opening into a body cavity does not
belong
 May not always be noticeable mass or lump
 Strangulation is a serious medical emergency
 Pain can be anywhere
 Signs and symptoms
o Former reducible mass no longer reducible
o Pain at hernia site
o Tenderness when hernia is palpated
o Red/blue skin discoloration
Patient assessment
 Ask about blood in vomit or black tarry stools
 Change in bowel habits an urination
 Weight loss
 Abdominal Examination
o Normal abdomen is soft and not tender
o Pain/tenderness: signs of acute abdomen
o Expose and assess abdomen
o Palpate gently
 Cannot treat causes of acute abdomen
o Take steps to provide comfort and lessen effects of shock
 Treat for shock even when not obvious
 Low-flow oxygen decreases oxygen
o Clean ambulance and equipment
o Wash hands even if wearing gloves
Kidney Dialysis
 Adverse effects
Toxicology
o Acute poisoning- 5 million ppl/yr
o Chronic is much more common
 Abuse of medication, alcohol, tobacco, drugs
o Deaths rare
 Decreasing since 1960s
o Study of toxic or poison sybstances
 Poison
 Any substance that can chemically damage body structure or impair
body function
 Substance abuse is misuse of any substance that is poison
 Primary responsibility
 Recognize poisoning, call medical control
 Ask patient
o What substance
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o When they took it
o How much did you ingest
o What actions have you taken
o How much do you weigh
Identifying the poison
 Try to determine nature of the poison
o Look around the immediate area for slues
o Place any suspicious material in plastic bag and take it with you
o Containers at scene can provide critical information
 How poison get in body
o Inhalation, absorption, ingestion, ingestion, injection
 Inhaled
o Move patient to fresh air immediately
o Supplemental oxygen
o Us SCBA to protect yourself
o Some patients may need decontamination
o All patient who inhaled poison require immediate transport
o Take containers to hospital
o Suicide attempt in vehicle
 Exhaust fumes high in CO
 Open door, may be overcome as well
 Contact HAZMAT
 Chemical suicide
 Absorbed poisons
o Affect skin in many ways
o Signs/symptoms
 History of exposure, liquid or powder on skin, burns,
itching, irritation, typical odors of substance
o If in eyes, irrigate quickly and thoroughly
 5-10 min for acid
 15-20 for alkalis
o Industrial setting
 Wash off immediately
 Obtain MSDS
o Only time you should not irrigate with water is when the poison
reacts violently with water
 Bruch chemical off
 Remove contaminated clothing
 Apply a dry dressing to the burn area
 Ingested Poisons
o 80%
 Drugs, liquids, household cleaners etc
 Usually accidental with children, deliberate with adults
and teens
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Signs, symptoms vary with
 Type, age, time passed
 Goal is to rapidly remove as much poison as possible
from GI tract
 Further care provided at emergency
department
 In past ipecac was used to induce vomiting
 Not used today
 Many EMS systems use activated charcoal
 Comes as suspension that binds to poison in
stomach and carries it out of system
 Injected Poisons
o Usually result of drug abuse, heroin or cocaine
o Signs/symptoms
 Weakness, dizziness, fever, chills, unresponsiveness,
excitability
o Impossible to dilute or remove
 Usually absorbed quickly into body
 Can cause intense local tissue destruction
o Monitor airway, provide high-flow oxygen, be alert for nausea
and vomiting, transport promptly
o Ask yourself
 Medication bottles around
 Alcoholic beverages around
 Syringes or drug paraphernalia
 Unpleasant or odd odor
 See anything suggesting drug lab
 Interventions
o Support ABCs
o Dilute airborne exposures with O2
o Remove contact exposures with water
o Consider activated charcoal for ingestions
o Contact medical control or a poison center to discuss treatment
options
o Report as much info as possible about poison
o Bring or have company fax MSDS to hospital if poisoning
occurred in work
o DUMBELS, SLUDGE
o RICES
o Rule of 9s-Body divided in different sections each about 9%
Epistaxis- nosebleed
Somatic=voluntary, Autonomic=involuntary
Spinal Column (top to bottom)
 Cervical (7)








o
o
o
Thoracic (12)
Lumbar (5)
Sacrum (5)
Coccyx (4)
Cushing’s triad
o Increased blood pressure
o Increased heart rate
o Cheyne-stokes respirations
Epidural bleeding
o Between skull and dura mater
Subdural
o Beneath dura mater but outside brain
Intracerebral
o Within tissue of brain itself
Pneumothorax
 Tracheal deviation late sign
 Lung sounds may be absent
 Occlusive dressing
 Taped only on 3 sides
 Monitor for tension pneumothorax
 Spontaneous
 Structural weakness, no trauma
 Weak are, ruptures
 Sudden unexplained chest pain, shortness of breath
 Simple
 No major changes in physiology
 Commonly due to blunt trauma with fractured ribs
 Can worsen to tension pneumothorax or other issues
 Tension
 Buildup of air pressure
 Release 1 side of dressing
Hemothorax
 Blood in pleural space
 Hemopneumothorax
 Air and blood
 S/S; shock, etc
Cardiac Tamponade
 Area around heart filling with fluid, pressure on heart, can’t pump
 S/S:
 Beck’s Triad- JVD, muffled heart siund, narrowing pulse pressure
 Altered mental status
 Prehospital treatment
 Support ventilations
o
o
o
o
o
o
o
o
 Transport rapidly
Rib fractures
 Common
 If upper 4 ribs, then severe trauma
 S/S:
 Localized tenderness
 Rapid, shallow respirations
 Patient holding affected portion of rib cage
 Treatment
 O2
Flail Chest
 2 or more ribs fractured in 2 or more ribs
 Moves opposite of normal
 Treatment
 Maintain airway
 O2
 Support ventilation
 Reassess
Pulmonary contusion
 Suspect it in all cases of sever blunt injury to chest
 Alveoli fill with blood-hypoxia
 Treatment
 Respiratory support, rapid transport
Sternal Fractures
 Increase suspicion for organ injury
Clavicle fractures
 Possible damage to neurovascular bundle
 Suspect upper rib fractures in medial clavicle fractures
 Be alert to pneumothorax development
Traumatic asphyxia
 Characterized bydistented neck veins, cyanosis, hemorrhage in eye
 Sudden sever compression of chest, rapid increase in pressure
 Underlying injury to heart-pulmonary contusion
 Treatment
 Ventilatory support
 Monitor vital during immediate transport
Myocardial contusion
 Bruising of heart muscle
 Unable to maintain adequate blood flow
 S/S
 Irregua
Commotio Cordis
 Injury caused by sudden direct blow to chest during a critical portion of
heartbeat
o
o
o
o
o
 May result in immediate cardiac arrest
 Defibrillate in first 2 min
Laceration of the great vessels
 Fatal hemorrhage
Abdomen
 4 quadrants
 RUQ
o Liver, gallbladder, duodenum, pancreas
 LUQ
o Stomach and spleen
 LLQ
o Descending colon, left half of transverse colon
 RLQ
o Large and small intestine, appendix
Injuries to Abdomen
 Open or closed
 Closed
 Compression
 Deceleration
 Pain can be deceiving
o Often diffuse, referred to different location
 Blood in peritoneal cavity produces acute pain in entire abdomen
 Difficult to determine location
 Open
 Foreign object enter abdomen, opens peritoneal cavity to outside
o Ex stab wounds
 Injury depends on velocity of object
o Low knives, handguns medium, rifles high
 Evisceration
o Bowel protrudes
Mechanism of Injury
 Direct blows, indirect blows, Twisting forces, High-energy forces
Fractures
 Closed or Open
 Described by whether bone I moved from normal position
 Nondisplaced vs displaced
 Greenstick- incomplete fracture passes only partway through the shaft
of a bone
 Comminuted- bone broken into more than two fragments
 Oblique- bone broken at angle
 Transverse-fracture occurs straight across bone
 Spiral-caused by teisting foce
 Incomplete- not all the way through
o

Suspect if
o Deformity, tenderness, guarding, swelling, bruising, crepitus,
false motion, exposed fragments, pain, locked joint

Sometimes a dislocation reduces itself
o Confirm by patient history
o If it does not reduce, it is a serious problem
Signs/symptoms
o Marked deformity or swelling
o Pain aggravated by attempt at movement
o Tenderness or palpitation
o Virtually complete loss of normal joint motion
o Numbness or impaired circ to limb or digit
Dislocations

o
o
o
o
o
o
Sprain
 Joint twisted or stretched beyond normal range
 Usually returns, usually no sever deformity
 S/S
o Point tenderness,
Strain
 Muscles or tendon
 Results from a violent muscle contraction or from excessive swelling
 Often no deformity and only minor swelling
Compartment syndrome
 Usually w/ fractured tibia or forearm of children
 Pain out of proportion to injury
 Pain on passive stretching, pallor, decreased sensation/power
Amputations
 Occur as result of trauma or surgical intervention
 Control bleeding, treat for shock
 Be aware of emotional stress
Complications
 Systemic changes
 Prevent contamination
 Brush debris away, do not enter/probe site
 Long term disability possible-devastating
 Reduce risk by
 Prevent further injury
 Reducing risk of infection
 Minimize pain by using cold and analgesia
 Transporting patients to appropriate medical facility
Assessing Severity
 Golden period is critical
 Prolonged hypoperfusion is bad
 Suspected open fracture or vascular injury is a medical emergency
o
o
o
o
o
 Platinum 10 min
 Most injuries not critical
Emergency Medical Care
 Primary assessment
 Stabilize ABCs
 Perform rapid scan
 Standard precautions
 Suspect internal bleeding
Splinting
 Splint all fractures, dislocations, sprains before moving patient
 Will help prevent
 Further damage
 Remove clothing from area
 Note/record neurovascular status
 Cover all wounds with a dry sterile dressing
 Do not move the patient before splint an extremity unless there is
danger
 Pad all rigid splints
 Maintain manual stabilization at joint above and below fracture site
 Apply manual traction and encounter resistance, splint in deformed
position
 Stabilize all suspected spinal injuries in a neutral in line position
 When in doubt splint
Inline traction splinting
 Act of pulling on body structure in direction of its normal alignment
 Goals
 Stabilize
 Align limb
 Avoid potential neurovascular compromise
 Imagine where uninjured limb would lie, pull gently along line of imaginary limb
until injured limb in that position
Rigid splints
 Firm material
 Applied to sides, front/back of injured extremity
 Prevent motion at injury site
 Takes 2 EMTs
 2 situations where must splint limb in deformed position
 When deformity is severe
 When you encounter resistance or extreme pain when applying gentle
traction
Formable splints
 Precontoured, inflatable air splint
 Comfortable, provides uniform contact, applies firm pressure to
bleeding wound, used to stabilize injuries below the elbow or knee


Drawbacks
 Zipper
o Traction splints
 Hare, Sager, Reel, Kendrick
 Proper application requires well trained EMTs
 Only used for isolated femur fracture
 Not for
o Upper extremity, close to or involving knee, hip, pelvis, partial
amputations, lower leg, foot, ankle injury
o Pelvic binder
o PASG/MAST Pants
 Use as splinting if unstable pelvic fracture or lower extremities
 ONLY
 Protocol-know
Environmental
o Factors
 Physical condition, age etc.
o Cold exposure
 5 ways-conduction, convection, evaporation, radiation, respiration
o Hypothermia
 Body temp goes below 95F
 Body loses ability to regulate temp, generate heat
 Key organs slow down
 Can lead to death
 Mild hypothermia
 Occurs when core temp is between 90 and 95F
 Alert and shivering
 Pulse rate, resp. are rapid
 Skin may be red, pale, or cyanotic
 Severe
 Core temp is <90F
 Shivering stops
 Muscular activity decreases
 Never assume cold, pulseless patient is dead.
o Local Cold Injuries
 Exposed body parts
 Extremities
 Ears, nose, face
 Important factors
 Duration
 Temperature
 Wind velocity
 Underlying factors
 Exposure to wet conditions





 Inadequate insulation
 Restricted circulation
 Fatigue
 Poor nutrition
 Alcohol/drug use
 Hypothermia
 Diabetes
 Cardiovascular disease
 Older age
Frostnip
 Localized cold injury
 Skin freezing, deeper tissues unaffected
 Usually affect ear, nose, fingers
 Usually not painful
Immersion foot
 Trench foot
 Occurs after prolonged exposure to cold water
 Common in hikers and hunters
Signs and symptoms
 Skin pale, cold to touch
 Normal color does not return after palpation
 Skin of foot may be wrinkled, can be soft
 Loss of sensation
Frostbite
 Most serious local cold injury
 Gangrene requires surgical removal
 Signs/Symptoms
o Frostbitten parts hard and waxy
o Feels firm to frozen, cold to touch
o Blisters and swelling may be present
o In light skinned people, skin may appear red with purple and
white or mottled and cyanotic
 Depth of damage will vary
 Superficial- only skin frozen
 Deep- deeper tissue frozen
 Hard to tell in field
Management of cold weather injuries
 Move patient from cold environment
 Do not allow patient to walk
 Remove wet clothing
 Place dry blankets over and under patient
 Give warm humidified option
 Handle patient gently




Do not massage extremities
Do not allow patient to eat, use any stimulants or smoke/chew tobacco
If patient is alert, shivering, responds appropriately, and core temp is
between 90 and 95-mild
o Apply heat packs or hot water bottle to groin axillary and
cervical regions
 Moderate to severe
o Passive rewarming should be reserved for an appropriate facility
o Prevent further heat loss
o Remove wet clothing, cover transport
 Care
o Remove from further exposure
o Handle injured part gently, protect from further injury
o O2
o Remove and wet or restricting clothing over injured part
o Consider active rewarming
o With frostnip, contact w/ warm object
o In field
 Immerse frostbitten part in water with a temp of
between 100 and 105F
 Dress are with dry sterile dressings
 If blisters have formed, do not break
o Get training to protect yourself
Heat Exposure
 Normal body temp 98.6
 Body tries to rid itself of excess heat
o Sweating
o Dilation of skin blood vessels
o Remove clothing, relocate to cooler environment
o Hyperthermia is a core them of 101 or higher
o Seizure-generate sweat-cool off
 Risk factors include
o High air temp-reduce radiation
o High humidity- reduce evaporation
o Lack of acclimation to heat
o Vigorous exercise-loss of fluid/electrolytes
 Persons at greatest risk
o Children-newborn, infants
o Geriatric patients
o Patients with heart disease, COPD, diabetes, dehydration,
obesity
o Patients with limited mobility
 Heat cramps-1st stage
o Painful muscle spasms occur after vigorous exercise
o


Do not only occur when it is hot outdoors, exact cause not
understood occur in leg or abdominal muscles
o Management
 Remove form environment
 O2
 Rest cramping muscle
 Replace fluids by math
 Cool patient with water spray/mist
Heat exhaustion-2nd
o Prolonged heat exposure
o Most common heat illness
o S/S
 Dizziness, weakness, faintness
 Change in LOC
 Muscle cramping
 Usually to do with vigorous activity
 Can onset at rest with old or young people
 Cold, clammy skin, ashen
 Dry tongue, thirst
 Normal vital signs
 Normal or slightly elevated body temp
o Management
 Move pax to coller environment, remove extra clothing
 O2-supine positions, elevate legs, fan
 Water by mouth if alert
 If nausea develops secure and transport on left side
Heat stroke-3rd
o Least common, most serious
o Body subjected more heat than it can handle- overwhelmed
o Untreated always results in death
o Typical onset
 Vigorous activities outside
 Poorly ventilated space
 Heat waves w/o sufficient air conditioning/poor
ventilation
 Child left unattended in a locked car on a hot day
o S/S
 Hot, dry , flushed skin
 Early on, wet, later hot and dry
 Falling loc
 Change in behavior, unresponsiveness
 Seizures
 Strong rapid pulse at first, becoming weaker with falling
blood pressure




 Increase respiratory rate
 Lack of perspiration
o Management
 Remove from environment
 Set A/C to max cooling
 Remove patient’s clothing
 100% O2, apply cool packs to neck, groin, armpits
 Cover patient with wet towels/sheets
 Fan patient
 Transport immediately to hospital- notify hospital
Radiation exposure
Drowning
o Near drowning-survives
o Wet vs dry
o Saltwater vs freshwater
o Risks
 Alcohol, seizures, geriatrics etc.
 Spinal w/ submersion
 Board, C-collar
o Resuscitation
 Never give up on resuscitating a cold water injury
 Hypothermia can protect vital organs from lack
of O2
 Diving reflex may cause immediate bradycardia- slow
heart rate- no shock
Descent Emergencies
o SCUBA diving
o Pressure injury
o Lungs, sinus cavities, middle ear, teeth, face
o Pain usually forces diver to return
o Perforated tympanic membrane- cold water may enter ear
through ruptured ear drum
 Diver may lose balance and orientation and run into
ascent problems
o Emergency at bottom
 Rare
 Inadequate mixing of tanks-wrong mix, or add CO to
apparatus
 Can cause drowning or rapid ascent
Ascent
o Aggressive resuscitation
o Air embolism
 Most dangerous and common
 Bubbles of air in blood vessels
o




Decompression sickness
 Bends
 Nitrogen
 Too rapid ascent , too deep for too long, repeated dives
on same day
o Hard to distinguish between air embolism and decompression
sickness
 Embolism-right away
 Decomp- can be hours later
o Treatment
 BLS
 Hyperbaric chamber
 Turn on left side-recovery position
 Remove obstruction
 O2, abdominal thrusts
 Warm
o Breath holding syncope
High altitude
o Dysbarism
o Altitude illness
o Acute mountain sickness
o HACE
Lightening
o Electrical burns
o Cardiovascular and nervous system commonly injured
 Respiratory or cardiac arrest
o Protect self, move patient to safe area, reverse triage- help the
dead people
Spider bites
o Brown recluse
o Black widow
GYN Emergencies
o Minor seeking care for STD/sexual assault is treated as emancipated minor
o A&P
 Ovaries
 Each side of lower abdomen
 Sometimes cramping during ovulation
o Puberty
 Ovulation/menstruation begins
 11-16 usually
 Continues until menopause ~50
o Pathophysiology
 Causes vary-sexual assault, etc.
 Pelvic Inlfammatroy Disease

o
o
o
Cause
o Casued by bacteria entering reproductive organs through cervix.
When infected…
 S/S
o Research
 STD-Chlamydia
 Most common bacterial STD in US. 2x common as others
 S/S
o Bleeding between periods, painful periods, abdominal pain,
fever, pain during sex, pain when urinating, itching/burning
 STD- Bacterial Vaginosis
 Mild infection-bacteria
 S/S 50% no symptoms
 Found during gyn exam
 Gonorrhea
 Contagious
 S/S
 Vaginal Bleeding
 Possible causes
o Abnormal cycle or chlamydia
o Trauma
o Ectopic pregnancy, spontaneous abortion, cervical polyps,
cancer
Patient Assessment
 Hard to diagnose in field
 Obtain accurate info
Scene Size-up
 Safety
 Involve police if suspected assault
 Preserve chain of evidence
 Have a female EMT
 MOI/NOI
 Often understood from dispatch information
 Sometimes will not emerge to patient history
Primary Assessment
 General Impression
 Stable or unstable, AVPU
 Airway/breathing
 Evaluate first
 Circulation
 Pulse, CTC
 Transport Decision
 Not usually life threatening
 If shock is possible, rapid transport

o
History taking
 Investigate chief complaint
 Ensure privacy/dignity protected
 SAMPLE
 Note allergies, medications
 Ask about period, STD
 If bleeding, how many pads
 Secondary Assessment
 Physical exam
o For gynecologic-limited and professional
o Protect privacy
o Use external pads to control bleeding
o Observe for vaginal discharge
 Vitals
o Note tachycardia, hypotension
o Monitoring
o Pulse ox
o Noninvasive blood pressure monitoring
o Us cuff and stethoscope first
 Reassessment
o Document everything
o Facts only
Normal changes in pregnancy
 Weight gain expected
 Not extreme
 Will challenge heart and musculosketal system
 Joints become loose, less stable
 Increased chance of slip and fall-balance changes
 1st stage-dilation of cervix
o Contractions, fetus enters birth canal
o Longest ~16hrs-longer if primiagravida(1st birth) than
multigravida-PCR ex. G2P2 – para=# of deliveries
o Contractions become regular, last about 30-60 sec
o If sac breaks early, provide supportive care and transport
 Fetus not ready to be born
 Head of fetus as it descends is called lightening
nd
 2 stage-deliver infant
o Fetus begins to encounter birth canal
o Ends when infant is born-spontaneous
o Contractions closer together
o Perineum will bulge significantly
o Crowning- infant’s head will appear at vaginal opening
 3rd stage- deliver placenta
o Beins with birth of infant and ends with delivery of placenta




Must completely separate from uterine wall
Always follow standard precautions to protect yourself,
infant, mother from exposure to bodily fluids
Complications
 Most women healthy
 Some may be ill
 Use O2 to treat any heart or lung disease in a pregnant patient-will not
hurt fetus
Hypertensive disorders
 Preeclampsia
o Common
o Pregnancy induced
o Can develop 30th after gestation or later
o Headache, seeing spots, swelling in hands/feet, anxiety,
hypertension
 Eclampsia
o Characterized by seizures as result of hypertension
o To treat
 Lie patient on side- pref. left
 Maintain airway
 O2
 If vomiting, suction airway
 Rapid transport, ALS
 Supine hypotensive syndrome
o Caused by compression of descending aorta and inferior vena
cava caused by pregnant uterus when the patient lies supine
o Hypotension results
 Bleeding
o Internal bleeding may be sign of ectopic pregnancy
 Pregnancy that develops outside uterus, most often
fallopian tubes
 Occurs about once in every 300 pregnancies
o Leading cause of maternal death in the first trimester is internal
hemorrhage following rupture of ectopic pregnancy
o Hemorrhage from vagina that occurs before labor begins may
be serious
o May be sign of spontaneous abortion/miscarriage
 In abruption placenta- placenta separates prematurely
from wall of uterus
 Placenta Previa- placenta develops over and covers
cervix
 Diabetes
o Develops duroing pregnancy in many women who have nto had
it previously
o
o




Gestational Diabetes-clear up after delivery
Treatment is same as for any other patient with diabetes
 Diet, exercise, insulin
Trauma
o Very possible for all common trauma, especially falls
o Pregnant women have an increased amount of overall blood
volume and a
o Trauma is leading cause of abruption placenta
o Significant vaginal bleeding with severe abdominal pain
o Not all pregnant women properly position their seatbelts
 Can cause harm to woman and fetus
 Assess pregnant women’s abdomen and chest for
seatbelt marks, bruising, trauma
o Cardiac arrest
 Focus is same as other patients
 Perform cpr and provide transport
 Notify receiving facility personnel that you have
pregnant trauma patient in cardiac arrest
o Assessment and management
 Focus is on woman
 Suspect shock based on MOI
 Be prepared for vomiting and aspiration
 Attempt to determine the gestational period to assist
you with determining the size of the fetus and the
position of the uterus.
 Maintain open airway, O2, adequate ventilation, assess
circulation, transport on left side
Cultural Considerations
 Diverse
 Different value system that affects pregnancy, choice of self-care, plan
for childbirth
 Certain cultures may not permit a male halth provider to assess or
examine a female patient
o Respect differences and honor requests from patient
o Competent, rational adult has right to refuse all or any part of
your assessment care
Teenage pregnancy
 US has one of highest rates
o Specific challenges
 May not know, or may be in denial
o Respect privacy
o Assess history away from parents
Preparing for delivery
 Consider on scene delivery when
o
o


Delivery can be expected within next few min
Natural disaster makes it hard to get to hospital
Questions
 How long have you been pregnant
 When are you due
 Is this your first baby
 Are you having contractions
o how far apart
o How long do they last
Preparing for delivery
 Do you feel as though you have bowel movement
 Have you had spotting or bleeding
 Has your water broken
 Were any of your previous children delivered by C-Section
 Have you had problems in a previous pregnancy
 Did you use drugs, alcohol, medications
 Chance of multiple birth
 Does your doctor expect complications
 If patient has delivered before, may be able to tell you she is about to
deliver
o If she has extremely frim abdomen or feels heed to push,
infant’s head is probably on rectums
o Inspect for crowning
 Once labor begins, cannot stop
o Never attempt to hold legs together
o No bathroom
 Only there to assist
 OB Kit
 Patient position
o Preserve modesty
o Elevate hips 2” to 4”
o Support head, neck
o Plan with crew where you will place baby
o Cover hips with sheet
o Place towels or sheets on floor around delivery area
o Open OB kit carefully
o Sterile gloves
 Delivery
o Partner at heat to soothe, comfort, O2
o Assess for crowning
o Do not allow explosive/abrupt delivery to occur
o Position yourself so you can see perineum at all times
o Delivering head
 Observe infant’s head as it exits vagina




 Support head with your gloved hands as it rotates
o Methods of reducing risk of perineal tearing
o If amniotic sac does not rupture at beginning of labor, it will
appear as a fluid filled sac emerging from the vagina
 it will suffocate infant
 puncture sac with clamp
 clear infant’s mouth, nose immediately
o As soon as head is delivered use one finger to feel whether
umbilical cord is wrapped around neck(nuchal cord)
o Usually you can slip cord gently over infant’s head
o If not, cut
o Suction fluids form airway
Delivering the Body
o Head usually rotates to one side or other
o Rotation helps deliver body
o Once head is born, rest of infant usually delivers easily
o Do not pull infant from birth canal
o Infant will be slippery and covered in vernix caseosa
Post-delivery care
o Dry off infant and wrap in blanket
o Place infant on one side with head slightly lower than rest of
body
o Wrap infant so only face exposed
o Warm towels
o Wipe mouth with sterile gauze pad
o Suction mouth, nose
o Hold below vagina until cord is cut
o Clamp, cut cord tie end with umbilical tape
Delivery of placenta
o Only assist
o Delivers itself, within few minutes of birth
o Never pull on cord
o Help slow bleeding by gently massaging the mother’s abdomen
with a firm, circular kneading motion
Care
o Record time of birth in PCR
o Emergency
 More than 30 min elapse and palcenta has not deliverd
 More than 500mL blood
 …
o Assessment, resuscitation
o Standard precautions
o Normal breathing immediately
o Normal pulse
o

If no repose
 Tap, flick sole of feet or rub back
 Begin resuscitation
 Position the airway, drying, etc
 Maximize effects
 Position infant on back with head down and
neck slightly extended
 Suction mouth, nose
 Rub back, flick/tap or slap soles of feet
 Additional
o Observe for spontaneous respirations, skin color, movement of
extremities
o Eval heart rate at base f umbilical cord
o If compressions required 120 per min
o 12% deliveries complicated by meconium
 Vigorous suctioning of infant after delivery
 APGAR
o Appearance, pulse, grimace/irritablilty, activity, respiration- 2 is
good, 1 is ok, 0 is bad-7 or higher total ideal
 Breach delivery
o Take longer
 Butt comes first, delivery has begun, best breech
 Provide emergency care, call ALS
 Medical control
o Same prep
o Head will almost always be face down
 Make a V with your gloved finger and position them in
the vagina to keep the wall from compressing infant’s
airway
 Limb Presentation
o No delivery
o Wrap in sterile dressing
o Hospital FAST
o O2
 Prolapse of Umbilical Cord
o Must be treated in hospital
o Umbilical cord domes out before infant
o Infants head will cut off circ
 Abortion
o Passage of fetus or placenta before 20 weeks
o Spontaneous or induced
o Most serious compilations bleeding, infection
o If woman is in shock, treat, transport promptly
Multiple gestation



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

Twins occur once in every 80 births
o Always be prepared for more than one resuscitation
o Typically smaller and delivery not difficult
o After 10 min after first birth, contractions will begin again,
process repeats
o May only be one placenta, or multiple
o Record time of birth for each twin separately
o Twins may be small=look premature
Abuse
 Increased chance of domestic violence and abuse in pregnant women
o Increase chance of miscarriage, premature delivery, low birth
weight
 Calm, professional approach
o Pay attention for danger
o Talk to patient in private, away from abuser if possible
Substance Abuse
 Effects of addiction
o Prematurity
o Pay attention to your safety
Premature
 Usualy gestation period 9 months, 40 weeks
 Normal is about 7lb
 Smaller, thinner
 Vernix missing or minimal
 Less body hair
 Require special care
 Resuscitative efforts
Post term
 Larger
 Difficult delivery
 Increased chance of injury
Pediatrics
o You may interact with more than one patient
 Family members or caregivers often need help and support
o Calm parent contributes to calm children
 Child acts same as parent
o Remain calm, efficient, professional, sensitive
o Taking a History
 Getting historical medical info is important to assess the child/infant
 Up until 4 years of age, history should be sought from primary caregiver
 At 4 years of age, child should be able to supply basic info related to
illness/injury
o Allow child to become familiar with you
 Use calm, reassuring voice
o
o
o
 Get on eye level
 Avoid rapid fire res and no Q’s
 Use appropriate questions
 Etc.
Physical exam
 Quality of cry and speech, breathing- used to determine airway and breathing in
responsive newborns, infants
 Skin color, temp, capillary refill are better indicator of perfusion than blood
pressure
 Look at interest of child in situation to determine mental status and orientation
Modified AVPU
 A=curios, alert
 V-turns head to sounds
 P=moans/cries to painful stimuli
 U= no activity to pain
 Hoarseness- upper airway obstructions
 Moaning- shock or decreased mental capacity
 Anxious w/ nasal flaring- in resp distress
 Grunting- ominous sign of resp distress
 Obtain resp rate prior to touching child
 Best place to listen for lung sounds- mid-clavicular, mid axillary
 Capillary refill is good indication of perfusion
 BP cuff
 Pediatric cuff
 Good systolic= 70+2x age in yrs
 Any life threats
 Normal behavior
 Child attentive, recognize parents/ caregivers
Assessment
 Primary
 Breathing
o Determine mental status
o Patent airway
o Eval breathing
 Circ
o Pulse
 Apical in neonate
 Infant- brachial
 Carotid/radial in children>1yr
o Skin
 Warmth, color, condition
 SAMPLE
 From parents
 OPQRST
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


 Parents
Baseline vitals
 Blood pressure seldom checked in children <3 yrs
Secondary Assessment
 Perform as time and condition permit
Reassessment
 Reassess every 5 min
Airway/breathing problems
 Resp distress
o Increased resp rate
o Nasal flaring
o Intercostal retractions
o Supraclavicular retractions
o Neck muscle use
o Audible noises of breathing
o See-saw respirations
o Any present- high flowO2 immediately
 Resp failure
o Cyanosis
o Decreased muscle tone- limp
o Accessory muscle use
o Poor peripheral perfusion
o Altered mental staus
o Grunting/bead bobbing
o If present- positive pressure ventilation w/ O2
 Resp arrest
o Resp rate less than 10 or irregular
o Limp muscles
o Unresponsive
o Slow/absent heart rate
o Hypotension if >3 yrs old
o Resp arrest leads quickly to cardiac arrest
 Airway obstructions
o High index of suspicion
o Partial
 Alert, pink, plae, stridor/crowing, retractions on neck or
intercostal spaces, crying or forceful cough
 Have pat assume pos of comfort, O2, transport
immediate
o Complete
 No crying, talking, cough, altered mental status,
cyanosis
 If closed, conscious- back blows or Heimlich
 Croup
o
o
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
Viral infection upper airway-swelling, airway narrowing
Stridor, seal bark
 Care
 Humidified O2, A/C
Epiglottitis
o Bacterial infection
 Inflammation/swelling of epiglottis
 50% mortality -37yrs of age
 Rapid onset w/ high fever
o S/S
 Pain on swallowing
 Drooling
 High fever, tripod, stridor, resp distress
 KNOW THIS
o Care
 Nothing in patients mouth
 Pos of comfort
 O2
 Pos pressur event with BVM
 Rapid transport
Asthma
o Swelling, constriction of bronchioles. Increased mucus
o Care
 Humidified O2
 Pos of comfort
 MDI-administer w/ medical direction
 Transport to hospital
Bronchiolitis
o Viral infection of bronchioles inflammation
 Humidified O2
 Not over 1 yr old
Cardiac arrest
o CPR
Care for resp emergencies
o Maintain patent airway
o Use OPA, NPA
o Suctioning
 Limit to 10 sec
 No damage
 Neonates/ infants rey need nasal suctioning with buld
syringe
o O2
 Use right size mask in tolerated
 Blow by O2
o

Positive pressure vent
 Right size bag and mask
 Chest rise
o Patient positioning
Common medical problems
o Seizures
 Febrile common
 Fever common cause
 2-5 yrs
 5% of all infants/children
 No permanent effects
 S/S
 Rigidity to arms, legs, back etc.
 Any seizure lasting longer than min is true
emergency-NOTE ON PCR
 Care
 Assess
 Airway, on side, suction, O2, transport
o Altered mental status
 Mostly same reasons as adult
 Care
 Suction, airway,O2, vitals
o Poisoning
 S/S depends on poison and exposure
 Caustic burns-acids/bases
 Care
 Assess
 Airway, suction, O2
 Acitveted charcoal-1/2 dose- 1g/kg
o Fever
 Quick, up to 105F
 Infection(meningitis), heat esposure
 Complications
 Seizure, hypglycemis etc.
 Care
 Remove from hot environment
 Cool, airway, assess, O2, cool with tepid water,
transport
o Shock
 Same as adults
 neonates have been known to go into shock from
hypothermia
 if occurs due to collapse of cardiovascular system,
usually preceded by failure of resp system

o
o
o

Care

Assess, remove from hot environ, airway, O2,
etc.
Submersion
 Can occur in any amount of water
 Hypothermia may compound
 Care
 Remove from water, assess, airway, O2,
suction, on side, CPR, AED, transport
Meningitis
 Infection of brain, spinal cord
 Can be reapidly fatal
 Bulging anterior fontanelle f properly bydrated
 High fever, rash, recent ear/ resp infection
 Care
 Protect self
 Assess, support ABCs, transport,, treat for shock
SIDS- sudden infant death syndrome
 Sudden death with no found cause
 1month-1yr
 Peak at 4 months
 Most cases healthy, premature
 Assessment
 Physical appearance, position, presence of
objects in crib or unusual/dangerous items in
room
 Appearance of room or house
 Presence of medications- baby and adult
 Circumstances surrounding discovery of baby
 Time baby put to bed, general health, birth
problems, recent illnesses, date and result of
last physical exam
 Care
 Attempt resuscitation unless rigor mortis or
dependent lividity
 Encourage caregivers to talk and tell story
 Do not provide false reassurance
 Transport
 Deliver baby in to hand of emergency dept staff
 Care to family
Trauma
o Leading cause of death and diabullity between 1-14 yrs
o All common causes
o Often no early signs of serious injuries
o
MOI
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Consider
 Unrestrained children are prone to head/neck
u=injuries
 Restrained may suffer from abdominal or
lumbar injuries
 Struck by cars while walking often incur head,
chest, lower extremity injuries
 Diving accidents often cause head, neck, spinal
injuries
 Burns to infant/child can be sever due to less
durable skin
 Sports- head, neck
Care
 Immobilize, transport etc.
Burns
 More critical in pediatrics
 More severe
 Hypothermia, fluid loss
 Cover burns with dry dressings rapid transport
 Any burn, critical burn
Child Abuse/neglect
 Must report
 500,000-4 million cases annually
 Thousands of deaths
 Lifetime problems
 Only cause of infant and child death to increase
over last 30 years
Terms to know
 Physical abuse
o Improper or excessive action taken so
as to injur or caus harm
 Neglect
o
Indicators
 Multiple abrasions, lacerations, incisions,
bruises broken bones multiple injuries or
bruising in various stages of healing
 Injuries on both front and back or to both sides
of body
 Unusual wounds
 Fearful nature
 Injuries to genitalia

o
o
Situations in which the injuries do not match
the mechanism of injury or that described by
caregivers
 Lack of adult supervision
 Untreated chronic illness
 Malnourishment, unsafe environment
 Delay in reporting injuries
 Abuse and neglect
 Bruises that are accidents found on lower arms,
knees, shins, iliac crest, forehead, under chin
 Suspicious found on buttock, genitalia, thighs,
ears, sides of face, trunk, upper arms
 Emergency care
 Safely gain entry to scene
 Deal with child
o Speack softly call child by name
o Do not ask to recreate situation or
answer difficult questions
 Examine child
o Toe to head
o DCAP-BTLS
o Matter of fact
o Do not question caregivers, or accuse
o Tell caregivers that child needs to go to
hospital
 Transport child
o Never allow child to be alone with
suspected abuser
 Notify/Document
 Convey suspicion to physician
 Document everything in objective manner
 Maintain total confidentiality
 Oral reports of auspected abuse or
maltreatment made by calling NYS child abuse
hotline
 Oral reports followed by written report within
48 hrs using form DSS-2221-A
Special Needs
 Some children/infants need advanced support, parents,
caregivers usually know what they are doing
 EMS called for problems that they cannot handle
Tracheostomy tubes
 Transport, suction w/ French catheter
 O2, ALS, transport, pos of comfort

o
o

If dislodged, seal nose, mouth w/mask use stoma, or
use all
Look for central lines(IV)
 Call ALS
 Correct life threats i.e. bleeding
 Transport w/ ALS
Shunts
 Usually malfunction or occlusion
 Care
 Take care of life threats
Geriatrics and Special Patients
o Geriatrics predisposed to lots of disease
 Hypertension, resp diseases, arthritis, heart disease
 Leading causes of death
 Heart disease, cancer, stroke, COPD, Diabetes, trauma
o Challenges w/ assessment
 Communication, hearing, vision, altered consciousness, meds, medical history
o Investigate chief complaint
 Find and account for all meds
 Complicated comms, but critical to find med history
o Vitals
 Heart rate should be in normal range, but may be changed by meds
 Weak, irregular common, may be difficult to find radial pulse
 BP
 Higher than normal
 Resp
 Should be same as younger adult
 Auscultate
o Pathophys of resp sys
 Predisposed
 Alveoli enlarged
 Slow w/ age
 Pneumonia
 Top 5 causes of death geriatric
 Pulmonary embolism
 Potential life threat
o Often confused w/ cardia, lung, or musculoskeletal issue
o Atherosclerosis
 Fat in arteries
 Can lead to myocardial infarction, stroke
 Affects 60% of people over 65
o Aneurysm
 Blood vessels stiff
 Heart valves stiff, degenerate
o
o
o
o
o
o
o
o
 Heart rate too fast, slow or erratic
Venous Stasis
 Loss of proper function of veins in legs that would normally carry blood back to
heart
 Blood clots
 Edema in legs, ankles
Heart attack
 Classic signs often not present
 Silent heart attacks common in women, people w/ diabetes
 Symptoms
 Dyspnea, epigastric and abdominal pain, nausea, vomiting, weakness,
fatigue, confusion, syncope
 Diaphoresis
 Cyanotic skin
 Edema
Heart failure
 Not able to maintain output
 Common
Dementia
 Slow onset, progressive disorientation, shot attn. span, loss of cognitive func
 May be caused by
 Alzheimer’s, DVA, Genetics
 May complicate ability to assess
 Confusion, anger, impaired judgement, unable to vocalize, unable to
follow commands, anxiety
Delirium
 Sudden change in mental status, consciousness, etc
 Look for
 Intoxication, withdrawal form alcohol, sedatives, med disorders, psych
disorders, malnutrition, vitamin deficiencies, and environmental
emergencies.
 Assess and manage for
 Hypoxia, hypovolemia, hypoglycemia
Syncope
 Assume life threat
 Caused by interruption of blood flow to brain
Stroke
 Preventable risk factors-smoking, drinking, obesity, sedentary lifestyle
 Less preventable- high cholesterol, hypertension
 Uncontrolled-cardiac disease, atrial fibrillation
Neuropathy
 Disorder of nerves of peripheral nervous system
 Weakness, cramps, spasms, tingling, numbness, itching, pain etc.
 Changes in BP, HR, constipation, bladder, sexual dusfunc
o
o
o
o
o
o
o
o
o
o
o
GI issues
 Diverticulitis
 Bleeding in upper/lower GI etc.
 Look for
 Hematemesis- bloody vomit
 Melena-dark tarry stool etc.
 Ask about NSAID and alcohol use
 Incontinence
 Enlarged prostate
 UTI, BTI
Endocrine system
 Hyperglycemia
 3 P’s
Osteoporosis
Osteoarthritis
 Destroys cartilage, bone spurs
Integumentary
 Skin becomes less pliable
 More tears, bruises, less sweat
Pressure ulcers
 Bed sores
Toxicology
 More susceptible to toxicity
 Problems when meds mixed, etc.
 Polypharmacy
 Refers to use of multiple prescription meds by one patient
 Can lead to overdose etc.
 Noncompliance occurs due to
o Financial challenges, inability to open caps, impaired cognitive,
vision, hearing ability
Depression
 Meds, therapy
 High suicide rate
 Risks- history, chronic disease, loss
Trauma and geriatrics
 Won’t recover as well
Driving
 Distraction, confusion
 Decreased hearing, vision equilibrium disorders, r=decreased mobility and
reaction, meds, condition i.e. hypoglycemia
Falls
 Common MOI
 Safety, environment factors
 Physiologic factors

 More likely for burns
 Higher mortality from penetrating trauma
o Abuse and Neglect
 Take advantage of older person
 Person, property, emotional
 Abusers were often abused
 Patient Assessment
 Try to find out what happened
 Suspect when concealed/avoided answers, or unbelievable answers
 Same as child abuse
 Same S/S as child abuse
Patients with special challenges
o Get ABCs correct
o Rely on guardian/parent for info
o Autism
 Spectrum
 Diagnosed by 3yo
o Down syndrome
 Mild-severe mental retardation
 Abnormalities
 Wide set eyes, protruding tongue, etc
 Increased risk for complications
 Approach in calm, friendly manner
 Soothe patient
o Tracheostomy tubes
 DOPE
o Shunt
 Fluid reservoir behind left ear
 Bulging fontanelles sign of distress
o Vagal nerve stimulators
 Controls seizures
 Contact medical control
o Colostomies and Ileostomies
 External bag, eliminates waste-opening between large inteing and surface of
body
o Assessment
 Ask caregiver
 Determine normal baseline status
 Ask what is different
 GO bags
o Home care
 Wide spectrum of needs and services
o Hospice, Terminally Ill
 DNR, MOLST


o Poverty, Homelessness
Vehicle Extrication
o Usually not responsible for rescue and extrication
o Our job patient care
o Rescue requires training beyond EMT level
o Extrication requires mental and physical prep
 Safety
 Mind-set, PPE
o Equipment should be appropriate to anticipated hazards
 Turnout gear, helmet, ear pro, fire extinguisher, blood, fluid impermeable
gloves, leather gloves over disposable gloves
o Vehicle safety systems
 Can be hazards after collision
 Shock absorbing bumpers may be loaded and can release and injure you
 Manufacturers req’d to install air bags on all new cars
o Air bags fill w/ nonharmful gas on impact and quickly deflate
 Steering wheel, dash etc.
o Safety primary concern
 Primary role
 Provide care
 Prevent further injury
o Provide care as extrication occurs around you
o Extrication
 Removal from entrapment or a dangerous situation or position
 Entrapment is a term used when a person is caught within an enclosed are with
no way out or has a limb or other body part trapped
o 10 phases
 Prep, en-route, arrival/scene size up, hazard control, support ops, gaining
access, emergency care, removal of patient, transfer of patient, termination
 Prep- training, check tools, equipment
 Part 800- equipment check
 Park uphill, up wind- mark scene
Terrorism
o B-Nice
o CBRNE
o Explosives preferred WMD
o Chemical agents
 Vesicants- blister agents
 Respiratory- choking agents
 Nerve
 Metabolic- cyanides
o Biologic agents
 Cause disease
 Virus
o
o
o
o
o
o
o
o
o
o
 Bacteria
 Toxins
Nuclear/radiologic terrorism
 2 known incidents- Hiroshima, Nagasaki
 Far easier to acquire, less expertise to use
 Dirty bombs- widespread panic
Basic patient care is the same
 Treatment will vary
Recognize event
 Most attacks covert
 Know DHS threat level
Observations
 Type or location, call, # of patients, victim’s statements, preincident indicators
Scene Safety
 Ensure scene is safe
 Stage away from sight
 Upwind
Responder safety
 Prevent seve from coming into cantact w/ agent
 Contamination occurs when you have diect contact w/ WMD
 Cross contamination occurs when you come in contact w/ contaminated person
Notification procedures
 Upon arrival-notify dispatchers
 Staging area
 Trained responders in PPE- only peole handle WMD
Response actions
 1st emt responds
 2nd…
 Other EMTs mau function as
 Med branch directors
 Triage etc.
Secondary devices
 Additional explosives set to explode after initial bomb
o Injure responders
Vesicant
 Primary route skin
 Blister, burn-mucus mebranes, resp tract
 S/S
 Irritation, skin pain, dis=coloration of skin, eye pain
 Sulfur mustard-IH
o Brownish-yellowish
o Lewisite (L), Phosgene oxime (CX)
o Similar wounds to mustard
 No antidote
o
o
o
o
o
o
o
o
 Decon before ABCs
 Transport-burn center
Pulmonary agents
 S/S
 Agents
 Chlorine-1st chem agent in warfare
 Phosgene
 Treatment
 Monitor ABCs transport
Nerve Agents
 Tabun, Sarin, Soman, V agents
 SLUDGEM, DUMBELS-know
 Treatment
 Duodenate
o Atropine, 2-PAM
o Multiple does may be needed
Metabolic Agents
 Hydrogen Cyanide, cyanogen chloride
 Dizziness, headache, vomiting
 Industrial settings
Biologic agents
 Communicability, incubation
 Viruses
 Smallpox,
 Ebola
 Anthrax
 Plague
Neurotoxins
 Botulinum toxin
 Botulism
 Ricin
Other EMT roles
 Syndromic surveillance
 Points of distribution (POD)
Radiologic/Nuclear devices
 RDDs
 Dirty bomb-injure victims
 Ineffective
Incendiaries and Explosives
