NREMT
Study Guide
By nremtpracticeexam.com
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Airway, Breathing & Ventilation
In this section of our NREMT Study Guide, we will help you prepare for the
airway, respiration, and ventilation portions of the EMT exam. It’s around
18–22% of the exam.
This section of our study guide covers the anatomy of the respiratory system,
the physiology of breathing, airway management, oxygen therapy, opening a
patient’s airway using different maneuvers, airway adjuncts used by EMTs,
and oxygen-delivery equipment.
After you have reviewed this section of the study guide, there will be practice
questions to test your knowledge of the material.
You can also download the complete study guide PDF for free.
Anatomy of the Airway
The airway is the path that air follows from the atmosphere to the alveoli. It is
divided into the upper and lower airways.
The Upper Airway
The upper airway’s function is to warm, filter, and humidify inhaled air. It
consists of all structures above the vocal cords.
●​ Nose and Mouth: The entry points for air. The nasal cavity is called the
nasopharynx, and the oral cavity is the oropharynx.
●​ Pharynx: The throat; a muscular tube that serves as a common
passageway for air and food. It extends from the back of the nose and
mouth down to the esophagus and larynx.
●​ Larynx: The voice box; a cartilaginous structure that marks the end of
the upper airway. It contains the vocal cords.
●​ Epiglottis: A leaf-shaped flap of cartilage at the base of the tongue that
covers the opening of the larynx during swallowing to prevent food and
liquid from entering the trachea.
●​ Cricoid Cartilage: A firm, complete ring of cartilage that forms the
lowest portion of the larynx. It is the only complete cartilaginous ring in
the upper airway.
The Lower Airway
The lower airway’s sole function is to conduct air to the site of gas exchange.
It begins below the larynx.
●​ Trachea: The windpipe; a tube that extends from the larynx into the
chest, held open by C-shaped cartilage rings.
●​ Carina: The point at which the trachea divides into the right and left
mainstem bronchi.
●​ Bronchi and Bronchioles: The mainstem bronchi enter each lung and
continue to branch into smaller and smaller tubes. The smallest of these
are the bronchioles.
●​ Alveoli: Microscopic air sacs at the end of the bronchioles. The alveoli
are the functional units of the lungs where gas exchange occurs. They
are encased in a network of pulmonary capillaries.
Opening a Patient’s Airway
Ensuring a patent airway is the first priority in patient care. In an unresponsive
patient, the tongue is the most common cause of airway obstruction.
Your initial assessment determines the priority.
●​ ABC (Airway, Breathing, Circulation): Used for most patients.
●​ CAB (Circulation, Airway, Breathing): Used for patients with obvious
signs of life-threatening external hemorrhage. Bleeding control is the
priority.
Opening and Clearing the Airway
Positioning for Airway Management:
●​ Sniffing Position: The optimal position for maintaining a patent airway
and for ventilation. The head and chin are thrust slightly forward. For a
supine patient, this can be achieved by placing a small towel under the
patient’s shoulders and back, which helps keep the trachea straight and
aligned.
Manual Airway Maneuvers:
●​ Head Tilt-Chin Lift: The primary method for opening the airway in a
non-trauma patient. Place the heel of one hand on the patient’s
forehead and apply firm pressure to tilt the head back. Place the
fingertips of your other hand under the bony part of the lower jaw and lift
the chin upward.
●​ Jaw-Thrust Maneuver: The preferred method if a cervical/spinal injury
is suspected. Kneel above the patient’s head, place your fingers behind
the angles of the lower jaw, and move the jaw upward with your index
and middle fingers while your thumbs help position the jaw. This
maneuver is performed without tilting or extending the head. Important:
If the jaw-thrust maneuver fails to open the airway, the head tilt-chin lift
must be used as a last resort, as a patent airway is the immediate
priority.
Foreign Body Airway Obstruction (FBAO):
●​ Mild/Partial Obstruction: The patient can still speak, cough, and
breathe. Wheezing or stridor may be present. Encourage the patient to
cough forcefully. Provide oxygen, place them in a position of comfort,
and transport rapidly. Do not perform abdominal thrusts.
●​ Severe/Complete Obstruction: The patient cannot speak, breathe, or
cough effectively. They may clutch their throat (the universal sign for
choking).
●​ Conscious Adult/Child: Perform abdominal thrusts (Heimlich
maneuver). Stand behind the patient, make a fist, and place the
thumb side against the patient’s abdomen just above the
umbilicus and below the xiphoid process. Press into the abdomen
with quick, inward and upward thrusts.
●​ Conscious Pregnant/Obese Patient: Perform chest thrusts in
the same location as chest compressions.
●​ Conscious Infant (Under 1 Year): Perform 5 back blows
between the shoulder blades with the heel of your hand, followed
by 5 chest thrusts on the lower part of the sternum with two
fingers.
●​ If Patient Becomes Unresponsive: Immediately begin CPR,
starting with chest compressions. Before attempting ventilations,
look inside the mouth for the object and remove it with a gloved
finger only if it is visible.
Suctioning:​
Suctioning is used to remove fluids like blood, vomit, or secretions from the
airway. A suction unit should generate a vacuum of at least 300 mmHg.
●​ Catheters:
1.​ Rigid (Yankauer/Tonsil-tip): Best for suctioning the oropharynx.
Its large diameter will not easily collapse.
2.​ Flexible (French/Whistle-tip): Used for suctioning the nose, a
stoma, or when the patient’s teeth are clenched.
●​ Technique:
1.​ Assemble the unit and test for adequate vacuum pressure.
2.​ Measure the catheter from the corner of the patient’s mouth to the
earlobe.
3.​ Turn the patient’s head to the side (if no c-spine injury).
4.​ Open the mouth and insert the catheter only as far as you can
visualize (to the depth measured).
5.​ Apply suction in a circular motion only while withdrawing the
catheter.
6.​ Crucial Time Limits: Suction for no longer than 15 seconds in
an adult, 10 seconds in a child, and 5 seconds in an infant.
Prolonged suctioning causes hypoxia and can stimulate the vagus
nerve, leading to severe bradycardia.
Assessment of Breathing
Assessing Breathing
Normal Respiratory Rates by Age:
●​ Adult (18+ years): 12 to 20 breaths/minute
●​ Adolescent (13-18 years): 12 to 16 breaths/minute
●​ School-Aged (6-12 years): 18 to 30 breaths/minute
●​ Preschooler (4-5 years): 22 to 34 breaths/minute
●​ Toddler (1-3 years): 24 to 40 breaths/minute
●​ Infant (0-12 months): 30 to 60 breaths/minute
Signs of Inadequate Breathing (Respiratory Distress/Failure):
●​ Rate: Too fast (tachypnea) or too slow (bradypnea) for the patient’s age.
●​ Rhythm: Irregular breathing pattern.
●​ Quality: Diminished, noisy, or absent breath sounds. Unequal or
shallow chest expansion.
●​ Effort: Use of accessory muscles in the neck, abdomen, or between the
ribs (retractions). Nasal flaring, especially in children. Tripod positioning.
●​ Skin: Cyanosis (bluish discoloration), pale, or cool, moist skin.
Signs of Inadequate Oxygenation (Hypoxia):
●​ Early Signs: Restlessness, irritability, apprehension, anxiety,
tachycardia (fast heart rate), and tachypnea.
●​ Late Signs: Altered mental status, confusion, lethargy, weak/thready
pulse, cyanosis, bradycardia (slow heart rate, especially in children),
and bradypnea.
Pulse Oximetry (SpO2):​
A pulse oximeter measures the percentage of hemoglobin that is saturated
with oxygen. It is a valuable tool but has significant limitations:
●​ Inaccurate Readings: Caused by dark/metallic nail polish, dirty fingers,
poor perfusion (hypovolemia, shock), severe peripheral vasoconstriction
(hypothermia, smoking), or bright ambient light.
●​ Carbon Monoxide (CO) Poisoning: This is the most critical limitation.
The pulse oximeter cannot differentiate between oxygen and carbon
monoxide bound to hemoglobin. A patient with severe CO poisoning will
have a falsely high SpO2 reading (e.g., 100%) despite being critically
hypoxic.
Lung Sounds (Auscultation):
●​ Stridor: A high-pitched, brassy, crowing sound heard primarily on
inhalation. Indicates a partial upper airway obstruction (e.g., foreign
body, croup, epiglottitis).
●​ Wheezing: A high-pitched whistling sound, most prominent on
exhalation. Caused by constriction of the lower airways (bronchioles).
Common in asthma, COPD, and anaphylaxis.
●​ Rhonchi: Low-pitched, noisy, rattling sounds, like snoring or rumbling.
Prominent on exhalation. Suggests mucus or fluid in the larger airways.
Common in bronchitis and pneumonia.
●​ Crackles (Rales): Wet, popping, or crackling sounds, like cellophane
being crumpled. Heard on inspiration. Caused by air passing through
fluid in the alveoli. The classic sound of pulmonary edema (CHF) or
pneumonia.
●​ Gurgling: Sound of fluid in the upper airway; requires immediate
suctioning.
●​ Snoring: Sound of the tongue partially obstructing the upper airway.
●​ Vesicular: Normal, clear breath sounds.
Interventions & Equipment
Airway Adjuncts
Airway adjuncts are used to maintain a patent airway in unresponsive or
semiconscious patients. They do not protect against aspiration.
●​ Oropharyngeal Airway (OPA): A curved plastic device that holds the
tongue off the posterior pharynx.
●​ Indications: Unresponsive patients without a gag reflex.
●​ Contraindications: Conscious patients or any patient with an
intact gag reflex. Also contraindicated for caustic substance
ingestion.
●​ Sizing: Measure from the corner of the patient’s mouth to the
earlobe.
●​ Insertion: Insert the OPA with the tip pointing toward the roof of
the mouth. Advance until you feel the soft palate, then rotate it
180° into place. For children, use a tongue depressor to hold the
tongue down and insert the OPA directly without rotation.
●​ Nasopharyngeal Airway (NPA): A soft, flexible tube inserted through a
nostril into the posterior pharynx.
●​ Indications: Semiconscious or unconscious patients with an
intact gag reflex who will not tolerate an OPA.
●​ Contraindications: Severe head injury with blood draining from
the nose or a history of a fractured nasal bone. Suspect a basilar
skull fracture if you see cerebrospinal fluid (CSF) draining from
the ears, ecchymosis under the eyes (raccoon eyes), or behind
one ear (Battle’s sign).
●​ Sizing: Measure from the tip of the patient’s nose to the earlobe.
●​ Insertion: Lubricate the airway well. Insert into the larger nostril
with the bevel facing the septum.
Oxygen Delivery
Oxygen Cylinders:
●​ Always “crack” the cylinder (briefly open the valve) before attaching the
regulator to remove dust.
●​ A full cylinder contains approximately 2,000 psi.
●​ Common Sizes and Constants (for calculating duration):
●​ D Cylinder: 350 L (Constant: 0.16)
●​ E Cylinder: 625 L (Constant: 0.28)
●​ M Cylinder: 3,000 L (Constant: 1.56)
●​ G Cylinder: 5,300 L (Constant: 2.41)
●​ H/K Cylinder: 6,900 L (Constant: 3.14)
Oxygen Delivery Devices:
●​ Nasal Cannula (NC):
●​ Flow Rate: 1–6 L/min
●​ O2 Concentration: 24–44%
●​ Use: For patients with mild hypoxia who cannot tolerate a mask
(e.g., COPD patients, claustrophobia). Not appropriate for patients
in significant distress.
●​ Non-Rebreather Mask (NRB):
●​ Flow Rate: 10–15 L/min
●​ O2 Concentration: Up to 90-95%
●​ Use: The preferred device for patients with adequate breathing
who are hypoxic and require high-flow oxygen.
●​ Key Point: Always fill the reservoir bag with oxygen before
placing the mask on the patient.
●​ Bag-Valve Mask (BVM):
●​ Flow Rate: 15 L/min
●​ O2 Concentration: Nearly 100% with a filled reservoir bag.
●​ Use: For patients in respiratory arrest or with inadequate
breathing (respiratory failure).
●​ Ventilation Rates: 1 breath every 6 seconds for adults; 1 breath
every 2-3 seconds for children/infants.
●​ Technique: Deliver each breath over 1 second, just enough to
produce visible chest rise. The two-person technique is far
superior for maintaining a good mask seal.
●​ Common Complications: Poor mask seal, incorrect head
position, gastric distention (from ventilating too fast or too
forcefully), barotrauma (lung injury from pressure), and decreased
cardiac output from increased intrathoracic pressure.
●​ Mouth-to-Mask (Pocket Mask):
●​ O2 Concentration: About 55% when supplemental oxygen is
attached at 15 L/min. A one-way valve prevents backflow of
secretions.
●​ Continuous Positive Airway Pressure (CPAP):
●​ Function: A non-invasive device that provides continuous
pressure to keep alveoli from collapsing, pushing fluid out of the
alveoli and improving gas exchange.
●​ Indications: Alert patients in moderate to severe respiratory
distress from conditions like pulmonary edema or COPD, with a
rapid breathing rate (>26/min) and low pulse oximetry (<90%).
●​ Contraindications: Respiratory arrest, hypoventilation,
hypotension (systolic BP < 90 mmHg), chest
trauma/pneumothorax, active GI bleed or vomiting, or inability to
tolerate the mask.
●​ Complications: Claustrophobia, gastric distention, and
hypotension due to decreased blood return to the heart.
●​ Venturi Mask: Delivers precise, low-to-moderate oxygen concentrations
(e.g., 24%, 28%, 35%, 40%) based on the selected adapter.
Advanced Airways (EMT Awareness)
While EMTs do not typically place these, you must be able to assist and
recognize them.
●​ Supraglottic Airway (e.g., King LT, i-gel): An airway device that sits
above the glottis. It is indicated for failed endotracheal intubation.
Placement is confirmed by bilateral breath sounds and an end-tidal CO2
detector.
●​ Endotracheal Intubation: The placement of a tube directly into the
trachea. The mnemonic BE MAGIC outlines the steps for a provider:
Bag-valve mask pre-oxygenation, Evaluate airway, Manipulate patient,
Attempt intubation, GI (use supraglottic if unable), Intubation, Confirm
placement.
●​ Tracheostomy Tube (e.g., Shiley): A tube placed in a surgical opening
(stoma) in the neck for long-term airway management. These patients
may require suctioning directly through the tube.
Pathophysiology of Respiratory Emergencies
Obstructive Diseases:
●​ Asthma: Chronic disease with acute exacerbations of
bronchoconstriction, inflammation, and mucus production. Presents with
wheezing, dyspnea, and anxiety.
●​ COPD (Chronic Obstructive Pulmonary Disease): A slow,
progressive disease, most often caused by smoking.
●​ Chronic Bronchitis: Inflammation of the bronchioles and
excessive mucus production, leading to a productive cough and
rhonchi (“wet lungs”).
●​ Emphysema: Destruction of the alveoli, which leads to trapping
of stale air. Causes an unproductive cough, barrel chest,
pursed-lip breathing, and wheezing (“dry lungs”).
●​ Anaphylaxis: A severe, systemic allergic reaction that can cause rapid
swelling of the upper airway (angioedema) and bronchoconstriction,
leading to stridor and wheezing.
Fluid-Related Emergencies:
●​ Acute Pulmonary Edema: Fluid builds up inside the alveoli, impairing
gas exchange. Usually a result of congestive heart failure (CHF).
Presents with severe dyspnea (especially when lying flat), crackles
(rales), and sometimes pink, frothy sputum.
●​ Pleural Effusion: A collection of fluid in the pleural space, outside the
lung. It compresses the lung and causes dyspnea.
Infectious Diseases:
●​ Pneumonia: An infection of the lung tissue that causes inflammation
and fluid buildup in the alveoli. Presents with fever, chills, a productive
cough, and localized crackles or rhonchi.
●​ Epiglottitis: A life-threatening bacterial infection causing severe
inflammation of the epiglottis. Classic signs are high fever, sore throat,
drooling, and stridor.
●​ Croup: A viral infection of the upper airway in children, characterized by
a low-grade fever and a “seal-bark” cough and stridor. Humidified
oxygen may be indicated for extended transport.
Vascular and Traumatic Emergencies:
●​ Pulmonary Embolism (PE): A blood clot (or air bubble/foreign body)
that lodges in the pulmonary arteries, blocking blood flow to a portion of
the lung. Presents with a sudden onset of dyspnea, sharp chest pain,
and tachycardia.
●​ Pneumothorax: Air in the pleural space, causing the lung to collapse.
●​ Spontaneous Pneumothorax: Occurs without trauma, common
in tall, thin men. Presents with sudden dyspnea and pleuritic chest
pain.
●​ Open Pneumothorax: An unsealed opening in the chest wall
allows air to enter the pleural space.
●​ Tension Pneumothorax: A life-threatening emergency where air
enters the pleural space but cannot exit. Pressure builds,
collapsing the lung and shifting the heart and great vessels
(mediastinal shift), which leads to obstructive shock. Signs include
severe respiratory distress, absent lung sounds on the affected
side, tracheal deviation (a late sign), JVD, and hypotension with
narrowing pulse pressures.
●​ Hemopneumothorax: Blood and air in the pleural space.
Toxicological Emergencies:
●​ Carbon Monoxide (CO) Poisoning: CO is an odorless, colorless gas
that displaces oxygen from hemoglobin. Presents with flu-like
symptoms, headache, confusion, and syncope. Treatment is high-flow
oxygen.
●​ Cyanide Poisoning: A rapidly acting poison that prevents cells from
using oxygen. Presents with dyspnea, flushed skin, tachycardia, altered
mental status, and seizures, leading to cardiac arrest.
Part 5: Special Populations & Considerations
Pediatric Patients
Children are not small adults. They have critical anatomical and physiological
differences.
●​ Anatomy:
●​ Tongues are proportionally larger.
●​ Tracheas are smaller, softer, and more easily obstructed.
●​ The cricoid ring is the narrowest part of the airway in a young
child.
●​ They are obligate nose breathers as infants.
●​ They rely heavily on their diaphragm for breathing (“belly
breathers”).
●​ Assessment:
●​ Use the Pediatric Assessment Triangle (PAT): Appearance
(muscle tone, interactiveness), Work of Breathing, and Circulation
to the Skin.
●​ Signs of Increased Work of Breathing in Children:
●​ Nasal flaring
●​ Grunting (an attempt to create PEEP)
●​ Retractions (substernal, intercostal)
●​ Head bobbing
●​ Tachypnea
●​ Tripod position
●​ Key Physiological Point: Bradycardia in a child is a sign of critical
hypoxia and imminent respiratory arrest. Children compensate for
shock with tachycardia; hypotension is a very late and ominous sign.
Capillary refill is a more reliable indicator of perfusion in children than
blood pressure.
Other Important Concepts
●​ Gastric Distention: A common complication of BVM ventilation,
especially in children. To alleviate it in a patient with a suspected spinal
injury, use a spinal motion restriction device to carefully roll the patient
to one side and apply firm but gentle pressure to the upper abdomen.
●​ Hyperventilation: Over-breathing that causes a drop in arterial CO2,
leading to respiratory alkalosis. This can be caused by anxiety or a
medical condition like diabetic ketoacidosis or an aspirin overdose. It
results in dizziness, numbness/tingling, and muscle spasms in the
hands and feet (carpopedal spasms).
●​ Body Temperature:
●​ Hyperthermia (Heat Stroke): Temperature >104°F.
●​ Hypothermia: Affects respiratory drive. At 92-89°F, respirations
and pulse slow. Below 88°F, the patient may become
unresponsive with very slow respirations.
●​ Burns: Airway compromise is a primary concern. Suspect airway burns
if there are facial burns, singed nasal hairs, or soot in the mouth. These
patients require high-flow oxygen and rapid transport, as swelling can
rapidly obstruct the airway. Cover burns with a dry sterile dressing.
●​ Acidosis/Alkalosis: The respiratory system plays a key role in
regulating the body’s pH balance. Acidosis is a buildup of acid (low pH),
and alkalosis is a buildup of base (high pH). Conditions like DKA cause
a metabolic acidosis, and the body compensates by breathing faster
and deeper (Kussmaul respirations) to blow off CO2.
Cardiology and Resuscitation
This section of our NREMT study guide covers the Cardiology and
Resuscitation portion of the NREMT exam.
We have it into different part starting from foundational anatomy and
physiology leading to patient assessment, interventions for specific cardiac
emergencies, and finally to the principles of resuscitation.
Part 1: Foundational Anatomy & Physiology
The Structure of the Heart
●​ Heart Wall Layers:
●​ Epicardium (Outer Layer): The outermost protective layer of the
heart.
●​ Myocardium (Middle Layer): The functional muscle of the heart,
responsible for the powerful contractions that pump blood. The
thickness of the myocardium varies, with the left ventricle being
the thickest since it has to pump blood throughout the body. An
Acute Myocardial Infarction (AMI) primarily affects this layer.
●​ Endocardium (Inner Layer): The innermost lining of the heart
chambers and valves, providing a smooth surface for blood flow.
●​ Heart Valves: These structures ensure the unidirectional flow of blood
through the heart’s four chambers.
●​ Tricuspid Valve: Located between the right atrium (RA) and the
right ventricle (RV).
●​ Bicuspid (Mitral) Valve: Located between the left atrium (LA)
and the left ventricle (LV).
●​ Pulmonary Valve: Located between the right ventricle (RV) and
the pulmonary artery.
●​ Aortic Valve: Located between the left ventricle (LV) and the
aorta.
The Vasculature
●​ Arteries & Veins: Arteries carry oxygenated blood away from the heart
(except for the pulmonary artery), while veins carry deoxygenated blood
toward the heart (except for the pulmonary veins).
●​ Capillary Sphincters: These are circular muscular walls that surround
capillaries. Controlled by the Autonomic Nervous System (ANS), they
constrict and dilate to regulate blood flow through capillary beds,
directing blood to areas where it is most needed.
The Concept of Perfusion
Perfusion is the circulation of blood within an organ or tissue in adequate
amounts to meet the cells’ current needs for oxygen, nutrients, and waste
removal.
●​ The Perfusion Triangle: For perfusion to occur, all three components
must function properly. The failure of any one part results in shock
(hypoperfusion).
1.​ The Heart (The Pump): It should pump blood effectively at an
adequate rate and force.
2.​ The Blood (The Fluid): There must be sufficient blood volume to
circulate.
3.​ The Blood Vessels (The Container): The vessels must have
adequate tone (resistance) to maintain pressure.
Key Physiological Concepts
●​ Vagus Nerve: A major nerve of the parasympathetic nervous system.
Stimulation of the vagus nerve (e.g., straining during a bowel
movement, severe pain) can cause a “vasovagal response,” leading to a
sudden drop in heart rate and blood pressure, which can result in
dizziness or syncope (passing out).
●​ Atherosclerosis: A disease process where cholesterol, calcium, and
other substances (plaque) build up inside the arteries. This narrows the
arteries, restricting blood flow and creating a rough surface where blood
clots can form, leading to conditions like AMI and stroke.
Part 2: Patient Assessment
Initial Triage & Priority Patients
Rapidly identify high-priority patients who require immediate intervention and
transport. These include patients with:
●​ Severe chest pain
●​ Poor perfusion (pale, cool, diaphoretic skin)
●​ Unresponsiveness or altered mental status
●​ Uncontrolled bleeding
●​ Pregnancy with complications
Vital Signs & Pulses
●​ Pulse Assessment:
●​ Check Duration: Should take no more than 10 seconds.
●​ Locations:
●​ Infant (< 1 year): Brachial pulse.
●​ Child/Adult (> 1 year): Carotid pulse for unresponsive
patients. Radial pulse for conscious patients.
●​ Qualities:
●​ Thready: Weak and rapid.
●​ Strong: Normal.
●​ Bounding: Abnormally strong.
●​ Rhythm: Regular vs. Irregular.
●​ Blood Pressure:
●​ Systolic (Top #): The pressure in the arteries during cardiac
contraction (systole).
●​ Diastolic (Bottom #): The pressure in the arteries when the heart
is at rest between beats (diastole).
●​ Normal Vital Signs by Age:
Age Group
Respiratory Rate
Heart Rate
Systolic BP
Newborn (0-30d)
30–50
100–180
70
Infant (1-12m)
20–40
70–190
70–100
Toddler (1-3y)
20–30
80–130
80–110
Pre-schooler (3-5y)
16–22
80–120
90–120
School age (6-12y)
14–20
70–110
100–120
Adolescent (13+)
12–20
60–100
120
Key Physical Findings
●​ Jugular Vein Distention (JVD): Swelling of the jugular veins in the
neck. It indicates increased pressure in the venous system due to blood
backing up. It is a key sign of:
●​ Right-sided heart failure (CHF)
●​ Cardiac tamponade
●​ Tension pneumothorax
●​ Pulmonary embolism
Part 3: Resuscitation Principles
The timely initiation of resuscitation is the most critical factor in survival from
cardiac arrest.
The Chain of Survival
1.​ Early Recognition & Activation of EMS: Recognizing the emergency
and calling for help.
2.​ Early, High-Quality CPR: Immediate chest compressions to circulate
blood.
3.​ Rapid Defibrillation: The single most effective treatment for Ventricular
Fibrillation (V-Fib).
4.​ Advanced Life Support (ALS): Advanced airway management and
medication administration.
5.​ Post-Cardiac Arrest Care: Integrated care in a hospital setting to
improve neurological outcomes.
6.​ Recovery: Physical, social, and emotional support for the patient after
survival.
Cardiopulmonary Resuscitation (CPR)
●​ When to Start: Initiate immediately for any patient who is unresponsive,
pulseless, and apneic. For pediatric patients, begin CPR if the pulse is
less than 60 beats/minute with signs of poor perfusion.
●​ Key Metrics:
1.​ Rate: 100–120 compressions per minute.
2.​ Depth: 2–2.4 inches (5–6 cm) for adults and children.
3.​ Ratio (Adult): 30 compressions to 2 breaths (30:2) for both 1 and
2 rescuers.
4.​ Ratio (Child/Infant): 30:2 for a single rescuer; 15:2 for two
rescuers.
●​ Procedure:
1.​ Confirm unresponsiveness, check for breathing and pulse
simultaneously (max 10 seconds).
2.​ If no pulse, begin compressions immediately. Attach the AED as
soon as it is available.
3.​ Check for a pulse again only when the AED advises or after 5
cycles (2 minutes) of CPR.
●​ Complications: Fractured ribs, fractured sternum, and lacerated liver
are possible but should not deter high-quality compressions.
Automated External Defibrillator (AED)
●​ Indications: Any patient who is unresponsive and pulseleless.
●​ Shockable Rhythms:
●​ Ventricular Fibrillation (V-Fib): Disorganized, chaotic electrical
activity.
●​ Pulseless Ventricular Tachycardia (V-Tach): Rapid, organized
electrical activity from the ventricles that is too fast to allow the
heart to fill, producing no pulse.
●​ Non-Shockable Rhythms:
●​ Asystole: Flatline; no electrical activity.
●​ Pulseless Electrical Activity (PEA): Organized electrical activity
is present, but the heart muscle does not contract or respond.
●​ AED Special Considerations:
●​ Pacemakers: Do not place pads directly over a pacemaker. Place
them at least one inch away.
●​ Medication Patches: Remove any transdermal patches and wipe
the area clean before applying pads.
●​ Hairy Chest: If pads do not adhere, quickly shave the area or use
a second set of pads to “wax” the area by applying and quickly
ripping them off.
●​ Water: Remove the patient from standing water. A small puddle or
snow is acceptable if the chest is wiped dry.
●​ Moving Vehicle: The vehicle MUST be stopped for the AED to
analyze the rhythm accurately and to ensure safety during a
shock.
●​ Pediatric Use:
●​ Infants/Children < 8 years: A manual defibrillator is preferred. If
unavailable, use an AED with a pediatric dose attenuator. If
neither is available, an adult AED may be used as a last resort.
Return of Spontaneous Circulation (ROSC)
●​ Signs of ROSC: The patient regains a palpable pulse or there is a
sudden, sustained increase in end-tidal CO2 (PETCO2).
●​ Post-ROSC Care:
1.​ Manage the airway. Provide assisted ventilations via BVM at a
rate of 10-12 breaths per minute (1 breath every 5-6 seconds) to
maintain an oxygen saturation of 92-98%.
2.​ Perform a neurological exam.
3.​ Obtain and transmit a 12-lead ECG if available.
4.​ Monitor vital signs closely and prepare for transport.
Transport & Termination Decisions
●​ Begin Transport When:
●​ ROSC occurs.
●​ 6–9 shocks have been delivered and the patient remains in arrest.
●​ The AED gives 3 consecutive “no shock advised” messages
separated by CPR cycles.
●​ Termination of Efforts (Considered by ALS/Medical Control):
●​ Arrest was not witnessed by EMS.
●​ No AED shock was ever delivered.
●​ No ROSC was achieved in the field.
Part 4: Pharmacological Interventions
The 6 Rights of Medication Administration
1.​ Right Patient
2.​ Right Medication
3.​ Right Dose
4.​ Right Route
5.​ Right Time (Indication & Expiration Date)
6.​ Right Documentation
Common Cardiac Medications
●​ Oxygen: Administer to maintain target saturation levels:
●​ Acute Coronary Syndrome (ACS): >90%
●​ Stroke: 95-98%
●​ Post-Cardiac Arrest: 92-98%
●​ Aspirin (ASA):
●​ Action: Inhibits platelet aggregation (prevents platelets from
clumping together to form clots).
●​ Indication: Chest pain suggestive of cardiac ischemia.
●​ Dose: 162–325 mg (2–4 low-dose tablets). Must be chewed.
●​ Contraindications: Allergy, history of bleeding disorders, recent
GI bleed, liver damage. Should not be given to children (risk of
Reye’s syndrome).
●​ Nitroglycerin (NTG):
●​ Action: Vasodilator; it relaxes blood vessels, which decreases the
workload on the heart and increases blood flow to the
myocardium.
●​ Indication: Chest pain in a patient with a prescription for
nitroglycerin.
●​ Dose: One tablet or spray (0.4 mg) sublingually. Can be repeated
every 5 minutes up to 3 doses if pain persists and criteria are met.
●​ CRITICAL Contraindications:
●​ Systolic BP less than 100 mmHg.
●​ Use of erectile dysfunction medications (sildenafil, tadalafil,
vardenafil) within the past 48 hours.
●​ Head injury.
●​ Bradycardia (HR < 50) or Tachycardia (HR > 110).
●​ Side Effects: Headache, hypotension, burning under the tongue.
Order of Operations for Chest Pain: Place the patient in a position of
comfort, administer oxygen if indicated, assist with Aspirin, and then assist
with Nitroglycerin if criteria are met.
Part 5: Pathophysiology of Specific Emergencies
Acute Coronary Syndrome (ACS) & Myocardial Infarction (AMI)
●​ ACS: An umbrella term for any condition caused by a sudden reduction
of blood flow to the heart (myocardial ischemia).
●​ Angina Pectoris: Chest pain caused by temporary ischemia.
●​ Stable Angina: Occurs with exertion and is relieved by rest or
nitroglycerin.
●​ Unstable Angina: Occurs at rest or is unpredictable. It is a sign
of an impending heart attack.
●​ Acute Myocardial Infarction (AMI) / Heart Attack: The death of
myocardial tissue due to a complete blockage of a coronary artery. The
pain is not relieved by rest or nitro and can last for hours. The left
ventricle is most commonly affected.
●​ Symptoms of ACS/AMI:
●​ Chest pain/pressure/heaviness (often described as “crushing” or
“squeezing”).
●​ Pain radiating to the jaw, arms (especially the left), back, or
abdomen.
●​ Dyspnea (shortness of breath).
●​ Diaphoresis (sweating), weakness, nausea/vomiting.
Congestive Heart Failure (CHF)
A condition where the heart muscle is damaged and cannot pump effectively,
leading to a backup of blood in the circulatory system.
●​ Left-Sided CHF: The left ventricle fails, causing blood to back up into
the lungs.
●​ Signs: Pulmonary edema, dyspnea (especially when lying flat),
hypoxia, crackles (rales) in the lungs, and sometimes pink,
frothy sputum.
●​ Right-Sided CHF: The right ventricle fails, causing blood to back up in
the systemic circulation.
●​ Signs: Jugular Vein Distention (JVD), peripheral edema
(swelling in the feet and legs), and abdominal distention (ascites).
Other Major Vascular Emergencies
●​ Aortic Aneurysm/Dissection: A tear in the inner layer of the aorta
allows blood to flow between the layers of the vessel wall. It is most
often caused by uncontrolled hypertension.
●​ Symptom: Sudden onset of a “sharp” or “tearing” chest pain that
radiates to the back or shoulder blades. This is a true emergency
requiring immediate transport; Aspirin and Nitro are
contraindicated.
●​ Pulmonary Embolism (PE): A blockage in the pulmonary arteries,
usually from a blood clot that traveled from the legs (DVT).
●​ Symptoms: Sudden onset of dyspnea, sharp (pleuritic) chest
pain, tachycardia, and hypoxia.
●​ Hypertensive Emergency: A sudden, severe elevation in blood
pressure (systolic > 180 and/or diastolic > 120) that can cause organ
damage.
●​ Symptoms: Severe headache, strong bounding pulse, dizziness,
and possibly pulmonary edema.
Cerebrovascular Accident (CVA) / Stroke
An interruption of blood flow to an area of the brain.
●​ Ischemic Stroke (85%): Caused by a blockage (thrombus or embolus).
●​ Hemorrhagic Stroke (15%): Caused by bleeding within the brain
tissue.
●​ Transient Ischemic Attack (TIA): “Mini-stroke” where symptoms
resolve on their own. It is a major warning sign of a future stroke.
●​ Signs of Stroke: Facial droop, arm drift, slurred speech, sudden vision
changes, difficulty walking.
●​ Stroke Mimics: Hypoglycemia, postictal state after a seizure, alcohol
intoxication. Always check a blood glucose level.
Cardiac Tamponade
Fluid or blood fills the pericardial sac, compressing the heart and preventing it
from filling properly. This leads to obstructive shock.
●​ Beck’s Triad: The classic signs of cardiac tamponade:
1.​ Hypotension (due to decreased cardiac output).
2.​ Jugular Venous Distention (JVD) (due to blood backing up).
3.​ Muffled Heart Sounds (due to the fluid insulating the sound).
Part 6: Shock (Hypoperfusion)
Shock is a state of circulatory collapse resulting in inadequate cellular
perfusion.
Stages of Shock
●​ Compensated Shock (Early): The body is still able to compensate by
increasing heart rate and constricting blood vessels.
●​ Signs: Anxiety, restlessness, altered mental status, rapid/thready
pulse, cool/clammy skin, narrowing pulse pressures.
●​ Decompensated Shock (Late): The body’s compensatory mechanisms
are failing.
●​ Signs: Falling blood pressure (hypotension is a late and
ominous sign), labored/irregular breathing, dull eyes/dilated
pupils, ashen/mottled/cyanotic skin.
Types of Shock
●​ Hypovolemic Shock: Caused by a loss of blood or fluid (e.g.,
hemorrhage, vomiting, diarrhea). Signs include tachycardia, rapid weak
pulse, cool clammy skin, and hypotension.
●​ Cardiogenic Shock: Caused by heart failure (pump failure), often after
an AMI. Signs are similar to hypovolemic shock but may also include
pulmonary edema.
●​ Obstructive Shock: Caused by a physical blockage of blood flow.
●​ Causes: Tension pneumothorax, Cardiac Tamponade, Pulmonary
Embolism.
●​ Distributive Shock: Caused by widespread vasodilation, leading to a
relative loss of fluid volume.
●​ Septic Shock: From severe infection. Presents with fever and
warm skin initially.
●​ Neurogenic Shock: From spinal cord injury. Presents with
bradycardia, hypotension, and warm/dry skin below the level of
the injury.
●​ Anaphylactic Shock: From a severe allergic reaction. Presents
with hives, wheezing, and hypotension.
●​ Psychogenic Shock: Fainting (syncope) from a temporary
vasodilation that reduces blood flow to the brain.
Key Shock-Related Syndromes
●​ Cushing’s Triad: Indicates severely elevated intracranial pressure
(ICP), often from a head injury. It is the opposite of shock.
1.​ Hypertension (with a widening pulse pressure).
2.​ Bradycardia.
3.​ Irregular Respirations (e.g., Cheyne-Stokes).
●​ Cheyne-Stokes Respirations: A breathing pattern of progressively
deeper and faster breathing, followed by a gradual decrease that results
in a temporary stop in breathing (apnea). It is a sign of brainstem injury
or severe CHF.
Trauma
This section of our NREMT study guide provides a comprehensive overview
of the essential knowledge required for the Trauma component of the NEMT
exam.
It covers patient assessment, management of life threatening injuries, specific
injury types by body system, and environmental trauma.
Initial Patient Assessment and Management
The Rapid Trauma Exam
The rapid trauma exam is a quick, systematic assessment to identify all life
threatening injuries. This head to toe survey should take no more than 90
seconds. A common mnemonic used during the exam is DCAP BTLS:
●​ Deformities
●​ Contusions
●​ Abrasions
●​ Punctures / Penetrations
●​ Burns
●​ Tenderness
●​ Lacerations
●​ Swelling
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale is a standardized tool used to assess a patient’s
level of consciousness by evaluating their eye, verbal, and motor responses.
The total score ranges from 3 (completely unresponsive) to 15 (fully alert and
oriented). A lower score indicates a more severe impairment of
consciousness.
The score is calculated by adding the points from each of the three
categories:
1. Eye Opening Response (E)
●​ 4 Points: Spontaneous (opens eyes without stimulation)
●​ 3 Points: To Speech (opens eyes to verbal command)
●​ 2 Points: To Pain (opens eyes to a painful stimulus)
●​ 1 Point: No Response
2. Verbal Response (V)
●​ 5 Points: Oriented (knows person, place, time, and event)
●​ 4 Points: Confused (answers questions but is disoriented in some way)
●​ 3 Points: Inappropriate Words (says logical words, but they are random
and not in context)
●​ 2 Points: Incomprehensible Sounds (makes sounds like moaning or
groaning, but no understandable words)
●​ 1 Point: No Response
3. Motor Response (M)
●​ 6 Points: Obeys Commands (can perform simple tasks when asked)
●​ 5 Points: Localizes Pain (purposefully moves to remove a painful
stimulus)
●​ 4 Points: Withdraws from Pain (pulls away from a painful stimulus)
●​ 3 Points: Abnormal Flexion (Decorticate posturing; flexes arms toward
the core)
●​ 2 Points: Abnormal Extension (Decerebrate posturing; extends arms
and legs stiffly)
●​ 1 Point: No Response
Scoring Interpretation:
●​ Total Score = E + V + M
●​ Mild Head Injury: GCS 13–15
●​ Moderate Head Injury: GCS 9–12
●​ Severe Head Injury: GCS 3–8 (A GCS of 8 or less typically indicates a
severe injury and the need for advanced airway management).
Prioritizing Interventions
The initial assessment focuses on immediate life threats.
●​ In cases of life threatening external bleeding, controlling the
hemorrhage takes priority over airway and breathing concerns (C ABC
approach).
●​ If a patient is not breathing upon assessment, your immediate focus
becomes providing ventilatory assistance, even if other major injuries
are present.
●​ Elevating an extremity to control bleeding is a controversial technique
and should only be performed if there are no impaled objects, un
splinted fractures, or risk to other wounds.
Head and Spine Trauma
Spinal Injury and Motion Restriction
Motion restriction of the neck is imperative for any patient with a suspected
spinal injury. Allowing the neck to remain unsecured may lead to further injury.
●​ Cervical Collar: If an appropriately sized cervical collar is unavailable,
a rolled towel or sheet can be placed around the patient’s head and
taped to the backboard. Continuous manual support should be provided
until the patient is fully secured. An ill fitting cervical collar should not be
used.
●​ Long Backboard: Used for spinal motion restriction for supine patients
with potential trauma injuries.
●​ Short Backboard (Kendrick Extrication Device): Can be used to
extricate a seated patient with a suspected spinal injury before they are
placed on a long backboard.
●​ Whiplash Injuries: These occur when a patient’s body is propelled
forward while their head and neck are left behind, commonly in rear end
impacts when a headrest is not properly positioned.
Helmet Removal
A helmet should only be removed if:
●​ It is a full face helmet.
●​ It allows for excessive head movement inside the helmet.
●​ It makes airway management or assessment difficult.
●​ It prevents adequate spinal motion restriction.
●​ The patient is in cardiac arrest.
Head Injuries
●​ Increased Intracranial Pressure (ICP): Signs include a unilaterally
fixed and dilated pupil, abnormal respirations (such as ataxic
respirations), bradycardia, and a widening pulse pressure (increasing
systolic, decreasing diastolic).
●​ Basilar Skull Fracture: A high energy head trauma. In addition to
general head injury signs, look for specific indicators: Cerebrospinal
Fluid (CSF) draining from the ears, Raccoon Eyes (ecchymosis under
the eyes), and Battle’s Sign (ecchymosis behind one ear).
●​ Epidural Hematoma: Bleeding below the skull but above the dura
mater, typically from an arterial bleed. It causes a rapid increase in
intracranial pressure. The patient may experience a brief loss of
consciousness, wake up and seem lucid, and then lose consciousness
again.
●​ Subdural Hematoma: A rupture of the bridging veins between the dura
mater and the arachnoid membrane. Onset of symptoms is often
gradual, developing over 1 to 2 days after the initial injury. Symptoms
include vomiting, pupillary changes, weakness, paralysis, headache,
and dizziness.
●​ Concussion: A mild traumatic brain injury. Symptoms include a
gradually improving mental status, headache, amnesia, nausea, and
loss of coordination.
Shock and Bleeding
Shock (Hypoperfusion)
In a trauma patient with cool extremities and tachycardia, you must assume
hemorrhagic shock until proven otherwise.
●​ Early Signs: Agitation, cool and clammy extremities, tachycardia.
●​ Late Signs: Weak or absent peripheral pulses, hypotension.
●​ Clinical shock is evident after a 25-30% blood volume loss, but
significant volume can be lost before signs appear.
Blood Volume
●​ The average adult male has about 6 liters of blood; the average female
has about 5 liters.
●​ A 10% loss is generally well tolerated, causing only mild tachycardia.
●​ A 20-25% loss causes the body’s compensatory mechanisms to fail,
leading to hypotension and decreased cardiac output.
●​ A 40% loss results in marked hypotension, decreased cardiac output,
and severe lactic acidemia.
Types of Bleeding
●​ Venous Blood: Dark red and flows steadily.
●​ Arterial Blood: Bright red and spurts with each heartbeat.
The Trauma Lethal Triad
This is a combination of three conditions that are often fatal in trauma
patients:
●​ Hypothermia: Low body temperature.
●​ Coagulopathy: Impaired ability for the blood to clot.
●​ Acidosis: Buildup of acid in the blood due to poor perfusion.
Musculoskeletal Trauma
Fractures
●​ General Signs: Crepitus (a grinding sound or sensation), shortening of
the limb, deformity, and false motion.
●​ Pelvic Fracture: This is a potentially fatal injury due to the risk of
massive internal hemorrhage. Several liters of blood can drain into the
pelvic space and retroperitoneal space. Signs include hypotension and
shock. Management includes applying a pelvic binder and using a
scoop stretcher or backboard.
●​ Femoral Shaft Fracture: Also a serious injury, with potential for 500 to
1000 mL of blood loss, leading to hypovolemic shock. Traction splints
are the indicated treatment.
Dislocations
●​ Subluxation: An incomplete dislocation of a joint or organ.
Compartment Syndrome
This is a painful condition caused by increased pressure within a muscle
compartment, which restricts blood flow and can damage muscle and nerves.
It typically develops within 6-8 hours of an injury.
Splinting
●​ Air Splint: Can be used to stabilize injuries below the knee or below the
elbow.
●​ Hand or Wrist: Splint the limb with the hand in a position of function,
with the wrist slightly bent down and fingers moderately flexed, often by
placing a soft roller bandage in the palm.
●​ Shoulder and Upper Arm: The sling and swathe method is used to
immobilize shoulder dislocations, clavicle fractures, and humeral
fractures.
Soft Tissue Injuries
●​ Contusion: A bruise. The dermis is intact, but there is bleeding
underneath, causing ecchymosis.
●​ Hematoma: A collection of blood within damaged tissue or a body
cavity.
●​ Abrasion: A wound of the superficial layer of skin (a scrape).
●​ Avulsion: An injury that separates layers of soft tissue, which may hang
as a flap or be completely detached.
●​ Amputation: The severing of a body part. The amputated part should
be wrapped in a sterile dressing, placed in a dry plastic bag, and kept
cool.
●​ Evisceration: Internal organs protrude from the peritoneum. Cover the
organs with sterile gauze moistened with sterile saline, then secure this
with an occlusive dressing. Do not attempt to push the organs back in.
Thoracic (Chest) Trauma
Flail Chest
A flail chest occurs when three or more adjacent ribs are fractured in two or
more places, causing a segment of the chest wall to move independently and
paradoxically (inward on inhalation, outward on exhalation) from the rest of
the chest. It causes extreme pain and difficulty breathing.
Burn Injuries
Burn Classifications by Depth
●​ Superficial (First Degree): Involves only the epidermis. Redness and
pain.
●​ Partial Thickness (Second Degree): Involves the epidermis and
dermis. Blistering, intense pain.
●​ Full Thickness (Third Degree): Extends through all skin layers. Skin
may be white, leathery, or charred. Nerve endings are destroyed, so the
burn itself may be painless.
Burn Severity
●​ Minor Burns:
●​ Full thickness <2% of body surface area (BSA).
●​ Partial thickness <15% BSA.
●​ Superficial <50% BSA.
●​ Moderate Burns:
●​ Full thickness 2 10% BSA.
●​ Partial thickness 15-30% BSA.
●​ Superficial >50% BSA.
●​ Severe Burns:
●​ Any full thickness burn involving the hands, feet, face, airway, or
genitalia.
●​ Any circumferential burn.
●​ Full thickness >10% BSA.
●​ Partial thickness >30% BSA.
●​ Burns associated with respiratory injury or fractures.
●​ Any moderate burn in a child under 5 or an adult over 55 is
classified as severe.
Environmental Trauma
Temperature Emergencies
●​ Hypothermia:
●​ Early Signs: Shivering, rapid breathing, redness or cyanosis of
the skin, tachypnea.
●​ Late Signs: Loss of coordination, muscle stiffness, slowed
pulses, confusion/lethargy, coma, weak pulse, dysrhythmias,
bradypnea, and eventually cardiac arrest.
●​ Heat Exhaustion: The most common heat emergency, often caused by
hypovolemia from excessive sweating.
●​ Signs: Dizziness, weakness, altered mental status,
nausea/vomiting, headaches, muscle cramps, and thirst.
●​ Treatment: Move to a cool environment, rehydrate, and flush skin
with water for 15-20 minutes.
High Altitude and Diving Emergencies
●​ High Altitude Sickness: Can lead to High Altitude Pulmonary Edema
(HAPE) or High Altitude Cerebral Edema (HACE).
●​ Scuba Diving Emergencies: Include Arterial Gas Embolism (AGE),
decompression sickness (the bends), and descent pains (the squeeze).
Eye Injuries
●​ Retinal Detachment: The retina is pulled away from the underlying
choroid. It is typically painless but presents with an increase in floaters,
flashes of light (photopsia), blurred vision, and the sensation of a curtain
or veil across the field of vision.
●​ Cataracts: A clouding of the lens of the eye, causing difficulty
distinguishing colors.
●​ Macular Degeneration: An irreversible loss of central vision, common
in the elderly. Risk factors include smoking, obesity, and sun exposure.
Medical Emergencies
This section of our NREMT study guide provides a direct and comprehensive
overview of common medical emergencies.
It covers patient assessment, specific abdominal and gastrointestinal
conditions, toxicology, allergic reactions, and endocrine emergencies.
Patient Assessment Fundamentals
Core Principles
●​ Sign vs. Symptom: A sign is an objective finding that an EMT can see,
hear, feel, or measure. It is a piece of clinical evidence. Examples
include a rash, bleeding, a blood pressure reading of 120/80 mmHg, or
wheezing heard on auscultation. A symptom is a subjective finding that
the patient feels and tells you about. It is part of their personal
experience. Examples include nausea, chest pain, dizziness, or a
headache.
●​ Vital Signs Monitoring: The frequency of vital sign assessment
depends on the patient’s stability. For an unstable patient (e.g., altered
mental status, signs of shock, severe pain), you must assess vitals at
least every 5 minutes. For a stable patient, you should assess vitals at
least every 15 minutes.
●​ Sphygmomanometer (BP Cuff) Sizing: Proper cuff size is critical for
an accurate reading. The bladder of the cuff should encircle 80% of the
arm’s circumference. The width of the cuff should be approximately two
thirds the length of the upper arm, from the armpit to the elbow crease.
A cuff that is too small will give a falsely high reading; a cuff that is too
large will give a falsely low reading.
●​ Assessing Response to Painful Stimuli: To determine the level of
consciousness in a non responsive patient, apply a central painful
stimulus. This tests the integrity of the central nervous system. Common
methods include:
●​ Pinching the earlobe.
●​ Pressing firmly on the bone above the eye (supraorbital foramen).
●​ Pinching the trapezius muscles in the neck/shoulder area.
●​ Performing a sternal rub (use with caution as it can cause
bruising).
Abdominal Emergencies
Anatomy of the Abdomen
●​ Right Upper Quadrant (RUQ): Contains the liver, gallbladder,
duodenum, and a portion of the pancreas. Pain here often points to
gallbladder or liver issues.
●​ Left Upper Quadrant (LUQ): Contains the stomach, spleen, and a
portion of the pancreas. Pain here can be related to the spleen or
pancreatitis.
●​ Right Lower Quadrant (RLQ): Contains the large and small intestines,
including the appendix. This is the classic location for appendicitis pain.
●​ Left Lower Quadrant (LLQ): Contains the large and small intestines,
including the descending and sigmoid colon. Pain here is often related
to diverticulitis.
Signs of Internal Abdominal Bleeding
●​ Cullen’s Sign: A bluish discoloration or bruising around the umbilicus
(belly button). It is a late sign of intraperitoneal hemorrhage (bleeding
within the abdominal cavity).
●​ Grey Turner’s Sign: Bruising along the flanks (the area between the
last rib and the top of the hip). It is a late sign of retroperitoneal
hemorrhage (bleeding behind the abdominal lining).
●​ Kehr’s Sign: Referred pain felt in the tip of the left shoulder when the
patient is lying down. This is caused by blood from an injured spleen
irritating the diaphragm. It is a classic sign of a ruptured spleen.
●​ Murphy’s Sign: Sharp pain and a sudden stop in inspiration when an
examiner presses on the RUQ during deep inspiration. This is a key
sign of acute cholecystitis (gallbladder inflammation).
Gastrointestinal (GI) Bleeding
●​ Signs of GI Bleeding: Dark, tarry, foul smelling stools (melena), vomit
with a “coffee grounds” appearance (partially digested blood), and bright
red bloody vomit (hematemesis).
●​ Upper GI Bleeding Causes:
●​ Mallory Weiss Syndrome: A tear in the mucous membrane lining
the lower esophagus, often caused by violent coughing or
vomiting.
●​ Boerhaave Syndrome: A full thickness rupture of the esophagus,
a true surgical emergency.
●​ Lower GI Bleeding Causes: Can be caused by conditions like
ulcerative colitis (inflammation of the colon) or diverticulosis.
Specific Abdominal Conditions
●​ Appendicitis: Inflammation of the appendix. Typically presents with
pain that starts around the umbilicus and migrates to the RLQ,
accompanied by nausea, vomiting, low grade fever, and rebound
tenderness.
●​ Cholecystitis/Gallstones: Inflammation of the gallbladder, often due to
gallstones. Presents with sharp RUQ pain that may radiate to the right
shoulder, nausea, vomiting, and fever. Pain often worsens after a fatty
meal.
●​ Pancreatitis: Inflammation of the pancreas. Presents with severe LUQ
and RUQ pain that often radiates straight through to the back. Pain is
constant and worsens after eating.
●​ Hepatitis: Inflammation of the liver. Presents with RUQ pain, jaundice
(yellowing of the skin and eyes), and fatigue.
Toxicology and Overdoses
●​ Opiates/Narcotics (e.g., heroin, fentanyl): Classic triad of signs
includes pinpoint pupils, respiratory depression, and
sedation/coma. Treat with naloxone.
●​ Sympathomimetics (e.g., cocaine, meth): Stimulants that cause
hypertension, tachycardia, dilated pupils, agitation, and
hyperthermia.
●​ Anticholinergics (e.g., Benadryl): Cause tachycardia, hyperthermia,
dilated pupils, and dry skin/mucous membranes. The mnemonic is:
“hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as
a hatter.”
●​ Cholinergics (e.g., organophosphates): Cause excessive fluid
secretions. The mnemonic is SLUDGEM: Salivation, Lacrimation
(tears), Urination, Defecation, Gastric upset, Emesis (vomiting), Miosis
(pinpoint pupils).
●​ Sedative Hypnotics (e.g., Xanax, Valium): Cause hypoventilation,
hypotension, slurred speech, and sedation. They generally do not affect
pupil size.
●​ Beta Blockers: Overdose causes bradycardia, hypotension, and
potentially hypoglycemia, especially in children.
●​ Activated Charcoal: Dose is 1 to 2 grams per kg. It is not effective for
ingestions of acids, alkalis, heavy metals, or petroleum products.
Allergic Reactions and Anaphylaxis
●​ Localized Reaction: Involves local heat, hives (urticaria), and redness
at the site of contact. This is caused by the release of histamine.
●​ Anaphylaxis: A severe, systemic reaction involving two or more body
systems. Signs include widespread hives, bronchospasm (wheezing),
hypotension (vasodilation), tachycardia, and anxiety.
●​ Bee Stings: Scrape the stinger away with a firm object. Do not use
tweezers.
●​ Medications:
●​ Epinephrine: The primary treatment for anaphylaxis. It is a
sympathomimetic that causes vasoconstriction (to raise blood
pressure) and bronchodilation (to open the airways).
●​ Diphenhydramine (Benadryl): An antihistamine that blocks the
effects of histamine. Main side effect is drowsiness.
●​ Albuterol: A bronchodilator that relaxes the smooth muscles of
the airways.
Endocrine Emergencies: Diabetes
●​ Normal Blood Glucose: 80–120 mg/dL.
●​ Hypoglycemia (Low Blood Sugar): Has a rapid onset. Signs are often
neurological: altered mental status, slurred speech, seizures. The skin
will be cool, pale, and clammy due to a sympathetic nervous system
response. Treat a conscious patient with oral glucose.
●​ Hyperglycemia (High Blood Sugar): Has a gradual onset over hours
or days. Signs are related to dehydration: intense thirst (polydipsia),
frequent urination (polyuria), and hunger (polyphagia). The skin is often
warm and dry.
●​ Diabetic Ketoacidosis (DKA): More common in Type 1 diabetes.
Characterized by severe hyperglycemia, dehydration, and ketoacidosis.
Presents with a fruity (acetone) breath odor and Kussmaul
respirations (rapid and deep breaths) as the body tries to blow off acid.
●​ Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS): More
common in Type 2 diabetes. Characterized by extremely high blood
glucose levels and profound dehydration, but without significant
ketoacidosis. Altered mental status can be severe.
●​ Type 1 vs. Type 2 Diabetes: Type 1 is an autoimmune disease where
the body does not produce insulin. Type 2 is a condition of insulin
resistance, often linked to lifestyle and obesity.
Other Medical Emergencies
●​ Seizures: The period after a seizure is the postictal state,
characterized by lethargy, confusion, and headache.
●​ Febrile Seizures: Occur in children under 6 due to a rapid spike in
temperature. Management is focused on passive cooling.
●​ Hypertensive Emergency: Systolic BP > 180 mmHg. Presents with
severe headache, ringing in ears, bounding pulse, and nosebleed.
●​ Neurological Deficits:
●​ Aphasia: Inability to understand or express speech.
●​ Agnosia: Inability to recognize or name common objects.
●​ Dysarthria: Slurred, difficult speech due to muscle weakness.
EMS Operations
This section of our NREMT study guide provides a comprehensive overview
of the essential knowledge required for the EMS Operations component of the
NEMT exam.
It covers the structure of EMS systems, operational roles and responsibilities,
incident management, scene safety, vehicle operations, medical legal
concepts, and communication.
The EMS System
EMS System Models and History
There are two primary models of EMS care delivery:
●​ Anglo American Model: The model used in the United States, which
focuses on bringing the patient to the hospital for definitive care.
●​ Franco German Model: A model common in Europe that focuses on
bringing the hospital to the patient, often with a physician responding to
the scene.
The origins of modern EMS can be traced to volunteer ambulances in World
War I, field care in World War II, and the use of field medics and rapid
helicopter evacuation in the Korean War. EMS as we know it today originated
in 1966 with the publication of “Accidental Death and Disability: The Neglected
Disease of Modern Society.” The Department of Transportation (DOT) is the
governing body for EMS and published the first EMS training curriculum in the
early 1970s.
Levels of EMS Training and Regulation
There are four nationally recognized training and licensure levels for EMS
providers:
●​ EMR (Emergency Medical Responder): Provides basic immediate
care until more advanced personnel arrive. Examples include law
enforcement officers, firefighters, park rangers, and ski patrollers.
●​ EMT (Emergency Medical Technician): Provides basic life support
(BLS), including airway management, CPR, bleeding control, and
assisting with a limited set of medications.
●​ AEMT (Advanced Emergency Medical Technician): Provides all EMT
skills plus some advanced life support (ALS) skills, such as IV therapy,
administration of more medications, and use of advanced airway
adjuncts.
●​ Paramedic: The highest level of prehospital provider with extensive
training in ALS, including endotracheal intubation, emergency
pharmacology, and cardiac monitoring.
EMS is regulated at multiple levels:
●​ Federal Level: The National EMS Scope of Practice Model provides
guidelines for EMS skills.
●​ State Level: State laws regulate EMS provider operations and
licensure.
●​ Local Level: The agency’s medical director decides the day to day
limits of EMS personnel through protocols.
Medical Direction
The physician medical director authorizes EMTs to provide medical care in the
field. This oversight is known as medical control.
●​ Online (Direct) Medical Control: Directions given over the phone or
radio by a physician.
●​ Offline (Indirect) Medical Control: Care is provided based on written
standing orders and protocols.
●​ Standing Orders: A type of offline medical control that is part of a
protocol. An example is giving oxygen to a patient with chest pain. If an
intervention requires contacting a physician for permission, it is not a
standing order.
Quality Improvement
●​ Continuous Quality Improvement (CQI): A system of internal and
external reviews and audits of all aspects of the EMS system. Periodic
run review meetings are held to discuss patient care and identify areas
for improvement.
●​ Quality Control: The responsibility of the medical director to ensure
that the appropriate medical care standards are met on each call.
Workforce Safety and Wellness
Stress Management
●​ Cumulative Stress: Prolonged, excessive stress that can cause
fatigue, appetite changes, GI issues, and sleep pattern issues.
●​ Delayed Stress (PTSD): Posttraumatic stress disorder that can occur
after a critical incident.
●​ General Adaptation Syndrome: A three stage response the body goes
through when exposed to stress: alarm, resistance, and exhaustion.
The Grieving Process
Patients, families, and providers may experience a grieving process with five
common stages: denial, anger, bargaining, depression, and acceptance.
Infection Control
●​ Handwashing: The most important practice. Wash hands vigorously for
at least 20 seconds.
●​ Personal Protective Equipment (PPE):
●​ Gloves: Must be worn for any potential contact with body fluids.
Should be removed by pinching the wrist and pulling the glove
inside out.
●​ Gown and Eye Protection: Required for situations with a high
risk of splashing, such as childbirth, uncontrolled bleeding,
vomiting, and suctioning.
●​ HEPA (N95) Mask: Required for patients with suspected
tuberculosis and when performing aerosol generating procedures
such as suctioning, CPR, and endotracheal intubation. It is NOT
required for bloodborne pathogens like HIV.
Hepatitis
Hepatitis is an inflammation of the liver.
●​ Hepatitis A, B, and C can all cause nausea, abdominal pain, and
malaise. Jaundice and right upper quadrant pain can develop weeks
after exposure.
●​ Hepatitis A is transmitted via the fecal oral route.
●​ Hepatitis B, C, and D can be transmitted through blood or sexual
contact.
●​ Hepatitis B and C can lead to chronic infection, cirrhosis, and cancer.
Vaccines are available for Hepatitis A and B.
Operations and Scene Management
Scene Size Up
The scene size up is the first component of patient assessment. Its steps are:
1.​ Take standard precautions (BSI/PPE).
2.​ Ensure scene safety.
3.​ Determine the Mechanism of Injury (MOI) or Nature of Illness (NOI).
4.​ Determine the number of patients.
5.​ Consider the need for additional or specialized resources.​
The general impression is the first part of the primary assessment, not
the scene size up.
Ambulance and Equipment Operations
●​ Ambulance Types:
●​ Type 1: A truck chassis with a modular ambulance body.
●​ Type 2: A standard van configuration.
●​ Type 3: A specialty van with a square patient compartment
mounted on the chassis.
●​ Ambulance Cleaning: Use a bleach and water solution to clean the
stretcher, rails, and mattress after each run and daily. Do not use
alcohol or aerosol sprays on these surfaces.
●​ Oxygen Cylinders: Should be replaced when they reach a designated
safe residual pressure, typically 200 or 500 psi.
Air Medical Operations (Helicopters)
●​ Landing Zone (LZ): Requires a flat area of at least 100 x 100 feet,
clear of debris, litter, and overhead obstacles.
●​ Safety:
●​ Approach the helicopter from the front in a crouched position,
between the 10 and 2 o’clock positions, only after the pilot gives
an OK signal.
●​ Secure the perimeter of the LZ, positioning emergency vehicles at
the corners with headlights facing inward.
●​ Wear eye protection during approach and take off.
●​ Ensure all patient equipment is secured.
●​ Do not smoke or have open flames within 50 feet of the aircraft.
Patient Lifting and Moving
●​ Lifting Technique: Keep your back straight and locked. Spread your
legs and bend at the knees, not the waist. Keep the patient’s weight
close to your body. Lift with your palms facing upward and avoid
twisting. Communicate with your partners.
●​ Emergency Move: Used when there is immediate risk of harm or you
cannot access another critical patient. The patient is dragged along the
long axis of the body without time for full immobilization. This can be
done by pulling on clothing at the neck/shoulder (unbuttoning the top
button), using a blanket, or grasping the wrists above the patient’s head.
●​ Patient Carrying Devices:
●​ Long Backboard: Used for spinal motion restriction. Assess
pulse, motor, and sensory function before and after securing the
patient.
●​ Scoop Stretcher: Fits around a patient in a supine position,
useful in confined spaces.
●​ Basket Stretcher (Stokes): Used for mountain, cliffside, or
technical rescues and vertical lifts. Can break into two sections.
●​ Flexible Stretcher: Used for moving patients through narrow
openings or down deep staircases.
●​ Vacuum Mattress: A device that molds around the patient as air
is removed, providing excellent immobilization.
●​ Bariatric Patients: Patients over 250 pounds require at least 4
providers. Request lifting assistance from dispatch.
Incident Management
Incident Command System (ICS) and NIMS
●​ ICS (Incident Command System): A standardized management tool
used in mass casualty incidents (3+ patients) to ensure safety and
efficient use of resources. It does not train or evaluate EMS systems.
●​ NIMS (National Incident Management System): A system created to
standardize incident management for all hazards across all levels of
government.
●​ ICS Command Section: Includes the Incident Commander (IC), Public
Information Officer, Safety Officer, and Liaison Officer.
●​ ICS Functional Sections: Finance, Logistics, Operations, Planning.
●​ Medical Incident Command Roles: Triage, Treatment, Transportation,
Staging, Rehabilitation, Extrication.
Mass Casualty Incidents (MCIs) and Triage
An MCI involves 3 or more patients or has the potential to produce multiple
casualties, overwhelming initial resources.
●​ Initial Actions: Request additional resources, establish Incident
Command, and begin primary triage.
●​ Triage Principle: Treatment does not begin until initial triage is
complete.
●​ Triage Categories:
●​ Red (Immediate): Life threatening problems with airway,
breathing, circulation (shock), severe burns, open
chest/abdominal wounds.
●​ Yellow (Delayed): Serious injuries that are not immediately life
threatening, like major bone injuries or burns without airway
compromise.
●​ Green (Minimal): Minor injuries like minor fractures or soft tissue
injuries; the “walking wounded.”
●​ Black (Expectant): Non survivable injuries, such as major open
brain trauma, cardiac arrest, or respiratory arrest when resources
are limited.
●​ Triage Systems:
●​ START (Simple Triage and Rapid Transport): Used for adults.
Assesses Respirations, Perfusion (pulse/capillary refill), and
Mental Status (follows commands).
●​ JumpSTART: Used for pediatric patients. An apneic child with a
pulse receives 5 rescue breaths; if they start breathing, they are
tagged Red. If not, they are tagged Black. A respiratory rate less
than 15 or over 45 is tagged Red.
●​ SALT (Sort, Assess, Lifesaving Interventions,
Treatment/Transport): Allows for immediate lifesaving
interventions like tourniquets or needle decompression during
triage. Adds a Gray category for patients expected to die.
●​ Hartford Consensus (THREAT): A protocol for mass shootings:
Threat suppression, Hemorrhage control, Rapid Extrication,
Assessment by medical, Transport.
Special Hazards and Operations
Hazardous Materials (HAZMAT)
●​ Safety: Always position yourself upwind and uphill.
●​ Hazard Zones:
●​ Hot Zone: Contaminated area.
●​ Warm Zone: Decontamination corridor.
●​ Cold Zone: Safe area for command post and patient treatment.
●​ Identification:
●​ DOT Placards: Diamond shaped symbols on transport vehicles.
●​ NFPA 704 System: Used on fixed facilities. A diamond with four
colored smaller diamonds: Red (flammability), Blue (health),
Yellow (reactivity), White (special). Risk is rated 0 to 4.
●​ Common Containers: Drums, cylinders, and carboys are used to
transport hazardous materials.
Weapons of Mass Destruction (WMDs) and Blast Injuries
●​ Chemical Agents:
●​ Nerve Agents: Cause SLUDGEM symptoms (Salivation,
Lacrimation, Urination, Defecation, Gastric upset, Emesis,
Miosis).
●​ Vesicants: Blistering agents.
●​ Pulmonary/Choking Agents: Cause lung injury and respiratory
distress.
●​ Cyanide Agents: Interfere with cellular oxygen use.
●​ Biologic Agents: Examples include viral hemorrhagic fevers like Ebola.
●​ Radiological Sources: Can emit alpha, beta, gamma (X rays), or
neutron radiation. Delta is not a form of energy.
●​ Blast Injuries:
●​ Primary: Injury from the blast wave itself (e.g., blast lung,
ruptured eardrums).
●​ Secondary: Injury from flying debris.
●​ Tertiary: Injury from the body being thrown against an object.
●​ Quaternary: Miscellaneous injuries (burns, crush injuries, toxic
inhalation).
●​ Quinary: Illness caused by toxic materials absorbed from the
blast.
Other Operational Hazards
●​ Water Rescue: Follow the sequence: Reach, Throw, Row, then Go. Be
aware of dangers like backwash, strainers, and boils.
●​ Motor Vehicle Collisions: Park 100 feet away in a “fend off” position.
Be aware of significant MOIs like rollovers, ejections, or death of
another occupant.
Medical, Legal, and Ethical Issues
Consent
●​ Expressed Consent: Permission given by a competent adult. Children
cannot give expressed consent.
●​ Implied Consent: Assumed for unresponsive or incompetent patients
who need emergency care.
●​ Involuntary Consent: Can be applied to mentally incompetent patients,
often with legal or law enforcement involvement.
Legal Principles
●​ Duty to Act: Your responsibility to provide patient care.
●​ Negligence: Failure to provide the standard of care.
●​ Assault: Placing a person in fear of immediate bodily harm.
●​ Battery: Unlawfully touching a person without their consent.
●​ False Imprisonment: Unauthorized confinement of a person.
●​ Good Samaritan Law: Provides legal protection for those who provide
emergency care in good faith.
●​ Physical Restraints: If used improperly, can cause asphyxia,
aspiration, acidosis, and cardiac death.
Patient Confidentiality and Reporting
●​ HIPAA: Patient information may only be disclosed for treatment,
payment (billing), or when legally required (e.g., suspected abuse,
subpoena).
●​ Special Reporting Situations: You may be required to report cases of
MCI, gunshot wounds, animal bites, infectious diseases, and physical or
sexual abuse.
Advance Directives
●​ DNR (Do Not Resuscitate): To be valid, a DNR must have the patient
or legal guardian’s signature, a physician’s signature, and an expiration
date. You must still provide supportive treatment like oxygen and pain
management.
Documentation and Communication
Patient Care Report (PCR)
The PCR is a legal document. An undocumented action cannot be proven to
have occurred.
●​ Information Included: Patient info, chief complaint, LOC, vitals,
findings, treatment provided, and all relevant times.
●​ Correcting Errors: Draw a single line through the mistake, write the
correct information, and add your initials. It is not necessary to retrieve
the original report or file a report with a supervisor for a simple
correction.
●​ SOAP Method: Subjective, Objective, Assessment, Patient Care.
Communication
●​ Dispatch Information: Collects the nature of the call, location, callback
number, patient’s age, chief complaint, and number of patients.
●​ Radio Report to Hospital: Be concise. Include your unit ID, ETA,
patient age/gender, chief complaint, brief history, key findings, treatment
provided, and the patient’s response. Do NOT include detailed medical
history or your personal opinion of the incident.
●​ Language Barriers: Use family members, friends, or a smartphone to
translate. It is inappropriate to refuse care or ask a patient to sign a
document in a language they do not understand.
Anatomical and Assessment Terminology
●​ Objective (Sign): A finding that can be seen, heard, felt, or measured
(e.g., rash, bleeding, fever).
●​ Subjective (Symptom): Something the patient tells you (e.g., “I feel
dizzy”).
●​ Directional Terms:
●​ Proximal: Closer to the origin or point of attachment.
●​ Distal: Farther from the origin or point of attachment.
●​ Superior: Nearer to the head.
●​ Inferior: Nearer to the feet.
●​ Lateral: Farther from the midline.
●​ Medial: Closer to the midline.
●​ Patient Positions:
●​ Prone: Lying face down.
●​ Supine: Lying face up.
●​ Fowler’s Position: Semi reclining with the head elevated (45 to
60 degrees).
●​ High Fowler’s Position: Sitting upright at 90 degrees.
Pharmacology Basics
As an EMT, your role in pharmacology is critical.
It involves understanding the fundamental principles of how medications work,
following strict safety procedures, and administering or assisting with a
specific, limited set of medications as authorized by your medical director.
Mastery of this subject ensures both patient safety and effective treatment.
This section of our study guide cover pharmacology basics required both for
your NREMT exam and working as an EMT.
Core Concepts in Pharmacology
●​ Pharmacology: The science of drugs, including their origin,
composition, pharmacokinetics, therapeutic use, and toxicology.
●​ Medication Names: You will encounter two names for every drug:
●​ Generic Name: A simple, non-proprietary name for a medication,
which is the official name listed in the U.S. Pharmacopeia (e.g.,
albuterol, ibuprofen).
●​ Trade Name (Brand Name): The brand name a manufacturer
gives to a medication (e.g., Ventolin®, Proventil® for albuterol;
Advil®, Motrin® for ibuprofen). You must be familiar with both.
●​ Pharmacodynamics: This is the study of what a drug does to the body.
It describes the mechanism of action. For example, nitroglycerin causes
vasodilation.
●​ Pharmacokinetics: This is the study of what the body does to a drug. It
involves the processes of:
●​ Absorption: How the drug gets from the site of administration
into the bloodstream.
●​ Distribution: How the drug travels through the body to its target
site.
●​ Metabolism: How the drug is broken down by the body (usually in
the liver).
●​ Excretion: How the drug is eliminated from the body (usually by
the kidneys).
●​ Indications vs. Contraindications:
●​ Indication: A specific sign, symptom, or condition for which a
medication is known to be beneficial. It is the reason you give the
drug.
●​ Contraindication: A condition or factor that makes administering
a particular drug dangerous or harmful. It is a reason you should
not give the drug.
●​ Side Effects vs. Untoward Effects:
●​ Side Effect: Any effect of a medication other than the one
desired. These are often predictable and may be harmless or
harmful (e.g., headache after taking nitroglycerin).
●​ Untoward Effect: A side effect that is harmful to the patient (e.g.,
hypotension after taking nitroglycerin).
Routes of Administration
The route of administration determines how quickly a medication is absorbed
and begins to take effect.
●​ Oral (PO): Swallowed by mouth. The drug is absorbed through the
gastrointestinal tract, which is a slow process.
●​ Sublingual (SL): Placed under the tongue to dissolve and be absorbed
by the rich network of capillaries there. This route bypasses the
digestive system, allowing for rapid absorption directly into the
bloodstream.
●​ Inhalation: Breathed into the lungs. The medication is absorbed across
the alveolar membrane, providing a very rapid onset of action.
●​ Intranasal (IN): Sprayed into the nostrils and absorbed through the
mucous membranes. This is another rapid route that avoids the need for
an injection.
●​ Intramuscular (IM): Injected directly into a large muscle (like the thigh
or deltoid). The medication is absorbed from the muscle into the
bloodstream. The onset is faster than oral but slower than IV or
inhalation.
The 6 Rights of Medication Administration
This is a mandatory safety check that must be performed every single time
you administer a medication to prevent errors.
1.​ Right Patient: Is this medication prescribed for this specific person?
2.​ Right Medication: Are you holding the correct medication in your
hand?
3.​ Right Dose: Are you giving the correct amount of the medication?
4.​ Right Route: Are you giving the medication via the correct route (e.g.,
sublingual, not oral)?
5.​ Right Time: Is it the right time and clinical condition to give this
medication? Is the medication expired?
6.​ Right Documentation: You must accurately record the medication
name, dose, route, and time of administration, as well as the patient’s
response to the treatment.
Core EMT Medications
Oxygen
●​ Class: Medical gas.
●​ Action: A naturally occurring gas that is essential for cellular
metabolism. Supplemental oxygen increases the concentration of
oxygen in the inspired air, which in turn increases the amount of oxygen
bound to hemoglobin in the blood.
●​ Indications: Documented or suspected hypoxia (SpO2 < 94%),
respiratory distress, shock, major trauma, or any critical patient.
●​ Contraindications: None in a true emergency. Use with caution in
patients with COPD, as high concentrations over time can theoretically
decrease their respiratory drive (hypoxic drive).
●​ Dose/Route: Varies by delivery device: 2–6 L/min via nasal cannula;
10–15 L/min via non-rebreather mask; 15 L/min via BVM. Administered
via inhalation.
Oral Glucose
●​ Class: Carbohydrate.
●​ Action: A simple sugar that is absorbed through the mucous
membranes in the mouth and from the GI tract, rapidly increasing blood
glucose levels.
●​ Indications: A conscious patient with a history of diabetes and an
altered mental status due to confirmed or suspected hypoglycemia.
●​ Contraindications: The patient is unconscious, unable to swallow, or
has lost their gag reflex.
●​ Dose/Route: One full tube (typically 15-25 grams), administered
orally/buccally (between the cheek and gum).
Activated Charcoal
●​ Class: Adsorbent.
●​ Action: Binds (adsorbs) to certain poisons and chemicals in the
stomach, preventing their absorption into the body.
●​ Indications: Ingested poisons within one hour of ingestion, as directed
by medical control or poison control.
●​ Contraindications: Ingestion of acids, alkalis, heavy metals, or
petroleum products; altered mental status; inability to swallow.
●​ Dose/Route: 1–2 grams per kg of body weight, administered orally as a
slurry.
Aspirin (ASA)
●​ Class: Anti-platelet agent.
●​ Action: Inhibits platelet aggregation, meaning it makes platelets less
“sticky” and prevents them from clumping together to form blood clots in
the coronary arteries.
●​ Indications: Chest pain of suspected cardiac origin.
●​ Contraindications: Known allergy, history of active bleeding disorders
(like hemophilia), recent GI bleed or ulcer.
●​ Dose/Route: 162–325 mg (2–4 low-dose tablets), administered orally.
The patient must chew the tablets.
Nitroglycerin (NTG)
●​ Class: Vasodilator.
●​ Action: Relaxes the smooth muscles of blood vessels, causing
systemic vasodilation. This decreases the workload on the heart
(decreases preload and afterload) and dilates the coronary arteries,
increasing blood flow to the myocardium.
●​ Indications: Chest pain in a patient who has a physician’s prescription
for nitroglycerin.
●​ Contraindications: Systolic BP < 100 mmHg; use of erectile
dysfunction medications (sildenafil, tadalafil, vardenafil) within the last
48 hours; suspected head injury.
●​ Dose/Route: 0.4 mg sublingually (tablet or spray); can be repeated
every 5 minutes up to a maximum of 3 doses, pending vital signs and
pain relief.
Epinephrine (Auto-Injector)
●​ Class: Sympathomimetic.
●​ Action: Mimics the effects of the sympathetic nervous system. It is an
alpha and beta-adrenergic agonist. Beta-1 effects increase heart rate
and contractility. Beta-2 effects cause bronchodilation. Alpha effects
cause vasoconstriction, which reverses vasodilation and raises blood
pressure during anaphylaxis.
●​ Indications: Anaphylaxis, characterized by respiratory distress and/or
signs of shock (hypotension).
●​ Contraindications: None in a true life-threatening anaphylactic
reaction. Use with caution in patients with a history of heart disease.
●​ Dose/Route: One auto-injector (0.3 mg for adults; 0.15 mg for children),
administered via intramuscular (IM) injection into the lateral thigh.
Albuterol (Metered-Dose Inhaler or Small-Volume Nebulizer)
●​ Class: Beta-2 agonist.
●​ Action: A selective beta-2 agonist that targets the smooth muscles of
the bronchioles, causing them to relax and leading to bronchodilation.
●​ Indications: Dyspnea and wheezing in a patient with a history of
asthma, COPD, or reactive airway disease.
●​ Contraindications: Known allergy, patient is unable to follow
commands or physically use the device.
●​ Dose/Route: One to two puffs from an MDI, or one vial in a nebulizer,
administered via inhalation.
Naloxone (Narcan)
●​ Class: Opioid antagonist.
●​ Action: Competitively binds to opioid receptors in the central nervous
system, blocking the effects of opioids and rapidly reversing respiratory
depression.
●​ Indications: Suspected opioid overdose in a patient with respiratory
depression or arrest (bradypnea or apnea) and constricted (pinpoint)
pupils.
●​ Contraindications: Known allergy (hypersensitivity).
●​ Dose/Route: Typically 2–4 mg administered intranasally (IN). Can also
be given via IM auto-injector.
Obstetrics & Gynecology
This section of our NREMT study guide provides a direct and comprehensive
overview of obstetric and gynecologic emergencies, covering pregnancy, labor
and delivery, delivery complications, and care of the newborn.
Pregnancy Fundamentals
Maternal Physiological Changes
●​ Blood Volume: Increases by up to 50%, which means a pregnant
patient can lose a significant amount of blood before showing signs of
shock.
●​ Heart Rate: Increases by 10-20 beats per minute.
●​ Respiratory System: Respiratory rate increases and tidal volume
decreases, making them more susceptible to hypoxia.
●​ Blood Clotting: Blood clots more easily, increasing the risk of
pulmonary embolism.
Supine Hypotensive Syndrome​
In a patient in her second or third trimester, the weight of the uterus can
compress the inferior vena cava when she lies supine. This reduces blood
return to the heart, causing a drop in blood pressure. To prevent this, all late
term pregnant patients should be transported tilted or lying on their left side.
Antepartum Emergencies (Complications Before Delivery)
Vaginal Bleeding
●​ Ectopic Pregnancy: A fertilized egg implants outside the uterus,
usually in a fallopian tube. Presents with sudden, severe, unilateral
lower abdominal pain and may have vaginal bleeding. This is a life
threatening cause of internal hemorrhage.
●​ Spontaneous Abortion (Miscarriage): Loss of a pregnancy before 20
weeks.
●​ Abruptio Placentae: The premature separation of the placenta from
the uterine wall. This is a life threatening condition that causes severe,
constant abdominal pain and dark red vaginal bleeding.
●​ Placenta Previa: The placenta implants low in the uterus and partially
or fully covers the cervical opening. The hallmark sign is painless,
bright red vaginal bleeding.
Hypertensive Disorders
●​ Preeclampsia: A condition developing after 20 weeks of gestation
characterized by hypertension, headaches, visual disturbances (seeing
spots), and edema (swelling).
●​ Eclampsia: The onset of seizures in a patient with preeclampsia. This
is a true life threatening emergency requiring immediate management of
the airway and transport.
Gestational Diabetes​
High blood sugar that develops during pregnancy, typically around the 24th
week. Symptoms include increased thirst, frequent urination, and fatigue.
Labor and Delivery
Stages of Labor
●​ First Stage (Dilation): Begins with the onset of regular contractions
and ends when the cervix is fully dilated (10 cm). This is the longest
stage. The amniotic sac may rupture (“water breaks”) during this stage.
●​ Second Stage (Expulsion): Begins when the cervix is fully dilated and
ends with the delivery of the baby. The mother will feel an intense urge
to push or have a bowel movement. Crowning occurs when the baby’s
head is visible at the vaginal opening.
●​ Third Stage (Placental): Begins after the baby is delivered and ends
with the delivery of the placenta, which typically occurs within 30
minutes.
Assisting with a Normal Delivery​
Delivery on scene is necessary if birth is imminent (crowning is visible).
1.​ As the head emerges, apply gentle pressure to prevent an explosive
delivery and support the perineum.
2.​ Once the head is delivered, check for a nuchal cord.
3.​ Suction the baby’s mouth and then the nose.
4.​ Guide the head downward to deliver the anterior (upper) shoulder.
5.​ Guide the head upward to deliver the posterior (lower) shoulder.
6.​ Be prepared for the rest of the body to deliver quickly. Support the baby.
7.​ Once the baby is delivered, clamp the umbilical cord 6 8 inches from the
baby, place a second clamp 2 3 inches further away, and cut between
the clamps.
8.​ After the placenta delivers, you can perform a uterine massage to help
control bleeding.
Delivery Complications
●​ Nuchal Cord: If the cord is wrapped around the baby’s neck, attempt to
slip it gently over the baby’s head. If too tight, you must clamp the cord
in two places and cut it immediately.
●​ Prolapsed Cord: The umbilical cord presents before the baby. This is
an extreme emergency.
●​ Intervention: Place the mother in a knee chest position or supine
with hips elevated. Insert a sterile, gloved hand into the vagina
and physically lift the baby’s presenting part off of the cord.
Maintain this position and transport immediately.
●​ Abnormal Presentations:
●​ Breech Presentation: The buttocks or feet present first. Support
the baby’s body as it delivers, but if the head does not deliver
within 3 minutes, you may need to form a “V” with your fingers
inside the vagina to create space for the baby to breathe.
●​ Limb Presentation: A single arm or leg presents first. This
cannot be delivered in the field. Place the mother in a head down,
pelvis elevated position and transport immediately.
●​ Meconium Staining: The presence of fetal stool (a greenish or
brownish yellow fluid) in the amniotic fluid, indicating fetal distress. If
meconium is present, you must aggressively suction the baby’s mouth
and nose as soon as the head is delivered and before the baby takes its
first breath.
Postpartum and Newborn Care
Immediate Newborn Care
1.​ Drying and Warming: Immediately dry the infant thoroughly with towels
and wrap them in a warm, dry blanket. This is the most important step to
prevent heat loss and stimulate breathing.
2.​ Positioning and Suctioning: Position the infant on their back with the
head slightly lower than the body. Suction the mouth and then the nose
with a bulb syringe.
3.​ Stimulation: If the baby is not breathing or crying, stimulate them by
rubbing their back or flicking the soles of their feet.
APGAR Score​
The APGAR score is assessed at 1 minute and 5 minutes after birth.
●​ Appearance: 2=Pink, 1=Body pink, extremities blue, 0=Blue/pale
●​ Pulse: 2=>100, 1=<100, 0=Absent
●​ Grimace: 2=Cries/pulls away, 1=Grimaces, 0=No response
●​ Activity: 2=Active movement, 1=Some flexion, 0=Limp
●​ Respiration: 2=Strong cry, 1=Slow/irregular, 0=Absent
At Risk Neonates and SIDS
●​ Neonates weighing less than 5.5 lbs or born before 36 weeks are
considered premature and are at high risk for complications.
●​ SIDS (Sudden Infant Death Syndrome) risk factors include maternal
smoking, maternal age less than 20, and low birth weight.
Patient Assesment
The patient assessment process is the single most important skill for an EMT.
It is a systematic, repeatable sequence designed to rapidly identify and
manage life-threatening conditions, investigate the patient’s complaint, and
determine the appropriate course of treatment and transport.
This section of our NREMT study guide breaks down the five essential
components of a complete patient assessment.
1. Scene Size-Up
The scene size-up begins the moment you are dispatched and continues as
you approach and arrive at the scene. It is a continuous process of ensuring
safety and operational readiness before you ever make patient contact.
●​ BSI / Standard Precautions / PPE: Your first priority is your own safety.
Before exiting the ambulance, you must determine what level of
personal protective equipment is necessary. At a minimum, this will be
gloves. You should anticipate the need for more advanced protection
based on dispatch information. For a patient with a cough and fever, you
should don a mask. For a childbirth or major trauma, you should have
eye protection and a gown readily available.
●​ Scene Safety: This is a dynamic assessment of your surroundings for
any potential hazards to your crew, the patient, or bystanders. Hazards
can include:
●​ Environmental: Traffic, weather conditions (ice, rain), unstable
surfaces, difficult terrain.
●​ Human-Related: Violent patients, hostile bystanders, crime
scenes, or weapons.
●​ Chemical/Biological: Hazardous materials, risk of infectious
disease.​
Never enter a scene that you have not deemed safe. If the scene
is unsafe, stage a safe distance away and request the appropriate
resources (e.g., law enforcement, fire department, HAZMAT).
●​ Mechanism of Injury (MOI) / Nature of Illness (NOI):
●​ MOI (Trauma): This is the physical force that caused the injury.
Understanding the MOI helps you develop an “index of suspicion”
for potential injuries. For example, in a head-on motor vehicle
collision (MVC), you should suspect head, spine, chest, and
abdominal injuries. For a fall, the height of the fall and the surface
the patient landed on are critical details.
●​ NOI (Medical): This is the type of medical condition the patient is
experiencing. You can gather clues from the dispatch information,
the scene itself (e.g., medication bottles, home oxygen), and
information from bystanders or family members.
●​ Number of Patients: It is crucial to quickly determine how many
patients you have. If the number of patients overwhelms your initial
resources (typically considered three or more patients), you must
declare a Mass Casualty Incident (MCI), establish command, and
request additional resources immediately.
●​ Additional Resources: Based on your scene size-up, determine if you
need help. This could include Advanced Life Support (ALS) for a critical
patient, the fire department for extrication or lifting assistance, or law
enforcement for scene control. Make these requests early.
2. Primary Assessment
The primary assessment is a rapid, hands-on evaluation to identify and treat
all immediate life threats. This process should be swift and systematic. The
guiding principle is to address problems as you find them.
●​ Form a General Impression: This is your “from the doorway”
assessment. Note the patient’s age, sex, and general appearance.
What is their position (e.g., tripod position suggests severe respiratory
distress)? What are their facial expressions (e.g., grimacing in pain,
anxious)? Are they tracking you as you approach? This initial
impression helps you determine if the patient is “sick” or “not sick.”
●​ Assess Level of Consciousness (LOC): Use the AVPU scale to
determine the patient’s responsiveness.
●​ Alert: The patient is awake, has their eyes open, and is aware of
you and their surroundings.
●​ Verbal: The patient is not alert but responds when you speak to
them (e.g., opens their eyes, moans, or speaks).
●​ Painful: The patient does not respond to your voice but responds
to a painful stimulus, such as a trapezius pinch or a sternal rub.
Note their response (e.g., purposeful movement, posturing).
●​ Unresponsive: The patient does not respond to any stimulus.
●​ Assess the Chief Complaint and Apparent Life Threats: Ask the
patient, “Why did you call 911 today?” to determine their chief complaint.
Simultaneously, perform a quick visual scan for any obvious, immediate
life threats, such as arterial bleeding. The approach to your ABCs
depends on this finding:
●​ ABC Approach: For most patients.
●​ C-ABC Approach: If the patient has obvious, life-threatening
external hemorrhage, your first priority is to control the bleeding
with direct pressure or a tourniquet. You cannot oxygenate blood
that is no longer in the body.
●​ Assess the Airway (A):
●​ Is it open? An alert patient who is speaking in full sentences has
an open airway. In an unresponsive patient, the tongue is the
most common obstruction. If the airway is not open, perform a
head tilt-chin lift (for medical patients) or a jaw-thrust maneuver
(for trauma patients).
●​ Is it clear? Listen for abnormal sounds like snoring (tongue),
gurgling (fluid), or stridor (obstruction/swelling). If the airway is not
clear, suction immediately.
●​ Assess Breathing (B):
●​ Is the patient breathing? If not, begin ventilations with a
bag-valve mask (BVM) immediately.
●​ Is the breathing adequate? You must assess three things:
1.​ Rate: Is it too fast (tachypnea) or too slow (bradypnea)?
2.​ Rhythm: Is it regular or irregular?
3.​ Quality/Tidal Volume: Is the patient moving an adequate
amount of air with each breath? Look for equal chest rise
and fall. Listen for abnormal lung sounds.
●​ Intervention: If breathing is inadequate (too fast, too slow, or too
shallow), provide supplemental oxygen and be prepared to assist
ventilations with a BVM.
●​ Assess Circulation (C):
●​ Pulse: In a conscious patient, assess the radial pulse. In an
unresponsive patient, assess the carotid pulse. Note the rate,
rhythm, and quality (e.g., “strong and regular,” “weak and
thready”).
●​ Skin: Assess the skin color, temperature, and condition. “Pink,
warm, and dry” is normal. “Pale, cool, and diaphoretic (sweaty)” is
a classic sign of shock (hypoperfusion).
●​ Bleeding: Perform a rapid body scan to identify and control any
major bleeding that was not found earlier.
●​ Make a Transport Decision: Based on your primary assessment
findings (altered mental status, ABC compromise), you will determine if
the patient is a high priority for immediate transport (“load-and-go”) or if
they are stable enough to allow for a more detailed assessment on
scene.
3. History Taking
This is the investigative portion of the assessment, where you gather
information about the chief complaint and the patient’s overall health.
●​ OPQRST (for investigating pain or other symptoms):
●​ Onset: What were you doing when this began? Did it start
suddenly or gradually?
●​ Provocation/Palliation: Does anything make it better or worse?
(e.g., movement, rest, leaning forward).
●​ Quality: Can you describe the feeling for me? (Use their words:
“crushing,” “tearing,” “sharp,” “dull,” “pressure”).
●​ Radiation: Does the feeling move or travel anywhere else in your
body?
●​ Severity: On a scale of 0 to 10, with 10 being the worst
imaginable, what number would you give it right now?
●​ Time: How long has this been going on? Has it been constant or
does it come and go?
●​ SAMPLE History (for gathering a general medical history):
●​ Signs/Symptoms: Start with the chief complaint and associated
symptoms.
●​ Allergies: Are you allergic to any medications, foods, or
environmental factors? What kind of reaction do you have?
●​ Medications: What medications do you take? Be sure to ask about
prescription drugs, over-the-counter medications, herbal
supplements, and any recreational drugs.
●​ Pertinent past medical history: Have you had any medical
problems in the past? Have you ever had this before?
●​ Last oral intake: When was the last time you had anything to eat
or drink? This is important in case the patient needs surgery.
●​ Events leading up to the incident: What was happening right
before this started?
4. Secondary Assessment
This is a more detailed, systematic physical examination to identify any
additional injuries or signs related to the patient’s condition.
●​ Systematic Approach: For any patient, you will assess three main
things:
1.​ Inspection: Look for abnormalities.
2.​ Palpation: Feel for tenderness, swelling, or deformities.
3.​ Auscultation: Listen to sounds, primarily lung and heart sounds.
●​ Trauma Patient: If the patient has a significant MOI or is unresponsive,
you will perform a complete head-to-toe secondary assessment,
systematically examining each body region using DCAP-BTLS
(Deformities, Contusions, Abrasions, Punctures, Burns, Tenderness,
Lacerations, Swelling). Remember to check pulse, motor function, and
sensation (PMS) in all four extremities.
●​ Medical Patient: For a conscious medical patient, the secondary
assessment is typically focused on the body system related to the chief
complaint. For a patient with chest pain, you would perform a detailed
cardiovascular and respiratory exam. For a patient with abdominal pain,
you would inspect and palpate all four abdominal quadrants.
●​ Vital Signs: Obtain a full set of baseline vital signs: blood pressure,
pulse, respiratory rate and quality, oxygen saturation (SpO2), and
assess the pupils for size, equality, and reactivity to light (PERRL). A
blood glucose level should be considered for any patient with an altered
mental status.
5. Reassessment
Reassessment is the ongoing process of monitoring your patient’s condition,
the effectiveness of your interventions, and identifying any new problems. It is
not a single event, but a continuous loop that continues until you transfer care
to a higher-level provider.
●​ Frequency:
1.​ Unstable Patient: Reassess every 5 minutes.
2.​ Stable Patient: Reassess every 15 minutes.
●​ Steps of Reassessment:
1.​ Repeat the Primary Assessment: Re-evaluate the patient’s
mental status (AVPU), and re-check their Airway, Breathing, and
Circulation (ABCs). Have there been any changes?
2.​ Reassess Vital Signs: Obtain and trend a new set of vital signs.
Compare them to your baseline.
3.​ Re-evaluate the Chief Complaint: Has the patient’s primary
symptom changed? For example, has their pain level increased or
decreased?
4.​ Check Interventions: Are your treatments working? Is the
bleeding controlled? Has the patient’s breathing improved after
the albuterol? Do you need to adjust or add any treatments?
Pediatric and Geriatric Care
This section of our NREMT study guide covers the critical differences in
anatomy, physiology, assessment, and management for pediatric and geriatric
patients.
These two groups represent the extremes of the age spectrum and are
considered special populations in EMS.
Their unique characteristics mean that assessment findings can be subtle,
conditions can deteriorate rapidly, and a specialized approach is required.
Pediatric Patients: Not Just Small Adults
The single most important principle in pediatric care is that children are not
miniature adults. Their anatomy, physiology, and emotional development
require a distinct approach to assessment and treatment. Errors often occur
when adult standards are applied to a child.
Key Anatomical and Physiological Differences
●​ Airway and Respiratory System: This is the area of greatest
difference and highest risk.
●​ Airway is Smaller and Softer: A child’s airway is significantly
narrower in diameter (like a drinking straw compared to a garden
hose) and is more easily obstructed by swelling, mucus, or foreign
bodies. The trachea is more flexible and can be “kinked” or
occluded if the head is hyperextended or hyperflexed.
●​ Tongue is Proportionally Larger: The tongue takes up a much
larger percentage of the oropharynx, making it the most common
cause of airway obstruction in an unconscious child.
●​ Obligate Nose Breathers: Infants, for the first several months of
life, breathe primarily through their noses. Therefore, simple nasal
congestion from a cold can cause significant respiratory distress.
●​ Larynx is Funnel-Shaped (Cricoid Ring is the Narrowest
Point): In children under 8, the cricoid cartilage is the narrowest
part of the airway. This anatomical feature makes them more
susceptible to inflammatory conditions like croup, which cause
swelling in this area.
●​ Reliance on Diaphragm: Children are “belly breathers,” meaning
their diaphragm does most of the work of breathing. Signs of
respiratory distress often include prominent use of abdominal
muscles and retractions. Fatigue of these muscles leads to
respiratory failure.
●​ Head and Body:
●​ Head is Proportionally Larger: A child’s head is larger and
heavier relative to their body, with a weaker neck to support it.
This makes them prone to head injuries from falls and can cause
the neck to passively flex and obstruct the airway when lying
supine. Placing a small towel or pad under the shoulders and
torso is often necessary to achieve a neutral, patent airway
position.
●​ Larger Body Surface Area: Children have a larger body surface
area to mass ratio. This means they lose heat much more rapidly
and are highly susceptible to hypothermia, even in mild
conditions. Keeping a child warm is a critical intervention.
●​ Cardiovascular System:
●​ Reliance on Heart Rate for Compensation: Children have a
smaller stroke volume (the amount of blood pumped with each
beat). To compensate for shock, they rely almost exclusively on
increasing their heart rate. Bradycardia (a slow heart rate) is a
grave sign, most often indicating severe hypoxia and impending
cardiac arrest.
●​ Hypotension is a Late Sign: Children can maintain their blood
pressure until they have lost a significant amount of blood volume.
When their blood pressure finally drops, they are in a state of
decompensated shock and will deteriorate very rapidly. Do not
wait for hypotension to treat for shock.
Assessment of the Pediatric Patient
●​ The Pediatric Assessment Triangle (PAT): This is a rapid, hands-off
assessment tool to form a general impression of the child’s condition in
the first 30 seconds, even before touching them.
1.​ Appearance: Assesses brain function and overall well-being.
Look for muscle Tone, Interactivity, Consolability, Look/gaze, and
Speech/cry (TICLS mnemonic). A child who is limp, unresponsive,
or cannot be comforted is considered very sick.
2.​ Work of Breathing: Assesses respiratory effort. Look for
abnormal sounds (stridor, wheezing, grunting), abnormal posture
(tripod position, head bobbing), retractions (skin pulling in
between the ribs), and nasal flaring. The presence of any of these
indicates significant respiratory distress.
3.​ Circulation to the Skin: Assesses perfusion. Look at the child’s
skin color. Pallor (pale skin), mottling (a patchy, marbled
appearance), or cyanosis are signs of poor perfusion and shock.
●​ Assessment Approach: Engage the parent or caregiver first. For
toddlers and preschoolers, perform a “toe-to-head” assessment to build
rapport and trust before approaching the more sensitive head and face
area. Speak calmly and get down to the child’s eye level.
●​ Vital Signs: Be familiar with the normal ranges for heart rate and
respiratory rate, which are significantly faster than an adult’s and
decrease with age. Capillary refill (<2 seconds) is a more reliable
indicator of perfusion in young children than blood pressure.
Common Pediatric Emergencies
●​ Respiratory Emergencies: The leading cause of cardiac arrest in
children is respiratory failure.
●​ Croup (Laryngotracheobronchitis): A viral infection of the upper
airway causing swelling around the larynx. Hallmarks are a
seal-bark cough, stridor, and low-grade fever, often worse at
night.
●​ Epiglottitis: A life-threatening bacterial infection causing severe
inflammation of the epiglottis. The child will appear very ill and
toxic, with a high fever, drooling, stridor, and often in a tripod
position. Do not attempt to examine the throat.
●​ Seizures:
●​ Febrile Seizures: Common in children 6 months to 6 years old,
caused by a rapid spike in body temperature. The seizure itself is
typically a brief tonic-clonic event, and the primary prehospital
treatment is passive cooling (e.g., removing excess clothing).
●​ Dehydration: A common problem, especially with vomiting and
diarrhea. Signs include dry lips and gums, sunken eyes, a sunken
fontanelle (the soft spot on an infant’s head), and poor skin turgor (skin
“tents” when pinched).
●​ Abuse and Neglect: Always maintain a high index of suspicion. Red
flags include injuries in various stages of healing, injuries with unusual
patterns (e.g., stocking-glove burns from immersion in hot water),
injuries to the genitals or buttocks, or a story that is inconsistent with the
injuries. Femoral fractures in non-mobile infants are highly suspicious
for abuse.
Geriatric Patients: The Complexity of Aging
Geriatric patients (generally defined as over 65) present unique challenges
due to the inevitable physiological changes of aging, the presence of multiple
chronic conditions (comorbidities), and the use of multiple medications
(polypharmacy).
Key Physiological Changes of Aging
●​ Cardiovascular System: Arteries stiffen (arteriosclerosis), leading to
hypertension and a wider pulse pressure. The heart’s electrical
conduction system can deteriorate, leading to arrhythmias like atrial
fibrillation. The heart’s ability to increase its rate and contractility to
compensate for shock is diminished.
●​ Respiratory System: The chest wall becomes stiffer, and respiratory
muscles weaken. This decreases the vital capacity and the ability to
cough effectively, which significantly increases the risk of pneumonia.
●​ Neurological System: The brain atrophies (shrinks), leaving more
space between the brain and the skull. This puts tension on the bridging
veins, making elderly patients highly susceptible to slow, chronic
subdural hematomas from even minor falls or head strikes. Sensation,
vision, and hearing may be dulled, leading to a diminished perception of
pain and a higher risk of injury.
●​ Musculoskeletal System: Osteoporosis (loss of bone density) makes
bones brittle and prone to fractures from minimal trauma. Hip fractures
after a fall are extremely common and can be a life-threatening event.
●​ Skin and Renal Systems: The skin becomes thinner, drier, and less
elastic, making it more susceptible to tearing. Kidney function declines,
which affects the body’s ability to clear medications and regulate fluid
and electrolyte balance.
Assessment of the Geriatric Patient
●​ The “GEMS” Diamond: A framework to remember the key aspects of a
thorough geriatric assessment.
●​ Geriatric Patient: Remember that geriatric patients often present
atypically. A heart attack may present as confusion, not chest
pain.
●​ Environmental Assessment: The patient’s home can provide
crucial clues. Assess for safety hazards (rugs, poor lighting), food
availability, cleanliness, and temperature.
●​ Medical Assessment: Be aware that a chief complaint of
weakness, dizziness, or altered mental status may be the only
sign of a serious underlying medical problem, such as a urinary
tract infection (UTI), pneumonia, or a silent myocardial infarction
(MI).
●​ Social Assessment: Determine if the patient has a social support
network (family, friends, home health aides). Are they able to care
for themselves? Social isolation is a significant risk factor.
●​ Assessment Challenges:
●​ Atypical Presentation: This is the most critical concept in
geriatric care. Do not dismiss vague complaints. Maintain a high
index of suspicion for serious conditions presenting with
non-specific symptoms.
●​ Altered Mental Status: Never assume confusion is “just old age”
or dementia. It is a sign of a new, serious underlying condition
until proven otherwise.
●​ Polypharmacy: The patient may be taking multiple medications
from multiple doctors. It is critical to get a complete list of all
medications. These can cause a wide range of side effects or
mask signs of shock (e.g., beta-blockers prevent the heart rate
from increasing).
Common Geriatric Emergencies
●​ Trauma from Falls: Falls are the leading cause of injury and
injury-related death in the elderly. Always have a high index of suspicion
for underlying medical causes of the fall (e.g., syncope, stroke, heart
attack). Expect potential head injuries (subdural hematoma) and hip
fractures.
●​ Acute Coronary Syndrome (ACS): Often presents atypically without
classic chest pain. Look for signs like syncope, unexplained weakness,
fatigue, confusion, or difficulty breathing.
●​ Stroke: The risk of both ischemic and hemorrhagic stroke increases
dramatically with age due to hypertension and atrial fibrillation.
●​ Congestive Heart Failure (CHF) and Pneumonia: These are very
common causes of respiratory distress in the elderly. Differentiating
between the two can be difficult, as both can present with crackles in the
lungs.
●​ Elder Abuse and Neglect: Be observant for signs of neglect (poor
hygiene, malnutrition, unsafe living conditions) or abuse (unexplained
bruises, pressure sores, fearful behavior). You are a mandated reporter.