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NANCY CAROLINE’S EMERGENCY CARE IN THE STREETS, SIXTH
EDITION
Errata Sheet
p. 1.17: Changed definition of Prospective Research to read: Research that defines a
clear problem prior to gathering data.
p. 2.7: Changed definition of fight-or-flight syndrome: “shunting blood away from
the gastrointestinal tract, and increasing blood flow to the cerebrum and skeletal
muscles.”
p. 7.12 Edit under Sympathetic Nervous System: The nerve fibers that release
norepinephrine are referred to as adrenergic nerve fibers.
p. 7.26 Edit to definition of neuromuscular blocking agents: . . . affect the somatic
(motor) nervous system by inducing paralysis.
Edit following term nondepolarizing neuromuscular blocking agents: All
neuromuscular blocking agents bind to the somatic ACh receptors at the
neuromuscular junction.
p. 7.27 Edit to Beta-1 receptors: Increase the heart rate, cause cardiac muscle to
contract, strengthen cardiac contraction, produce automaticity, and trigger cardiac
electrical conduction.
p. 8.4 Deleted the sentence: Sodium is also a major component of the circulating
buffer, sodium bicarbonate (NaHCO3).
p. 8.5 Edit under Chloride: Chloride concentration is a primary determinant of
stomach pH.
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Edit under Osmosis: Changed (eg, a cell wall) to (eg, a cell membrane)
p. 8.6 Figure 8-5 caption should read: Skin tenting is a sign of dehydration.
p. 8.7 Under Isotonic Solutions: Changed (concentration of sodium) to
(concentration of solute)
p. 8.8 Third sentence: “patients receiving dialysis because dialysis therapy
dehydrates the cells.” Deleted the rest of the paragraph.
p. 8.20 and 8.21 Reworked Skill Drill 8-3 (based on comments from Hope’s customer
at Huron): Removed Step 3 and altered language to accommodate.
p. 11.10 Clarified the explanation of minute alveolar volume:
It is important to understand the concepts of minute volume (VM) and minute
alveolar volume (VA). Minute volume is simply the amount of air that moves in and
out of the respiratory tract per minute; it is determined by multiplying the tidal
volume by the respiratory rate (VM = VT × RR). Minute alveolar volume (VA) is the
amount of air that actually reaches the alveoli per minute and participates in gas
exchange; it is determined by multiplying the tidal volume (minus dead space
volume) by the respiratory rate. For example:
500 mL (VT) – 150 mL (VD) × 16 breaths/min = 5,600 mL (VA)
Minute volume will increase if the tidal volume, respiratory rate, or both, increases.
Conversely, minute volume will decrease if the tidal volume, respiratory rate, or
both, decreases. As the respirations become faster, however, they typically become
more shallow (reduced tidal volume). When respirations are too rapid and too
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shallow, the inhaled air may reach only the anatomic dead space before it is
promptly exhaled, resulting in decreased minute alveolar volume.
Table 11-1 demonstrates how tidal volume and respiratory rate can
influence a patient’s minute alveolar volume and, therefore, overall breathing
adequacy. This information will prove useful for assessing a patient’s breathing
adequacy and identifying patients who require assisted ventilation.
p. 11.11 Replaced current Table 11-1 with the following:
Table 11-1
How Tidal Volume and Respiratory Rate Affect
Minute Alveolar Volume
Example 1: Normal tidal volume and respiratory rate
(500 mL [VT] – 150 mL [VD]) × 16 breaths/min = 5,600 mL (VA) Good!
Example 2: Reduced tidal volume and a normal respiratory rate
(250 mL [VT] – 150 mL [VD]) × 14 breaths/min = 1,400 mL (VA) Not good!
Example 3: Reduced tidal volume and a slow respiratory rate
(350 mL [VT] – 150 mL [VD]) × 6 breaths/min = 1,200 mL (VA) Not good!
Example 4: Reduced tidal volume and a fast respiratory rate
(200 mL [VT] – 150 mL [VD]) × 40 breaths/min = 2,000 mL (VA) Not good!
p. 11.45 Replaced the section on automatic transport ventilators (pages 11.4511.46) with the following:
Automatic Transport Ventilators
The automatic transport ventilator (ATV) is basically a FROPVD attached to a
control box in which the variables of ventilation—tidal volume and respiratory
rate—can be set, thus allowing accurate regulation of a patient’s minute volume
(Figure 11-37). The ATV is used for intubated patients who need extended periods
of ventilation.
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Most ATVs are small and compact. The mechanical simplicity, durability, and
portability of the ATV make it a valuable prehospital ventilation device. It frees up
your hands to tend to other non-airway-related tasks.
The respiratory rate on the ATV is usually set at the midpoint or average for
the patient’s age. Tidal volume is usually set between 6 and 7 mL/kg, but can be
adjusted based on the patient’s chest rise and clinical response.
Like the FROPVD, the ATV is dependent on an oxygen source. It also has a
pressure relief valve, which can lead to unrecognized hypoventilation in patients
with poor lung compliance (eg, COPD, CHF), increased airway resistance (eg,
asthma), or airway obstruction. Table 11-10 describes the steps for using an ATV.
p. 11.45 Replaced text on Automated Transport Ventilators.
Automatic Transport Ventilators
The automatic transport ventilator (ATV) is basically a FROPVD attached to a
control box in which the variables of ventilation—tidal volume and respiratory
rate—can be set, thus allowing accurate regulation of a patient’s minute volume
(Figure 11-37). The ATV is used for intubated patients who need extended periods
of ventilation.
Most ATVs are small and compact. The mechanical simplicity, durability, and
portability of the ATV make it a valuable prehospital ventilation device. It frees up
your hands to tend to other non-airway-related tasks.
The respiratory rate on the ATV is usually set at the midpoint or average for
the patient’s age. Tidal volume is usually set between 6 and 7 mL/kg, but can be
adjusted based on the patient’s chest rise and clinical response.
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p. 11.46 Added section on Continuous Positive Airway Pressure.
Continuous Positive Airway Pressure
Continuous positive airway pressure (CPAP) delivers positive pressure to the
airways of a spontaneously breathing patient during the respiratory cycle. With
CPAP, the patient exhales against positive pressure (positive end-expiratory
pressure [PEEP]); this prevents atelectasis, forces fluid from the alveoli, and
improves pulmonary respiration. CPAP is an effective treatment for patients with
pulmonary edema (ie, CHF), and has been shown to reduce the need for intubation
when used in conjunction with drug therapy. CPAP has also proven useful for
patients with acute bronchospasm (ie, asthma) and obstructive lung disease.
CPAP is delivered through a tight-fitting face mask that is attached to an
oxygen source; the amount of PEEP can be adjusted between 2.5 and 10 cm H2O.
Patient anxiety is common during initial CPAP therapy; coaching and reassurance
are often needed to facilitate compliance. After applying the CPAP device, observe
for signs of clinical improvement, which include decreased work of breathing,
increased ease in speaking, decreases in respiratory and heart rate, and increased
SaO2.
p. 11.53 Figure 11-46 caption should read: A straight (Miller) blade with three
additional size blades shown.
p. 11.93 Although the spelling of the term “butrophenones” is used in many places,
we changed to the more common spelling: “butryrophenones”
Under “Barbiturates”, deleted “as primary induction agents.”
p. 13.40 Added an explanation of Babinski reflex: Babinski reflex occurs when the
great toe flexes and the others fan out. The presence of this reflex in adults indicates
neurological injury.
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p. 19.18 Control of External Bleeding – We revised this language slightly to reflect
the new National Registry Skill Sheet on Bleeding Control, which recommends use of
a tourniquet
Control of External Bleeding
External bleeding is bleeding that can be seen coming from a wound when the
integrity of the skin has been violated. Bleeding can be characterized according to
the type of blood vessel that has been damaged. Arterial bleeding occurs in spurts,
and the blood is usually bright red because of the fully saturated hemoglobin.
Venous bleeding is more likely to be slow and steady, and the color of the blood is
darker because it is relatively deoxygenated. In reality, most open wounds show a
combination of arterial and venous bleeding. Capillary bleeding is characterized by a
slow, even flow of bright or dark red blood and is present in minor injuries, such as
abrasions or superficial lacerations.
Five methods are used in the field to control external bleeding: direct pressure,
elevation, pressure point control, immobilization, and a tourniquet.
Direct Pressure
Application of pressure over a bleeding wound stops blood from flowing into the
damaged vessels, allowing the platelets to seal the vascular walls.
If possible, use a sterile dressing to exert pressure, and then use your gloved hand to
apply pressure over the bleeding site. The steps for controlling bleeding are:
1.
Apply a dry, sterile dressing over the entire wound. Apply pressure to
the dressing with your gloved hand (Step 1).
2.
Maintain the pressure, and secure the dressing with a roller bandage
(Step 2).
3.
If bleeding continues or recurs, leave the original dressing in place.
Apply a second dressing on top of the first, and secure it with another roller bandage
(Step 3).
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4.
Splint the extremity to stabilize the injury, even if there is no
suspected fracture, which helps to minimize movement, further control the
bleeding, and keep the dressing in place (Step 4).
To maintain pressure, apply a pressure dressing over the site. On an extremity, one
effective way of maintaining uniform pressure on a bleeding site is to apply an air
splint over the dressed wound. If one or both of the lower extremities are bleeding,
you can use the PASG to apply pressure, as discussed in Chapter 18. Maintain
pressure over the bleeding site until the bleeding stops or until the patient reaches
the hospital and other personnel take responsibility for care.
Some commercially available pressure dressings allow for simultaneous dressing of
the wound and application of pressure. If one of these products is not available,
standard dressing material may be used in conjunction with triangular bandages to
create localized pressure. This type of dressing will often allow you to focus on other
tasks while pressure is applied. Always assess distal circulation before and after you
apply a pressure dressing. Adjust the dressing as needed in case of a complication,
such as loss of distal pulse, diminished sensation, or change in skin color and
temperature distal to the dressing.
Elevation
In cases of venous bleeding from an extremity, the rate of bleeding can be
substantially slowed by elevating the extremity above the level of the heart. This
measure alone will not control bleeding, but it may be helpful in conjunction with
other measures, such as direct pressure.
Pressure Point Control
When direct pressure is not sufficient to control bleeding or when the same artery is
associated with a number of bleeding points, pressure point control may help slow
the bleeding. The artery chosen must be fairly superficial and overlie a hard
structure against which it can be compressed. Three pressure points are typically
used: (1) the temporal artery, which overlies the temporal bone of the skull and is
used to control bleeding from the scalp; (2) the brachial artery, which overlies the
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humerus and is used to control bleeding from the forearm; and (3) the femoral
artery, which can be compressed against the pelvis and is used to control bleeding
from the leg.
Recent studies have brought into question the effectiveness of using pressure points
in severe hemorrhage. It is acceptable, if allowed by protocol and local policy, to
move directly to the use of a tourniquet without attempting pressure point control.
If a tourniquet is deemed necessary, it should be applied quickly and not released in
the prehospital setting.
Immobilization
Any movement of an extremity, even an uninjured extremity, promotes blood flow
within that extremity. When the extremity is also injured, motion may disrupt the
clotting process and lacerate more blood vessels. It follows that preventing motion
of an injured extremity will have the opposite effects. Advise the patient to make
every effort to minimize movement. If that is not possible and conditions warrant,
apply a splint to prevent motion.
An air splint or padded board works well to keep an upper or lower extremity
immobilized. Use of an air splint gives a double benefit—splinting and direct
pressure. Remember to assess distal pulses, motor function, and sensation distal to
the splint before and after application.
Tourniquet
In the civilian setting, it is rarely necessary to use a tourniquet for control of
external hemorrhage. Bleeding control can almost always be achieved by one or
more of the four methods already described. Furthermore, use of a tourniquet has
been associated with potential hazards, including damage to nerves and blood
vessels and, when the tourniquet is in place for an extended period, loss of the distal
extremity. A tourniquet applied too loosely, by contrast, may increase bleeding if it
occludes venous return without hampering arterial outflow.
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In military settings, application of a tourniquet would occur more often owing to the
nature of injuries experienced during battle. In addition, rapid transport to a
medical facility is typically more difficult on the battlefield than in civilian situations.
In such a scenario, a tourniquet may be lifesaving, particularly in patients with a
traumatic partial amputation of a limb.
p. 21.32 and 28.12: Standardized values for normal ICP at 0 to 10.
p. 29.12: Changed normal blood glucose from 70-120 mg/dL to 80-120 mg/dL.
p. 23.19 Deleted Figure 23-16A because it shows sealing a sucking chest wound on
all four sides.
p. 27.22 Deleted text to “The resistance against which the ventricle contracts . . .”
p. 27.36 First two paragraphs under Management of Left-Sided Heart Failure: We
replaced this text with information about CPAP as an effective treatment.
p. 27.89 Definition of P wave: changed “ventricles” to “atria”.
p. 28.22 Under Administration of Dextrose/Glucose: Fifth line down, changed
“hyperglycemia” to “hypoglycemia”.
p. 29.13 Directly above Hyperglycemia and Diabetic Ketoacidosis, added the
following paragraph: If vascular access is not available, glucagon, 1 mg by
intramuscular injection, should be given.
p. 32.13 Replaced sentence in first column about priapism with the following:
Priapism—a sustained, painful penile erection—can be caused by conditions such
as spinal injury and the use of erectile dysfunction drugs (eg, Viagra, Levitra, Cialis).
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p. 33.8 Table 33-1: Removed under Drug Examples, Narcotic: Ambien and
secobarbital
p. 33.14 Changed caption of Figure 33.7 to read: Drugs such as nasal decongestants
and diet pills stimulate the sympathetic nervous system and can be detrimental to
patients with an underlying cardiovascular disease.
p. 33.19 Fifth bullet in left column; added: “and for patients who are dependent on
benzodiazepines because it will precipitate seizures.”
p. 33.22 Last full paragraph in right column replaced with new information about
cyanide poisoning treatment (administering amyl nitrite, sodium nitrite, and
sodium thiosulfate).
p. 34.7 Under Leukemia; edited sentence starting with “Leukemia can cause anemia
. . .”. Now reads: Leukemia can cause anemia and thrombocytopenia (decrease in
platelets). Leukemia can also cause overproduction of some specific types of white
blood cells, resulting in overall white cell counts that are extremely high (severe
leukocytosis).
In Chapters 38 and 39, we standardized definitions for parity and gravidity – “The
medical term for any pregnancy is gravid or gravidity; the term for delivery of an
infant is parity.”
p. 39.34 Fourth bullet from the bottom, left column: Added word “Ectopic” before
“pregnancy”.
p. 41.18 Replaced Figure 41-12: Equipment too large for infant in original image.
p. 50.15 In section Corrosives: Acids and Bases: “high” and “low” are reversed
throughout this section (ie, acids have a low pH and bases have a high pH).
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M.3 Equation in upper right; changed to: total amount of fluid to be administered (in
mL)  drop factor*
M.5 Changed “Amyl Nitrate” and “Sodium Nitrate” to “Amyl Nitrite” and “Sodium
Nitrite”
M.9 Flumazenil, Contraindications: Added “benzodiazepine dependence”
M.10 Glucagon, Mechanism of Action: Changed first line to read: Increases blood
glucose level by stimulating glycogenolysis.
M.14 Nalaxone Hydrochloride (Narcan), Mechanism of Action: Changed second
line to read: “reverse respiratory depression secondary to opiate drugs”
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