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About the
Authors
Adam Peddicord
Co-Founder, Pass with PASS, LLC
Adam has been a Paramedic since 1998 and started his fire
service career in 1993. He is currently the EMS Coordinator and
a Captain/Paramedic at Newport (KY) Fire/EMS Department
where he also serves as the Medical Commander of the
Newport Police Department SWAT Team.
He holds multiples Associate’s Degrees along with a Bachelor’s
and Master’s Degree in Nursing and is a board-certified Family
Nurse Practitioner. As a Nurse Practitioner, Adam has
experience in orthopedics and addiction medicine. Adam has
over 20 years of experience in EMS education through the
University of Cincinnati and Gateway Community and Technical
College.
Brandon Schoborg
Co-Founder, Pass with PASS, LLC
Brandon is currently the EMS Education Manager of a hospital
and college based EMT/Paramedic Program in Kentucky.
Previously, he was the EMS Education Manager for the
Columbus (OH) Division of Fire, Director of EMS Education at
Cleveland Clinic Akron General, Assistant Paramedic Program
Coordinator at a community college in Kentucky and the
Assistant EMS Coordinator, Engineer/Paramedic, and SWAT
Paramedic with the Newport Fire/EMS Department in Kentucky
for 8 years. He began his teaching career at the University of
Cincinnati Clermont College.
He completed his paramedic education at the University of
Cincinnati in 2010. Brandon has an Associate’s Degree in EMSParamedic, Bachelor’s Degree in Health Science, and a MBA in
Healthcare Management.
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Disclaimer
All procedures listed in the study guide should only be performed
by appropriately licensed/certified, authorized, and trained personnel
as your local government, state, or country allow.
Medication dosages may differ across the country, any
medication dosages in the study guide are relatively standardized,
however, we encourage you to check your local protocol and/or
program’s preferred dosages.
Copyright © 2021 by Pass with PASS, LLC. All rights reserved. No
part of the material protected by this copyright may be reproduced or
utilized in any form, electronic or mechanical, including
photocopying, recording, or by any information storage and retrieval
system, without written permission from the copyright owner.
Reference herein to any specific commercial product, process, or
service by trade name, trademark, manufacturer, or otherwise does
not constitute or imply its endorsement or recommendation by Pass
with PASS, LLC.
Although we make every effort to ensure that the material
contained within the study guide is current and accurate, we cannot
guarantee accuracy. However, please know, that accurate and
current study guides is extremely important to us and we
continuously review our guides for quality assurance.
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Table of Contents
1
The NREMT Exam
Page 5
2
Medical Terminology
Page 7
3
Respiratory & Airway
Page 19
4
Cardiology
Page 49
5
Neurology
Page 64
6
Toxicology & Pharmacology
Page 78
7
Trauma
Page 91
8
Medical
Page 108
9
Special Populations
Page 135
10
EMS Operations
Page 138
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1
CHAPTER 1
THE NREMT
EXAM
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Chapter 1: The NREMT Exam
The NREMT Exam
The National Registry examinations are broken •
into two segments: the cognitive exam (“the
written”) and the psychomotor exam (“handson”).
•
The cognitive exam is computer based and is
adaptive, meaning that the exam will tailor it’s
questions based on your performance and the
level of difficulty of each question. Once the
•
exam is 95% confident that you have reached
the level of competency or is 95% confident
that you cannot reach competency, the exam
will stop (as long as you have answered the
minimum amount of questions, 135, or have
not exceeded the total time allowed, 2 hours
and 15 minutes).
Pilot Questions: 35 questions that are
not factored into the student’s
performance.
Calculator: An onscreen calculator is
available during testing. You are not
permitted to bring your own calculator.
Pediatrics: 15% of the questions in each
of the five categories are pediatric
based questions.
This study guide will primarily focus on the
cognitive examination.
Topic Area
Percentage of Questions
Airway, Respiration, & Ventilation
18 – 22%
Cardiology & Resuscitation
21 – 25%
Trauma
14 – 18%
Medical/OB-GYN
26 – 30%
EMS Operations
11 – 15%
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2
CHAPTER 2
Medical
Terminology
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Chapter 2: Medical Terminology
Medical Terminology
Do not underestimate the power of medical terminology! A good understanding
and working knowledge of medical terminology will often be a lifeline on the
NREMT exam. Most often, signs and symptoms will not be described using
“common language”, rather it will be described using medical terminology.
For example…
“You are dispatched to a 13 year old male who is dyspneic. Upon your arrival, you find
the patient in the tripod position, gasping for air. As your EMT partner applies oxygen
via non-rebreather mask, you auscultate lung sounds and hear bilateral expiratory
wheezes. As you expose the patient, you observe urticaria on the patient’s neck,
chest, and back. What is your primary impression of this patient?”
A.
B.
C.
D.
Asthma
Croup
Anaphylaxis
Epiglottitis
That was a pretty simple and straightforward question, but notice that medical
terminology was used at almost every opportunity…”dyspneic, auscultate, bilateral,
urticaria.” If you did not know that “dyspneic” = short of breath, “auscultate” = to
listen, “bilateral” = both sides, and “urticaria” = hives, this question could have been
a lot more difficult to understand and ultimately come up with the correct answer.
By the way, it was “C – Anaphylaxis”
We know that medical terminology isn’t the most invigorating thing to put your
time and energy into, but believe us, studying medical terminology thoroughly will
payoff on test day. Now, let’s get to it!
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Chapter 2: Medical Terminology
A
Aerobic → the presence of air or oxygen.
Agonist → to enhance an expected response.
Anaerobic → the absence of air or oxygen.
Aniscoria → a condition characterized by unequal pupil size.
Antagonist → to inhibit or counteract the effects of other drugs or undesired effects.
Anion → an ion with a negative charge.
Aphasia → inability or difficulty in speaking.
Apnea → the cessation of spontaneous respirations.
Ascites → abnormal accumulation of fluid in the abdomen.
Ataxia → failure of muscle coordination.
Atrophy → shrinkage of a cell or muscle.
Aura → sensation (may be visual, smell, taste, etc.) that may precede a migraine or seizure.
B
Benign → nonmalignant, often not problematic.
Bile → secreted by the liver, stored in gallbladder.
Blebs → collection of air between the lung and visceral pleura that can result in spontaneous
pneumothorax.
Bruit → an abnormal sound or murmur due to a narrowing of the vessel.
Bursa → a sac containing synovial fluid that helps ease friction between tendons and bone.
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Chapter 2: Medical Terminology
C
Carcinogens → cancer-causing agents.
Cartilage → smooth and firm connective tissue.
Cation → an ion with a positive charge.
Cell → basic unit of life.
Cerumen → ear wax found in external ear canal.
Chyme → mass of partially digested food passed from stomach to the duodenum.
Cilia → small, hair-like structures.
Coma → deep state of unconsciousness, unarousable.
Confabulation → made up stories to fill in gaps of lost memory.
Congenital → present at birth.
Contrecoup → occurs at a site opposite of the side of impact.
Crepitus → a grating sound or sensation often caused by bone on bone rubbing, or with inflammation in
joints.
D
Dehydration → an excessive loss of water or fluids from the body.
Demarcation → line or visible mark between living and necrotic tissues.
Dendrites → found at the end of neurons, allows propagation of message towards cell body.
Dentalgia → is a toothache.
Dermatomes → specific area that is supplied by a single spinal nerve.
Dysarthria → poor articulation of speech. Often due to affected muscles used in speaking.
Dyskinesia → disorder related to involuntary muscle movements.
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Chapter 2: Medical Terminology
D
(continued)
Dysplasia → abnormal growth of a cell.
Dysphagia → difficulty in swallowing.
Dysuria → difficult or painful urination.
E
Edema → excess fluid in the interstitial spaces.
Epidemic → a widespread occurrence of an infectious disease in a community at a particular time.
Erythrocytes → red blood cells.
F
Facilitated diffusion → a carrier-mediated process moving substances from areas of high concentration to low
concentration.
Fascia → connective tissue that surrounds or separates muscles.
Fecalith → fecal impaction in the colon.
Fibrinogen → blood protein used in clotting cascade.
Frailty → characterized by exhaustion, slowed performance, weakness, weight loss, low physical activity, often
seen in the elderly.
G
Gait → walking or moving on foot.
Ganglia → a group of nerve cell bodies in the peripheral nervous system.
Gestation → period from fertilization of ovum to birth of fetus.
Globulins → simple proteins classified by their size, mobility, and solution.
Glomerulus → mass of capillaries found at the beginning of each nephron.
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Chapter 2: Medical Terminology
H
Hematuria → blood in the urine.
Hemiparesis → one-sided weakness; often seen in those with CVA’s.
Hemolysis → breakdown of red blood cells.
Hemophilia → hereditary bleeding disorders due to missing factors for proper blood coagulation.
Hemoptysis → coughing up blood.
Host → an animal or human with exposure to an infectious agent.
Hydrocele → a fluid-filled sac along the spermatic cord.
Hymen → a mucous membrane covering the vaginal outlet.
Hyperemia → increased blood flow to an organ.
Hyperopia → distant vision is clear, but near vision is often blurry (farsightedness).
Hyperplasia → excessive increase in the number of cells.
I
Idiopathic → unknown cause.
Idiosyncrasy → an abnormal response to a drug.
Incontinence → inability to control bowel or bladder function.
Infarction → death of tissue from lack of oxygen.
Inferior → down/bottom, toward the feet.
Infiltration → how fluids pass into tissues.
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Chapter 2: Medical Terminology
J
Jejunum → part of the small intestine.
Joule → measurement of electrical energy.
K
Keloid → excessive scar tissue that goes beyond the original border.
Kyphosis → abnormal curvature of the spine, increased convexity as viewed laterally.
L
Lactate → found in cells during metabolism, byproduct of lactic acid.
Laryngitis → inflammation of the larynx.
Lobules → small lobes.
Luxation → a complete dislocation.
M
Malaise → general weakness.
Malignant → cancerous, has ability to metastasize or spread.
Mania → a mood disorder characterized by hyperactivity, agitation, excitement and occasional violent and selfdestructive behavior.
Melena → black, tarry stools containing digested blood.
Metastasis → movement or spreading of cancer cells from location to another.
Myalgia → muscle pain.
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Chapter 2: Medical Terminology
N
Necrosis → death of a cell or a group of cells as the result of disease, ischemia, or injury.
Neoplasia → new and abnormal growth that may be malignant or benign.
Nephron → the structural and functional unit of the kidney.
Nocturia → excessive urination at night.
Nucleus → controlling body of a cell.
Nystagmus → involuntary jerking actions of the eyes.
O
Oliguria → diminished ability to create or pass urine.
Orchitis → inflammation of the testicle that may be painful.
Osmolality → osmotic pressure of a solution.
Osmosis → the diffusion of solvent (water) through a membrane from a less concentrated solution to a more
concentrated solution.
Ostomy → a surgical opening that creates a hole from the inside of the body to the outside.
Ovum → a female egg or egg cell.
P
Parenteral → any medication route other than the oral route.
Paresthesia → sensation of numbness tingling or “pins and needles.”
Pathogen → a cause of a disease.
Phobia → anxiety disorder characterized by an obsessive, irrational, and intense fear of a specific object or
activity.
Photophobia → a sensitivity to light that is abnormal.
Plasma → the fluid part of blood.
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Chapter 2: Medical Terminology
P
(continued)
Platelets → fragments of cells that are responsible for initiating the clotting process.
Poikilothermia → inability to regulate the body temperature in comparison to the ambient temperature.
Polycythemia → unusually large number of red blood cells in the blood as a result of their increased production
by the bone marrow. Often caused by COPD and/or right ventricular failure/enlargement.
Polyuria → excessive urination.
Priapism → a painful and persistent erection.
Pulsus paradoxus → abnormal decrease in systolic blood pressure (10-15mmHg) during inspiration.
Q
Quadriplegia → weakness or paralysis of all four extremities and the trunk. Often occurs after a high-level
cervical spine fracture.
R
Referred pain → pain felt at a site away from its origin.
Renin → enzyme secreted by the kidneys that is involved in the release of angiotensin; plays an important role in
maintenance of blood pressure.
Rhinitis → inflammation of the mucous membranes of the nose.
Rhonchi → abnormal, course, rattling respiratory sounds, usually caused by secretions in the bronchial airways or
muscular spasm/constriction.
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Chapter 2: Medical Terminology
S
Sciatica → pain that radiates along the path of the sciatic nerve.
Sclera → the white outer layer of the eyeball.
Slander → false statements about a person.
Solutes → the minor component in a solution that is dissolved in solution.
Stridor → high-pitched musical sound caused by an obstruction in the trachea or larynx.
Stroke volume → volume (amount in milliliters) of blood ejected from one ventricle in a single heartbeat. Normal
range is 60 – 100 with average being 70mL.
Subluxation → a partial dislocation.
Surfactant → substance that reduces the surface tension of the pulmonary fluids.
Synapse → junction between two nerve cells. Most often referred to with regards to sympathetic
(norepinephrine) and parasympathetic nervous systems (acetylcholine).
Synergism → the combined action of two agents is greater than the action of the agents independently.
T
Tendons → bands of connective tissue that connect muscle to bone.
Tetany → involuntary contraction of skeletal muscles.
Tetraplegia → weakness or paralysis of all four extremities and the trunk (another term for quadriplegia).
Tidal volume → volume (or amount) of air inspired or expired in a single breath.
Tort → personal harm or injury caused by civil versus criminal wrongs.
Trismus → limited jaw range of motion commonly caused by muscle spasms of the jaw. Can be primary symptom
in tetanus.
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Chapter 2: Medical Terminology
U
Untoward effects → side effects that prove harmful to the patient.
Urea → a nitrogen containing waste product.
Uremia → excess of urea and other nitrogen based wastes in the blood.
Urticaria → hives.
V
Ventilation → mechanical movement of air into and out of the lungs.
Vesicants → an agent that causes blistering.
Virulence → the harmfulness of a disease or poison.
Viscosity → the degree of friction between liquid molecules.
Volvulus → twisting of the intestines.
W
Wheals → small areas of swelling that result from an allergic reaction. Similar to hives (urticaria).
X
Xiphoid process → smallest of three parts of the sternum. Articulates caudally with the body of the sternum and
laterally with the seventh rib. Can fracture with inappropriate hand placement during CPR.
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Chapter 2: Medical Terminology
Z
Zone of coagulation → central area of a burn wound that has sustained the most intense contact with the
thermal source.
Zone of hyperemia → area in which blood flow is increased as a result of the normal inflammatory response to
injury in a burn.
Zone of stasis → area of burn tissue that surrounds the critically injured area from a burn.
Zygote → a fertilized ovum (egg).
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3
CHAPTER 3
Respiratory &
Airway
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Chapter 3: Respiratory & Airway
Key Terms
Air Out
Air In
Ventilation:
The process of air movement into
and out of the lungs
Perfusion:
The circulation of blood through
the lung tissues (alveoli)
Blood transition
through capillary
membrane
Diffusion:
The process of gas exchange
(carbon dioxide and oxygen)
O2 In
CO2 Out
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Chapter 3: Respiratory & Airway
Respiratory Anatomy
Nasopharynx
Oropharynx
Trachea
Respiratory center is housed in
the brainstem, more specifically
the medulla oblongata
Bronchi
Lungs
Epiglottis
Vocal Cords
Glottic Opening
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Chapter 3: Respiratory & Airway
Lung Sounds
Crackles (rales): fine, bubbling sound heard on auscultation of the lung. Produced by air
entering the distal airways and alveoli that contain serous secretions.
Rhonchi: abnormal, coarse, rattling respiratory sounds, usually caused by secretions in the
bronchial airways.
Stridor: abnormal, high-pitched, musical sound caused by an upper airway obstruction
(subglottic).
Wheezing: form of rhonchi, characterized by a high pitched, musical quality. Produced in the
lower airways (bronchioles).
Stridor
Rhonchi
(upper airway/subglottic
inspiratory)
(expiratory wheezing)
Rales
(inspiratory/expiratory)
Wheezes
Crackles
(expiratory)
(end-inspiratory)
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Chapter 3: Respiratory & Airway
Respiratory Patterns
Eupnea: normal respirations
Tachypnea: increased (fast) respirations
Bradypnea: decreased (slow) respirations
Apnea: no respirations (not breathing)
Cheyne Stokes: abnormal respirations with regular, periodic breathing with intervals of apnea
and a crescendo-decrescendo pattern of respirations.
Biot’s: abnormal respirations characterized by regular deep inspirations followed by regular or
irregular periods of apnea.
Apneustic: abnormal rapid respirations associated with deep, gasping inspirations – most
often associated with stroke or trauma.
Kussmaul’s: rapid and deep respirations – most often associated with diabetic ketoacidosis
(DKA) as a compensatory mechanism in an attempt to correct the body’s metabolic acidosis
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Chapter 3: Respiratory & Airway
Airway Adjuncts & Devices
Oropharyngeal Airway:
Used on patients without gag reflex, moves tongue forward as it curves
back to pharynx
Measured from center of mouth to angle of jaw
Insert device along roof of mouth, rotate 180 degrees to sit anatomically
(can insert in “normal” position in pediatrics)
Nasopharyngeal Airway:
Used in patients with intact gag reflex, moves tongue and soft tissue
forward to provide channel for air.
Measured from patient’s nostril to the tip of the earlobe or to the angle of
the jaw
Bevel always goes towards the nasal septum
Nasal Cannula:
Liters/Minute: 1 – 6
Oxygen Concentration: 24 – 44%
Nebulizer:
Nebulized albuterol, ipratropium, and epinephrine
Liters/Minute: 4 – 6 (hand-held); 6 – 8 (mask)
Non-Rebreather Mask:
Liters/Minute: 12 – 15
Oxygen Concentration: 80 – 100%
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Chapter 3: Respiratory & Airway
Airway Adjuncts & Devices
Bag Valve Mask:
Liters/Minute: at least 15
Use two rescuers when possible to deliver ventilations
Deliver breath over 1 second of time, allow for adequate exhalation
Squeeze bag until you see chest rise, release bag
Average tidal volume in adult patient is 500mL
Average dead space in adult patient is 150mL
12 breaths per minute in adults
20 breaths per minute in pediatrics
CPAP (Continuous Positive Airway Pressure):
Tight fitting mask, not a leak tolerant system
Centimeters of water pressure (cmH2O): 4 – 20
Most protocols do not exceed 10cmH2O
Indications for CPAP:
F: Flail Chest
N: Near Drowning
C: COPD
P: Pulmonary Edema, Pulmonary Embolism
A: Asthma, ARDS
P: Pneumonia
“Go get
the F’n
CPAP!”
Typically not used in pediatrics (< 12 years of age), however, pediatric
CPAP is gaining traction in prehospital setting.
In pediatric CPAP, all settings are the same, it’s simply a smaller mask.
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Chapter 3: Respiratory & Airway
Supraglottic Airways
Laryngeal Mask Airway:
Sizes 1 – 5
Inserted through mouth into pharynx
Advanced until resistance is felt as end of tube “seats” in the
hypopharynx
Black line marked on LMA should rest midline against patient’s upper lip
Confirm placement through traditional methods
i-gel:
Non-inflatable cuff
Designed to rest over the larynx
Insertion is same as LMA, but without inflation
Takes less than 5 seconds to insert, faster than LMA
King LT-D Airway:
Similar to i-gel and LMA
Single tube with two cuffs, that is placed into the esophagus, large
balloon is inflated in the esophagus
Holes between the two cuffs allow for ventilations to be delivered near
the glottis
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Chapter 3: Respiratory & Airway
Intubation
Miller Blade:
Straight blade, sizes 1 – 4
Tip of blade is applied directly to the epiglottis to expose vocal cords
Typically recommends for infant intubation → provides greater
displacement of the tongue
May be better for anterior airways
Macintosh Blade:
Curved blade, sizes 1 – 4
Tip of blade is inserted into the vallecula → displaces tongue to the left to
lift the epiglottis without touching it
May reduce chance of dental trauma
Stylet:
May be inserted through ET tube before intubation, adds rigidity and
shape to tube
Must be recessed 1 - 2” into the tube, should not pass the “Murphy’s Eye”
Bougie:
60 – 70cm in length
Can be used in place of stylet, performs very well in difficult and anterior
airways
Patient can be “intubated” with the bougie, then ET tube is slid over
bougie into the airway (remove bougie after tube is in place)
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Chapter 3: Respiratory & Airway
Intubation
Endotracheal Tube:
Sizes: 0.5 – 10
Average Adult Male: 7.5
Average Adult Female: 7
Direct placement through glottis opening into trachea
Confirm placement with traditional methods – capnography is gold
standard!
Things to Remember:
“DOPE” (diagnosing tube problems)
Displacement or dislodgement
Obstruction
Pneumothorax
Equipment failure
Pediatric Tube Size Formula:
(16 + age*) / 4
*age in years
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Chapter 3: Respiratory & Airway
Arterial Blood Gases
One of the most fierce enemies of the paramedic student, arterial blood gases. ABGs are
the often argued, “Why does this apply to me as a paramedic student…I’m not drawing blood
gases in the prehospital setting!?”
You’re right, most paramedics are not drawing blood gases in the prehospital setting, but
ABGs aren’t going anywhere soon…so as the phrase goes, “If you can’t beat em’, join em’!”
When approaching ABG interpretation, try to keep things in their simplest form (I know,
simple and ABGs seem like oxymoron's). But seriously, when making an ABG interpretation,
you are looking at three values (pH, CO2, HCO3) to determine what is happening with the pH is it low (acidic), normal, or high (alkalotic) and then determine if the CO2 or the HCO3
correlates with the pH.
The most critical step in ABG interpretation is knowing what values are considered normal.
pH: 7. 35 – 7.45
Carbon Dioxide, CO2: 35 – 45
Bicarb, HCO3: 22 – 26
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Chapter 3: Respiratory & Airway
Arterial Blood Gases
A mnemonic often discussed with ABGs is “ROME”
“Respiratory Opposite, Metabolic Equal”
ROME refers to the directions that the pH and CO2 or HCO3 move in correlation with one
another.
Respiratory Opposite:
In respiratory-caused conditions, when the pH decreases (< 7.35, acidic) the CO2 increases
(> 45, acidosis)
Conversely, when the pH increases (> 7.45, alkalosis) the CO2 decreases (< 35, alkalosis)
Metabolic Equal:
In metabolic-caused conditions, when the pH decreases (< 7.35, acidic) the HCO3 decreases
(< 22, acidosis)
Conversely, when the pH increases (> 7.45, alkalosis) the HCO3 increases (> 26, alkalosis)
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Chapter 3: Respiratory & Airway
Arterial Blood Gases
Respiratory Acidosis: Hypoventilation (retaining too much CO2)
Treatment: increase ventilatory rate
Respiratory Alkalosis: Hyperventilation (blowing off too much CO2)
Treatment: decrease ventilatory rate
Metabolic Acidosis: Build up of lactic acid – lactic acidosis, diabetic ketoacidosis, renal
failure, sepsis, toxic ingestion
Treatment: controlling respiratory rate, IV fluids, sodium bicarbonate
Metabolic Alkalosis: Rare, loss of hydrogen ions (vomiting or gastric suction) –
consumption of large amounts of baking soda or antacids
Treatment: correct underlying condition
Example
pH 7.28
CO2: 54
HCO3: 24
What is the pH doing? It’s below 7.35 therefore it’s acidic.
Now, which of the other values are also acidic?
CO2! A normal CO2 is 35 – 45, the given value is 54 which is higher than normal and is
acidic.
The HCO3 is within a normal range.
Interpretation: Respiratory Acidosis
Believe it or not, as paramedic students, we cover ABGs on a surface level – there is much more to ABG
interpretation, but a basic understanding of interpretation and the most common causes of abnormalities is
what we are most concerned with!
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Chapter 3: Respiratory & Airway
Capnography
Hear us when we say, “Capnography is the GOLD standard in endotracheal tube
intubation and confirmation!”
Capnography is an AHA Class I recommendation for cardiac arrest patients –
essentially meaning that there is no patient risk and all benefits.
We’ve already discussed normal values of carbon dioxide (CO2) so, let’s jump right into
the actual capnography waveform (or “capnogram”).
CO2
Phase 1: The respiratory baseline. It is flat when no CO2 is present and corresponds to
the late phase of inspiration and the early part of expiration.
Phase 2: The respiratory upstroke. This represents exhalation of a mixture of deadspace gases and alveolar gases from alveoli with the shortest transport time.
Phase 3: The respiratory plateau. It reflects the airflow through uniformly ventilated
alveoli with a nearly constant CO2 level. The highest level of the plateau is called the
“ETCO2” and is recorded as such by the capnometer.
Phase 4: The inspiratory phase. It is a sudden down stroke and ultimately returns to
the baseline during inspiration. The respiratory pause restarts the cycle.
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Chapter 3: Respiratory & Airway
Capnography Waveforms
Normal
Square box waveform
ETCO2 = 35 – 45mmHg
Dislodge Endotracheal Tube (ETT)
Loss of waveform
Loss of ETCO2 reading
Management: Replace ETT
Esophageal Intubation (or apnea)
Absence of waveform
Absence of ETCO2 reading
Management: Ventilate or intubate
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Chapter 3: Respiratory & Airway
Capnography Waveforms
CPR
Square box waveform
ETCO2 = 10 – 15mmHg
Management: Change rescuers if ETCO2 falls
below 10mmHg
Obstructive Airway
“Shark fin” waveform
With or without prolonged expiratory phase
Can be seen before actual “attack” or
“exacerbation”
Bronchospasm → asthma, COPD,
anaphylaxis, FBAO
Management: Bronchodilators & treat
underlying cause
(albuterol, atrovent, racemic epinephrine,
epinephrine)
ROSC
During CPR, sudden increase of ETCO2 above
10 – 15mmHg
Management: Check femoral or carotid pulse
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Chapter 3: Respiratory & Airway
Capnography Waveforms
Rising Baseline
Patient is rebreathing CO2
Management: Check equipment for adequate
oxygen flow, allow more time for exhalation,
ensure cuff has good seal
Hypoventilation
Prolonged waveform
ECTO2 > 45mmHg
Management: Assist ventilations, increase
respiratory/ventilatory rate
Hyperventilation
Shortened waveform
ECTO2 < 35mmHg
Management: Slow respirations/ventilatory
rate
Consider other causes: DKA, sepsis, TCA
overdose, methanol ingestion
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Chapter 3: Respiratory & Airway
Capnography Waveforms
Breathing Around ETT
Angled, sloping down stroke on waveform
Ruptured cuff or ETT too small
Management: Check cuff and tube size,
possible re-intubation
Curare Cleft
Neuromuscular blockade is wearing off
Patient takes small breath that causes the
cleft
Management: Consider re-administration of
neuromuscular blockade medication
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Chapter 3: Respiratory & Airway
Respiratory Emergencies
COPD
Asthma
Pneumonia
ARDS
Pulmonary Embolism
Hyperventilation Syndrome
Pneumothorax
Acute Mountain Sickness
High Altitude Pulmonary Edema
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Chapter 3: Respiratory & Airway
COPD
Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term that covers both
chronic bronchitis and emphysema. You may have found that asthma is at times classified
under the COPD umbrella, but many argue because it is fully reversible, it is not considered
COPD. For us, we will just leave it at chronic bronchitis and emphysema.
Management:
Oxygen and bronchodilators
Albuterol: 2.5mg in 3mL
Consider CPAP
Contact ALS for advanced airway management
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Chapter 3: Respiratory & Airway
Asthma
Asthma is two-pronged issue: bronchoconstriction and inflammation. BLS prehospital
treatment is aimed at bronchodilation (albuterol), while ALS prehospital treatment is aimed
at bronchodilation, reducing inflammation, and relaxing the smooth muscle of the airways.
Consider calling ALS anytime an asthma attack is suspected.
Management:
Oxygen and bronchodilators
DuoNeb: Albuterol: 2.5mg in 3mL / Ipratropium: .5mg
IV fluids
Consider CPAP
Contact ALS for advanced airway management
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Chapter 3: Respiratory & Airway
Pneumonia & ARDS
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Chapter 3: Respiratory & Airway
Pulmonary Embolism
Rapid onset of difficulty breathing and chest pain – especially high suspicion in the patient
without a significant cardiac or respiratory history.
Common patients:
Bedridden (chronically or after surgery)
Long flights
History of deep vein thrombosis (DVT)
Female patient (teens – 40’s) on birth control
(birth control produces increased levels of estrogen and progesterone which have been proven to increase
blood clots)
History of smoking
Signs & Symptoms
Obstructive Shock
PE will develop into
Obstructive Shock
Once patient has
entered shock state,
administer 20mL/kg
fluid boluses,
repeating as needed
to support BP
Rapid onset of dyspnea
Cough
Pain
Anxiety
Hypertension
Tachypnea
Tachycardia
Crackles, wheezes, rhonchi
Treatment
Identification and Rapid Transport!
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Chapter 3: Respiratory & Airway
Hyperventilation Syndrome
CALM DOWN!
But seriously…try to coach your patient to calm down. Hyperventilation syndrome is often
produced by an anxiety or panic attack. Try to move them to a quiet, calm, and controlled
environment and coach them to slow down their breathing (apply oxygen if needed).
Remember, hyperventilation will cause too much CO2 to be eliminated, so put the patient on
capnography and monitor their CO2.
Other Potential Causes:
Hypoxia
Cardiac or pulmonary disease
Infection/fever
Pain
Pregnancy
Drug use
Signs and Symptoms:
Dyspnea
Tachypnea
Chest pain
Carpopedal spasms
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Chapter 3: Respiratory & Airway
Pneumothorax
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Chapter 3: Respiratory & Airway
High Altitude Emergencies
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Chapter 3: Respiratory & Airway
Medications:
Albuterol
Beta-2 Agonist → Bronchodilator → Dilated the bronchioles in the lower airways
Indications → asthma, COPD, wheezing breath sounds
Dosage → 2.5mg in 3mL of normal saline, nebulized
Patients commonly will have rescue inhalers → follow protocol to administer or contact
medical control
Patients will likely have increased heart rate and “jitters” after administration
Medication must be breathed deeply to reach alveoli → encourage patient to take deep
breaths and hold as long as possible
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Chapter 3: Respiratory & Airway
Medications:
Oxygen
Oxygen is a medication!
Never withhold oxygen from any patient → A patient in respiratory distress qualifies for highflow oxygen
1 – 15LPM, depending on device
Target SPO2 levels of 94 – 99% → especially in infants, suspected stroke and MI patients
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Chapter 3: Respiratory & Airway
Review Questions
1.) In the adult patient, the average tidal volume is: _________mL.
2.) Most commonly, the maximum cmH2O we should administer through CPAP is: ______cmH2O.
3.) When using the Miller blade, the tip of the blade is applied directly to the ________ to expose the cords.
4.) When using the Macintosh blade, the tip of the blade is inserted into the ______________.
5.) Which mnemonic should be used to assist in diagnosing endotracheal tube problems? ____________
6.) A normal ETCO2 level is: ____ to ____.
7.)When the pH falls below 7.35, it is considered to be: ___________.
8.) The normal HCO3 (or bicarbonate) range is: ____ to ____.
9.) What is considered to be the “gold standard” in confirming endotracheal tube placement?
____________________
10.) This type of patient, is commonly referred to as a “pink puffer” due to polycythemia. He or she can also
experience clubbing of the fingers, a non-productive cough, and a barrel-chest appearance.
________________________
11.) This type of patient is chronically hypoxic and therefore experience chronic cyanosis. Additionally, he or
she has a productive cough and is typically overweight. __________________
12.) In the pneumonia patient, you would typically expect to find a fever and unilateral / bilateral (circle one)
diminished breath sounds.
13.) If left untreated, a pulmonary embolism will develop into _______________ shock.
14.) Which characteristic type of capnography waveform is seen during an asthma attack or COPD
exacerbation? ___________________________
15.) How much anatomical dead space is typically found in the adult patient? ___________________
16.) The oxygen concentration from a nasal cannula is: ____ to ____%.
17.) What is the medical term for cramping of the fingers (as seen in hyperventilation syndrome)?
_________________________________________
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Want more Respiratory &
Airway review?
Check out our AEMT Respiratory & Airway Study
Guide or our Respiratory & Airway Review Lecture for
more in-depth information!
www.passwithpass.com
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4
CHAPTER 4
Cardiology
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Chapter 4: Cardiology
Cardiac Anatomy
Valve Anatomy
Chordae Tendineae
Papillary Muscle
Right Atrium
Left Atrium
Pulmonic Valve
Mitral Valve
Tricuspid Valve
Aortic Valve
Right Ventricle
Left Ventricle
Valve Order:
“Toilet Paper My A..”
Three Layers of Heart Muscle
Endocardium: Innermost layer
Myocardium: Middle layer
Pericardium or Epicardium: Outer layer
“Peri”/”epi” mean “around” or “on top of”
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Chapter 4: Cardiology
Cardiac Conduction
Intrinsic Rates
Sinoatrial (SA) Node: 60 – 100
Atrioventricular (AV) Node: 40 – 60
Purkinjes: 15 – 40
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Chapter 4: Cardiology
Cardiac Emergencies
Stable Angina
Unstable Angina
Variant Angina
Left Sided Heart Failure
Right Sided Heart Failure
Cardiac Tamponade
Myocardial Infarction
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Chapter 4: Cardiology
Angina
Angina is the term for “pain in the chest”. It occurs when the heart’s demand for oxygen
exceeds the blood’s oxygen supply. It’s commonly caused by atherosclerosis and coronary
artery disease (CAD). It may also results from a spasm of the coronary arteries (Variant
Angina).
There are three types of angina and they are primarily categorized by their cause and
duration:
Management:
Relieve anxiety/pain
Place patient in a position of comfort
Administer oxygen
Establish IV access
Contact ALS for 12 Lead EKG
Consider medication administration (MONA)
Oxygen
Aspirin
Nitroglycerin
Contact ALS for additional pain control if necessary
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Chapter 4: Cardiology
Heart Failure
Primarily, we are concerned with two types of heart failure: left-sided and right-sided.
Knowing the differences between the causes, signs and symptoms, and treatments are
critical to your success on the NREMT!
Causes of Right and Left Heart Failure
Right Heart Failure
Left Heart Failure
Left Heart Failure (#1 cause)
Cor Pulmonale (right ventricular hypertrophy)
Right Ventricular Infarct
Tricuspid Valve Damage
Pulmonic Valve Damage
Pulmonary Embolism
Pulmonary Edema
Hypertension
Left Ventricle Infarct
Mitral Valve Damage
Aortic Valve Damage
Cardiomyopathy
Signs and Symptoms of Right and Left Heart Failure
Right Heart Failure
JVD
Peripheral Edema
Ascites (abdominal swelling)
Sacral/Scrotal Edema
Orthopnea
Hepato-Jugular Reflex
Left Heart Failure
Anxiety
Tachycardia
Hypertension
Pale, Sweaty Skin
Paroxysmal Nocturnal Dyspnea
Orthopnea
Rales/Crackles
Pink Frothy Sputum (late sign)
Pulsus Paradoxus
Pulsus Alternans
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Chapter 4: Cardiology
Heart Failure
Primarily, we are concerned with two types of heart failure: left-sided and right-sided.
Knowing the differences between the causes, signs and symptoms, and treatments are
critical to your success on the NREMT!
Treatment of Right and Left Heart Failure
Right Heart Failure
Left Heart Failure
Position of Comfort
Oxygen
Contact ALS for 12 Lead EKG
Fluid administration (Starling’s Law)
**Always monitor lung sounds and abdomen with
fluid administration“**
Position of Comfort
Oxygen
Contact ALS for 12 Lead EKG
Nitroglycerin
CPAP
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Chapter 4: Cardiology
Cardiac Tamponade
A cardiac tamponade often occurs due to blunt trauma (think steering wheel to the chest).
Tamponade carries a heavy mortality rate but before we jump into mortality, let’s review
what happens in tamponade…
The heart is surrounded by a sac, called the
pericardial sac. This sac has three layers (or
linings). The innermost lining is the visceral
pericardium (visceral to the vasculature!), then the
parietal pericardium, then the fibrous pericardium.
In between the visceral pericardium and parietal
pericardium is 25mL of pericardial fluid.
Beck’s Triad
When a tamponade occurs, there is an excess
accumulation of fluid that builds up in the
pericardial sac. Because the sac is tough (think
leather) it does not expand well with this excess
fluid – this excess fluid and lack of expansion puts
more pressure on the heart which prevents it from
filling and pumping like it needs to. This causes
cardiogenic or obstructive shock (EMS Standards
recognize Tamponade as both forms of shock).
Tamponade can be caused by trauma, an MI,
pericarditis, or neoplasms.
Management
ABCs
Oxygen
IV Access
Fluid Bolus (20mL/kg)
Contact ALS for Vasopressor
Key Signs
&
Symptoms
Hypotension
Other Signs & Symptoms
Chest Pain, Dyspnea, Orthopnea, Narrowing
Pulse Pressure, Electrical Alternans, Pulsus
Paradoxus, Altered LOC
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Chapter 4: Cardiology
Cardiogenic Shock
Causes:
Impaired myocardial contractility (MI)
Impaired ventricular emptying (left-sided heart failure)
Tension pneumothorax
Cardiac tamponade
Trauma (cardiac contusion)
Signs and Symptoms:
Systolic BP < 80mmHg
Respiratory distress
Chest pain
Weakness
Altered mental status
Hypotension
Tachycardia
Management:
Rapid transport
Position of comfort
Oxygen
Identify and treat underlying problems
IV access/fluid administration*
Contact ALS for additional medications/treatment
Fluid Administration:
Listen to lung sounds first!
If dry: give fluids, 100 – 200mL boluses, (Starling’s Law)
If wet: do not give fluids
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Chapter 4: Cardiology
Dissecting Aortic Aneurysm
Most common aortic catastrophe → affects three times as many people as “AAA”
Signs and Symptoms:
Syncope
Absent or reduced pulses
Unequal blood pressure readings (right side vs. left side)
Unequal pulse strength (right side vs. left side)
Heart failure
“Tearing” sensation in chest or back (this is a big one!)
Flank pain
Scapular pain
Pain radiating into legs
Management:
Rapid transport to hospital with emergency surgery capabilities
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Chapter 4: Cardiology
Myocardial Infarction
Portion of the myocardium dies (“infarcts”) as a result of inadequate oxygenated blood
supply
Other terms for Myocardial Infarction → “AMI, MI, Heart Attack”
Blockage of a coronary artery leads to myocardial ischemia (low oxygen), injury, and the
infarction (muscle/tissue death).
“Sudden Death” → Death that occurs within 2 hours of symptom onset
Cardiac Arrest
Chain of Survival:
Immediate recognition and activation
Early CPR
Rapid defibrillation
Effective ALS
Integrated post-cardiac arrest care
Recovery
Adult:
Carotid Pulse Check
100 – 120 compressions/minute
30:2 (single or multiple rescuer)
Compressing 2” – minimize interruptions
to no more than 10 seconds
Start CPR in Neonate/Infant/Child if pulse <
60
Shockable Rhythms:
Ventricular Fibrillation & Pulseless Ventricular
Tachycardia
Pulse/Breathing Check:
5 – 10 seconds in all patients
2 minutes/5 cycles for all patients
Child:
Carotid Pulse Check
100 – 120 compressions/minute
30:2 (single rescuer) | 15:2 (multiple rescuers)
Compressing 1/3 of patient’s chest (or 2”)
Infant:
Carotid or Brachial Pulse Check
100 – 120 compressions/minute
30:2 (single rescuer) | 15:2 (multiple rescuers)
Compressing 1/3 of patient’s chest (or
1.5”)
Neonate:
Brachial Pulse Check
100 – 120 compressions/minute
3:1 compression/ventilation ratio
Compressing 1/3 of patient’s chest (or
1.5”)
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Chapter 4: Cardiology
Cardiac Medications:
Aspirin
Antipyretic, Antiplatelet Aggregator → Blocks platelet aggregation (prevents platelets from
stick together, thus, reduces risk of clot formation)
Indications→ Chest pain, acute coronary syndrome
Contraindications → children, known hypersensitivity, active ulcer disease, signs of or
history of stroke
Dose → 81 – 324mg (1 baby aspirin table = 81mg)
1 adult table = 325mg
If patient has taken aspirin in last 24 hours, give remaining tablets to total 324mg
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Chapter 4: Cardiology
Cardiac Medications:
Nitroglycerin
Potent Vasodilator
Indications:
Chest Pain → Contact ALS for 12 Lead first and establish IV access
Pulmonary Edema → Administer with CPAP to help with evacuating fluid from the alveoli
Dose: 0.4mg SL (3 times, every 3 – 5 minutes as needed, 1.2mg maximum total dose)
*Monitor blood pressure with each dose → do not administer with systolic blood
pressure under 100mmHg (some protocols may vary)
*Obtain IV access prior to administration when possible, always obtain Contact
ALS for 12 Lead prior to administration to rule in/out RVI
Nitro-Bid is the paste form of nitroglycerin and is applied in a 1” circle (15mg TD) to upper left
chest area
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Chapter 4: Cardiology
Review Questions
1.) The innermost layer of the heart is the: _________________
2.) The muscles that protrude from the endocardium and assist with valve closure are called the:
_______________ muscles.
3.) The intrinsic rate of the AV node is ____ to ____ beats per minute.
4.) When treating a suspected heart failure patient with JVD, ascites, and clear lung sounds, that he or she
is experiencing left / right (circle one) sided heart failure.
5.) The number one cause of right-sided heart failure is ____________________________.
6.) The number one cause of left-sided heart failure is _____________________________.
7.) Jugular vein distention, muffled heart sounds, and hypotension collectively describe _______________
Triad; which is specific to ______________ _____________.
8.) If left untreated, a myocardial infarction and cardiac tamponade will lead to ________________ shock.
9.) Which medication is a potent vasodilator? _________________
10.) Which medication is administered in chest pain and is classified as an antiplatelet aggregator?
_______________
11.) A heart rate greater than 100 is referred to as ________________.
12.) Upon leaving the lungs, which vessel returns the oxygenated blood to the left atrium?
_______________________
13.) When the newborn’s heart drops below 60, _________ should be initiated.
14.) What is the middle layer of the heart muscle called? ___________________
15.) True or False: A blood pressure should be obtained prior to administering or assisting with nitroglycerin
administration.
16.) The Bundle of HIS delivers the electrical impulses down to the _____________________.
17.) What is the maximum amount of time that should be spent on a pulse check? _________ seconds
18.) Where should the pulse check occur on a 9-month old infant? ___________ artery
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Want more
Cardiology review?
Check out our Paramedic Cardiology Study Guide or
our Cardiology Review Lecture for more in-depth
information!
www.passwithpass.com
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5
CHAPTER 5
Neurology
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Chapter 5: Neurology
The Nervous System
Body’s principal control system
Network of cells, tissues, and organs regulate bodily functions via electrical impulses
transmitted through nerves
Endocrine system: related to the nervous system, exerts control via hormones
Circulatory system: assists in regulatory functions by distributing hormones and chemical
messengers
Dendrites:
Receive chemical
messages from other
neurons – messages
then converted into
impulses
Soma: Central cell body
Axon: Sends messages (impulses) to
other neurons
Synapse: Connects here
Synapse: Small gaps that
separate neurons (between axon
of one neuron and the dendrites
of the other)
Axon Terminal: Buds at end of axon
from which chemical messages
(impulses) are sent
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Chapter 5: Neurology
CNS Anatomy
The spine has 33 vertebrae
Cervical Spine: 7 vertebrae
Thoracic Spine: 12 vertebrae
Lumbar Spine: 5 vertebrae
Sacral Spine: 5 vertebrae
Coccyx Spine: 4 vertebrae
Meninges:
Main job is to protect or “PAD”
Pia Mater: innermost layer, directly on CNS
Arachnoid Mater: middle layer, web-like (arachnoid = spider)
Dura Mater: Outermost layer (“durable”)
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Chapter 5: Neurology
Cranial Nerves
CN I: Olfactory: Smell
CN II: Optic: Vision
CN III: Oculomotor: eye movement,
pupillary constriction
CN IV: Trochlear: down and inward eye
movement
CN V: Trigeminal: jaw movement
CN VI: Abducens: lateral eye movement
CN VII: Facial: facial movement
CN VIII: Vestibulocochlear: hearing and
equilibrium
CN IX: Glossopharyngeal: swallow,
phonation
CN X: Vagus: parasympathetic nervous
system
CN XI: Accessory: shoulder shrug
CN XII: Hypoglossal: tongue movement
“On Occasion Our Trusty Truck Acts Funny Very Good Vehicle
Any How”
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Chapter 5: Neurology
Brain Anatomy
Cerebrum: The “actual” brain itself…when you think of “brain” you probably picture the
cerebrum.
Reticular Activating System:
Responsible for maintaining
consciousness and ability to
respond to stimuli
Frontal Lobe
Temporal Lobe
Temporal Lobe
Parietal Lobe
The brain receives ~ 20% of body’s
total blood flow per minute
Consumes 25% of body’s glucose
Occipital Lobe
Diencephalon (interbrain): Involuntary actions
(temperature, sleep, water balance, stress, emotions)
Mesencephalon (midbrain): Pons, Medulla Oblongata
(Respirations, blood pressure, heart rate)
“We live and die in the brainstem”
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Chapter 5: Neurology
Mental Status
AEIOU TIPS: Mnemonic to rule in/rule out
reasons for altered mental status and/or
unconsciousness
Alcohol
Epilepsy
Insulin
Overdose
Uremia
Trauma
Infection
Psychogenic
Stroke/Syncope
Severity of AMS: DERM
Depth of coma
Eyes
Respiratory pattern
Motor function
Babinski Reflex: dorsiflexion of the
great toe and fanning of others –
indicates dysfunction of the CNS
Glasgow Coma Score: This is a must
know! “Extra Value Meal $4.56”
Decorticate Posturing: Deep cerebral
brainstem injury – flexes towards the
“cord”
Decerebrate Posturing: Deep cerebral
brainstem injury (more severe than
decorticate)
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Chapter 5: Neurology
Stroke
Ischemic (Occlusive): Most common (80%), cerebral artery blocked by clot
→ Results in ischemia, inadequate blood supply to brain tissue, progresses to brain
muscle infarction
→ Possible TPA (fibrinolytic) candidate, gain last time seen normal, etc.
→ Typically a more gradual onset
Hemorrhagic (Bleed): Less common (20%), bleeding can be within brain or on outer
surface of brain.
→ Sudden onset, severe headache
Transient Ischemic Attack (TIA): Temporary interference with blood supply to brain (“mini
stroke”).
→ Lasts for few minutes to several hours, symptoms fully resolve in no more than 24
hours
→ No evidence of residual brain or neurologic damage
Check blood glucose on all suspected stroke patients
Gain a good history from patient or family members,
specifically, time of symptom onset/last seen normal
Be cautious with oxygen administration – do not give
oxygen unless SPO2/patient presentation warrant
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Chapter 5: Neurology
Seizures
Generalized
Electrical discharge in small area of brain
Spreads to involve entire cerebral cortex
Causes widespread malfunction
Partial
Confined to limited portion of brain
Localized malfunction
May spread and become generalized
Includes tonic-clonic and absence seizures
Tonic-clonic = “grand mal seizure”
Generalized motor seizure
Produces loss of consciousness
Simple or Complex
Specific progression of events:
Aura
Simple:
Focal motor, sensory, Jacksonian seizures
Chaotic movement or dysfunction of one
area of the body
No loss of consciousness
Loss of consciousness
Complex:
Temporal lobe or psychomotor seizures
Tonic phase, hypertonic phase
Distinctive auras:
Unusual smell, taste, sound
Metallic taste in mouth is common
Clonic phase
Status Epilepticus
Post seizure
Two or more generalized motor seizures
without intervening return of
consciousness
Management:
Postictal
Petit-Mal/Absence Seizures
Brief, generalized seizure
10 to 30 second loss of consciousness or
awareness
Eye or muscle fluttering
Occasional loss of muscle tone
Move objects from around patient
Oxygen
IV access
Contact ALS for benzodiazepine
administration
#1 cause of seizure activity is noncompliance with medications
Obtain BGL on all seizure patients
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Chapter 5: Neurology
Syncope & Headaches
Syncope
Sudden, temporary loss of consciousness caused by insufficient blood flow to the brain.
Regains consciousness when lying supine.
Potential Causes:
Cardiovascular conditions
Hypovolemia
Non-cardiovascular disease
Idiopathic (unknown cause)
Headaches
Acute (sudden)
Chronic (constant or recurring)
Generalized (all over)
Localized (specific area)
Range from mild to severe
Vascular
Migraines & Cluster Headaches
Significant percentage are tension
headaches
Continuous throbbing headache with fever,
confusion, and/or nuchal rigidity = think
meningitis
Migraines
Lasts minutes to hours to days
Usually very intense, throbbing pain
Photosensitivity
Nausea/Vomiting
Often unilateral
Occur commonly in women
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Chapter 5: Neurology
CNS Conditions
Bells Palsy
Sudden, unilateral weakness or paralysis of the facial muscles
Occurs due to dysfunction of seventh cranial nerve (facial nerve)
Often follows viral infection
Herpes Simplex Virus can also be a cause
Trigeminal Neuralgia
Also called “Tic Doloureux”
Extremely painful, affects 5th cranial nerve (trigeminal nerve)
Electrical shock type spasms and pain
Tends to be chronic
Antiseizure medications used as treatment
Alzheimer’s and Pick’s
Results from death and disappearance of nerve cells in cerebral cortex.
Marked atrophy of the brain
Pick’s → permanent form of dementia similar to Alzheimer’s disease
Tends to affect only certain areas of the brain, rare condition
Huntington’s & Creutzfeldt-Jakob
Huntington’s Disease → Genetic defect in chromosome 4
Adult onset and early onset types
Creutzfeldt-Jakob → Form of brain damage
Rapid decrease in mental function and movement, results from protein called “prion”
No treatment
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Chapter 5: Neurology
CNS Conditions
Muscular Dystrophy
Genetic disease
Progressive muscle weakness
Degeneration of skeletal or voluntary muscle fibers
Multiple Sclerosis
Unpredictable disease of CNS
Inflammation of nerve cells
Demyelination or destruction of myelin sheath – protective covering of nerve body
Nerves unable to conduct impulses properly
Duchenne Dystrophy
Most common childhood muscular dystrophy
Onset by age 6
Symmetrical weakness/wasting
Progresses to death
Guillain-Barre Syndrome
Serious disorder
Body’s immune system mistakenly attacks peripheral nerves
Leads to nerve inflammation that causes muscle weakness
Parkinson’s Disease
Degenerative changes in basal ganglia due to dopamine deficiency
Rhythmical muscular tremors
Rigidity of movement
Droopy posture
Usually occurs after 40 years of age
Leading cause of neuro disability > 60
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Chapter 5: Neurology
CNS Conditions
Amyotrophic Lateral Sclerosis (ALS)
“Lou Gehrig’s Disease”
Progressive motor neuron disease
Disease of the motor tracts of the lateral columns and anterior horns of the spinal cord
Results in progress muscular atrophy, increased reflexes, spastic irritability of muscles
No cure
Spina Bifida
Neural tube defect
Failure of one or more of fetal vertebrae to close in utero
Nerve damage is permanent
No cure
Poliomyelitis (Polio)
Infectious, inflammatory viral disease of CNS
May result in permanent paralysis
New cases are rare
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Chapter 5: Neurology
Review Questions
1.) What is the middle layer of the meninges? ________________ ______________
2.) When a patient’s pupils are unable to constrict or dilate, you would suspect an injury to the ____________
cranial nerve.
3.) Which cranial nerve does parasympathetic nervous system primarily function on? ___________
4.) Which system is responsible for maintaining consciousness? ________________________
5.) True or False: We want to be aggressive with oxygen therapy in the suspected stroke patient, aiming for
oxygen saturation levels of 100%.
6.) The number one cause of seizures in the adult patient is: ________________________________
7.) Parkinson’s Disease is caused by a lack of ______________.
8.) Bell’s Palsy occurs due to a dysfunction of the ___________ cranial nerve.
9.) Two or more generalized motor seizures without intervening return of consciousness is called
___________ ___________.
10.) Temporary interference with blood supply to the brain that may last minutes to hours is called a
________________________________________.
11.) Which type of stroke is the most common? ______________________
12.) The cervical spine has a total of ____ vertebrae.
13.) The thoracic spine has a total of ____ vertebrae.
14.) The lumbar spine has a total of ____ vertebrae.
15.) The outermost layer of the meninges is called the ___________ ___________.
16.) _____________ receive chemical messages from other neurons and then convert those messages into
impulses.
17.) The brain consumes ______% of the body’s glucose.
18.) What should be obtained on all seizure patients? _______________
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Want more
Neurology review?
Check out our Paramedic Medical Study Guide or our
Neurology Review Lecture for more in-depth
information!
www.passwithpass.com
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77
6
CHAPTER 6
Toxicology &
Pharmacology
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Chapter 6: Toxicology & Pharmacology
Toxicology
“Good to Know” Antidotes
Alcohol Use Disorder (AUD)
Benzodiazepines = Flumazenil (Romazicon)
Beta Blockers = Glucagon
Calcium Channel Blockers = Calcium
Cyanide = Hydroxocabalamin
Opioids = Narcan
Tricyclic Antidepressants = Sodium
Bicarbonate
Dystonic Reaction = Benadryl
Nutrition deficiencies → mainly Thiamine
Cholinergic
Pesticides (organophosphates, carbamates)
Nerve agents (sarin, soman)
Signs & Symptoms:
“SLUDGE”
Salivation
Lacrimation
Urination
Defecation
GI Upset
Emesis
Wernicke Encephalopathy:
Develops sudden with ataxia, nystagmus,
speech disturbances, signs of neuropathy,
stupor, coma
Korsakoff’s Psychosis:
Mental disorder found with Wernicke
Encephalopathy
Apathy, poor memory, retrograde amnesia,
confabulation (story telling), dementia
Usually considered irreversible
Permanently handicapped by memory loss
Hypoglycemia in the Alcoholic Patient:
Contact ALS to administer Thiamine with
Dextrose
**Unable to metabolize glucose without
adequate thiamine
Headache, Dizziness, Weakness, Bradycardia,
Nausea
Management:
ABCs, Decon
Contact ALS for advanced
medications/treatment
Cirrhosis of the Liver:
Alcoholics are prone to cirrhosis (scarring of
the liver)
Cirrhosis is the #1 cause of esophageal varices
Esophageal Varices:
Swollen veins in the esophagus
Often rupture and hemorrhage
35% mortality rate with hemorrhage
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Chapter 5: Medical Emergencies
Medications:
Naloxone (Narcan)
Opioid Antagonist → Blocks opioid receptor sites
Administered to…
Unknown/unresponsive patients
Opioid overdose patients
Typically administered intranasally by the EMT
1mL of medication (1mg) per nostril
2mg single dose
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Chapter 6: Toxicology & Pharmacology
Toxicology
Black Widow Spider:
Red hour glass on back
Females = venomous
< 1 hour, muscle spasms and cramps (neurotoxin)
Diazepam and Calcium Gluconate
Brown Recluse Spider:
Fiddle-shaped
Localized pain in 1 – 2 hours
Bite is surrounded by an ischemic ring, outlined by a red halo
May cause death
Poisonous Snakes:
Pit vipers: rattlesnakes, cottonmouth or water moccasin, and
copperhead.
Vertical, elliptical pupils and a triangular head
Hemolysis
Intravascular coagulation
Convulsions
Acute renal failure
Management:
ABCs, IV access, extremity → immobilize in neutral position,
do not use ice packs or tourniquets
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Chapter 6: Toxicology & Pharmacology
Pharmacology Key Terms
Pharmacology:
The science of drugs used to
prevent, diagnose, and treat.
Pharmacodynamics:
The study of how a drug acts on
a living organism.
Pharmacokinetics:
The study of how the body handles a drug over a
period of time, including the processes of
absorption, distribution, biotransformation, and
excretion.
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Chapter 6: Toxicology & Pharmacology
Pharmacology Key Terms
Affinity:
Drug’s desire to attach to a receptor
Oxygen vs. CO
Agonist:
A drug with both affinity and efficacy
that attaches a receptor and causes
some effect to occur
Efficacy:
Drug’s ability to create an action once
it has attached itself to a receptor
Antagonist:
A drug that inhibits other drugs from
attaching to a given receptor site
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Chapter 6: Toxicology & Pharmacology
Drugs: Their Name and Source
Official Name: The name that appears in the United States Pharmacopeia (USP) or the
National Formulary (NF). Most often, the official name is the same as the generic name and is
not capitalized.
Generic Name: nonproprietary – furosemide
Trade Name: proprietary - Lasix
Pharmacognosy: Natural drug sources of medications
Plant Sources:
Atropine Sulfate → Atropa Belladona Plant
Morphine Sulfate → Opium Plant
Digitalis → Purple Foxglove
Mineral Sources:
Sodium Bicarbonate
Calcium Chloride
Animal Sources:
Insulin → swine and cows
Oxytocin → swine
Synthetic (man-made) Sources:
Lidocaine (Xylocaine)
Diazepam (Valium)
Midazolam (Versed)
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Chapter 6: Toxicology & Pharmacology
Medication Administration
Right Medication
Right Dose
Right Time
Right Route
Right Patient
Right Documentation
Half-Life of a Medication
Time it takes to metabolize or eliminate half the total amount (peak concentration) of a drug
in the body.
A drug is considered eliminated from the body after 5 half-lives have passed.
Example: Drug X has a half-life of 2 hours, if 50mg of the drug is given, in 2 hours there will be
25mg remaining, in another 2 hours, there will be 12.5mg …
Therapeutic Index
Represents the relative safety of a drug
Determined by two factors:
Lethal Dose 50 (LD50) → dose that kills 50% of the animals the drug is given to.
Effective Dose 50 (ED50) → dose that provides therapeutic effects in 50% of a given
population
Therapeutic Index Formula: LD50 / ED50
The closer that ratio is to 1, the more dangerous the drug is.
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Chapter 6: Toxicology & Pharmacology
Fluids, Fluids, Fluids!
Colloids: Contain molecules (usually protein = Albumin) that are too large to pass through
the capillary membrane.
Blood
Packed Red Blood Cells
Blood Plasma
Plasma Substitutes → Hetastarch
Crystalloids: Do not contain large molecules (protein).
Can be divided into three groups:
Hypertonic: Any solution that is greater than
the isotonic concentration of 0.9%. Living
cell is placed in a solution that has a higher
solute concentration (and a lower water
concentration) than that inside the cell.
Hypotonic: Any solution that is less than an
isotonic concentration of 0.9%. Living cell is
placed in a solution that has a lower solute
concentration (and a higher water
concentration) than that inside the cell.
Water exits the cell and enters the solution,
causes cell to dehydrate (crenate) and
possibly die.
Too much water can enter the cell and
cause it to burse (lyse).
Isotonic: Any solution that is equal to a concentration of 0.9%. Living cell is placed in a
solution that has the same solute and water concentrations as the solution inside the cell.
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Chapter 6: Toxicology & Pharmacology
Autonomic Nervous System
Pharmacology
Peripheral Nervous System: Provides nearly every organ with a double set of nerve fibers.
Sympathetic: Adrenergic, fibers exit from thoracic and lumbar regions of spinal cord.
Parasympathetic: Cholinergic, fibers exit from cranial and sacral portions of spinal cord.
Parasympathetic Nervous System:
Also called: Cholinergic System /
Craniosacral System
Sympathetic Nervous System:
Also called: Adrenergic
System/Thoracolumbar System
Function: Maintain vegetative state, normal
body activity
Function: “Fight or Flight”, increase body
system activities
Neurotransmitter: Acetylcholine
Neurotransmitter: Norepinephrine
Major Nerves: Vagus Nerves (CN X)
Deactivating Enzymes:
Monoamine Oxidase (MAO)
Catechol-o-methytransferase (COMT)
Deactivating Enzyme: Acetylcholinesterase
“Para Aces in Vagus”
Parasympatholytic:
Blocks the effects of the parasympathetic
nervous system (Atropine)
“Lytic” → blocks
Sympathomimetic:
Mimics the effects of the sympathetic
nervous system (epinephrine)
“Mimetic” → Mimics
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Chapter 6: Toxicology & Pharmacology
Sympathetic Nervous System
Two Types of Receptors:
Alpha-Adrenergic Receptors
Alpha 1
Alpha 2
Beta-Adrenergic Receptors:
Beta 1
Beta 2
Alpha 1 Receptors:
Vasoconstriction
Pupillary Dilation
Decreased Renin Secretion
Beta 1 Receptors:
“You have 1 heart”
Beta 2 Receptors:
“You have 2 lungs”
Stimulation Causes:
Stimulation Causes:
Increased Heart Rate (Chronotropy)
Bronchodilation
Increased Contraction (Inotropy)
Vasodilation
Increased Automaticity/Conduction
Impulse (Dromotropy)
Selective Beta 2 Agonist
Albuterol
Nonselective Beta 2 Agonist
Dopamine
Selective Beta-Blocking Agents
Beta 1 – cardioselective agents – metoprolol, atenolol
Nonselective Beta-Blocking Agents
Beta 1 and Beta 2 Blocking – labetalol, nadolol, propranolol
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Chapter 6: Toxicology & Pharmacology
Review Questions
1.) You are treating a patient who has overdosed on amitriptyline, what is the antidote?
________________________
2.) What mnemonic is often paired with cholinergic poisoning? __________________
3.) The #1 cause of esophageal varices is ______________.
4.) What medication should be considered in the hypoglycemic chronic alcohol patient? _________
5.) What is the medical term for “scarring of the liver”? __________________
6.) Glucagon is the antidote for which type of medication overdose? __________________
7.) When treating a patient with suspected cyanide poisoning, what medication should be considered?
____________________________
8.) True or False: A venomous snake bite should have constricting bands placed above and below the bite.
9.) The drug’s desire to attach to a receptor. __________________
10.) A drug that inhibits other drugs from attaching to a given receptor site. _________________
11.) Atropine Sulfate is derived from the ___________ _____________ plant.
12.) After _____ half-lives have passed, the drug is considered fully eliminated.
13.) The therapeutic index is calculated by dividing ______ by ______. The closer that ratio is to 1, the more
dangerous the drug is.
14.) What is the common protein found in colloid solutions? ________________
15.) A hypertonic solution will cause the cell to ________.
16.) A hypotonic solution will cause the cell to ________.
17.) What is the neurotransmitter of the parasympathetic nervous system? ____________________
18.) What is the neurotransmitter of the sympathetic nervous system? _____________________
19.) What is a common parasympatholytic administered in the prehospital setting? _____________
20.) Beta 1 receptors work on the _________ and Beta 2 receptors work on the __________.
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Want more Toxicology
and Pharmacology
review?
Check out our Paramedic Medical Study Guide or our
Toxicology and Pharmacology Review Lecture for
more in-depth information!
www.passwithpass.com
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7
CHAPTER 7
Trauma
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Chapter 7: Trauma
Trauma
Kinematics of Trauma
Motorcycle Crashes
Head-On Impact:
Over the handlebars → head and neck trauma, compression injuries to the chest and
abdomen.
If feet remain on footrests during impact → mid-shaft femur fracture(s), perineal injuries
Angular Impact:
Rider is often caught between motorcycle and second object (vehicle, barrier, etc.)
Crush type injuries, open fractures to the femur, tibia, fibula
Fracture/dislocation of malleolus
Laying Motorcycle Down:
Massive abrasions (road rash) → treat as you would a burn
Fractures to the affected side
Vehicle vs. Pedestrian
Vehicle vs. Pedestrian
Pediatric Patients
Adult Patients
Tend to face oncoming vehicle
Turn away from vehicle
Frontal impact → above knees/pelvis
Lateral or posterior impacts
Initial impact → femur and pelvic injuries,
internal hemorrhage
Initial impact → bumper striking lower legs
(lower leg fractures)
Secondary impact → thrown backwards, head
and neck flexing forward
Secondary impact → hits hood/windshield,
femur, pelvis, thorax, spine fractures
Third impact → thrown to downward onto
ground
Third impact → thrown to ground, hip and
should injuries, deceleration injuries,
fractures/hemorrhage
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Chapter 7: Trauma
Types of Impact
Car Crash: Frontal Impact (Head-On)
Down and Under Pathway:
Travels downward into the vehicle seat and forward into the dashboard or steering column
Knees become leading part of body – upper legs absorb most of impact - knee dislocation,
patellar fracture, femoral fracture, fracture or posterior dislocation of hip, fracture of
acetabulum, vascular injury and hemorrhage
Chest wall hits steering column or dashboard, head and torso absorb energy – tamponade,
cardiac contusion, pneumothorax
Up and Over Pathway:
Body strikes the steering wheel – ribs and underlying structures absorb momentum – rib
fractures, ruptured diaphragm, hemo/pneumothorax, pulmonary contusion, cardiac contusion,
tamponade, myocardial rupture, aortic aneurysm.
If head strikes windshield first → suspect cervical fracture (axial loading injury)
Car Crash: Lateral Impact
Vehicle is struck from the side
(“T-bone collision”)
Fracture of clavicle, ribs, or pelvis
Pulmonary contusion
Ruptured liver or spleen
(depending on side involved)
Head and neck injury
Car Crash: Rotational Impact & Rollover
Crashes
Rotational: produces same injuries as
commonly found in head-on and lateral
crashes
Rollover: ejection, may have several types of
injuries
Car Crash: Rear End Impact
Vehicle struck from behind – back and neck
injuries → hyperextension
Blast Injuries (Explosions/Bombs)
Primary Blast: pressure wave → injuries to ears (eustachian tubes), lungs, CNS, eyes, GI tract
Secondary Blast: flying debris – blunt, penetrating, and lacerating injuries
Tertiary Blast: patient is thrown and injured by impact on ground or other objects
Kinetic Energy = .5mass X velocity2
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Chapter 7: Trauma
Burns
First Degree (Superficial): Reddened skin, pain at burn site, involves only epidermis, no
blistering. Heals spontaneously in 2 -3 days.
Second Degree (Partial Thickness): Intense pain, white to red skin, blistering, moist-mottled
skin, involves epidermis and dermis.
Third Degree (Full Thickness): Dry, leathery skin (white, dark brown, or charred), painless, all
dermal layers/tissues may be involved.
Fourth Degree: Involvement of muscle and bone, charred appearance, painless
Parkland Formula:
4mL X kg X %TBSA burned = 24 hour infusion
1st half over first 8 hours, 2nd half over next 16 hours
Rule of 9s – Adult
>20% TBSA, 2nd and 3rd degree burns only
Rule of 9s – Pediatric
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Chapter 7: Trauma
Burns
Inhalation Injury
Toxic inhalation: synthetic resin combustion → cyanide and hydrogen sulfide → systemic
poisoning → more frequent than thermal inhalation burn
Signs and Symptoms of Inhalational Injury Above Glottis
The upper airway “normalizes” the temperature of the inspired air (which is great, because it
protects our lower airway from these extreme temperatures), however, it sustains the
impact of the superheated air.
Facial burns, signed nasal or facial hair, “sooty” sputum, hypoxemia, stridor, red mucus
membranes, grunting respirations.
Signs and Symptoms of Inhalational Injury Below Glottis
Steam inhalations more likely to reach lower airways – has 4,000 times the heat carrying
capacity than dry air.
Wheezes, crackles or rhonchi, productive cough, hypoxemia, bronchial spasm
Carbon Monoxide Poisoning
Affinity for hemoglobin is 250 times greater than oxygen → creates carboxyhemoglobin
Odorless, tasteless gas
Cherry red skin only presents at levels > 40% (late sign)
“Multiple people feeling ill in same residence/building” → nausea/vomiting, headache,
decreased LOC, weakness, tachypnea, tachycardia
CO produces false pulse oximetry reading
High flow, high concentration oxygen is best treatment for these patients
Acid vs. Alkali Burns
Acids → burning process lasts just 1 – 2 minutes → will cause coagulation
Alkalis → burning process lasts minutes to hours → will cause liquefaction necrosis
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Chapter 7: Trauma
Head, Face, & Neck Trauma
Le Fort Fractures
Types of Amnesia:
Retrograde Amnesia: no recall of events before the
injury.
Antegrade Amnesia: in ability to create new
memories; exists after recovery of consciousness
https://www.aao.org/oculoplastics-center/le-fort-fractures
Types of Head Bleeds
Increased Intracranial Pressure
“Cushing’s Triad” = MUST KNOW
Normal ICP range = 10 – 15mmHg or less
Treatment:
SPO2 > 94%
Capnography monitoring of 35 – 40mmHg
Treatment (Evidence of Herniation):
Hyperventilation to yield ETCO2 of 30 – 35mmHg
Evidence of Herniation: Cushing’s Triad OR unresponsive patient
with bilateral, dilated pupils AND decerebrate posturing with no
motor response to a painful stimuli
Cushing’s
Triad
Systolic Blood Pressure
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Chapter 7: Trauma
Spinal Cord Injuries
Axial Loading: Vertical compression of the spine results when direct forces are sent down
the spinal column. Compression fracture or crushed vertebral bodies → T12 to L2
Central Cord Syndrome: Hyperextension cervical injuries → greater impairment of the
upper extremities than of the lower extremities, paralysis of arms, sacral sparing
(preservation of sensory or voluntary motor function of the perineum, buttocks, scrotum,
or anus)
Anterior Cord Syndrome: Usually seen in flexion injuries – decreased sensation of pain
and temperature below level of lesion, intact light touch and position sensation, paralysis
below the level of the lesion.
Brown-Sequard Syndrome: Hemitransection of the spinal cord – weakness or paralysis of
the extremities on the same side (ipsilateral) of the injury with loss of pain and
temperature sensation on the opposite side (contralateral)
Hemitransection, simply put,
means “half” the cord has
been transected. An easy
way to remember this is the
“-” between Brown &
Sequard. Think of the hyphen
as being a “half” transection.
https://www.sciencedirect.com/topics/medicine-and-dentistry/dermatome
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Chapter 7: Trauma
Chest & Abdominal Trauma
Hemothorax/Tension Pneumothorax Similarities:
tachypnea, dyspnea, cyanosis, diminished or decreased breath sounds, tracheal deviation
(late sign), asymmetrical chest rise
Hemothorax/Tension Pneumothorax Differences:
Hemothorax
Accumulation of blood in the pleural space
May be massive: 2 – 3L
Tension Pneumothorax
Accumulation of air in the pleural space
Dullness on percussion (hyporesonance)
Narrow pulse pressure
Hypotension/hypovolemia
No JVD
JVD
Hyperresonance on percussion
Subcutaneous emphysema
Patient’s will become hypotensive in late
stages (obstructive shock)
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Chapter 7: Trauma
Chest & Abdominal Trauma
Flail Chest
“Two or more adjacent ribs are fractured in two or more places”
Signs and Symptoms
Bruising
Tenderness
Crepitus
Paradoxical motion with inspiration and expiration (late sign)
Treatment
SPO2 and ETCO2 monitoring
Assist ventilations to achieve SPO2 > 94%
Consider CPAP
Consider intubation (as needed)
Traumatic Asphyxia
“Severe crushing injury to the chest and abdomen, results
in increased intrathoracic pressure”
Forces blood from the right side of the heart to the upper
thorax, neck and face.
Face will have a purple/red appearance
Management
ABC’s & hypovolemia/shock management
https://intjem.biomedcentral.com/articles/10.1007/s12245-010-0204-x
Commotio Cordis
Leading cause of death in youth baseball in US
(2 – 3 deaths per year)
Blunt chest trauma, timed during upstroke of T wave (relative refractory period – “R on T
phenomenon”
Induces ventricular fibrillation
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Chapter 7: Trauma
Chest & Abdominal Trauma
Diaphragmatic Rupture
Sudden compression of abdomen results in
increased intra-abdominal pressure
Signs and Symptoms
Abdominal pain, shortness of breath,
decreased breath sounds, bowel sounds heard
over thorax
Management
Oxygen/ventilatory support
Fluids
Rapid transport
Cardiac Tamponade
See “Cardiac Tamponade” in “Chapter 4:
Cardiology” for detailed information.
Evisceration
Protrusion of an internal organ(s) or the
peritoneal contents through a wound
Management
Cover eviscerated contents with moist,
sterile dressing
Cover moist dressing with dry dress to
conserve organ temp
Never attempt to place organs back in
cavity
Solid Organ Injury
Rapid and significant blood loss
Solid organs most injured = liver and spleen
Both can be life threatening
Hollow Organ Injury
Sepsis, wound infection, abscess
formation → spillage of their contents is
primary concern
Liver
Largest organ in abdominal cavity
Often injured by trauma to 8th – 12th ribs on
right side
Second most commonly injured intraabdominal organ
Mortality rate = 54%
Stomach → not often injured by blunt
trauma
Spleen
Left upper quadrant
40% of patients have no
symptoms…immediately
Pain in left shoulder (Kehr’s Sign)
Colon and small intestine → more likely to
be injured by penetrating trauma than blunt
trauma
Abdominal Trauma Treatment
Stabilize the patient & rapid transport
Oxygen
Permissive hypotension = 80 – 90mmHg
Check for other injuries
Reassess every 5 minutes
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Chapter 7: Trauma
Fractures
Ligaments → connect bone to bone
Types of Fractures
Tendons → connect muscle to bone
Sprain → stretching and tearing of
ligaments
Strain → overstretching and/or
overexertion of muscle
Blood Loss Associated with Fractures
Rib = 125mL
Radius or Ulna = 250 – 500mL
Humerus = 500 – 750mL
Tibia or Fibula = 500 – 1,000mL
Femur = 1,000 – 2,000mL
Pelvis = 1,000mL +
Greenstick → most common fracture in
children
Injury Presentations
Hip Fracture
Affected leg is shortened and externally rotated
*Fractures closer to the head of the femur may present similarly to anterior hip dislocation →
shortened leg and an internally rotated.
Hip Dislocation
Affected leg is shortened and internally rotated.
Usually a posterior dislocation of the femoral head.
Femur Fracture
Affected leg is shortened and externally rotated with mid-thigh swelling (from
hemorrhage)
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Chapter 7: Trauma
Types of Shock
Commonly Associated with Trauma
20mL/kg boluses, PRN
20mL/kg boluses, PRN
100 – 200mL boluses, PRN
Stages of Shock
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Chapter 7: Trauma
SCUBA Diving Emergencies
Diving Gas Laws:
Boyle’s Law: if temperature remains constant, volume of a given mass of gas is inversely
proportional to the absolute pressure.
When pressure is doubled, the volume of gas in halved. Popping or squeezing sensation in ears.
Dalton’s Law: pressure exerted by each gas in a mixture of gases is the same pressure that
gas would exert if it alone occupied the same volume.
Henry’s Law: at a constant temperature, the solubility of a gas in a liquid solution is
proportionate to the partial pressure of gas.
Descent Diving Injuries
“The Squeeze” → Results from the compression of
gas in an enclosed space as the ambient pressure
increase with descent under water.
Pain
Sensation of “fullness”
Headache
Disorientation
Vertigo
Nausea
Bleeding from nose or ears (think eustachian tubes)
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Chapter 7: Trauma
SCUBA Diving Emergencies
Ascent Injuries
Air Embolism: most serious complication of pulmonary barotrauma → major cause of death
and disability among divers.
Occurs when ascending too quickly or holding breath while ascending to surface. Diver loses
consciousness immediately after resurfacing.
Signs and Symptoms: Difficulty breathing, stroke-like symptoms (vertigo, confusion, visual
disturbances, focal neurologic deficits)
Management:
Oxygenation and airway protection
Transport in left lateral recumbent position
Hyperbaric oxygen therapy (“recompression”)
Decompression Sickness (“the bends, diver’s paralysis, caisson disease, dysbarism”):
Multisystem disorder that results when nitrogen in compressed air converts back from
solution to gas → results in formation of bubbles in the tissues and blood. (Henry’s Law).
Signs and Symptoms: Joint pain, rashes, itching, “bubbles under the skin”, chest pain, cough
,shortness of breath
Management:
Oxygenation and airway protection
Transport in left lateral recumbent position
Hyperbaric oxygen therapy (“recompression”)
Nitrogen Narcosis (“rapture of the deep”): nitrogen becomes dissolved in the blood and
crosses the blood-brain barrier. Causes CNS depression effects similar to alcohol which can
seriously impair the diver’s thinking and lead to lethal errors. Usually becomes evident at
depths of 75 – 100’.
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Chapter 7: Trauma
Environmental Emergencies
https://www.grepmed.com/images/3297/hypothermia
-cardiology-clinical-osborn-jwave-ekg-ecg
Hypothermia
Core body temp (CBT) of less than 95 degrees → lose the ability to shiver
Osborn wave (“J wave”) may be present at junction of the QRS and ST segment
Mild hypothermia: 89.8 – 95
Moderate hypothermia: 82.5 – 89.7
Severe hypothermia: < 82.4
Increased risk of enter Ventricular Fibrillation
Management:
Handle with care
Move to warm environment and start rewarming process
Remove wet/cold clothing
Heat Stroke
CBT > 104
Heat Exhaustion
CBT up to 103
Signs & Symptoms
Severe cramps
Dizziness
Nausea
Profuse sweating
Headache
Management:
Move to cool environment
Administer replacement fluids
Cool patient with a cool water spray
Signs & Symptoms
Confusion/irrational behavior
Coma
Flushed skin
Pulmonary edema
Dysrhythmias
GI bleeding
Clotting disorders
Reduced renal function
Hepatic injury
Electrolyte abnormalities
**Sweating may be absent**
Management:
Move to cool environment
Cool by fanning, keep the skin wet
Administer fluids
Administer benzodiazepines for seizures
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Chapter 7: Trauma
Review Questions
1.) In a blast injury, the pressure wave occurs during which phase of the blast? _______________
2.) If a patient’s head strikes the windshield, what type of spinal cord injury should be suspected?
______________________
3.) This type of EKG finding is characteristic in the hypothermic patient. ____________________
4.) When calculating the Parkland Formula, only ____ and ____ burns are calculated.
5.) After calculating the Parkland Formula, the first half of fluid should be given during the first _____ hours.
6.) Carbon monoxide has an affinity for hemoglobin that is _____ times greater than that of oxygen.
7.) _____________ skin is a late finding in high carbon monoxide levels.
8.) This type of inhalation burn has the greater likelihood of reaching the lower airways. _____________
9.) This type of burn causes liquefaction necrosis. ________________
10.) This type of burn causes coagulation. _______________
11.) Bradycardia, irregular respirations, and an increasing blood pressure collectively form ___________
_______.
12.) This type of head bleed is arterial in nature and most commonly involves the middle meningeal artery.
______________
13.) The inability to create new memories. ___________________
14.) This type of head bleed is venous in nature and is more common than epidural bleeds. ___________
15.) A hemitransection of the spinal cord is called _________- ________ __________.
16.) What is a major difference between a hemothorax and a tension pneumothorax? ____________
17.) Blunt chest trauma, timed during the upstroke of the T-wave that produces ventricular fibrillation.
___________________________________
18.) The most common type of fracture in the pediatric patient. ___________________
19.) Left untreated, a tension pneumothorax will develop into ______________ shock.
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Want more Trauma
review?
Check out our Paramedic Trauma Study Guide or our
Trauma Review Lectures for more in-depth
information!
www.passwithpass.com
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8
CHAPTER 8
Medical
Emergencies
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Chapter 8: Medical Emergencies
Gynecology & Pregnancy Terms
Dysmenorrhea: pain during menstruation
→ Headache, faintness, dizziness, nausea, diarrhea, backache, and leg pain
→ Caused by muscular contractions of the myometrium, infection, inflammation
→ Presence of an intrauterine device (IUD)
Mittelschmerz: pain may occur as a result of follicular rupture and bleeding from ovary
during menstrual cycle
→ Pain in the right or left lower abdominal quadrant during normal mid-cycle of
menstrual period
→ Differentiate pain from appendicitis or other surgical emergencies
Gravida: # of times a women has been pregnant (including current)
Para: # of live birth (infants born after 20 weeks’ gestation)
Antepartum: the maternal period before delivery
Intrapartum: the maternal period during delivery
Postpartum: the maternal period after delivery
Term: a pregnancy that has reached 40 weeks gestation
First Stage of Labor: Begins with contractions and ends when the cervix is fully dilated
(10cm)
Second Stage of Labor: Measured from full dilation to delivery of the newborn
Third Stage of Labor: Begins with delivery of the baby and ends with placental delivery
Precipitous Birth: onset of labor to birth is less than 3 hours
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Chapter 8: Medical Emergencies
Gynecologic & Pregnancy
Emergencies
Ovarian Cyst: Thin walled, fluid-filled sac on the
surface of the ovary
May result in significant hemorrhage
Abdominal pain may be caused by rapid
expansion, torsion or acute rupture
Vaginal bleeding or a late/missed period at time
of rupture
Localized, one-sided lower abdominal pain
https://www.completewomencare.com/ovarian-cysts/
Third leading cause of maternal death; typically
found at 8 – 12 weeks gestation
Vaginal bleeding, crampy abdominal pain, spotting
Rigid, stiff, board-like abdomen
After rupture, severe abdominal pain, vaginal
spotting, internal hemorrhage, sepsis, and shock
Management
IV & fluids
Pain management
RAPID TRANSPORT
Ectopic
Ectopic Pregnancy: pregnancy that develops
outside of the uterus (fallopian tube or ovary)
Normal
Management
IV & fluids
Pain management
Rapid transport
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Chapter 8: Medical Emergencies
Gynecologic & Pregnancy
Emergencies
Placenta Previa:
Placental implantation in the lower uterine
segment, partially or completely covering the
cervical opening
Abruptio Placenta:
Partial or full detachment of a normally
implanted placenta at more than 20 weeks
gestation
Occurs in about 5/1000 deliveries
Occurs in about 1% of all pregnancies;
results in fetal death in about 15% of cases
Signs and Symptoms
Third-trimester pain (aching)
Signs & Symptoms
Third-trimester pain (stabbing)
Painless
Painful
Bright Red Bleeding
Dark Red Bleeding
Strongly associated with # of previous Csections & deliveries
Localized uterine tenderness
Most common cause of pre-term bleeding
Preeclampsia
Gestational hypertension after 20 weeks and
at least one of the following:
Proteinuria (protein/blood in urine)
Low platelets
Impaired liver function
Renal insufficiency
Pulmonary edema
Visual or cerebral disturbances
Severe HTN characterized by systolic > 160
and diastolic > 110
Eclampsia
Preeclampsia + Seizure = Eclampsia
Tonic-clonic activity (Grand Mal Seizures)
Labor can begin suddenly/progress rapidly
Left lateral recumbent positioning
Oxygen
IV access
Contact ALS for anti-seizure medications
Each seizure increases fetal mortality by
10%
Can occur up to 4 weeks postpartum, rare
IV, oxygen (PRN), calm transport
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Chapter 8: Medical Emergencies
Gynecologic & Pregnancy
Emergencies
Postpartum Hemorrhage
500mL of blood loss after delivery
Occurs within first 24 hours
Accounts for 25% of obstetric deaths
Management → Fundal massage (releases oxytocin → helps with uterine contraction),
encourage newborn breastfeeding, administer oxytocin (10U/1L, infuse at 20 – 30
drops/minute)
Amniotic Fluid Embolism
Amniotic fluid enters maternal circulation during labor, delivery, or immediately after through
lacerations of endocervical veins, lower uterine segment, or uterine veins.
Occurs in 6 – 15 per 100,000 deliveries
Maternal mortality rate is high
Signs and symptoms mimic that of a pulmonary embolism (PE)
see “Chapter 3: Respiratory & Airway)
Trauma During Pregnancy
ABCs first
Aggressive resuscitation
After first trimester, never transport pregnant patient flat on back
(Supine Hypotensive Syndrome)
Transport on left side → if spinally immobilized, “prop up” right side of backboard 6 – 12” to
achieve a leftward lean
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Chapter 8: Medical Emergencies
Delivery & Complications
See Stages of Labor on “Gynecology & Pregnancy Terms” page
Imminent Delivery
Regular contractions, 45 – 60 seconds in length, at 1 – 2 minute intervals
Intervals are measured from beginning of one contraction to the beginning of
next
Contractions > 5 minutes apart → transport
Mother has urge to bear down or has sensation of bowel movement
Crowning occurs
Mother believes delivery is imminent → always believe your patient!
Delivery
1. Crowning occurs → apply gentle counter pressure to fetus’ head (prevents explosive
delivery)
2. Observe for nuchal cord with delivery of head
3. Grab head with hands over ears to support head as it rotates for shoulder presentation
4. Once shoulders deliver, rest of baby delivers very quickly → use dry towel to
grasp/support
5. Suction airway (mouth then nose) only if meconium staining is present along with
signs/symptoms of respiratory distress or coarse gurgling.
6. Dry newborn → Record sex and time of birth
Once baby is delivered/evaluated, cut umbilical
cord:
1. Cord should have stopped pulsating
2. Clamp cord → if baby does not need
resuscitation, allow for 30 seconds to 1
minute after delivery to clamp/cut
3. Clamp 4 – 6” away from the newborn (in two
places)
4. Cut between the clamps – do not take the
clamps off!
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Chapter 8: Medical Emergencies
Delivery & Complications
“The Golden Minute”
Assign APGAR score at 1 and 5 minutes after birth
10 = best possible condition (unlikely in prehospital setting)
7 – 9 = generally normal
4 – 6 = moderately depressed
0 – 3 = severely depressed
Shoulder Dystocia
** score of < 6 = likely resuscitation
Cephalopelvic Disproportion
Newborn’s head is too large to pass
through birth canal
Oxygen administration, IV access, rapid
transport
Fetal shoulders are wedged against symphysis
pubis, blocking shoulder delivery
Common, 1:300
Position patient in McRobert’s Maneuver and apply
gentle pressure to suprapubic area
Rapid transport
Breech Presentation
Largest part of fetus (head) is delivered last; more common in multiple births
Do not push!
Rapid transport, call for assistance, oxygen administration, consider anti-contraction
medication
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Chapter 8: Medical Emergencies
Delivery & Complications
Umbilical Cord Prolapse:
→ Cord passes through the cervix at same
time or in advance of fetus
→ Cord is compressed against fetus →
diminishing fetal oxygenation from placenta
→ Occurs in 1:10 deliveries
Management
Assess for cord pulsation.
→ If pulsating, wrap with moist sterile
dressing and then dry dressing to maintain
temperature, continue to asses for pulse
→ If not pulsating, insert two gloved fingers
into vagina and attempt to move baby off
of cord, may also place mom in knee chest
position. Continue methods until cord
begins pulsating and follow directions
above.
Nuchal Cord:
Cord is wrapped around fetus’ neck during
delivery.
Try to remove the cord from the fetus’ neck
during delivery, if unable, clamp in two places
and cut immediately!
https://fineartamerica.com/art/umbilical+cord
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Chapter 8: Medical Emergencies
Pediatrics
Age
Awake Rate
Sleeping
Rate
Respiratory
Rate
Blood
Pressure
Neonate
100 – 205
90 – 160
40 – 60
80 + (2 x age*)
Infant
100 – 180
90 – 160
30 – 53
80 + (2 x age*)
Toddler
98 – 140
80 – 120
22 – 37
80 + (2 x age*)
Preschooler
80 – 120
65 – 100
20 – 28
80 + (2 x age*)
School-Aged
75 – 118
58 – 90
18 – 25
80 + (2 x age*)
Adolescent
60 - 100
50 – 90
12 – 20
80 + (2 x age*)
*age in years
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Chapter 8: Medical Emergencies
Pediatrics
Respiratory Differentiation
Viral or bacterial (bacterial is the most life-threatening)
Stiff neck → Kernig’s and/or Brudzinski’s Sign
Fever (high fever)
Petechiae
Meningitis
Petechiae → pink/red rash (spots on skin)
Life threatening → Protect yourself with N95 mask!
Purpura
Purpura → dark purple lesions
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Chapter 8: Medical Emergencies
Endocrinology
Endocrine Glands
Exocrine Glands
Ductless
Release chemical products through ducts
Secrete hormones directly into circulation
Have localized effects
Widespread effects
Act on distant tissues
Hormones…
Just read the names to determine their effect/role
“Growth hormone releasing hormone (GHRH)”
Releases growth hormone
“Growth hormone inhibiting hormone (GHIH)”
Inhibits growth hormone release
Terms:
Anabolism: Build up, uses energy
Catabolism: Breakdown, no energy required
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Chapter 8: Medical Emergencies
Endocrine Anatomy
Hypothalamus: Located deep within the cerebrum of the brain.
Hypothalamic cells – nerve cells or neurons, receive messages from
ANS and detect internal conditions. Gland cells produce and release
hormones.
Pituitary Gland: “Master Gland”. Size of a pea, broken into “anterior”
and “posterior” glands.
Anterior responds to hypothalamic hormones.
Posterior responds to nerve impulses from hypothalamus.
Has direct impact on endocrine glands throughout body.
Anterior Pituitary Gland
Posterior Pituitary Gland
Adrenocorticotropic hormone (ACTH)
Adrenal cortexes
Antidiuretic hormone (ADH)
Retention of water
Thyroid stimulating hormone (TSH)
Thyroid
Oxytocin
Follicle stimulating hormone (FSH)
Gonads or sex organs
Luteinizing hormone (LH)
Gonads
Uterine contraction
Lactation
Diabetes Insipidus
Large volumes of urine
Inadequate ADH secretion
Prolactin (PRL)
Female mammary glands
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Chapter 8: Medical Emergencies
Endocrine Anatomy
Thyroid: Two lobes, butterfly shaped, located in neck anterior and
inferior to larynx.
Produces three hormones:
Thyroxine (T4) → stimulates cell metabolism
Triiodothyronine (T3) → stimulates cell metabolism
Calcitonin → lowers blood calcium levels
Parathyroid: Four small glands located on posterior lateral surfaces
of thyroid.
Secretes parathyroid hormone (PTH) → increases blood calcium
levels
PTH is antagonist of calcitonin; balance of PTH and calcitonin
determines level of blood calcium
Thymus: In mediastinum, just behind the sternum. During childhood,
it secretes thymosin → maturation of “T” lymphocytes responsible
for cell-mediated immunity. The “T” of “T” lymphocytes (or “T” cells)
stands for “thymus”.
Disappears after childhood – cannot be seen on chest x-ray
Pancreas: Located in LUQ, retroperitoneal behind stomach. Has both
endocrine and exocrine tissues.
Endocrine tissue known as “Islets of Langherns”
Alpha: Glucagon → raises blood sugar
Beta: Insulin → lowers blood sugar
Delta: Somatostatin
Exocrine tissues secrete digestive enzymes.
Glycogenolysis → Glucagon
stimulates breakdown of
glycogen
Gluconeogenesis → New
glucose from non-sugar
sources
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Chapter 8: Medical Emergencies
Endocrine Anatomy
Pineal Gland: Located in roof of thalamus in brain. Releases
hormone melatonin in response to changes in light. Melatonin may
affect mood.
Adrenal Gland: Subdivided into “Adrenal Cortex” and “Adrenal
Medulla”
Adrenal Cortex
Posterior Pituitary Gland
Outermost layer
Middle layer
Steroids
Glucocorticoids → increase BGL
Catecholamines
Adrenal Medulla
Nerve cells and gland cells
Secretes epinephrine (adrenalin)
Norepinephrine
Mineralocorticoids → salt/fluid balance
Androgenic hormones → same effect as
secreted by gonads
Female Gonads
Ovaries produce eggs
Male Gonads
Tests produce sperm cells
Sexual maturation → puberty and
subsequent reproduction
Sexual maturation → puberty and
subsequent reproduction
Ovaries (female gonads)
Paired organs about size of almond
Located in pelvis on either side of uterus
Produce estrogen and progesterone
Testes (male gonads)
Located outside abdominal cavity in
scrotum
Testosterone → secondary male sexual
characteristics and sperm development
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Chapter 8: Medical Emergencies
Diabetes
Diabetes Mellitus: Inadequate insulin activity. Insulin is critical to maintaining blood
glucose levels and enables the body to store energy as glycogen, protein, and fat.
Type II Diabetes
Type I Diabetes
“Juvenile Diabetes”
Insulin resistance
Beta cell destruction
Very low production of insulin (if any)
Insulin-Dependent Diabetes Mellitus (IDDM) →
requires insulin injections for homeostasis
Less common than Type II, but more serious
Accounts for most diabetes-related deaths
If untreated, blood glucose levels rise because
cells cannot take up circulating sugar
BGL of 300 – 500 not uncommon
Constant thirst (polydipsia), excessive urination
(polyuria), ravenous appetite (polyphagia),
weakness, weight loss
Ketosis result of fat catabolism
May proceed to diabetic ketoacidosis
Diabetic Ketoacidosis (DKA)
No insulin → BGL rises with fast onset
Body switches to fat catabolism → ketones
Kussmaul’s respirations
Ketones on breath
BGL ~> 500mg/dL
Treatment → give fluids and transport
Non-insulin-dependent diabetes mellitus
(NIDDM)
Some patients may require insulin
Heredity and obesity play a role
Far more common than Type I
Untreated presents with lower level of
hyperglycemia and fewer major signs of
metabolic disruption
May proceed to hyperglycemic hyperosmolar
non-ketotic syndrome (HHNK)
Hyperglycemic Hyperosmolar Non-Ketotic
Syndrome (HHNK)
Cells resistant → BGL rises with slow onset
Severe dehydration (osmotic diuresis)
BGL much higher than DKA → ~ >1,000mg/dL
Higher mortality than DKA
Treatment → give fluids and transport
Hypoglycemia
BGL < 60, treat with oral sugar (if conscious)
Contact ALS for Dextrose/Glucagon
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Chapter 8: Medical Emergencies
Thyroid Disorders
Thyrotoxicosis (Hyperthyroid)
“Thyroid Storm”
Mild form of hyperthyroidism
Brought on by infection, stress, or surgical
manipulation of thyroid
Hypothyroidism
Low levels of thyroid hormones produced,
cold intolerant
Often associated with Grave’s Disease
Goiter (enlarged thyroid)
Exophthalmos (protruding eyes)
Hyperthyroidism
Excessive levels of thyroid hormones
produced, heat intolerant
Severe tachycardia, heart failure, dysrhythmias,
shock, hyperthermia, agitation, coma, delirium
Myxedema
Graves Disease
Type of excessive thyroid activity characterized
by a goiter and protruding eyes
Most often occurs in young women
May arise as a result of an autoimmune process
in which an antibody stimulates the thyroid cells
Form of hypothyroid → may be associated
with inflammation of thyroid gland
(Hashimoto’s)
Thickening of the skin, most notably the lips,
nose, and throat
Coma is rare, precipitated by exposure to
cold, infection, heart failure, trauma, drugs,
stroke, hypoxia, and hypoglycemia
Characterized by hypothermia and decreased
LOC
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Chapter 8: Medical Emergencies
Adrenal Disorders
Cushing Syndrome
High Cortisol & Aldosterone Levels
Mainly affects women 30 – 50 years old
May be caused by adrenal gland tumor, adrenal
gland enlargement or long-term administration
of corticosteroid drugs
(prednisone, dexamethasone or
methylprednisolone)
Signs and Symptoms
Face appears to be round (“moon face”) and
red
Weight gain, muscle atrophy of arms/legs
Low Cortisol &
Aldosterone
Addison’s Disease
Low Cortisol & Aldosterone Levels
Purple stretch marks on abdomen, thighs, and Caused by any disease process that destroys
the adrenal cortices
breasts (“striae”)
Increased facial hair, buffalo hump on back,
hypertension, insomnia, depression, diabetes
Most common cause is shrinking the adrenal
tissue
High Cortisol &
Aldosterone
Progressive weakness, weight loss, and
anorexia
Skin hyperpigmentation (redness/pinkness)
Hypotension
Hyponatremia
Hyperkalemia
GI disturbances (nausea, vomiting, diarrhea)
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Chapter 8: Medical Emergencies
Abdominal & GI Emergencies
Visceral Pain: “organ pain”, caused by stimulation of autonomic nerve fibers that
surround an organ.
Compression and inflammation of solid organs
Distention or stretching of hollow organs
Cramping, gas-type pain
Pain is generally diffuse, difficult to localize
Somatic Pain: produced by bacterial or chemical irritation of nerve fibers in the
peritoneum (peritonitis).
Usually constant and localized to a specific area
Sharp or stabbing pain
Referred Pain: pain in a part of the body considerably removed from the tissues that
cause the pain.
Grey’s Turner: Bruising of the skin of the
flanks or loin in retroperitoneal
hemorrhage and acute hemorrhagic
pancreatitis
Cullen’s Sign: The appearance of irregularly
formed hemorrhagic patches on the skin
around the umbilicus
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Chapter 8: Medical Emergencies
GI Bleeds
GI Bleed Treatment:
ABCs
Left lateral recumbent/high semi-fowler’s position (protect airway)
Oxygenation via non-rebreather mask
IV access
Antiemetic for nausea/vomiting
Fluid replacement as needed
Mallory Weiss Tear (Upper GI Bleed):
Laceration of the esophagus caused by excessive “retching” and vomiting - associated
with bulimia. Tear does not extend through entire esophagus
Boerhaave Syndrome (Upper GI Bleed): Rupture of esophagus from prolonged “retching”
and vomiting. Tear travels entirely through the esophageal wall.
Allows for passage of blood, air, and food out of the esophagus and into the
mediastinum.
90% mortality rate in 48 hours if untreated
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Chapter 8: Medical Emergencies
Abdominal & GI
Acute Gastroenteritis: Inflammation of the stomach and intestines with sudden vomiting
and diarrhea.
Causes: ETOH and tobacco use, NSAID use, chemotherapeutic agents, alkalotic/acidic
ingestion.
Treatment → airway management & hydration
Chronic Gastroenteritis: Long-term mucosal changes or permanent mucosal damage.
Causes: microbial (H-Pylori → fecal/oral route or through contaminate food or water)
Peptic Ulcers: #1 cause of upper GI bleeds. Erosions cause by gastric acid – may occur
anywhere in the GI tract. Duodenal ulcers occur in proximal portion of the duodenum.
Occurs more in males than females.
Causes: NSAIDS, nicotine, ETOH, H-Pylori
Signs and Symptoms: nausea and vomiting, massive hemorrhage is possible
Treatment → Antacids and bleeding control
Zollinger-Ellison Syndrome: Acid secreting tumor provokes ulcerations – chronic ulcers
may result in anemia
Ulcerative Colitis: Unknown cause, occurs in the rectum and large intestine, bloody
diarrhea/ stool with mucus.
Signs and Symptoms: nausea, vomiting, fever, weight loss
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Chapter 8: Medical Emergencies
Abdominal & GI
Crohn’s Disease: Can occur anywhere in the GI tract
Who/Why → familial link, white females, high stress, Jewish population
What → GI bleeding, weight loss, intermittent abdominal cramping/pain,
nausea/vomiting/diarrhea, fever
RAPID ONSET
Diverticulosis: #1 cause of lower GI bleed – outpouchings of tissue that push through
intestinal wall
Diverticulitis: Inflammation of diverticula due to infection
Signs and Symptoms: lower left-sided pain, fever, elevated WBCs, nausea/vomiting,
tenderness on palpation
Irritable Bowel: Abdominal pain, cramping, increased gas, altered bowel habits, food
intolerance, abdominal distention
Bowel Obstruction: Blockage of bowel lumen
→ hernias – opening in wall
→ Intussusception – telescoping effect
→ Volvulus – knotting
→ Adhesions
Causes: Foreign bodies, gallstones, tumors, adhesions from abdominal surgery, bowel
infarction
Appendicitis: Inflammation of vermiform appendix (junction of large and small
intestines). Occurs mostly in young adults. Acute appendicitis is the most common
surgical emergency in the field. Rupture leads to peritoneal irritation → sepsis
Location: Appendicitis pain starts periumbilical (around the umbilicus) and radiates to
the RLQ.
McBurney's Point → 1 – 2 inches between anterior iliac crest and umbilicus
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Chapter 8: Medical Emergencies
Abdominal & GI
Cholecystitis vs. Cholelithiasis
Cholecystitis: Inflammation of the gallbladder, caused by gallstones. Acute attack = RUQ
pain and can occur after a “fatty” meal. Murphy’s sign → right costal tenderness.
Cholelithiasis: the actual formation of the gallstones, causes 90% of cholecystitis cases.
Pancreatitis: Inflammation of the pancreas.
Four main causes:
Metabolic = alcoholism
Mechanical = gallstones
Vascular = thromboembolus or shock
Infectious = infectious disease
30 – 40% Mortality
Can have decreased blood flow resulting in ischemia
Lesions can erode and hemorrhage
Hepatitis Types
A: Fecal/Oral Route → poor handwashing
B: Bloodborne pathogens
C: Blood transfusions → needle sharing
D: Dormant use activated by HBV
E: Waterborne
G: Developed after transfusion
Signs and Symptoms
RUQ pain
Jaundice
Nausea/vomiting
Malaise
Photophobia
Pharyngitis
Coughing
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Chapter 8: Medical Emergencies
Immunology
Immune System
Primary system involved in allergic reactions
Main Goal → Destruction or inactivation of pathogens, abnormal cells, & foreign molecules
such as toxins
Immunity (Two Types)
Cellular immunity → direct attack of foreign substance by specialized cells of immune
system. Physically engulf and deactivate (example: phagocytosis – think “PacMan”)
Humoral immunity → more complicated chemical attack of invading substance
Antibodies are used to accomplish the attack
Immunoglobulins (“Ig’s”)
5 different types of Ig’s but be most familiar with IgE
Allergen attaches to IgE of basophils and mast cells, which then produces histamines
Histamine release produces → bronchoconstriction, increased intestinal motility,
vasodilation, and increased vascular permeability
Histamine release leads to the allergic reaction and/or anaphylaxis
Anaphylaxis
Sudden onset (30 – 60 seconds) → the quicker the reaction, the more severe
“Feeling of Impending Doom”
Laryngeal edema/laryngospasm/complete airway obstruction
Tachypnea → wheezes, increasing diminished lung sounds
Diffuse rash, hives *raised on skin*
Management
Cardiac monitoring (ALS)
Consider early ALS for advanced airway management
Oxygen is 1st line medication
Epinephrine Auto-Injector (“Epi Pen”) → hold injector in place for 10 seconds → rectus
femoris and vastus lateralis (thigh muscles)
Contact ALS for additional medications
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Chapter 5: Medical Emergencies
Medications:
Epinephrine (Epi Pen)
Prescribed/used during severe allergic reaction/anaphylaxis
Vasoconstrictor
Anaphylaxis causes massive vasodilation = hypotension
Adult Dose → 0.3mg (over 66 pounds)
Pediatric Dose → 0.15mg (up to 66 pounds)
Increased heart rate and blood pressure will occur after administration
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Chapter 8: Medical Emergencies
Distributive Shock
Anaphylaxis will eventually lead into “Anaphylactic Shock” which is a subset of “Distributive
Shock”
For all subsets of distributive shock, see below!
20mL/kg boluses, PRN
10 - 20mL/kg boluses, PRN
20mL/kg boluses, PRN
Typically, Distributive Shock is a “pipes” problem, meaning the “shock state” is coming from
massive and prolonged vasodilation.
It is not a “fluids” problem as you see in Hypovolemic Shock or a “pump” problem as you see
in Cardiogenic and Obstructive Shock.
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Chapter 8: Medical Emergencies
Review Questions
1.) Gravida is: _______________________________________________
2.) This stage of labor begins with contractions and ends when the cervix is fully dilated. _________
3.) An ectopic pregnancy is typically found between ____ and ____ weeks’ gestation.
4.) A pregnancy complication that occurs in the third trimester that is painful with dark red bleeding.
_____________ __________
5.) A postpartum hemorrhage is defined as blood loss of greater than _______mL within first 24 hours after
delivery.
6.) What are two ways to help control postpartum hemorrhage? ____________________________
7.) Twenty minutes after delivering a healthy newborn, the mother is experiencing a sudden onset of
difficulty breathing. What do you suspect? ___________________
8.) An APGAR score should be assigned at ____ and ____ minutes after birth.
9.) The most common surgical emergency seen in the field that starts as periumbilical pain. ________________
10.) When a newborn’s head is too large to pass through the birth canal. ______________________
11.) When the umbilical cord is wrapped around the fetus’ neck during delivery, it is termed:
_____________________.
12.) Petechiae and purpura are characteristic findings of _______________.
13.) This respiratory condition typically occurs in kids between 6 months and 4 years of age and produces a
stridorous sound.
14.) Laryngotracheobronchitis is another term for __________.
15.) Endocrine glands are __________ and secrete hormones directly into circulation.
16.) Type I Diabetes can develop into which hyperglycemic condition? ______________________
17.) Which is more common, Type I or Type II diabetes? _________________
18.) Which thyroid condition is associated with cold intolerance? ______________
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Want more Medical
review?
Check out our Paramedic Medical Study Guide or our
Medical Review Lectures for more in-depth
information!
www.passwithpass.com
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9
CHAPTER 9
Special
Populations
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Chapter 9: Special Populations
Special Populations
Cerebral Palsy: General term for non-progressive disorders of movement and posture
Cystic Fibrosis: Inherited metabolic disease of the lungs, sweat glands, and digestive
and reproductive systems.
Production of thick mucus → predisposes the patient to chronic lung infections
Management:
Oxygen
Positive Pressure Ventilation (CPAP)
Nebulized saline (to loosen mucus)
Suctioning as needed
Huntington Disease: Genetically programmed degeneration of neurons in the brain.
Causes uncontrolled movements, loss of intellectual faculties, and emotional
disturbance.
Management:
Incurable, supportive care in the prehospital setting
Muscular Dystrophy: Inherited muscle disorder with a slow, but progressive
degeneration of muscle fibers. Diagnosed early, child is unable to sit up and walk at
common age.
Management:
No effective treatment exists, supportive care in the prehospital setting
Multiple Sclerosis: Demyelination of the myelin sheath → thought to be an autoimmune
disease in which the body begins to attack the myelin in the CNS, causing scarring and
nerve damage
Signs and Symptoms: Fatigue, vertigo, clumsiness, unsteady gait, slurred speech, blurred
vision
Management:
No cure exists, supportive care in the prehospital setting
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Chapter 9: Special Populations
Special Populations
Guillain-Barre Syndrome: Acute or subacute type of progress polyneuropathy
Prominent weakness with some sensory changes → begins in legs and spreads upward
to arms and body. Causes total or near-total paralysis over time.
Patients often require mechanical ventilation
Most patients do recover from GBS, some may have persistent weakness
GBS can last days to weeks, follows symptoms of a respiratory or GI viral
infection
Parkinson Disease: Degeneration of nerve cells in the basal ganglia of the brain. This
degeneration causes a lack of dopamine.
Results in muscles becoming overly tense → tremors, joint rigidity, and slow movement.
Typically begins in one hand/arm and progresses over time
**Leading cause of neurologic disability in people older than 60 years
Amyotrophic Lateral Sclerosis (ALS) → “Lou Gehrig's Disease”
Motor neuron disease → nerve fibers in the brain and spinal cord degenerate.
Weakness is first noticed in the hands and arms; accompanied by fasciculations.
Progresses to involve muscles of all four extremities and those involved in respiration
and swallowing.
In final stages, patients are unable to speak, swallow, or move.
Management: Supportive care, airway management
Sickle Cell Disease → inherited disease that causes an abnormal shape and size of red
blood cells.
Sickle Cell Anemia → “SCD” will result in sickle cell anemia. Because of the abnormal
RBC shape, they are prematurely destroyed by the body.
Incredibly painful disease that does not have a cure. Prominent in African American
males. Prehospital treatment = IV fluids and analgesia for pain management.
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10
CHAPTER 10
EMS Operations
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Chapter 10: EMS Operations
Communications
Radio Bands & Frequencies
Ultrahigh Frequency (UHF)
Very High Frequency (VHF)
Radio Communications
Simplex Transmissions: transmit and receive on same frequency; cannot do both
simultaneously → dispatch systems and on-scene communications
Duplex Transmissions: simultaneous two-way communications by using two frequencies for
each channel → works like a telephone
Ambulance Standards
Oversight for EMS usually falls to state governments; requirements for ambulance service
written in state statute or regulations.
National standards and trends have influence on development of laws.
State standards set minimum standards, rather than gold standard, for operation.
Local and/or regional EMS systems more detailed and approach to gold standard.
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Chapter 10: EMS Operations
Ambulance Design
Type I: conventional truck cabchassis with modular ambulance
body
Type II: standard van, forward
control integral cab-body ambulance
Type III: specialty van, forward
control integral cab-body ambulance
Medium Duty Ambulance: designed
to handle heavier loads
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Chapter 10: EMS Operations
Air Medical Operations
Launch Information
→ Requesting agency identity, contact radio frequencies, call back cell phone number
→ Local weather conditions
→ Presence of hazardous materials
→ Number of patients; basic medical description
Landing Zone
→ Landing Zone Officer should be designated; coordinates incoming aircraft operations
with incident commander (IC)
→ Selection of site: site preparation, site protection and control, air-to-ground
communications, updating IC on estimated time of arrival
→ LZ, ideally 100’ by 100’ with little to no slope
→ Clear of readily visible debris or obstructions
→ If area is dusty, consider lightly watering area with fog pattern
→ Never necessary to have charged hose line pointing at aircraft
→ Mark LZ with cones (daytime) or strobes (nighttime)
→ Avoid shining lights up towards aircraft
→ Avoid using flares
LZ Site Prep Mnemonic:
HOTSAW
Hazards
Obstructions
Terrain
Surface
Animals
Wind/weather
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Chapter 10: EMS Operations
Triage
Primary Triage
Used at the site to rapidly categorize patient conditions for treatment and transport needs
Secondary Triage
Used at the treatment area, where patients are triaged again. Patients are labeled with tags
to assign priorities.
START Triage
60 second assessment
Assesses ability to walk, respiratory effort, pulses/perfusion, and neurological status
Step 1: Ability to walk → walk and understand basic commands = delayed
Step 2: Respirations:
Absent respirations = dead
< 10 or > 30 = critical
Normal respirations = delayed
Step 3: Pulses/Perfusion
Absent pulse = dead
Present at carotid and absent radial = critical
Step 4: Mental Status
Alert and Oriented?
Have patient perform motor task
Patient who can perform both tasks = delayed
If the patient does not have any serious injuries and is alert and oriented = hold
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Chapter 10: EMS Operations
Hazardous Materials
NFPA 704 (“Global Harmonized System”)
Fixed at facilities to identify hazardous materials
HazMat Zones
Hot Zone: site of contamination
Warm Zone: contamination reduction zone
Cold Zone: safe zone – no contaminants
Tox Terms
LEL – Lower Explosive Limit
UEL – Upper Explosive Limit
IDLH – Immediately Dangerous to Life or Health
Terrorism Targets
Public buildings, major infrastructures, historical
buildings, divisive businesses (abortion clinics, etc.)
CBRNE Agents
Chemical
Biological
Radiologic
Nuclear
Explosive
Self Protection
Time, Distance, Shielding
Smell of Freshly Cut Grass – Think Phosgene
Levels of PPE
Level A → Highest level of protection, full encapsulating suit, SCBA
Level B → Highest level of respiratory protection, lower level of skin protection, SCBA,
chemical resistant clothing.
Level C → Used during transport of contaminated patients, face mask, chemical splash suit,
coveralls.
Level D → Work uniform, provides minimum protection
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Chapter 10: EMS Operations
Review Questions
1.) What chemical smells like freshly cut grass? ____________________
2.) The ideal landing zone should be _______ x ______ feet.
3.) Which level of PPE offers the highest level of protection in hazardous materials situation? ____________
4.) What three components are critical to self protection during hazardous material incidents? __________,
_______________, ________________.
5.) How should the landing zone be marked during the day? _________ How should it be marked at night?
_____________
6.) What is the mnemonic for landing zone site preparation? _______________
7.) When operating an emergency vehicle, you must drive with _______ _________. (not included in guide)
8.) The hot zone is the site of ______________.
9.) Making false statements about a person is termed: __________________ (see medical terminology)
10.) What are the CBRNE agents? ______________, ________________, ______________, ______________,
______________
11.) Simultaneous two-way communications by using two frequencies for each channel → works like a
telephone. ___________________
12.) Transmit and receive on same frequency; cannot do both simultaneously → dispatch systems and onscene communications. _______________________
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Want more EMS
Operations review?
Check out our EMS Operations Study Guide or our
EMS Operations Review Lecture for more in-depth
information!
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Final Steps…
As you finish this study guide, you are probably feeling on the top of your game! But, the
journey isn’t over yet. You still have to conquer that exam, which you WILL do!
Check out some of our tips before taking the exam!
➢ Do not pay attention to the timer – less than 1% of candidates fail because of time
➢ Do not pay attention to the question number, a percentage of students will get all of the
possible questions regardless of their performance – the question number doesn’t
matter!
➢ Get a good night’s sleep and eat a good breakfast before the exam – do not
underestimate this!
➢ Do not over study on exam day, “tying loose ends” is fine, but no heavy studying – stop
reviewing several hours before the exam. Your brain needs rest too.
➢ Beat the test one question at a time, pause, relax, take a deep breath and pick the best
answer.
➢ 35 questions will be pilot questions and will not be scored. So, if you get a really difficult
questions, just assume it’s a pilot question and give your best answer by process of
elimination – don’t dwell!
➢ Read every question twice – a lot of students skip over key words and information –
reading each question twice will help you pick up on information you didn’t catch the first
time.
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