Hatzalah of Miami Dade
Test Review Chapters 22-30








Arteries take oxygenated blood away from the heart, while veins bring deoxygenated blood
back to the heart.651
The heart requires constant perfusion to function properly. The brain and spinal cord can be
injured for 4-6 minutes without perfusion. Kidneys can be damaged for 45 minutes of
inadequate perfusion. Skeletal muscles demonstrates evidence of injury after 2 hours of
inadequate perfusion. These times are based on a normal body temperature. 654
Bleeding will never stop if a clot doesn’t form, unless the injured vessel is completely cut off
from the main blood supply. A number of medications, including aspirin, interfere with normal
clotting. 656
A very small portion of the population lacks one or more of the blood’s clotting factors, called
hemophilia. Sometimes bleeding may occur spontaneously in hemophilia. Because the patient’s
blood doesn’t clot all injuries, no matter how trivial, are potentially serious. 656
The basic method for controlling bleeding is to apply direct local pressure to the bleeding site.
Pressure stops the flow of blood and permits normal coagulation (blood clot). 659
Nose bleeds can be controlled by leaning the patients head forward and pinching the nostrils
together. In the event of a head trauma and you see bleeding form the nose, do not attempt to
stop the blood flow. It may be difficult to control. Applying pressure may force blood leaking
through the ears and nose to collect within the head. 666 & 766
The sympathetic side of the ANS, which is responsible for the fight-or-flight response, will
assume more control of the body’s functions during a state of shock. This response of the ANS
will release hormones such as epinephrine. These hormones can cause changes in certain body
functions such as an increase in heart rate, tachycardia, and in the strength of cardiac
contractions. These actions are designed to maintain pressure in the system and , as a result,
perfusion of all organs. When hypoperfusion occurs the body removes blood form the skin and
directs it towards more important organs to sustain their life with oxygen and nutrients. carbon
dioxide is one of the primary waste products of cellular work in the body and is removed from
the body by the lungs. This is the reason adequate ventilation and oxygenation is one of your
primary concerns. 680
Damage to the spinal cord, particularly at the upper cervical levels, may cause significant injury
to the part of the nervous system that controls the size and the muscle tone of the blood
vessels. This is called neurogenic shock. The most important functions that are under control of
the nervous system, in an acute injury setting, is the ability to control body temperature,
Hypothermia. Hypovolemick shock is a loss of blood or fluids. It also occurs with sever thermal
burns. In this case, it is intravascular plasma that is lost, leaking from the circulatory system into
the burned tissues that lie adjacent to the injury. Septic Shock is the condition in which the









toxins damage the vessel walls, causing them to become leaky and unable to contract well.
Septic shock is almost always a complication of some very serious illness, injury, or surgery. 682
Expect shock if a patient has conditions of in order of most sever: 1)multiple severe fracturs,
2)abdominal or chest injury 3)spinal injury 4)a severe infection 5)major heart attack 6)and
anaphylaxis. 684
A contusion, or bruise, results from blunt force striking the body. The epidermis remains intact,
but cells within the dermis are damaged. The depth of the injury varies, depending on the
amount of energy absorbed. The buildup of blood produces a characteristic blue or black
discoloration called eccymosis. 700
An abrasion is a wound of the superficial layer of the skin, caused by friction. A laceration is a
jagged cut caused by a sharp object or a blunt force that tears the tissue, while an incision is a
sharp, smooth cut. The depth of it can vary. 705
A penetrating wound is an injury resulting from a sharp, pointed, object, such as a knife, ice pick,
splinter, or bullet. Such objects leave relatively small entrance wounds, so there may be little
external bleeding. However those objects can damage structures deep within the body and
cause unseen extensive bleeding. 706
An open wound in the abdominal cavity may expose internal organs. In some cases, the organs
may even protrude through the wound, called evisceration. Do not touch or move the exposed
organs. Rather cover the wound with sterile gauze compresses moistened with sterile saline
solution and secured with sterile dressing. 711-712
An open neck injury can be life threatening. If enough air is sucked into a blood vessel, it can
actually block the blood flow in the lungs, sending the patient into cardiac arrest, called air
embolism. Penetrating injuries to the neck can cause profuse bleeding from laceration of the
great vessles in the neck- the carotid arteries or the jugular veins. Injuries to these large vessels
may also allow air to enter the circulatory system and cause a pulmonary embolism. Cover the
wound with an occlusive dressing. Apply manual pressure, but do not compress both carotid
vessels at the same time. 714 & 769
A burn injury appears where the electricity enters and exits. The entrance wound may be quite
small, but the exit wound can be extensive and deep. Always look for both entrance and exit
wounds. 723-724
Any laceration caused by a human tooth can result in a serious, spreading infection. Remember
this if you have occasion to treat someone who has been punched in the mouth: the person who
delivered the punch may also need treatment. All wounds require bandaging. In general
dressings and bandages, have 3 primary functions: 1) to control bleeding 2) to protect wound
from further damage. 3) To prevent further contamination and infection. If patient complains of
numbness and tingling, check circulation and readjust the bandage. 726-727
The eyeball, or globe, keeps its global shape as a result of the pressure of the fluid contained
within its two chambers. The clear, jellylike fluid near back of the eye is called the vitreous
humor. If the globe is ruptured and this gel leaks out, it cannot be replaced. The inner surface of
the eyelids and the exposed surface of the eye itself, the conjunctiva, are kept moist by fluid
produced by the lacrimal glands, often called tear glands. The white of the eye, called the sclera,









extends over the surface of the globe. This is extremely tough, fibrous tissue that helps maintain
the eyes globular shape and protect the more delicate inner structures. 736
Certain elements of the patient’s history are particularly important. Therefore as you perform
your assessment with eye injuries, always note and record the patient’s signs and symptoms,
including their severity and duration, the details of how the injury occurred, any reported
changes in vision, the use of any eye medications, and any history of eye surgery. 738
With an impaled object in an eye, the appropriate treatment is to stabilize the object and cover
both eyes. Never attempt to remove the object. If person has another life threatening injury as
well, make sure to stabilize everything before moving forward in your assessment.742-745
Removing contact lenses should be limited to patients with chemical burn injuries. To remove
soft contact lenses, instill one or two drops of saline or irrigating solution. Next, pinch off the
lens with your gloved thumb and index finger. 750
Injuries about the face often lead to partial or complete obstruction of the upper airway.
Bleeding from facial injuries can be very heavy, producing large blood clots in the upper airway.
Control bleeding by applying direct manual pressure with a dry, sterile dressing. Do not apply
excessive pressure if there is a possibility of an underlying skull fracture. 760 & 764
When doing your ongoing assessment with patients with facial or throat injuries, reassess
interventions and treatment you have provided to the patient because of the ease in which
injuries can affect associated systems, such as respiratory, circulatory, and nervous systems. 763
The external ear is composed of the head, and external auditory canal, which leads in toward
the tympanic membrane, or eardrum. The external auditory canal is a favorite place for children
to place foreign bodies such as peanuts or candy. All such items should be removed by a
physician in the emergency department. Never try to manipulate the object because you may
press it further into the auditory canal and cause permanent damage to the tympanic
membrane. 766
In any chest injury, damage to the heart, lungs, great vessels, and other organs in the chest can
be complicated by the accumulation of air in the pleural space, called pneumothorax. In this
condition, air enters through a hole in the chest wall or the surface of the lung as the patient
attempts to breathe, causing the lung on that side to collapse. 784
Usually a spontaneous pneumothorax, is not related to any major injury but simply happens
with normal breathing or may occur during times of strenuous physical activity such as exercise.
In blunt and penetrating chest injuries, blood can collect in the pleural space from bleeding
around the rib cage, or from a lung or great vessel, called hemothorax. You should suspect a
hemothorax if the patient has signs and symptoms of shock or decreased breath sounds on the
affected side. An indication that the lung is being compressed by the blood. When you are
reassessing the patient if you find him to be hypotensive, if the patients status is getting worse,
then suspect that the patients aorta or vena cava may be compressed. 786
Rib fractures are very common, particularly in older people, whose bones are brittle. Be aware
that a fractured rib that penetrates not the pleural space may lacerate the surface of the lung,
causing a pneumothorax, a tension pneumothorax, a hemothorax, or a hemopneumothorax.
One sign of this development can be crackly feeling to the skin in the area (also called crepitus






or subcutaneous emphysema), which indicates that air escaping from the lacerated lung is
leaking into the chest wall. Be sure to relay this finding to the hospital personnel. Ribs may be
fractured in more than one place. If three or more ribs are fractured in two or more places or if
the sternum is fractured along with several ribs, a segment of chest wall may be detached from
the rest of the thoracic cage, known as flail chest. In what is called paradoxical motion, the
detached portion of the chest wall moves opposite of normal. 787
Blunt trauma to the chest may injure the heart itself, making it unable to maintain adequate
blood pressure. There is much debate in the medical literature about how to assess myocardial
contusion, or bruising of the heart muscle. Often the pulse rate is irregular, but dangerous
rhythms such as ventricular tachycardia and ventricular fibrillation are uncommon. Still you
should suspect myocardial contusion in all cases of severe blunt injury to the chest. 789
Patients with abdominal injuries generally have one principle complaint: pain. A very common
sign of significant abdominal injury is tachycardia as the heart increases its pumping action to
compensate for blood loss, an early indication of compensated blood loss and shock. In some
cases, the abdomen may become distended from the accumulation of blood and fluids. Blunt
injuries include bruises or other visible marks. 800
Seat belts have prevented many thousands of injuries and saved many lives, including those
people who otherwise would have been ejected from a smashed car. The airbag, which is
standard in today’s vehicles, represents a great advance in automotive safety. In head on
collisions, it can be a genuine lifesaver. However, because frontal airbags don’t provide
protection in a side impact or rollover, they must be used in combination with safety belts. 801
If the chief complaint involves sexual or physical assault, the patient may be hesitant to discuss
what happened. Bleeding from the reproductive or genitourinary organs is common after sexual
assault, but again, patients may be hesitant to discuss this or to be examined to determine
severity. Movement of the body or the abdominal organs irritates the inflamed peritoneum,
causing additional pain. To minimize this pain, patients will lie still, usually with the knees drawn
up, and their breathing will be rapid and shallow. For the same reason, they will contract their
abdominal muscles, a sign called guarding. 804-805
Injuries of the kidney are not unusual and rarely occur in isolation. This is because the kidneys lie
in such a well protected area of the body. Suspect kidney damage if the patient has a history or
physical evidence of any of the following:1) an abrasion, laceration, or contusion in the flank 2) a
penetrating wound in the region of the lower rib cage (flank) or the upper abdomen 3) fractures
on either side of the lower rib cage or the lower thoracic or upper lumbar vertebrae 4) a
hematoma in the flank region. 809
General rules apply to the treatment of injuries involving the external male genitalia: 1) make
the patient as comfortable as possible 2) use sterile, moist compresses to cover area that have
been stripped of skin 3) apply direct pressure with dry, sterile gauze dressings to control
bleeding 4) never move or manipulate impaled instruments or foreign bodies in the urethra 5) if
possible, always identify and bring the avulsed parts to the hospital with the patient.
Remember, these are rarely life threatening injuries and should not be given priority over other,
more sever wounds. 810









In the last trimester of pregnancy, the uterus is large and may obstruct the vena cava,
decreasing the amount of blood returning to the heart if the patient is placed in a supine
position (supine hypotensive syndrome). As a result blood pressure may decrease. The patient
should be carefully placed on her left side so that the uterus will not lie on the vena cava. If the
patient is secured to a backboard, tilt the board to the left. 811
Skeletal muscle tissue is directly attached to the bone by tough, ropelike fibrous structures
known as tendons, which are extensions of the fascia that covers all skeletal muscle. 821
Joints are formed wherever two bones come into contact. Joints are held together by ligaments.
Fracture is a broken bone. A dislocation is a disruption of a joint in which the bone ends are no
longer in contact. 822
A fracture is also described by whether the bone is moved from its normal position. A
nondisplaced fracture is a simple crack of the bone that me be difficult to distinguish from a
sprain or simple contusion. A displaced fracture produces actual deformity, or distortion, of the
limb, by shortening, rotating, or angulating it. 825
Minor musculoskeletal injuries consist of minor sprains or fractures or dislocations of digits.
Moderate injuries include: open fractures of digits, nondisplaced long bone fractures,
nondisplaced, pelvic fractures, major sprains of a major joint. Serious injuries include: displaced
long bone fractures, multiple hand and foot fractures, open long bone fractures, displaced pelvic
fractures. Dislocation of major joints, multiple digit amputations, laceration of major nerves or
blood vessels. Sever life threatening injuries: multiple closed fractures, limb amputations,
fractures of both long bones of the leg. Critical injuries: multiple open fractures of the limbs,
suspected pelvic fractures with hemodynamic instability. 829
By preventing movement of fracture fragments, bone ends, a dislocated joint, or damaged soft
tissues, splinting prevents from further injury to muscles, spinal cord, peripheral nerves, and
blood vessels from broken bones, Laceration of the skin by broken bones, restriction of distal
blood flow resulting from pressure of the bone ends on blood vessels, excessive bleeding of the
tissues at the injury site, increased pain from movement of bone ends, and paralysis of
extremities resulting from a damaged spine. 836
Application of in line traction is the act of pulling on a body structure in the direction of its
normal alignment. 838
The glenohumeral joint (shoulder joint) is where the head of the humorous, the supporting bone
of the upper arm, meets the lenoid fossa of the scapula. Shoulder dislocations are very painful.
The shoulder joint will usually be locked, and the shoulder will appear squared off or flattened.
Some patients may also report some numbness in the hand because of either nervous or
circulatory compromise. Be sure to check pulse, motor, and sensory functions. 850
Fracture of the pelvis often results from direct compression in the form of a heavy blow that
literally crushes the pelvis. Stable patients can be secured to a long backboard or a scoop
stretcher to stabilize isolated fractures of the pelvis. Place a pneumatic antishock garment
(PASG) on the backboard or stretcher before transferring the patient to the backboard.
Remember, the PASG is only a temporary stabilization device and must be removed within 24
hours. 856-857






The CNS is further protected by the meninges, three distinct layers of tissue that suspend the
brain and the spinal cord within the skull and the spinal cord. The outer layer, the dura mater, is
a tough, fibrous layer that closely resembles leather. This layer forms a sac to contain the CNS,
with small openings through which the peripheral nerves exit. 872
The part of the nervous system that regulates or controls our voluntary activities, is called the
somatic nervous system. The brain interprets the sensory information that it receives from the
peripheral and cranial nerves and responds by sending signals to the voluntary muscles.
Autonomic nervous system regulates the body functions that occur without conscious effort.
The ANS controls the functions of many body’s vital organs, over which the brain has no
voluntary control. 875
Laceration or rupture of a blood vessel inside the brain or in the meninges that cover the brain
will produce intracranial bleeding (hematoma) in one of three areas: 1) beneath the dura but
outside the brain-subdural hematoma 2) within the substance of the brain tissue itselfintracranial hemorrhage 3) outside the dura and under the skull- epidural hematoma. 879
Effects of cerebral edema and increased intracranial pressure may be increased blood pressure,
decreased pulse rate, and irregular respirations. This triad of signs is called Cushing’s reflex. 880
In some instances, you will have to apply firm compression for several minutes to control
bleeding. If you suspect a skull fracture, do not apply excessive pressure to the open wound.
Otherwise, you may increase, intracranial pressure or push bone fragments into the brain.
A patient who is involved in full contact sports may be wearing bulky pads to protect various
body regions, such as shoulder pads. Leaving a helmet in place whenever possible is preferred
so the body will maintain an inline neutral position. If helmet must be removed, be sure to
provide padding to compensate for shoulder pads and maintain in line position of the body.
Motorcycle helmets often have a shield covering the face. This too, can be unbuckled to allow
access to the airway. If the shield cannot be removed, then the helmet must be removed.
Remember, you do not need to remove a helmet if you can access the patient’s airway, the
head is snug inside the helmet, and the helmet can be secured to an immobilization device. 900904