Emergency Medical Responder

B. Kidd 2007 revised 2009 revised 2010 1
EMERGENCY MEDICAL
RESPONDER
CANADIAN RED CROSS

B. Kidd 2007 revised 2009 revised 20102

PURPOSE OF THE COURSE

EMERGENCY MEDICAL
RESPONDER
The purpose of the Canadian Red Cross
Emergency Medical Responder course is to
provide the responder with the knowledge
and skills necessary in an emergency to help
sustain life, reduce pain, and minimize the
consequences of injury or sudden illness until
the next level of care takes over.

EMERGENCY MEDICAL
RESPONDER CONT
This course is designed to meet the
National Competency Profiles for the
practitioner level of emergency medical
responder (EMR) established by the
Paramedic Association of Canada
(PAC).

EMERGENCY MEDICAL
RESPONDER CONT
In March 2000, National Occupational
Competency Profiles (NOCP) were
established for four levels of pre-
hospital care by PAC. On June 29,
2001, the updated NOCPs were
approved by the directors of PAC.

THE FOUR LEVELS OF CARE
 EMERGENCY MEDICAL RESPONDER
 PRIMARY CARE PARAMEDIC
 ADVANCED CARE PARAMEDIC
 CRITICAL CARE PARAMEDIC

COURSE OBJECTIVES
AT THE CONCLUSION OF THE COURSE,
PARTICIPANTS SHOULD BE ABLE TO:
 Describe how to work as a professional
 Identify ways to participate in EMR continuing
education
 Describe the medical-legal aspects of the
EMR profession
 Recognize and apply provincial and federal
legislation relevant to the EMR

COURSE OBJECTIVES CONT
 Demonstrate how to function effectively in a
team environment
 Demonstrate effective decision-making
abilities at the EMR level
 Demonstrate effective oral communication
skills
 Demonstrate effective written communication
skills

 Explain how to use non-verbal
communication skills
 Demonstrate effective interpersonal skills
 Identify strategies for maintaining good
physical and mental health
 Demonstrating safe lifting and moving
techniques
 Demonstrate the ability to triage

 Demonstrate how to create and maintain a
safe working environment
 Demonstrate how to obtain a casualty/patient
history
 Demonstrate how to complete a physical
assessment and interpret finding(s)
 Demonstrate how to assess vital signs
 Demonstrate how to maintain an airway

COURSE OBJECTINES CONT
 Explain how to prepare oxygen delivery
devices
 Demonstrate the delivery of oxygen and
administer manual ventilation
 Demonstrate how to provide CPR
 Demonstrate basic care for soft tissue injuries
 Demonstrate immobilization techniques for
fractures

COURSE OBJECTIVES cont
 Demonstrate how to integrate differential
diagnosis, decision-making skills, and
psychomotor skills in providing care to
casualties/patients
 Explain how to care for casualties/patients of
special populations
 Demonstrate how to conduct ongoing
assessment and interpret results

 Describe how to prepare an ambulance for
service
 Describe how to operate an ambulance or
similar emergency vehicle
 Describe how to prepare a casualty/patient
for air transport
 Describe how to transfer a casualty/patient to
an air ambulance

COURSE CONTENT
 The content of the course is based on the
Paramedic Association of Canada: National
Occupational Competency Profiles at the
Emergency Medical Responder level.
 Prerequisites: Standard First Aid with CPR-
C

COURSE LENGTH
 The Emergency Medical Responder course
is designed to be taught in 80 hours. Less
time may be needed if participants are AED
certified.

PARTICIPANT MATERIALS
 The 2008 Emergency Care Manual ISBN:
978-1-58480-404-8
 For written evaluations, each participant will
receive at the appropriate time a mid-course
exam, final exam and answer sheets

UNIT 2
THE EMERGENCY MEDICAL RESPONDER
AND THE EMERGENCY SCENE

EMR /LEGAL AND ETHICAL ISSUES
Primary points:
 EMS systems throughout Canada vary
 EMS systems can be provincial services or
city services or privately owned services
 Paramedic Association of Canada (PAC) in
2001 developed competencies and
curriculum to address standardization across
the country

Primary points:
 The emergency medical services (EMS) is
network of community resources, including
personnel, equipment, and supplies, that
provide care to people who suffer a sudden
illness or injury.
 The EMS system was developed as a
multitiered, national system of emergency
health care

CONT
 EMS systems throughout Canada vary
 EMS systems can be provincial services or
city services or privately owned services
 Paramedic Association of Canada (PAC) in
2001 developed competencies and
curriculum to address standardization across
the country

EMR LEAGAL AND ETHICAL
ISSUES CONT
An effective EMS system ideally has the
following components:
 Regulation and Policy
 Resource Management
 Human Resources, Training, and Continuing
Education
 Communications
 Transportation

EMR LEGAL/ETHICAL ISSUES CONT
CONT:
 Public Information and Education
 Medical Control
 Trauma Systems
 Evaluation
 Facilities

CONT
 The EMS systems functions as a series of
linked events that bring medical care to
people as quickly as possible
 These links begin the actions of the lay
rescuer, who recognizes a problem and
activates the system by calling EMS/9-1-1.
The dispatcher determines what help is
needed and sends the appropriate personnel

CONT
 The first person to arrive on the scene, who is
trained to provide a higher level of care than the
average citizen, is often referred to as a first
responder
 Traditionally, first responders have been law
enforcement and fire fighter personnel

CONT
 The responder often provides a critical
transition between the initial actions of the
person who calls for help and the care
provided by more highly trained personnel,
such as paramedics or hospital personnel

CONT
 The higher the person’s level of training, the
more advanced the skills the person can
perform
 Pre-hospital care ends when the ill or injured
person arrives at the hospital emergency
department and the emergency staff takes
over. At this point, the hospital staff use
whatever resources are needed to care for
the patient

CONT
 The responder has a professional duty to
respond to an emergency and provide care to
the sick and injured at the scene. This
implies that the responder is properly trained
and has ready access to appropriate
equipment and supplies

CONT
Emergency Medical Responders have six
primary responsibilities:
1. Ensuring safety for themselves and
bystanders
2. Gaining access to the ill or injured person(s)
3. Identifying any immediate life threatening
conditions

CONT
4. Obtaining more advanced medical care
when needed
5. Providing care for the ill or injured patient(s)
6. Assisting more advanced medical personnel
when required

Emergency Medical Responders also have
several secondary responsibilities including
but not limited to:
 Summoning specialized assistance if
required
 Controlling and directing bystanders
 Recording your actions (PCR)
 Reassuring or comforting the ill, injured and
family

CONT
Legal Considerations
Law suits against those who give emergency
medical care are extremely rare. By
understanding and abiding by some basic
legal principles, Emergency Medical
Responders may avoid legal action in the
future.

CONT
 Either as a result of case law, statute, or job
description, an EMR could have a duty to act
at any time. EMRs are expected to act
appropriately in the event of an emergency.
 Acting appropriately means performing to a
certain standard of care expected of a person
with your training and working in your
position.

CONT
 If an EMR fails to act or live up to the
established standard of care, and this failure
causes damage to another person, the EMR
can be sued
 To help avoid lawsuits, the EMRs are to do
only what they are trained and authorized to
do. EMRs must stay within their standard of
care.

CONT
Negligence
Negligence is the failure to follow a
reasonable standard of care, resulting in the
damage (injury or death)
Four components must be present for a
lawsuit charging negligence to be successful:

CONT
1. Duty of care
2. Breach of duty
3. Causation of damage due to what
someone did or failed to do
4. Damage caused

EMR LEGAL/ETHICAL ISSUES
CONT
SCOPE OF PRACTICE
Is defined as the range of duties and skills an
EMR is allowed and expected to perform
when necessary
An EMR is governed and regulated by legal,
ethical, and medical standards
These standards establish the scope of
practice for the EMR

CONT
Paramedic Association of Canada has
developed four levels
1. Emergency Medical Responder
2. Primary Care Paramedic
3. Advanced Care Paramedic
4. Critical Care Paramedic

CONT
Profiles for each level providing a set of
competencies have been created
Individual organizations and educational
institutes may exceed training based on their
operational needs
Having national standards sets the stage for
consistency across the country

CONT
MEDICAL CONTROL
Is the process by which a physician directs the care
given by prehospital care professionals to ill or
injured patients
The physician oversees training and development of
protocols
Protocols are standardizes procedures to be
followed when providing care to patients of illness or
injury

CONT
CONT
The Medical Director directs the care given
through standing orders
Standing orders allow certain types of care or
treatment without speaking to the physician
This type of medical control is called indirect
or off-line medical control

CONT
CONT
Procedures that are not covered by standing
orders require the EMR to speak directly with
a physician
This can be done through cell phone, radio or
telephone
This type of medical control is called direct
on-line medical control

CONT
CONT
Be aware of the
variations that may
differ from province to
province

CONT
ETHICAL RESPONSIBILITIES
EMR’s have an ethical responsibility to carry
out their duties and responsibilities in a
professional manner
They must show compassion when dealing
with a patient’s physical or mental needs and
communicate sensitively and willingly at all
times

CONT
CONT
As a professional, you should strive to
develop your skills to surpass the standards
established in your province or region
And practice and master the skills presented
in this course

CONT
CONT
Continue with further training, such as
workshops, continuing medical education,
conferences, and supplemental or advanced
educational programs
Be honest in reporting your actions and
events that occurred at the scene or while
responding to an emergency

CONT
CONT
Make it a personal goal to be a person whom
others trust and can depend on to give
accurate reports and provide effective care
Conduct a regular self-review of performance
with respect to patient care, communication
with the patient, partners. and agency
members, and documentation in order to
improve personally

EMR LEGAL/ETHICAL ISSUES CONT
CONT
Remember that proper documentation can
help provide an accurate and legal document
should legal action occur. Keep careful
written records and write your record as soon
as possible after the emergency while the
facts are fresh.
Refer to YEMS DOCUMENTATION
STANDARDS, May 2006

CONT
COMPETENCE
Refers to the patient’s ability to understand
the questions of the EMR and to understand
the implications of decisions made
EMRs need to obtain permission from
competent patients before beginning any
care

CONT
In certain cases, such as intoxication, drug
abuse, or an altered level of consciousness,
or when the patient has a serious injury that
could affect his judgment, or is mentally ill or
challenged, the patient is not considered
competent to make rational decisions

CONT
In such cases where the patient still refuses
treatment, a law enforcement officer may be
required to obtain the necessary legal
authority for care to be provided by the EMR

CONT
CONSENT
Unless injury or illness is life threatening, a
parent or guardian who is present must give
consent for minors
It is important to explain (to the parent or
guardian) the consequences if care is not
provided to the minor
Use terms that the parent or guardian will
understand

CONT
It may be necessary to request the presence
of a law enforcement officer in order to treat a
minor
Do not argue with the parent or guardian as
this may create an unsafe scene
Some adults may be under legal guardian
care. In this case, you will need the
guardian’s consent to provide care

CONT
Refer to Policy and Procedure on “Care and
Consent”
Cultural or religious beliefs may prevent a
person from receiving care. In these
situations, respect the person’s wishes;
however, if you feel the patient is in danger if
left untreated, then you may have to request
law enforcement for assistance

CONT
ADVANCED DIRECTIVES AND DO NOT
RESUSCITATE ORDERS
Advanced directives and Do Not Resuscitate
(DNR) orders are written instructions from
patients and signed by his/her physician
They protect a person’s rights to refuse
resuscitation efforts

CONT
These orders are usually written for people
who have terminal illnesses or extreme
advanced age
These orders may differ from province or
region
Some provinces have instituted the new NO
CPR bracelet

CONT
The person wears the bracelet, which is
applied by the family doctor and cannot be
removed. The bracelet has an ID number
along with a 1-800 number that can be
accessed to confirm identity of the patient
Advanced directives are often found in
extended care homes. The DNR stated for
the individual patient, may have different
degrees of intervention

CONT
An EMR has a scope of practice and an
important role within the EMS system
There are legal and ethical implications that
guide the actions of EMRs

CONT
Summary
EMRs need certain characteristics to do their
job well
EMRs must be aware of certain
responsibilities
There are legal and ethical implications that
guide the actions of EMRs

CONT
EMRs have a scope of practice and an
important role within the EMS system.

HEALTH AND SAFETY FOR THE
EMR
STRESS MANAGEMENT
Stress management steps include
recognizing the signs and symptoms of
stress, seeking professional help if
necessary, balancing work, recreation, family,
and health
The EMR’s family may react with lack of
understanding, fear, stress, and frustration to
the EMR’s responsibilities

EMR CONT
CONT
A critical incident is a specific situation that
causes a responder to have an unusually
strong emotional reaction that interferes with
his or her ability to function, either
immediately or later on. This reaction can
produce stress called Critical Incident Stress
(CIS)

EMR CONT
CONT
Critical Incident Stress can build up over a
period of days, weeks, months, or even years
Some warning signs of stress can be;
irritability toward co-workers, and friends,
inability to concentrate, difficulty sleeping,
increased sleeping or nightmares, anxiety,
indecisiveness, guilt, increased use of alcohol
and others

EMR CONT
COPING WITH CRITICAL INCIDENT STRESS
The emotional impact of the situation may be more
than you can handle without help
Critical Incident Stress Management (CISM) is the
process of educating, preventing, or mitigating the
effects from exposure to an abnormal or highly
unusual event
Critical Incident Stress Debriefing (CSID), one
component of a CISM program, is a type of meeting
held within 24 to 72 hours of an incident

EMR CONT
CONT
During CSID, participants are encouraged to have
an open discussion of feelings, fears, and reactions
triggered by the incident
A defusing is less formal and less structured
Defusing is sometimes done at the scene or shortly
thereafter
An advantage of defusing is that it allows for
immediate initial venting

EMR CONT
HAZARDOUS MATERIALS
As an EMR, you may encounter a number of
special response situations
When approaching any scene, the EMR
should be aware of dangers involving toxic
chemical.
When toxic substances are involved, EMR’s
need specialized training to deal with the
situation

EMR CONT
CONT
When dealing with a hazardous materials
(HAZMAT) situation, such as a chemical spill,
the EMR will work within a structured system
that provides guidance in managing such a
scene

EMR CONT
COMMON PROBLEMS
A hazardous material is any chemical substance or
material that can pose a threat to the health, safety,
property of an individual
Your local EMS office should have information on
when and where programs are available (2004
EMERGENCY RESPONSE GUIDELINES manual
found in your ambulance is one piece of program
literature available)

EMR CONT
CONT
Whenever there is a chemical leak or spill,
the potential of a HAZMAT incident exists.

EMR CONT
SAFETY IS THE PRIME CONCERN
Safety of the EMR crew, the patient(s), and
bystanders should be of primary concern
While en route to potential HAZMAT scene,
obtain as much information as possible from
the dispatcher

EMR CONT
APPROACHING THE SCENE
Never enter a scene that is not safe. In a
HAZMAT incident, you will need the expertise
of a highly trained HAZMAT team to make
the scene safe

EMR CONT
CONT
When approaching the scene, use extreme
caution. If you suspect that you are involved
in a HAZMAT situation, remember these
general procedures:
 Stay upwind and uphill from the incident
 Stay well away from the area
 Keep people away from the danger zone

EMR CONT
 CONT
 Look for clues that indicate hazardous
materials
 Never enter a HAZMAT area unless you are
trained as a HAZMAT Technician
 The EMR should know how to activate the
local HAZMAT response team

EMR CONT
 CONT

EMR CONT
PRIMARY POINTS
 There are risks EMR’s
face on a regular basis
and it is important to
maintain the health and
safety of emergency
responders

EMR EQUIPMENT
Emergency Medical Responders should be
familiar with equipment used in local EMS
systems. Typical equipment used in the
EMS systems include:
 Regulation and Policy
 Stretchers and cots
 Stair chairs
 Portable stretchers

EMR EQUIPMENT CONT
CONT
 Long and short backboards
 Trauma kits
 Airway kits
• Equipment must be maintained in safe,
working condition
• EMR’s who attempt to provide care with
malfunctioning equipment may harm the
patient as well as themselves

EMR EQUIPMENT CONT
CONT

TELECOMMUNICATION DEVICES
The ability to effectively communicate clearly
and efficiently is necessary in every
component of the EMS system
Emergency Medical responders should be
familiar with telecommunications equipment
used in the local EMS systems.
Telecommunications equipment must be
maintained in working condition

TELECOMMUNICATION DEVICES
CONT
Operators of telecommunications equipment
must have the knowledge of local laws
governing the appropriate use and operation
of equipment often used by emergency
responders such as mobile and portable
radios

UNIT 3
PREVENTING DISEASE TRANSMISSION

Preventing Disease Transmission cont
Knowing the methods in which a disease is
transmitted is important for implementing
proper infection control measures and large
scale prevention campaigns. Each disease
has transmission characteristics based on the
nature of the microorganism that causes it

Transmission by Direct Contact
Direct contact transmission requires physical
contact between an infected person and a
susceptible person, and the physical transfer
of microorganisms. Direct contact includes
touching an infected individual, kissing,
sexual contact, contact with oral secretions,
or contact with body lesions.

This type of transmission requires close
contact with an infected individual, and will
usually occur between members of the same
household or close friends and family.

Diseases spread exclusively by direct contact
are unable to survive for significant periods of
time away from a host. Sexually transmitted
diseases are almost always spread through
direct contact, as they are extremely sensitive
to drying.

Transmission by Indirect Contact
Indirect contact transmission refers to
situations where a susceptible person is
infected from contact with a contaminated
surface.

Some organisms (such as Norwalk Virus)
are capable of surviving on surfaces for an
extended period of time. To reduce
transmission by indirect contact, frequent
touch surfaces should be properly
disinfected.

Frequent touch surfaces (fomites) include:
 Door knobs, door handles, handrails
 Tables, beds, chairs
 Washroom surfaces
 Cups, dishes, cutlery, trays
 Medical instruments
 Computer keyboards, mice, electronic devices with
buttons
 Pens, pencils, phones, office supplies
 Children's toys

Transmission by Droplet Contact
Some diseases can be transferred by
infected droplets contacting surfaces of the
eye, nose, or mouth. This is referred to as
droplet contact transmission. Droplets
containing microorganisms can be generated
when an infected person coughs, sneezes, or
talks.

Droplets can also be generated during certain
medical procedures, such as bronchoscopy.
Droplets are too large to be airborne for long
periods of time, and quickly settle out of air.

Droplet transmission can be reduced with the
use of personal protective barriers, such as
face masks and goggles. Measles and SARS
are examples of diseases capable of droplet
contact transmission.

Airborne Transmission
Airborne transmission refers to situations
where droplet nuclei (residue from
evaporated droplets) or dust particles
containing microorganisms can remain
suspended in air for long periods of time.
These organisms must be capable of
surviving for long periods of time outside the
body and must be resistant to drying.

Airborne transmission allows organisms to
enter the upper and lower respiratory tracts.
Fortunately, only a limited number of
diseases are capable of airborne
transmission.

Fecal-oral Transmission
Fecal-oral transmission is usually associated
with organisms that infect the digestive
system. Microorganisms enter the body
through ingestion of contaminated food and
water.

Inside the digestive system (usually within the
intestines) these microorganisms multiply
and are shed from the body in feces.

If proper hygienic and sanitation practices are
not in place, the microorganisms in the feces
may contaminate the water supply through
inadequate sewage treatment and water
filtration. Fish and shellfish that swim in
contaminated water may be used as food
sources.

If the infected individual is a waiter, cook, or
food handler, then inadequate hand washing
may result in food being contaminated with
microorganisms.

Diseases capable of airborne transmission
include:
 Influenza
 Whooping cough
 Pneumonia
 Tuberculosis
 Polio

Vector-borne Transmission
Vectors are animals that are capable of
transmitting diseases. Examples of vectors are
flies, mites, fleas, ticks, rats, and dogs. The most
common vector for disease is the mosquito.
Mosquitoes transfer disease through the saliva
which comes in contact with their hosts when they
are withdrawing blood. Mosquitoes are vectors for
malaria, West Nile Virus, dengue fever, and
yellow fever.

Vectors add an extra dimension to disease
transmission. Since vectors are mobile, they
increase the transmission range of a disease.
Changes in vector behaviour will affect the
transmission pattern of a disease.

It is important to study the behavior of the
vector as well as the disease-causing
microorganism in order to establish a proper
method of disease prevention.

In the case of malaria, insecticides were
sprayed and breeding grounds for
mosquitoes were eliminated in an attempt to
control the spread of malaria.

HOW DISEASES SPREAD
For a disease to spread, all four of the following
conditions must be met:
 A pathogen is present
 There is enough pathogen present
 The patient is susceptible to the pathogen
 The pathogen passes through the correct entry site

Biting is not the only way vectors can transmit
diseases. Diseases may be spread through
the feces of a vector. Microorganisms could
also be located on the outside surface of a
vector (such as a fly) and spread through
physical contact with food, a common touch
surface, or a susceptible individual.

Pulmonary tuberculosis (TB) is a
contagious bacterial infection caused by
Mycobacterium tuberculosis (M.
tuberculosis). The lungs are primarily
involved, but the infection can spread to other
organs

Hepatitis C is a virus-caused liver
inflammation which may cause jaundice,
fever and cirrhosis. Persons who are most at
risk for contracting and spreading hepatitis C
are those who share needles for injecting
drugs and health care workers or emergency
workers who may be exposed to
contaminated blood.

Hepatitis A is an inflammation (irritation and
swelling) of the liver caused by the hepatitis A
virus

Most people who become infected with
hepatitis B get rid of the virus within 6
months. A short infection is known as an
"acute" case of hepatitis B.

Approximately 10% of people infected with
the hepatitis B virus develop a chronic, life-
long infection. People with chronic infection
may have symptoms, but many of these
patients never develop symptoms. These
patients are sometimes referred to as
"carriers" and can spread the disease to
others.

Having chronic hepatitis B increases your
chance of permanent liver damage, including
cirrhosis (scarring of the liver) and liver
cancer.

HIV infection is a viral infection caused by the
human immunodeficiency virus (HIV) that
gradually destroys the immune system,
resulting in infections that are hard for the
body to fight.

Causes, incidence, and risk factors
Acute HIV infection may be associated with
symptoms resembling mononucleosis or the
flu within 2 to 4 weeks of exposure. HIV
seroconversion (converting from HIV
negative to HIV positive) usually occurs
within 3 months of exposure.

People who become infected with HIV may
have no symptoms for up to 10 years, but
they can still transmit the infection to others.
Meanwhile, their immune system gradually
weakens until they are diagnosed with AIDS.

Acute HIV infection progresses over time to
asymptomatic HIV infection and then to early
symptomatic HIV infection and later, to AIDS
(advanced HIV infection).

HIV Infection (acute HIV infection) -->early
asymptomatic HIV infection -->early symptomatic
HIV infection -->AIDS.
Most individuals infected with HIV will progress to
AIDS if not treated. However, there is a tiny subset
of patients who develop AIDS very slowly, or never
at all. These patients are called non-progressors

Universal Precautions
Universal precautions are infection control
guidelines designed to protect workers from
exposure to diseases spread by blood and
certain body fluids.

In the workplace, universal precautions
should be followed when workers are
exposed to blood and certain other body
fluids, including:
 semen
 vaginal secretions
 synovial fluid
 cerebrospinal fluid

 pleural fluid
 peritoneal fluid
 pericardial fluid
 amniotic fluid

Universal precautions do not apply to:
 Feces
 nasal secretions
 Sputum
 sweat
 tears
 urine

 Vomitus
 saliva (except in the dental setting, where
saliva is likely to be contaminated with blood)
Universal precautions should be applied to all
body fluids when it is difficult to identify the
specific body fluid or when body fluids are
visibly contaminated with blood.

How can workers prevent exposure to
blood and body fluids?
Barriers are used for protection against
occupational exposure to blood and certain
body fluids.
These barriers consist of:
 Personal protective equipment (PPE)
 Engineering controls
 Work practice controls

Personal Protective Equipment (PPE) –
PPE includes gloves, gowns, shoe covers,
goggles, glasses with side shields, masks,
and resuscitation bags.

The purpose of PPE is to prevent blood and
body fluids from reaching the workers' skin,
mucous membranes, or personal clothing. It
must create an effective barrier between the
exposed worker and any blood or other body
fluids.

Work Practice Controls
Refers to practical techniques that reduce the
likelihood of exposure by changing the way a
task is performed.

Examples of activities requiring specific
attention to work practice controls include:
hand washing, handling of used needles and
other sharps and contaminated reusable
sharps, collecting and transporting fluids and
tissues according to approved safe practices.

Is universal protection required by law?
Occupational Health and Safety is regulated
in Canada in each of the fourteen
jurisdictions (provincial, territorial and
federal). Some jurisdictions may have also
developed specific modifications of infection
control guidelines.

Engineering Controls
Engineering controls refer to methods of
isolating or removing hazards from the
workplace. Examples of engineering controls
include: sharps disposal containers, laser
scalpels, and ventilation including the use of
ventilated biological cabinets (laboratory
fume hoods).

EXPOSURE CONTROL PLAN
COMPONENTS
Determination of Exposure:
 Determines who is at risk for ongoing contact with
blood and other bodily fluids
 Creates a list of tasks that pose a risk for contact
with blood or other bodily fluids
 Includes personal protective equipment (PPE)
required

COMPONENTS:
Education and Training:
 Explains why a qualified individual is required to
answer questions about communicable diseases
and infection control, rather than relying on
packaged training material
 Includes the availability of an instructor able to
train ambulance personnel regarding blood
borne and airborne pathogens

COMPONENTS:
Education and Training:
 Ensures that the instructor provides appropriate
education, which is the best means for correcting
many myths surrounding these issues.

COMPONENTS:
Hepatitis B Vaccine Program:
 Spells out the vaccine offered, its safety and
efficacy, record keeping, and tracking
 Addresses the need for post vaccine antibody titers
to identify individuals who do not respond to the
initial three-dose vaccination series

COMPONENTS:
Personal Protective Equipment (PPE):
 Lists the PPE offered and why it was selected
 Lists how much equipment is available and where to
obtain additional PPE
 States when each type of PPE is to be used for
each risk procedure

COMPONENTS:
Cleaning and Disinfection Practices:
 Describes how to care for and maintain vehicles
and equipment
 Identifies where and when cleaning should be
performed, how it is to be done, what PPE is to be
used, and what cleaning solution is to be used

COMPONENTS:
Cleaning and Disinfection Practices:
 Addresses medical waste collection, storage
and disposal

COMPONENTS:
Tuberculin Skin Testing/Fit Testing:
 Addresses how often employees should undergo
skin testing
 Address how often fit testing should be done to
determine the proper mask to protect the attendant
from tuberculosis
 Addresses all issues with the HEPA respirator
masks

COMPONENTS:
Compliance Monitoring:
 Addresses how the service or department
evaluates employee compliance with each
aspect of the plan
 Ensures that employees understand what
they are to do and why it is important

COMPONENTS:
Compliance Monitoring:
 States that noncompliance should be
documented
 Indicates what disciplinary action should be
taken in the face of continued noncompliance

COMPONENTS:
Record Keeping:
 Outlines all records that will be kept, how
confidentiality will be maintained, and how records
can be assessed and by whom

UNIT 4
HUMAN BODY SYSTEMS

HUMAN BODY SYSTEMS
Anatomical position

HUMAN BODY SYSTEMS CONT

Side View

The human skeleton consists of 206 bones.
We are actually born with more bones (about
300), but many fuse together as a child grows
up. These bones support your body and allow
you to move. Bones contain a lot of calcium
(an element found in milk, broccoli, and other
foods). Bones manufacture blood cells and
store important minerals.

The longest bone in our bodies is the femur
(thigh bone). The smallest bone is the stirrup
bone inside the ear. Each hand has 26
bones in it. Your nose and ears are not made
of bone; they are made of cartilage, a flexible
substance that is not as hard as bone.

Joints
Bones are connected to other bones at joints.
There are many different types of joints,
including: fixed joints (such as in the skull,
which consists of many bones), hinged joints
(such as in the fingers and toes), and ball-
and-socket joints (such as the shoulders and
hips).

Differences in males and females: Males
and females have slightly different skeletons,
including a different elbow angle. Males have
slightly thicker and longer legs and arms;
females have a wider pelvis and a larger
space within the pelvis, through which babies
travel when they are born.

Body Cavities

Body Cavities and Membranes
 Dorsal body cavity
 Cavity subdivided
into the cranial
cavity and the
vertebral cavity.
 Cranial cavity
houses the brain.
 Vertebral cavity
runs through the
vertebral column
and encloses the
spinal cord

The cavities, or spaces, of the body contain
the internal organs, or viscera.

Thoracic Cavity
The thoracic, or chest cavity contains the
heart, lungs, trachea, esophagus, large blood
vessels, and nerves. The thoracic cavity is
bound laterally by the ribs and the diaphragm

Abdominal and pelvic cavity:
The lower part of the ventral
(abdominopelvic) cavity can be further
divided into two portions: abdominal portion
and pelvic portion. The abdominal cavity
contains most of the gastrointestinal tract as
well as the kidneys and adrenal glands.

BODY SYSTEMS
The Circulatory System
The circulatory system is the body's transport
system. It is made up of a group of organs
that transport blood throughout the body. The
heart pumps the blood and the vascular
system transport it. Oxygen-rich blood leaves
the left side of the heart and enters the
biggest artery, called the aorta.

The aorta branches into smaller arteries,
which then branch into even smaller vessels
that travel all over the body. When blood
enters the smallest blood vessels, which are
called capillaries, and are found in body
tissue, it gives nutrients and oxygen to the
cells and takes in carbon dioxide, water, and
waste..

The blood, which no longer contains oxygen
and nutrients, then goes back to the heart
through veins. Veins carry waste products
away from cells and bring blood back to the
heart, which pumps it to the lungs to pick up
oxygen and eliminate waste carbon dioxide

Respiratory System
The respiratory system brings air into the
body and removes carbon dioxide. It includes
the nose, trachea, and lungs. When you
breathe in, air enters your nose or mouth and
goes down a long tube called the trachea.

Upper airway

Lung

The trachea branches into two bronchial
tubes, or primary bronchi, which go to the
lungs. The primary bronchi branch off into
even smaller bronchial tubes, or bronchioles.
The bronchioles end in the alveoli, or air
sacs.

Oxygen follows this path and passes through
the walls of the air sacs and blood vessels
and enters the blood stream. At the same
time, carbon dioxide passes into the lungs
and is exhaled.

Digestive System
The digestive system is made up of organs
that break down food into protein, vitamins,
minerals, carbohydrates, and fats, which the
body needs for energy, growth, and repair.

After food is chewed and swallowed, it goes
down the esophagus and enters the stomach,
where it is further broken down by powerful
stomach acids. From the stomach the food
travels into the small intestine. This is where
your food is broken down into nutrients that
can enter the bloodstream through tiny hair-
like projections.

The excess food that the body doesn't need
or can't digest is turned into waste and is
eliminated from the body.

Endocrine System
The endocrine system is made up of a group
of glands that produce the body's long-
distance messengers, or hormones.
Hormones are chemicals that control body
functions, such as metabolism, growth, and
sexual development.

Endocrine
glands

The glands, which include the pituitary gland,
thyroid gland, parathyroid glands, adrenal
glands, thymus gland, pineal body, pancreas,
ovaries, and testes, release hormones
directly into the bloodstream, which
transports the hormones to organs and
tissues throughout the body.

Skeletal System
The skeletal system is made up of bones,
ligaments and tendons. It shapes the body
and protects organs. The skeletal system
works with the muscular system to help the
body move. Marrow, which is soft, fatty tissue
that produces red blood cells, many white
blood cells, and other immune system cells,
is found inside bones.

Urinary System
The urinary system eliminates waste from the
body, in the form of urine. The kidneys
remove waste from the blood. The waste
combines with water to form urine. From the
kidneys, urine travels down two thin tubes
called ureters to the bladder. When the
bladder is full, urine is discharged through the
urethra.

Reproductive System
The reproductive system allows humans to
produce children. Sperm from the male
fertilizes the female's egg, or ovum, in the
fallopian tube. The fertilized egg travels from
the fallopian tube to the uterus, where the
fetus develops over a period of nine months.

Nervous System
The nervous system is made up of the brain,
the spinal cord, and nerves. One of the most
important systems in your body, the nervous
system is your body's control system. It
sends, receives, and processes nerve
impulses throughout the body.

These nerve impulses tell your muscles and
organs what to do and how to respond to the
environment. There are three parts of your
nervous system that work together: the
central nervous system, the peripheral
nervous system, and the autonomic nervous
system

The central nervous system consists of the
brain and spinal cord. It sends out nerve
impulses and analyzes information from the
sense organs, which tell your brain about
things you see, hear, smell, taste and feel.

The peripheral nervous system includes
the craniospinal nerves that branch off from
the brain and the spinal cord. It carries the
nerve impulses from the central nervous
system to the muscles and glands.
The autonomic nervous system regulates
involuntary action, such as heart beat and
digestion.

Immune System
The immune system is our body's defense
system against infections and diseases.
Organs, tissues, cells, and cell products work
together to respond to dangerous organisms
(like viruses or bacteria) and substances that
may enter the body from the environment.

There are three types of response systems in the
immune system: the anatomic response, the
inflammatory response, and the immune
response.
The anatomic response physically prevents
threatening substances from entering your body.
Examples of the anatomic system include the
mucous membranes and the skin. If substances
do get by, the inflammatory response goes on
attack.

The inflammatory system works by
excreting the invaders from your body.
Sneezing, runny noses, and fever are
examples of the inflammatory system at
work. Sometimes, even though you don't feel
well while it's happening, your body is fighting
illness.

When the inflammatory response fails, the
immune system goes to work. This is the
central part of the immune system and is
made up of white blood cells, which fight
infection by gobbling up antigens. About a
quarter of white blood cells, called the
lymphocytes, migrate to the lymph nodes and
produce antibodies, which fight disease.

Muscular System
The muscular system is made up of tissues
that work with the skeletal system to control
movement of the body. Some muscles—like
the ones in your arms and legs—are
voluntary, meaning that you decide when to
move them.

Other muscles, like the ones in your stomach,
heart, intestines and other organs, are
involuntary. This means that they are
controlled automatically by the nervous
system and hormones—you often don't even
realize they're at work.

The body is made up of three types of muscle tissue:
skeletal, smooth and cardiac. Each of these has
the ability to contract and expand, which allows the
body to move and function.
Skeletal Muscles help the body move.
Smooth muscles, which are involuntary, are located
inside organs, such as the stomach and intestines.
Cardiac muscle is found only in the heart. Its
motion is involuntary

Lymphatic System
The lymphatic system is also a defense
system for the body. It filters out organisms
that cause disease, produces white blood
cells, and generates disease-fighting
antibodies.

It also distributes fluids and nutrients in the
body and drains excess fluids and protein so
that tissues do not swell. The lymphatic
system is made up of a network of vessels
that help circulate body fluids. These vessels
carry excess fluid away from the spaces
between tissues and organs and return it to
the bloodstream.

Skin
Skin is the flexible tissue (integument)
enclosing the body of vertebrate animals. In
humans and other mammals, the skin
operates a complex organ of numerous
structures (sometimes called the
integumentary system) serving vital
protective and metabolic functions.

It contains two main layers of cells: a thin
outer layer, the epidermis, and a thicker inner
layer, the dermis. Along the internal surface
of the epidermis, young cells continuously
multiply, pushing the older cells outward.

At the outer surface the older cells flatten
and overlap to form a tough membrane and
gradually shed as calluses or collections of
dead skin. Although the epidermis has no
blood vessels, its deeper strata contain
melanin, the pigment that gives color to the
skin.

The underlying dermis consists of connective
tissue in which are embedded blood vessels,
lymph channels, nerve endings, sweat
glands, sebaceous glands, fat cells, hair
follicles, and muscles. The nerve endings,
called receptors, perform an important
sensory function.

 They respond to various stimuli, including contact,
heat, and cold. Response to cold activates the
erector muscles, causing hair or fur to stand erect;
fright also causes this reaction. From the outer
surface of the dermis extend numerous projections
(papillae) that fit into pits on the inner surface of the
epidermis so that the two layers are firmly locked
together.

It also waterproofs the body, preventing
excessive loss or gain of bodily moisture.
Human skin performs several functions that
help maintain normal body temperature.

Its numerous sweat glands excrete waste
products along with salt-laden moisture, the
evaporation of which may account, in certain
circumstances, for as much as 90% of the
cooling of the body.

Its fat cells act as insulation against cold; and
when the body overheats, the skin's
extensive small blood vessels carry warm
blood near the surface where it is cooled.

The skin is lubricated by its own oil glands,
which keep both the outside layer of the
epidermis and the hair from drying to
brittleness. Human skin has remarkable self-
healing properties, particularly when only the
epidermis is damaged.

Even when the injury damages the dermis,
healing may still be complete if the wounded
area occurs in a part of the body with a rich
blood supply.

Deeper wounds, penetrating to the underlying
tissue, heal by scar formation. Scar tissue
lacks the infection-resisting and metabolic
functions of healthy skin; hence, sufficiently
extensive skin loss by widespread burns or
wounds may cause death.

PRIMARY SURVEY
UNIT 5

PRIMARY SURVEY CONT
PRIMARY SURVEY
 For each patient you attend, you will be
expected to attempt to perform a a primary
survey
 A primary survey is a check for conditions or
injuries that are life threatening to the patient

PRIMARY SURVEY CONT
The Primary Survey consists of the following
components:
 Establishing the safety of the scene that you
are entering
 Forming a general impression on approach
 Assessing the patient’s level of
consciousness LOC)
 Stabilizing the head and neck if required

PRIMARY SURVEY CONT
 Assessing ABC’s
 Patient’s Airway
 Patient’s Breathing
 Patient’s Circulation
 Performing a rapid body survey for life
threatening injuries or conditions
 Treat for shock
 Apply oxygen

PRIMARY SURVEY CONT
IS THE SCENE SAFE
Be aware of the following:
 Hazards
 Other victims of patients involved in the
scene
 Mechanism of Injury
 Environment

PRIMARY SURVEY CONT
Rescue Scene
Evaluation

PRIMARY SURVEY CONT

PRIMARY SURVEY CONT
HAZARDS
What types of elements are going to involve
you in the same situation as your patient?
Is there fire, gases, danger from other people
etc?

PRIMARY SURVEY CONT
Before we jump to assess any patient, we
must first evaluate the scene. The 1994
revision of the EMT-basic curriculum points
out that scene size-up must come before
patient assessment, and for good reason—it
ensures the safety of the responding crew,
bystanders and the patient.

PRIMARY SURVEY CONT
Make sure a gas fireplace is not the cause of
your patient's unconscious state and have
the family place pets securely in another
room so they don't attack you when you
approach the owner to begin your
assessment.

PRIMARY SURVEY CONT

PRIMARY SURVEY CONT
The need to determine an area's safety
seems obvious at an accident. However, it's
also appropriate when responding to a
medical call at a patient's home where scene
size-up factors don't always seem as
apparent.

PRIMARY SURVEY CONT
Will a dog bite you when you touch the
patient? Has carbon monoxide caused the
individual to feel ill? Use your training and
your senses to determine scene safety.

PRIMARY SURVEY CONT
 Act like a detective. View the entire scene.
Look at the patient as well as the area
immediately surrounding the patient. Scan in
increasingly larger concentric circles until you
feel sure the scene is safe.

PRIMARY SURVEY CONT
Listen to the patient, bystanders and family
members present. At a crash and other
dangerous scenes, listen for sounds
unnatural to the environment. Do you hear
the whistling of a natural gas line? Do you
hear the dripping of hazardous fluids?

PRIMARY SURVEY CONT
Use your nose. What do you smell? Do you
smell gasoline? Do you smell the unpleasant
odor of a gastrointestinal bleed?

PRIMARY SURVEY CONT
Glass, sharp metal, battery acid, hydraulic
fluid and body fluids all pose hazards you
must consider and manage during scene
size-up.

PRIMARY SURVEY CONT

PRIMARY SURVEY CONT
Use your hands, feet and other appropriate
parts of your body to gather information about
the scene. As you approach the scene, do
you walk through fluids? Can you detect
metal or glass beneath your vibrum soles? If
you decide it's unsafe—don't enter.

PRIMARY SURVEY CONT
OTHER VICTIMS OR PATIENTS INVOLVED
IN THE SCENE
Are you sure that this is the only patient? Ask
bystanders, ask the patient if the patient is
able to tell you. Take a look around.

PRIMARY SURVEY CONT
Next determine the number of patients
involved on scene. More often than not the
answer is apparent, but always ask, “Does
the incident truly involve only one patient?” At
crash scenes, ask every patient if they know
of others who may be injured.

PRIMARY SURVEY CONT
At medical scenes, if external factors, such as
carbon monoxide, caused the illness, then
determine whether other people in the area
could be affected

PRIMARY SURVEY CONT
MECHANISM OF INJURY
After determining the scene is safe, ask
yourself: What is the mechanism of injury or
nature of the illness? This is sometimes
obvious, but you can misinterpret either if you
view only a few items on scene or hear only a
few points about the medical patient's
condition.

PRIMARY SURVEY CONT
The earliest textbooks referenced size-up as
our first opportunity to determine the
mechanism of a patient's injury. That remains
true today.

PRIMARY SURVEY CONT
Assessing the mechanism of injury helps you
determine the potential for harm and injuries
the patient has sustained. Ask specific
questions about the mechanism based on the
scene. For a car crash, ask questions like:
How fast was the car traveling? Was the
patient restrained? What did the car hit?

PRIMARY SURVEY CONT
For falls, ask: How far did the patient fall?
What kind of surface did they land on
(concrete vs. grass, for example)? What part
of their body hit first?

PRIMARY SURVEY CONT
You can determine some information by
asking the patient. For unresponsive medical
or trauma patients, ask family, friends or
bystanders for pertinent information. Other
information will be obtained from clues on
scene (e.g., amount of damage the vehicle
sustained).

PRIMARY SURVEY CONT
When assessing the nature of illness, attempt
to determine the patient's chief complaint and
place the patient's medical problem into a
broad category. Examples: respiratory
distress, cardiac problems or allergic
reactions.

PRIMARY SURVEY CONT
Ask the patient questions that will explain why
they activated EMS (e.g., Why did you call
the ambulance today?).

PRIMARY SURVEY CONT
ENVIRONMENT
What is the climate condition that your patient
is found in?
Do you need help to get to your patient? Is
the patient trapped? Is there electricity
involved? Do I need Police aid?

PRIMARY SURVEY CONT
Do you need more help? It's often difficult to
determine when you may need additional
help on scene. Commonly, you need
additional personnel for lifting and moving the
patient.

PRIMARY SURVEY CONT
Request assistance early. You may also need
assistance from other agencies, such as the
public works department, water department,
gas or electric company, to assist on scene.
Recognize the need and act quickly to
request these resources.

PRIMARY SURVEY CONT
Realize the need for additional help early to
prevent delays in treatment or transport while
you wait for additional help.

PRIMARY SURVEY CONT
PATIENT OVERVIEW
When approaching the patient, do so if
possible, from the patient’s view point.
Observe the patient’s body position, any
angulation of limbs, skin color and texture,
any bodily fluids on the scene, patient’s ability
to talk.

PRIMARY SURVEY CONT
Body Substance Isolation.
Take body substance isolation precautions
prior to touching the patient. The two primary
devices for accomplishing this task remain
gloves and eye wear.

PRIMARY SURVEY CONT
Wear glasses or goggles with side shielding
in the presence of body fluids or if there's a
chance you'll be exposed to them.
When the possibility of splashing fluids is
present, such as during an emergency child-
birth, wear a mask and gown.

PRIMARY SURVEY CONT

PRIMARY SURVEY CONT
ASSESS THE PATIENT”S LEVEL OF
CONSCIOUSNESS (LOC)
Level of Consciousness can be assessed by
using the acronym AVPU:
 A—Alert: Is the patient alert? If so, are they
oriented to person, place, time and purpose?

PRIMARY SURVEY CONT
 V—Responsive to verbal stimuli: If not alert,
do they respond to verbal stimuli? If you ask,
“Sir, can you hear me?” and he opens his
eyes or responds in any way, he responds to
verbal stimuli.

PRIMARY SURVEY CONT
 P—Responsive to painful stimuli: If a patient
doesn't respond to verbal stimuli, try a painful
stimulus. Test a patient's pain response in
their head area because you'll most likely
have positioned yourself there.
If you obtain an initial response to pain, check
an additional response on the torso.

PRIMARY SURVEY CONT CONT
A pinch or squeeze at the trapezius muscle
can obtain a torso response. In the event a
patient exhibits paralysis in a body region,
attempt to elicit a response to pain in several
areas.

 U—Unresponsive: If you perceive no
response to painful stimuli, the patient is
unresponsive.

CONT
Remember that a patient who has a LOC of
Verbal, Painful and Unresponsive are
deemed unstable and are considered a load
and go patient once the primary survey has
been completed

Assessing Life Threats
 After assessing responsiveness, look for
threats to life. Life-threatening bleeding is a
classic example of a life threat you must
control before continuing your assessment.

STABILIZE THE NECK IN CASE OF
SUSPECTED DELICATE SPINE
In situations where you suspect by
mechanism of injury that a patient’s cervical
spine should be stabilized the neck needs to
be stabilized at this time. At all times, the
patient needs to be asked where trauma has
occurred, if his neck is sore or painful.

ASSESS THE PATIENT’S AIRWAY
Does the patient have an adequate airway?
Assess for sounds such as high pitch noises
or other sounds.

ASSESS THE PATIENT FOR ADEQUATE
BREATHING
 Fall and rise of the chest
 Increased effort on inspiration
 Accessory muscle use
 Distressed breathing
 Cyanosis to the skin, lips, nail beds

Evaluate airway, breathing and circulation. Is
the airway patent? Ensure it's open and free
of substances or objects. It's usually easy to
determine if the airway is clear when your
patient is responsive and can speak to you.
For unresponsive patients, open and look into
the airway.

Use caution in moving the neck if the patient
may have sustained a neck injury. Remove
any fluid or substance found in the mouth of
an unresponsive patient.

Observe the patient's breathing. Note the
rate and quality of the respirations. Average
respiratory rates for adults are 12-20 breaths
per minute. Breathing less than 8 /min in an
adult, less than 10 /min in a child, less than
20 /min in an infant

PRIMARY SURVEY CONT
Note if the patient has shallow, deep or
labored breaths. Later in the assessment you
may elect to distinguish if the respirations
follow any particular pattern.

ASSESS THE PATIENT’S CIRCULATION
 If the patient is conscious use the radial
artery to assess circulation
 If the patient is unresponsive use the carotid
artery to assess circulation
 Circulation/Pulse check should usually take
no more than ten seconds

Note the circulation and determine the rate
and quality. An adult heart at rest should beat
60-100 times per minute. Rates higher or
lower should cause concern. A heart rate
below 60 is considered bradycardia; one
greater than 100 is tachycardia.

Additional history you obtain later in the
assessment may assist in determining
whether or not rates higher or lower are truly
significant for this patient.

Also note the quality of a patient's pulse.
Determine if it's regular or irregular, weak or
strong. For conscious patients, initially
assess their radial pulse. Assess the carotid
pulse of an unresponsive patient.

Skin Color & Temperature
While feeling for a pulse, you are also in
position to determine the color, temperature
and condition of the patient's skin.

Most patients will present to you with warm
and dry skin that has normal appearance and
color. Assess skin color in a mucous
membrane, such as the inside of the mouth.
It should be pink for everyone—regardless of
skin color.

Note any abnormal skin color. Common
colors of concern include—cyanosis,
resulting from low oxygen levels; red from
exposure to sun or associated with carbon
monoxide poisoning; yellow from various
disease etiologies.

You can usually determine skin temperature
and condition at the same time as skin color.
Normally it's warm. It should also be dry. You
may find the skin clammy or moist or
dehydrated. Assess the skin turgor, and note
if the patient is dehydrated

Patient Priority.
The last step of the initial assessment is to
identify the priority patient. You can
accomplish this via several methods.

First note the patient's condition. If you
observe threats to life, classify the patient as
a load-and-go—one you should rapidly
evaluate and transport to an appropriate
facility with necessary interventions
performed in the back of the ambulance.

Patient conditions that warrant immediate
transport include:
 Altered sensorium —a patient with an
abnormal level of consciousness;
 Respiratory compromise —any problem
with the airway or respiration; or

The detailed physical exam is a head-to-toe
examination, not much different from the
focused assessment. However, more time is
allowed, and this exam is more thorough than
the focused examination.

Perform this head-to-toe assessment on a
multi-system trauma patient within 60-90
seconds. Assess the patient in great detail,
but look for additional life threats or
conditions that require immediate care. Start
at the head. Inspect and palpate from the
front to the back of the cranium. Observe and
feel for injuries.

Neck
Prior to securing a C-collar in place, be sure to
palpate all areas it will cover.
Look first, then feel. Note the position of the trachea;
it should be in the midline. Check for distended or
flat jugular veins. Gently feel the C-spine. As you
continue the assessment, additional crew members
may place a cervical collar on the patient.

Chest
Expose the chest. As you finish your neck
assessment, start at the manubrium and
palpate bilaterally on both sides of the
clavicles. Assess the sternum. Fan your
fingers out and assess the chest wall. Assess
as far as you can around the posterior chest
wall.

Look for paradoxical respiration. Use your
stethoscope to auscultate the lungs for breath
sounds bilaterally, high in the anterior axillary
line. Lung sounds should remain present and
equal.

Abdomen
Observe and palpate the four quadrants of
the abdomen. Note abnormalities, such as
tenderness or rigidity. Patients are often
ticklish, so you may need to place your hand
and wait a couple of seconds prior to
palpating the four areas.

Pelvis
Flex and compress the pelvic bones by
placing your hands on the iliac crest and
pushing gently to the posterior and midline of
the patient. If the patient has any signs of
injury or complains of pain in the pelvic area,
basic level providers should not palpate it.

Suspicion of injury is sufficient. Palpation will
only cause the patient pain and possible
further injury. Advanced level providers
should palpate the region even if they
suspect injury to note the degree of injury.

Lower extremities
If your attempts to straighten an injured
extremity cause excessive discomfort for the
patient, immobilize the extremity in a position
of comfort. Evaluate pulse, sensation and
motor function at the feet. Common sense
should guide this process.

If you have difficulty obtaining a radial pulse
(barely palpable or absent), you have no
reason to spend time assessing for pedal
pulses. If the patient proves unresponsive to
painful stimulus in the initial assessment, they
probably won't respond to sensation in the
lower extremity.

Upper extremities
Move to the arms and evaluate them in the
same manner as the legs.

Posterior of the patient
Use the time prior to cervical immobilization
to assess the patient's carotid pulse and
jugular veins, skin, spine and clavicles. With
appropriate help, logroll the patient and
assess their posterior from head to toe.

Ideally, you should have put a cervical collar
in place prior to this maneuver with another
emergency responder keeping the neck in
line with the body throughout the move.

Single-system or specific-injury trauma
If the patient has a specific injury, such as a
lacerated finger, then that injury becomes the
focus of your examination. A head-to-toe
evaluation is not required—it's that simple.
However, you must still evaluate the
mechanism.

If the injury occurred while the patient cut a
bagel, then tend just to the wound. However,
if the injury resulted from a fall down a flight
of steps and the patient tells you he was
lucky and only injured his finger, revert to the
multi-system examination. Assess the patient
from head to toe, explaining to the patient
why you are doing so.

Specific medical system
The focused history and physical examination
for a patient presenting with a specific
medical situation, such as chest pain, often
requires multi-tasking. You must obtain
subjective information while simultaneously
performing the physical assessment and
providing interventions.

The EMS provider must question, assess and
treat on the basis of findings from the initial
assessment. The difference between
advanced skill providers and basic skill
providers becomes perhaps most
distinguishable at this point.

CONT
 At this point, you should be able to make a
decision whether to treat as stable or
unstable
 If transporting you would load the patient on
the appropriate lifting device and transport,
continuing with your secondary survey en
route to the hospital/nursing station

AS PRIMARY SURVEY SESSMENT
CONT
CONT
 If you are waiting for more advanced medical
aid to arrive it would be appropriate to
position the patient in a position of comfort
and carry on with the secondary survey
 Unstable patients need to have their ABC’s
checked every 5 minutes, whereas stable
patients can be checked every 15 minutes or
thereabouts

THE SECONDARY SURVEY
UNIT 6

THE SECONDARY SURVEYCONT
THE SECONDARY SURVEY
 Chief Complaint
 Patient History
 Vitals
 Pain History
 Head to Toe or Toe to Head
 Immobilize (if needed)

CONT
CHIEF COMPLAINT
 The Chief Complaint is what the patient tells
you i.e. “I feel dizzy”, “My leg hurts” etc
 If the patient is unresponsive then the chief
complaint would be “found unresponsive”

CONT
Patient History
To assess a medical patient with multiple
complaints (e.g., weakness and dizzy spells),
use the SAMPLE acronym:

CONT
SIGNS & SYMPTOMS
A sign is what you observe about the patient.
This would include labored breathing,
cyanosis and pallor skin color. A symptom is
something the patient feels and reports to
you. Example: Squeezing chest pain or
dizziness.

CONT
ALLERGIES
Ask if the patient has allergic reactions to any
medications. Also inquire about
environmental allergies. If a bee stung an
allergic patient, you may not need much
additional information to guide your treatment
of life-threatening conditions.

CONT
MEDICATIONS
Ask if the patient takes any prescription
medications. Also inquire about over-the-counter
drugs, vitamins and herbs. You may need to ask
about some medications based on a specific
condition that presents. Example: Ask a female with
shortness of breath if she takes birth control pills.
Ask a male who reports taking Viagra if he also
takes nitroglycerin.

ASSESSMENT CONT
PERTINENT HISTORY
Ask about the patient's pertinent history.
Obtaining an in-depth history is not required.
Use this information to further examine the
patient's medical problem.

CONT
LAST INS AND OUTS
Ask about the patient's last intake of food and
drinks. The last bowel movement or urination
or body output. Vomiting, profuse sweating,
bleeding etc

CONT
EVENTS LEADING TO THE ILLNESS
Ask the patient what they were doing when
they first noted that they felt ill or sustained
the injury.

CONT
VITALS
 Blood Pressure
 Pulse: Rate, strength, character
 Respirations: Rate, depth, character
 Skin: Color, temperature, texture
 Level of Consciousness (LOC)

CONT
PAIN HISTORY
Continue your assessment of the medical
patient by using the acronym OPQRST.
ONSET—Determine when the patient's
symptoms began. This refers to the current
incident. Patients may have a history of years
for some conditions.

CONT
POSITION, PROVOCATIVE AND
PALLIATIVE—What is the position of the
patient? Do they feel comfortable in that
position? Example: A congestive heart failure
patient may want to sit up.

CONT
If we attempt to lay them flat, we assist in
their deterioration. Therefore, leave or place
the patient in their position of comfort.

CONT
Next, determine what provokes the patient's
condition What makes the condition worse?
You may do something while caring for the
patient that, in fact, makes it worse. Example:
Lowering the bent leg of a patient
complaining of hip pain after a fall.

CONT
As you lower the leg, the patient may scream
that the pain is getting much worse.
Immediately stop lowering the leg, return it to
a position of comfort and check for a pulse in
the extremity.

CONT
Also, determine what makes the patient feel
better. This is the palliative aspect. It most
likely will result from the care you provide.

CONT
QUALITY OF THE PAIN—Refrain from using
the word pain around the patient. It's best to
use the word discomfort. If you keep
associating pain with their condition, it
frequently escalates. Allow the patient to
describe their discomfort in their own words.
Don't put words in their mouth.

CONT
RADIATE—Does the discomfort move
(radiate) anywhere on the patient? Classic
chest pain patients will say the discomfort
moves down their arm, into their jaw or back.
Again, don't lead the patient.

ASSESSMENT CONT
SEVERITY OF THE PAIN—You can
determine the severity of a patient's
discomfort a number of ways. However, using
a scale from one to 10—10 being the worst—
works well in the field.

CONT
TIME—Determine the time of onset and
duration of this event. Medical conditions are
often chronic and linger for hours, days,
weeks or months prior to people calling for
EMS assistance.

CONT
HEAD TO TOE OR TOE TO HEAD
This a very intense inspection of the patient’s
body to see if there are any other injuries that
may have come to light in the last few
minutes. Virtually ever square inch of the
patient is palpated and motor skills are tested

You must perform a detailed physical
examination on every multi-system trauma
patient. Perform the detailed examination of a
multi-system trauma patient in the back of the
ambulance during transport whenever
possible. If you must delay transport, perform
the detailed physical exam on scene.

The ambulance serves as your office—a
place that should give you the best control of
patient management. The lighting is usually
better and the temperature more balanced.
Outside sources should no longer distract
you.

Frequently, providers miss injuries in the
rapid evaluation of the focused history and
physical exam. Use the detailed physical
examination to take a slower, more careful
look at the patient.
The detailed physical exam is a head-to-toe
examination, not much different from the
focused assessment. However, more time is
allowed, and this exam is more thorough than
the focused examination.

CONT
Spend more time at the head of the patient
Evaluate the eyes, ears, nose and mouth more
thoroughly. Evaluate the pupils for size and
symmetry. Check the ears for fluids (blood or
cerebral spinal fluid). Observe the nose for blood
or clear fluids. Explore the mouth for objects and
fluids.
Reevaluate the neck
This may require that you open the cervical
collar so you can palpate the circumference of
the neck.

CONT
Evaluate the chest thoroughly
Although your focused assessment should be
complete and thorough, you can achieve
greater detail at this point in the assessment,
particularly in crash situations that may result
in injuries to the chest.

Utilize the same techniques that you use in
the focused assessment. However, evaluate
the lung sounds in greater detail, checking
multiple fields.

CONT
Reassess the abdomen
Look and feel for deformity and rigidity. Be
sure to observe the patient for signs of
discomfort in every region.

CONT
Reassess the pelvis
With your hands on the iliac wings, push
gently to the posterior and the midline. Feel
and observe for injuries. If you noted injury in
the focused assessment, reassessment is
unnecessary.

CONT
Reassess the extremities
Often minor injuries to the extremities will be
over-looked while you focus more on the
head, neck and chest during the focused
history and physical examination. Attempt to
assess pulse, sensation and motor function in
the extremities.

CONT
Check posterior surfaces
The posterior reassessment is usually
modified in a moving ambulance because it's
best for the patient to remain secured to the
stretcher. However, you can still reach and
palpate most areas of the patient's posterior
surfaces to detect bleeding, deformities and
patient discomfort.

CONT
A detailed physical exam may appear to be
not be possible if the patient's condition is so
severe that all of your time is spent
controlling threats to life. However you must
attempt to assess all areas of the body

CONT
Trauma, single-system or specific injury
A detailed head-to-toe physical exam is
generally not required for a patient with a
specific injury. If the mechanism of injury
leads you to suspect the patient may have
other injuries, conduct a more thorough
evaluation of the patient.

CONT
Medical, multi-system
Medical patients with multi-system
presentation or vague signs and symptoms
should be thoroughly evaluated. As such,
these patients should receive a detailed
physical examination. Again, common sense
will determine to what degree you need to
perform this evaluation in the field setting

CONT
Medical, specific system
Frequently providers overlook the detailed
physical evaluation in specific-system
situations. Remember that chest pain
patients who fall to the floor can fracture their
femur or hip or injure their spine. If time and
patient condition allow, perform a detailed
physical exam.

CONT
Ongoing assessment is a continuous process
of patient care. At its essence, this repeats
the initial assessment. You must always
consider the general impression of each
patient's condition. Are they getting better,
getting worse or remaining the same?

CONT
Continuously monitor the patient's level of
consciousness. Again, view your evaluation
in terms of whether your patient is improving,
staying the same or deteriorating.

CONT
Do you discover any additional threats to life?
If so, treat them. Have you corrected all
initially observed threats to life, and have you
monitored them throughout the care you
rendered in the field?

Monitor the airway. Ensure its patency. If
advanced procedures have been performed,
monitor placement of the advanced airway
frequently.

CONT
Continually reassess the patient's breathing.
The rate and quality should remain at the
forefront of your respiratory assessment. If
the patient is being ventilated, continuously
monitor the rate and quality of respiration.

CONT
As the old saying goes, “You should have
your finger on the pulse of the situation.” This
means palpating the pulse of the patient and
noting its rate and quality. While obtaining
this information, condition yourself to note the
skin's color, temperature and condition.

CONT
Monitor and reevaluate each patient's priority.
Often, patients without high priority conditions
will begin to deteriorate. Should this occur,
announce to other crew members that the
situation has changed and the patient is now
a load-and-go priority patient.

CONT
Do this in a discrete manner to avoid causing
additional stress to the patient or panic family
members.

CONT
Reassess all performed interventions and
share all information obtained throughout the
assessment with the crew and receiving
hospital medical staff. In addition, note this
information appropriately on the Patient Care
Report on the completion of the call.

CONT
Summary
Properly assessing the patient is the most
important aspect of what we do. All decisions
made about patient care are based on our
assessment. Follow an organized, methodical
assessment plan each time you encounter a
patient.

CONT
Remember the five major aspects of patient
assessment:
1. Scene size-up;
2. Initial assessment;
3. Focused history and physical examination;
4. Detailed physical examination; and
5. Ongoing assessment.

ASSESSMENT CONT
Scene size-up
 Is the scene safe?
 What is the mechanism of injury or nature of
illness?
 How many patients are present?
 Do I need more help?
 Do I have what I need for body substance
isolation?


ASSESSMENT CONT
Initial Assessment
 General impression;
 Level of consciousness;
 Threats to life;
 Airway;
 Breathing;
 Circulation;
 Skin color, temperature, condition; and
 Priority of the patient.

MEASURING BLOOD PRESSURE
UNIT 7

Measuring Blood Pressure CONT
 OBJECTIVES:
 At the end of this unit participants will be able
to demonstrate how to measure blood
pressure through palpation and through
auscultation

 Blood pressure is the force exerted by blood
against the blood vessel walls as it travels
throughout the body
 If the circulatory system is working properly,
blood pressure remains constant and within a
normal range
 If the circulatory system is failing, blood
pressure reflects this failure by becoming
weaker.

 Blood pressure is created by the pumping
action of the heart
 A blood pressure cuff is used to measure a
person’s blood pressure
 cuffs come in sizes for small, average and
large arms
 Inside the cuff is a rubber bladder that wraps
around the arm and can be inflated to slow
blood flow.

 MEASURING BLOOD PRESSURE
 Blood pressure is measured in units called
millimeters of mercury (mmHg).

 In measuring blood pressure, two different
numbers are usually recorded. The first
number reflects the pressure in the arteries
when the heart is contracting. This is called
the systolic pressure. The second number
reflects the pressure in the arteries when the
heart is resting and refilling. This called the
diastolic number.

 Blood pressure is reported by giving the
systolic number first and then the diastolic
number second (S/D)

 To determine either the systolic or the
diastolic pressure, you need to determine
when the blood pulses through the brachial
arteries. This can be done by feeling the
radial artery as you inflate the cuff or by
listening to the surging blood through the
brachial artery with stethoscope.

 Average blood pressure by age group:
 Up to 28 days 80/40
 1 -- 12 months 80/40
 1 -- 8 years 90/50
 Over age 8 120/80

 Summary
 There are two ways of measuring blood
pressure: palpation and auscultation
 Auscultation is more precise, requiring a
stethoscope
 Level of proficiency increases with practice

UNIT 8
RESPIRATORY EMERGENCIES

RESPIRATORY EMERGENCIES CONT

RESPIRATORY ARREST/APNEA
Apnea means absence of spontaneous
breathing from any cause. Apnea can be
intermittent and temporary (as occurs with
obstructive sleep apnea) or prolonged.
Prolonged apnea is also called respiratory
arrest

cont
Prolonged apnea (respiratory arrest) is a life-
threatening disorder that requires immediate
medical attention and first aid
Any episode of apnea, even a temporary one,
in which a person turns blue, has a seizure,
becomes limp, or remains drowsy or
unconscious, requires prompt medical
attention.

Apnea can occur for many different reasons.
The most common causes of apnea in infants
and small children are generally quite
different from the most common causes in
adults.

In infants and children, the most common
cause of cardiac arrest (lack of an effective
heartbeat) is a preceding respiratory arrest.
In adults, the opposite usually occurs: cardiac
arrest leads to respiratory arrest

Common causes of apnea in infants and
young children include:
 Prematurety
 Bronchilitis or pneumonia
 Foreign object aspiration or choking
 Breath holding spells

 Seizures
 Meningitis or encephalitis
 Gastrophageal reflux
 Bronchospasm (asthma)

Common causes of apnea in adults include:
 Obstructive sleep apnea
 Choking
 Drug overdose, especially drugs such as
alcohol, narcotic analgesics, barbiturates,
anesthetics, and other depressants
 Cardiac arrest

Other causes of apnea include:
 Near-drowning
 Head or brain stem injury
 Irregular heartbeat (arrhythmias)
 Metabolic disorders
 Nervous system disorders

Treatment
If there is any interruption in spontaneous
breathing or if breathing has stopped
begin assisted breathing

CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD)
 Emphysema and chronic bronchitis are the
two most common conditions in the COPD
family

CONT

CONT
 Emphysema is a disease in which the alveoli
lose their elasticity, become distended with
trapped air, and stop working
 Results in the lungs not being able to
exchange oxygen and carbon dioxide in the
blood.

CONT
 COPD patients build up high levels of carbon
dioxide in the blood. Due to consistently high
levels, the body looks to oxygen levels to
determine the need to breathe.
 In COPD patients, low amounts of oxygen
trigger the increase in breathing, whereas in
healthy people high levels of carbon dioxide
trigger the increase in breathing

CONT
 Cigarette smoking is the most important
known factor to cause COPD
 The average Canadian with COPD is 65
years of age and has a history of smoking
 COPD is more common in people who reside
in urban areas compared to those that live in
urban areas

CONT
 COPD patients that are not acutely short of
breath will be receiving low concentrations of
oxygen from their home unit, which is usually
delivered through a nasal cannula
 In a COPD patient with true hypoxic drive,
increased levels of oxygen could signal the
body to slow down or stop breathing
altogether.

CONT
 The priority in this
situation is the delivery
of high flow oxygen to
the patient

PNEUMONIA
 Term used to describe a group of illnesses
characterized by lung infection and fluid or
pus filled alveoli
 The result is inadequate oxygen in the blood

CONT

CONT
 Pneumonia is caused
by bacteria or virus, but
can also be caused by
irritants such as smoke,
or aspirated materials
such as vomit.

CONT
 Signs and Symptoms may include:
 Respiratory distress
 Rapid breathing
 Pleuritic chest pain, usually worsens on breathing
 Productive cough with pus in the sputum
 Fever, usually exceeding 38 degrees C.
 Chills

ACUTE PULMONARY EDEMA
 Pulmonary edema can be caused by heart or
lung damage
 It occurs when fluid builds up in the lungs
around the tissue and the alveoli
 These patients are usually found sitting
upright, leaning forward

CONT

 As the fluid builds up in the lungs the amount
of oxygen entering the blood decreases
 Patient’s presenting with acute pulmonary
edema may have their ventilation assisted

CONT
Signs and symptoms may include:
 Shortness of breath with sudden onset
 Rapid, labored breathing
 Cyanosis
 Frothy pink, blood tinged sputum (late)
 Distended neck veins
 Anxiety

CONT
 Restlessness
 Anxiety
 Exhaustion
 Rapid pulse
 Cool, clammy skin
 Crackles in the lungs or abnormal heart
sounds

It is important to have the patient dangle
his/her legs to promote pooling of blood in the
lower extremities

TREATMENT
Oxygen is given via nasal prongs or a face
mask

PULMONARY
EMBOLISM

CONT
A pulmonary embolus is a blockage of an artery in
the lungs by fat, air, clumped tumor cells, or a
blood clot
Pulmonary emboli are most often caused by blood
clots in the veins, especially veins in the legs or in
the pelvis (hips). More rarely, air bubbles, fat
droplets, amniotic fluid, or clumps of parasites or
tumor cells may obstruct the pulmonary vessels.

The most common cause of a pulmonary
embolism is a blood clot in the veins of the
legs, called a deep vein thrombosis (DVT).
Many clear up on their own, though some
may cause severe illness or even death

 The clot or embolus dislodges and ends up in
the pulmonary arteries, obstructing blood
supply to that part of the lung
 It is a surprising common disorder
 The clot or embolus may be small, medium
or large
 It usually begins as a venous disease

CONT
Risk factors for a pulmonary embolism include:
 Prolonged bed rest or inactivity (including long
trips in planes, cars, or trains)
 Oral contraceptive use
 Surgery (especially pelvic surgery)
 Childbirth
 Massive trauma

CONT
 Burns
 Cancer
 Stroke
 Heart attack
 Heart surgery
 Fracture of the hips or femur
 Persons with certain clotting disorders may also
have a higher risk

Symptoms of pulmonary embolism may be
vague, or they may resemble symptoms
associated with other diseases. Symptoms
can include:
 Cough
 Begins suddenly
 May produce bloody sputum (significant amounts
of visible blood or lightly blood streaked sputum)

 Sudden onset of shortness of breath at rest or with
exertion
 Splinting of ribs with breathing (bending over or
holding the chest)
Chest pain
 Under the breastbone or on one side
 Especially sharp or stabbing; also may be burning,
aching or dull, heavy sensation
 May be worsened by breathing deeply, coughing,
eating, bending, or stooping

Signs and Symptoms cont
 Raid breathing
 Rapid heart rate (tachycardia)
 Wheezing
 Clammy skin
 Bluish skin discoloration
 Nasal flaring
 Pelvis pain

Signs and symptoms cont
 Leg pain in one or both legs
 Swelling in the legs (lower extremities)
 Lump associated with a vein near the surface
of the body (superficial vein), may be painful
 Low blood pressure
 Weak or absent pulse
 Lightheadedness or fainting

Signs and symptoms cont
 Dizziness
 Sweating
 Anxiety

TREATMENT
Emergency treatment and hospitalization are
necessary. In cases of severe, life-
threatening pulmonary embolism, definitive
treatment consists of dissolving the clot with
thrombolytic therapy. Anticoagulant therapy
prevents the formation of more clots and
allows the body to re-absorb the existing clots
faster.

Management of patients with respiratory
emergencies involves oxygen administration
and maintaining a comfortable position for the
patient.

ASTHMA
Asthma is a disease in which inflammation of
the airways causes airflow into and out of the
lungs to be restricted. The muscles of the
bronchial tree become tight and the lining of
the air passages swells, reducing airflow and
producing the characteristic wheezing sound.

ASTHMA

Many of the same substances that trigger
allergies can also trigger asthma. Common
allergens include pollen, dust mites, mold
and pet dander. Other asthma triggers
include irritants like smoke, pollution, fumes,
cleaning chemicals, and sprays.

Asthma symptoms can also be triggered by
respiratory infections, exercise, cold air,
tobacco smoke and other pollutants, stress,
food, or drug allergies. Aspirin and other non-
steroidal anti-inflammatory medications
(NSAIDS) provoke asthma in some patients.

ASTHMA:
Common triggers

During an asthma attack smooth muscles
located in the bronchioles of the lung
constrict and decrease the flow of air in the
airways. The amount of air flow can further
be decreased by inflammation or excess
mucus secretion

Asthma symptoms can be substantially
reduced by avoiding exposure to known
allergens and respiratory irritants.

When an asthma attack occurs, the muscles
of the bronchial tree become tight and the
lining of the air passages swells, reducing
airflow and producing the characteristic
wheezing sound. Mucus production is
increased.

Most people with asthma have periodic
wheezing attacks separated by symptom-free
periods. Some asthmatics have chronic
shortness of breath with episodes of
increased shortness of breath.

Other asthmatics may have cough as their
predominant symptom. Asthma attacks can
last minutes to days, and can become
dangerous if the airflow becomes severely
restricted.

Asthma is found in 3-5% of adults and 7-10%
of children. Half of the people with asthma
develop it before age 10, and most develop it
before age 30. Asthma symptoms can
decrease over time, especially in children.

Many people with asthma have an individual
and/or family history of allergies, such as hay
fever (allergic rhinitis) or eczema. Others
have no history of allergies or evidence of
allergic problems

Symptoms
 wheezing
 usually begins suddenly
 is episodic
 may be worse at night or in early morning
 aggravated by exposure to cold air
 aggravated by exercise

 cough with or without sputum (phlegm)
production
 Shortness of breath that is aggravated by
exercise
 breathing that requires increased work
 Intercostal retractions (pulling of the skin
between the ribs when breathing

Emergency symptoms:
 Extreme difficulty breathing
 Bluish color to the lips and face
 severe anxiety due to shortness of breath
 Rapid pulse
 Sweating
 Decreased level of consciousness (severe
drowsiness or confusion) during an asthma attack

Additional symptoms that may be associated
with this disease:
 Nasal flaring
 Chest pain
 tightness in the chest
 abnormal breathing pattern, in which
exhalation (breathing out) takes more than
twice as long as inspiration (breathing in)
 breathing which temporarily stops

Treatment
Treatment is aimed at avoiding known
allergens and respiratory irritants and
controlling symptoms and airway
inflammation through medication. Allergens
can sometimes be identified by noting which
substances cause an allergic reaction.

 If the patient has a metered-dose inhaler you
may assist the patient, making sure that the
medication is for that patient.
 Apply high flow oxygen
 Transport with patient in a comfortable sitting
position
 Monitor vitals

Bronchitis
Acute Bronchitis generally follows a viral
respiratory infection. Initially, it affects your
nose, sinuses, and throat and then spreads
to the lungs. Sometimes, you may
get another (secondary) bacterial infection in
the airways. This means that bacteria infect
the airways, in addition to the virus.

Bronchitis

Bronchitis is often caused by prolonged
exposure to irritants (most commonly
cigarette smoke).
The disease gets worse over time.

Chronic Bronchitis is a long-term condition.
People have a cough that produces
excessive mucus. To be diagnosed with
chronic bronchitis, you must have a cough
with mucus most days of the month for at
least 3 months.

As the condition gets worse, you become
increasingly short of breath, have difficulty
walking or exerting yourself physically, and
may need supplemental oxygen on a regular
basis.

The following things can make bronchitis
worse: Air pollution, certain occupations (like
coal mining, textile manufacturing, or grain
handling), infection, and allergies

People at risk for acute bronchitis include:
 Elderly, infants, and young children
 Smokers
 People with heart or lung disease

Symptoms
The symptoms of either type of bronchitis
include:
 Cough that produces mucus; if yellow-green
in color, you are more likely to have a
bacterial infection
 Shortness of breath worsened by exertion or
mild activity

 Wheezing
 Fatigue
 Fever -- usually low
 Chest discomfort

Additional symptoms of chronic bronchitis
include:
 Frequent respiratory infections (such as colds
or the flu)
 Ankle, feet, and leg swelling

 Blue tinged lips from low levels of oxygen
 Even after acute bronchitis has cleared, you
may have a dry, nagging cough that lingers
for several weeks.

 Treatment
 Transport in comfortable position usually
seated up right

HYPERVENTILATION
Hyperventilation is rapid or deep breathing,
usually caused by anxiety or panic. This over
breathing, as it is sometimes called, actually
leaves you feeling breathless.

Considerations
Feeling very anxious or having a panic attack
are the usual reasons that your patient may
hyperventilate. However, rapid breathing may
be a symptom of an underlying disease, such
as a heart or lung disorder, bleeding, or an
infection.

Common Causes
 anxiety and nervousness
 stress
 panic attack
 situations where there is a psychological
advantage in having a sudden, dramatic
illness (for example, somatization disorder)

 stimulant use
 lung disease such as asthma, COPD, or
pulmonary embolism (blood clot in the lung)
 infection such as pneumonia or sepsis

 cardiac disease such as congestive heart
failure or heart attack
 severe pain
 bleeding
 drugs (such as an aspirin overdose)
 pregnancy
 ketoacidosis and similar medical conditions

When you breathe, you inhale oxygen and
exhale carbon dioxide. Excessive breathing
leads to low levels of carbon dioxide in your
blood, which causes many of the symptoms
that you may feel if you hyperventilate.

 Treatment
 Try to calm the patient carefully and safely.
 Administer high flow oxygen
 Transport patient in a comfortable sitting
position

 Jugular Vein Distention (JVD)
 The jugular veins normally distend slightly in
someone who is supine with normal blood
volume.
 If possible, the jugular veins should be
assessed with the person sitting at a 45
degree angle

 If 2/3 of the jugular vein is filled or engorged
from the base of the neck up towards the
angle of the jaw, then JVD is present
 Do not have someone with a suspected
spinal injury sit up to check this.

Anaphylaxis
Anaphylaxis is an acute systemic (whole
body) type of allergic reaction which occurs
when a person has become sensitized to a
certain substance or allergen and is again
exposed to the allergen.

Some drugs, such as those used for pain
relief or for X-rays, may cause an
anaphylactic reaction on first exposure.

ANAPHYLAXIS

Histamines and other substances released
into the bloodstream cause blood vessels to
dilate and tissues to swell. Anaphylaxis may
be life-threatening if obstruction of the airway
occurs, if blood pressure drops, or if heart
arrhythmias occur.

HIVES

Hives are raised red welts of various size on
the surface of the skin, often itchy, which
come and go. Also called uticaria, hives is
usually part of an allergic reaction to drugs or
food.

This overreaction can cause symptoms from
the mild (hives) to the severe (anaphylactic
shock) upon subsequent exposure to the
substance.

FOOD ALLERGIES

The body's immune system normally reacts to
the presence of toxins, bacteria or viruses by
producing a chemical reaction to fight these
invaders. However, sometimes the immune
system reacts to ordinarily benign substances
such as food or pollen, to which it has
become sensitive.

An actual food allergy, as opposed to simple
intolerance due to the lack of digesting
enzymes, is indicated by the production of
antibodies to the food allergen, and by the
release of histamines and other chemicals
into the blood.

INSECT BITES

Allergic reaction to bee stings occurs when a
person becomes sensitized to the venom
from a previous sting. This reaction is
different from the reaction to the poison in the
bite of a black widow spider, which injects a
potent toxin into the blood.

Ordinarily, bee venom is not toxic and will
only cause local pain and swelling. The
allergic reaction comes when the immune
system is over sensitized to the venom and
produces antibodies to it. Histamines and
other substances are released into the
bloodstream, causing blood vessels to dilate
and tissues to swell.

Severe reactions can lead to anaphylactic
shock, a life-threatening series of symptoms
including swelling of the throat and difficulty
breathing. Persons who develop an allergy to
bee stings should carry prescription bee sting
kits to counteract the reaction to bee venom.

MEDICATIONS

A true allergy to a medication is different than
a simple adverse reaction to the drug. The
allergic reaction occurs when the immune
system, having been exposed to the drug
before, creates antibodies to it.

On subsequent exposure to the drug these
antibodies cause release of histamines. If
severe, this reaction can result in a life-
threatening situation known as anaphylactic
shock.

ANTIBODIES

Antigens are large molecules (usually
proteins) on the surface of cells, viruses,
fungi, bacteria, and some non-living
substances such as toxins, chemicals, drugs,
and foreign particles. The immune system
recognizes antigens and produces antibodies
that destroy substances containing antigens.

Some drugs (polymyxin, morphine, x-ray dye,
and others) may cause an anaphylactoid
reaction (anaphylactic-like reaction) on the
first exposure. This is usually due to a toxic
reaction, rather than the immune system
mechanism that occurs with "true"
anaphylaxis. The symptoms, risk for
complications without treatment, and
treatment are the same, however, for both
types of reactions.

Anaphylaxis occurs infrequently. However, it
is life-threatening and can occur at any time.
Risks include prior history of any type of
allergic reaction

Symptoms develop rapidly, often within
seconds or minutes. They may include the
following:
 Difficulty breathing
 Wheezing
 Abnormal (high-pitched) breathing sounds
 Confusion

 Slurred speech
 Rapid or weak pulse
 Blueness of the skin (cyanosis), including the
lips or nail beds
 Fainting, lightheadedness, dizziness
 Hives and generalized itching
 Anxiety

 Sensation of feeling the heart beat
(palpations)
 Nausea, vomiting
 Diarrhea
 Abdominal pain or cramping
 Skin redness
 Nasal congestion
 Cough

 Pneumonia
 Pneumonia is term used to describe a group
of illnesses characterized by lung infection
and pus-filled alveoli
 The result is inadequate oxygen in the blood

 Pneumonia is caused by bacteria or virus but
can be caused by irritants such as smoke or
aspirated materials such as vomit.
 The type caused by chemical irritation or
aspiration is called pneumonitis. People with
pneumonia may complain of fever and chills

 Signs and symptoms include but not limited
to:
 Difficulty breathing, rapid breathing,pleuritic
chest pain, usually worse with breathing,
productive cough with pus in the sputum or
mucous, fever, usually exceeding 38 degrees
C., chills

 There may be other symptoms as well, such
as:
 nausea, vomiting, headache, tiredness and
muscle aches.

 Treatment
 Transport in a comfortable position
 Monitor vitals
 Transport to an advance care facility.

CARE FOR RESPIRATORY DISTRESS
General Care:
 Maintain normal body temperature
 Have patient rest in most comfortable
position

SPECIFIC CARE cont
 Reduce heat and humidity
 Administer supplemental oxygen
 Monitor vital signs
 Transport to advanced care

KEY POINTS OF RESPIRATORY ARREST
 Life threatening
 Caused by illness, injury, or choking
 Often preceded by respiratory distress
 Body systems will progressively fail

GIVE BREATHS
 Adults: 1 breath every 5 seconds
 Children: 1 breath every 3 seconds
 Infants: 1 breath every 3 seconds

AIRWAY OBSTRUCTIONS
ANATOMICAL:
 Tongue
 Swelling of the throat
MECHANICAL:
 Food
 Toy
 Fluid

AIRWAY OBSTRUCTION
PARTIAL:
 Patient can still move air to and from the
lungs; can speak, cough
COMPLETE:
 Patient is unable to speak, breathe, or cough;
no air movement

 Summary
 The most common causes of breathing
disorders are asthma, bronchitis,
emphysema, hyperventilation,anaphylaxis,
and COPD
 Some breathing emergencies may lead to
respiratory arrest if not cared for immediately.
Respiratory arrest is life threatening

 In respiratory arrest, breathing stops. Rescue
breathing is a way of supplying oxygen to a
non-breathing patient by breathing air into
their lungs
 Management od patients with respiratory
emergencies involves oxygen administration
and maintaining a comfortable position for
nthe patient

Question
You respond to a dispatch reporting a person with
severe shortness of breath. Arriving at the scene,
in what position would you expect to find the
patient?
A. Lying in bed
B. Tripod position
C. Walking back and forth
D. Semi-fowler’s position

Answer
(B) Patients who are severely short of breath
will most likely place themselves in a tripod
position. Leaning forward with their hands on
their knees.

Question
You are assessing a 56 year old male. On
examination you note the patient has a thin, barrel-
shaped chest and diminished breath sounds with
wheezes and rhonchi on exhalation. He purses his
lips when he breathes, His skin is cool and clammy
with a pink complexion. His breathing rate is about
28 breaths per minute. You would suspect this

A. Congestive heart failure
B. Emphysema
C. Asthma
D. bronchitis

Answer
(B) The patient has typical signs and symptoms
associated with emphysema.

Question
You are treating a 22 year old female at the local
food store. The patient is short of breath and stated
that it came on suddenly and is a sharp, and
stabbing pain in the left side of her chest. She is
breathing about 26 times per minute. Her skin is
cool and clammy. She is very restless and anxious.
The only medication she states that she takes is
birth control pills. You should suspect:

A. Ectopic pregnancy
B. Heart attack
C. Pulmonary embolism
D. Asthma

Answer
(C)
A pulmonary embolism is a common side effect of birth control pills.
Other causes include:
Surgery
Prolonged immobilization
Thrombophlebitis
Certain medications
Multiple fractures

UNIT 8
BREATHING DEVICES

BREATHING DEVICES
Bag Valve Mask

BREATHING DEVICES CONT
A BVM Resuscitator (Bag Valve Mask) is a
part of the usual equipment for advanced life
support patient treatment in medical
emergencies. It is a bag which is self-filling
with air or additional oxygen (O2) can be
added.

The BVM directs the gas inside it via a one-
way valve when compressed by a rescuer;
the gas is then delivered through a mask and
into the patient's trachea and into the lungs.

This technique is regularly necessary in
medical emergencies when the patient's
breathing is insufficient or has ceased
completely. The BVM Resuscitator is used in
order to manually provide mechanical
ventilation.

Nasal Cannula

The nasal cannula is a device used in the
hospital at home to deliver supplemental
oxygen to a patient or person in need of extra
oxygen. This device is a plastic tube which
fits around the head of a person and a set of
two prongs which are placed in the nose or
nares of the person.

These prongs are where the oxygen flows out
of. To get oxygen through the nasal cannula
it has to be hooked up to an oxygen tank,
portable oxygen generator, or to a wall
connection in a hospital via a flow meter. The
nasal cannula can have a flow which ranges
from 1 liters per minute to 6 liters per minute.

There are also infant or neonatal nasal
cannula which use flows of less than a liter
per minute, these also have smaller prongs.
The oxygen percentage ranges from 24%
oxygen to 35% approximately

NONREBREATHER MASK

Non-Rebreather masks achieve close to 85%
oxygen by minimizing room air entrainment. It
accomplishes this by attaching a reservoir
bag to the mask filled with 100% oxygen. The
reservoir bag has a flap valve to block
exhaled gas from entering. exhaled gas is
directed out the side ports of the mask.

These side ports have flap valves on the
outside of the mask to block air on inspiration
and instead draws gas from the 100%
oxygen source in the reservoir bag. In actual
practice, one of the side port flap valves on
the mask is removed as a safety precaution
to allow room air entrainment should the
oxygen tubing become disconnected.

POCKET MASK

The pocket mask allows the attendant to
ventilate safely. The distance from the
patient’s mouth allows the rescuer to check
patient's mouth color, secretions and chest
movement.

An optional oxygen inlet facilitates delivery of
supplemental oxygen during ventilation of a
non-breathing patient or for inhalation by a
spontaneously breathing patient.

OROPHARYNGEAL AIRWAY

Oropharyngeal Airway
The Oropharyngeal airway is essentially a
curved hollow tube that is used to create
an open conduit through the mouth and
posterior pharynx.

A rough guide for choosing the correct size is
to hold the airway beside the patient's
mandible, orienting it with the flange at the
patient's mouth and the tip at the angle of
jaw. The tip should just reach the angle of the
jaw.

To avoid pushing the tongue into the
posterior pharynx; start with the curve of the
airway inverted, and then rotate the airway as
the tip reaches the posterior pharynx.
Alternatively a tongue depressor can be used
to move the tongue out of the way as the
airway is passed.

Whichever technique is chosen the attendant
must be certain that the airway is indeed
in the right position. If there are problems
ventilating the patient after insertion of
the airway then it should be removed and
reinserted.

NASOPHARYNGEAL AIRWAY

Nasopharyngeal Airway
The nasopharyngeal airway is a soft rubber
or plastic hollow tube that is passed
through the nose into the posterior pharynx.

The tubes come in sizes based on the
internal diameter (i.d.) of the tube. The larger
the internal diameter the longer the tube.
An 8.0 – 9.0 i.d. is used for a large adult, a
7.0 – 8.0 i.d. for a medium adult and a 6.0 –
7.0 i.d. for a small adult.

These tubes can be used when the use of an
oropharyngeal airway is difficult, such as
when a patient is clenching their jaw. As well,
the nasopharyngeal airway is generally better
tolerated than the oropharyngeal airway in a
semiconscious patient.

To insert, the nasopharyngeal airway is
lubricated with water soluble lubricant
or anesthetic jelly along the floor of the nostril
into posterior pharynx behind the tongue.

PRECAUTIONS DURING OXYGEN
DELIVERY
 Do not operate around flames or sparks
 Do not stand cylinder up right
 Do not use grease, oil, or petroleum products
to lubricate
 Check oxygen flow before placing delivery
device on a casualty

Airway - Suctioning (Basic)
Clinical Indications
 Obstruction of the airway (secondary to
secretions, blood, or any other
 substance in a patient who cannot maintain or
keep the airway clear.)
Procedure:
 Ensure the suction unit is operable and rigid
 suction tip is in place.

 Examine the oropharynx and remove any
potential foreign bodies or material that may
possibly occlude the airway during the
procedure.
 Remove any oxygenation devices.
 Pre-oxygenate the patient.
 Explain the procedure to the patient if they
are coherent.

 Insert the distal end of the suction catheter
into the back of the mouth with suction
applied (you should still be able to visualize
the end of the suction catheter.)
 Occlude the port of the suction catheter and
in a sweeping motion slowly remove any
vomitus, blood, or other secretions. (No
longer than 10 sec)

 Clear suction catheter with water.
 Reattach ventilation device and oxygenate
patient.
 Record the time and results in the electronic
PCR
 The patient may assist with this procedure if
they are conscious.

UNIT 7
CARDIAC EMERGENCIES

CARDIAC EMERGENCIES CONT

Heart Failure
The term "heart failure" should not be
confused with cardiac arrest, a situation in
which the heart actually stops beating.
Heart failure, also called congestive heart
failure, is a disorder in which the heart loses
its ability to pump blood efficiently.

 Or can be the result of a heart attack
(myocardial infarction), ischemic heart
disease, or cardiomyopathy (any disease that
affects the myocardium)
 or as the ventricles of the heart start to fail,
there is a back up of fluids and blood in the
circulatory system

 Or backing up of fluids causing a build up in
the lungs (pulmonary edema) and body
tissues
 Or an acute myocardial infarction usually
causes the left ventricle to be damaged
 Or chronic hypertension causing the left
ventricle to suffer long term effects from
having to pump against restricted peripheral
arteries.

 Or with left-sided heart failure, blood backs
up into the left atrium and pulmonary veins
 Or as veins fill up, the serum component of
blood is forced out of the capillaries into the
alveoli.
 Or serum mixes with the air in the lungs and
produces foam (pulmonary edema)

 Right sided heart failure most commonly
occurs due to left-sided failure. Left sides
heart failure increases the workload for the
right side, and eventually, the right side is no
longer able to keep up with demand, and
failure starts to occur.
 Right sided failure may also be a result of
pulmonary embolism, long standing COPD,
or myocardial infarction

 Right sided failure causes blood to back up
behind the right ventricle, which increases
pressure in the systemic veins
 As a result, this increased pressure in the
veins can be seen in the veins that run close
to the body surface, such as the juglar vein in
the neck

 Continued pressure will result in the fluid
pooling in the tissues, which can be identified
by the peripheral edema
 This is most noticeable in the patient’s feet
and ankles when the patient is standing or
sitting or the lower back if the patient is
bedridden
 Right sided heart failure by itself is seldom a
life-threatening emergency

 Heart failure is almost always a chronic, long-
term condition, although it can sometimes
develop suddenly. This condition may affect
the right side, the left side, or both sides of
the heart.

As the heart's pumping action is lost, blood
may back up into other areas of the body,
including:
 The liver
 The gastrointestinal tract and extremities
(right sided heart failure)
 The lungs (left sided heart failure)

With heart failure, many organs do not
receive enough oxygen and nutrients, which
damages them and reduces their ability to
function properly. Most areas of the body can
be affected when both sides of the heart fail

Heart failure becomes more common with advancing
age. Patients are also at increased risk for
developing heart failure if they are overweight, have
diabetes, smoke cigarettes, abuse alcohol, or use
cocaine

Symptoms
 Weight gain
 Swelling of the feet and ankles
 Swelling of the abdomen
 Pronounced neck veins
 Loss of appetite
 Nausea and vomiting

 Shortness of breath with activity, or after lying
down for a while
 Difficulty sleeping
 Fatigue, weakness, faintness
 Sensation of feeling the heart beat
(palpations)
 Irregular or rapid pulse
 Decreased alertness or concentration

 Cough
 Decreased urine output
 Need to urinate at night
 Infants may sweat during feeding (or other
exertion).

Some patients with heart failure have no
symptoms. In these people, the symptoms
may develop only with these conditions:
 Infections with high fever
 Anemia
 Abnormal heart rhythm (arrhythmias)
 Hyperthyroidism
 Kidney disease

STABLE ANGINA

Definition
Angina is chest pain caused by too little blood
flow to the heart muscle. The pain usually
begins slowly and gets worse over a period of
minutes before going away.

The right coronary artery supplies blood from
the aorta to the right side of the heart

Stable angina typically occurs when you exert
yourself, and is quickly relieved
with medication or rest. It is also called
chronic angina. Angina chest pain that lasts
longer than a few minutes or occurs with rest
is considered unstable angina

The most common cause of angina is
coronary heart disease (CAD). Angina
pectoris is the medical term for this type of
chest pain.
Situations that increase blood flow to the
heart may cause angina in people with CAD.
These include exercise, heavy meals, and
stress.

The risk factors for angina pectoris include:
 Male gender
 Cigarette smoking
 High cholesterol levels (in particular, high
LDL and low HDL cholesterol)
 High blood pressure

 Diabetes
 Family history of coronary heart disease
before age 55
 Sedentary lifestyle
 Obesity

Less common causes of angina include:
 Coronary artery spasm (also called
Prinzmetal's angina)
 Diseases of the heart valves
 Heart failure
 Abnormal heart rhythms
 Anemia

Symptoms of Stable Angina
 Occurs after activity, stress, or exertion
 Lasts 1 to 15 minutes
 Is usually relieved with rest or nitroglycerin

The most common symptom is a feeling of
tightness, heavy pressure, or squeezing or
crushing chest pain that:
 Occurs under the breastbone or slightly to the
left
 Is not clearly focused in one spot
 May spread to shoulder, arm, jaw, neck,
back, or other areas
 May feel like gas or indigestion

Treatment
The goals of treatment are to reduce
symptoms and prevent complications.
 Rest
 Take nitroglycerin (only if prescribed by your
doctor)

HEART ATTACK

Definition
A heart attack (myocardial infarction) occurs
when an area of heart muscle dies or is
permanently damaged because of an
inadequate supply of oxygen to that area

Most heart attacks are caused by a clot that
blocks one of the coronary arteries (the blood
vessels that bring blood and oxygen to the
heart muscle). The clot usually forms in a
coronary artery that has been previously
narrowed from changes related to
atherosclerosis.

The atherosclerotic plaque (buildup) inside the
arterial wall sometimes cracks, and this
triggers the formation of a clot, also called a
thrombus
A clot in the coronary artery interrupts the
flow of blood and oxygen to the heart muscle,
leading to the death of heart cells in that
area.

The damaged heart muscle loses its ability to
contract, and the remaining heart muscle
needs to compensate for that weakened
area.
Occasionally, sudden overwhelming stress
can trigger a heart attack.

The risk factors for coronary artery disease
and heart attack include:
 Smoking
 Too much fat in your diet
 Many of the risk factors listed are related to
being overweight.

Symptoms
Chest pain behind the sternum (breastbone)
is a major symptom of heart attack, but in
many cases the pain may be subtle or even
completely absent (called a "silent heart
attack"), especially in the elderly and those
with diabetes.

Often, the pain radiates from your chest to
your arms or shoulder; neck, teeth, or jaw;
abdomen or back. Sometimes, the pain is
only felt in one these other locations.

The pain typically lasts longer than 10 minutes
and is not fully relieved by rest or
nitroglycerine, both of which can relieve pain
from angina

The pain can be intense and severe or quite
subtle and confusing. It can feel like:
 squeezing or heavy pressure
 a tight band on the chest
 "an elephant sitting on [your] chest“
 bad indigestion

 Sweating, which may be profuse
 Feeling of "impending doom“
 Anxiety

Other symptoms you may have either alone
or along with chest pain include:
 Shortness of breath
 Cough
 Lightheadedness – dizziness
 Fainting
 Nausea or vomiting

Heart attacks account for 1 out of every 5
deaths. It is a major cause of sudden death in
adults.

Treatment
The goals of treatment are to stop the
progression of the heart attack, to reduce the
demands on the heart so that it can heal, and
to prevent complications.

Oxygen is usually given, even if blood oxygen
levels are normal. This makes oxygen readily
available to the tissues of the body and
reduces the workload of the heart.

Cardiac Arrest
Cardiac arrest is the sudden, abrupt loss of
heart function. The victim may or may not
have diagnosed heart disease. It's also called
sudden cardiac arrest or unexpected cardiac
arrest. Sudden death occurs within minutes
after symptoms appear.

Causes of Cardiac Arrest
The most common underlying reason for
patients to die suddenly from cardiac arrest is
coronary heart disease. Most cardiac arrests
that lead to sudden death occur when the
electrical impulses in the diseased heart
become rapid (ventricular tachycardia) or
chaotic (ventricular fibrillation) or both.

This irregular heart rhythm (arrhythmia)
causes the heart to suddenly stop beating.
Some cardiac arrests are due to extreme
slowing of the heart. This is called
bradycardia.
.

Other factors besides heart disease and heart
attack can cause cardiac arrest. They include
respiratory arrest, electrocution, drowning,
choking and trauma. Cardiac arrest can also
occur without any known cause

The Hearts Electrical System
 The electrical system of the heart determines
the pumping action of the heart. Under
normal conditions, specialized cells in the
heart initiate and carry on electrical activity.

 The normal point of origin of the electrical
impulse is the sinoatrial node (SA), which is
situated in the upper part of the heart’s right
atrium.
 The electrical impulse moves to the
atrioventricular node (AV), which is situated
between the two atria and ventricles, through
conduction pathways within the heart muscle

 From the AV node, the electrical signal is
sent to the ventricles through other pathways.
 These electrical impulses are the stimuli that
cause the heart muscle to contract and pump
blood out of it’s chambers and throughout the
body

 Cardiac monitors are used to read the
electrical impulses in the heart.
 An electrocardiogram (ECG, EKG) is the
product of transferring those electric impulse
images to a strip of graph paper.
 The normal conduction of impulses without
any disturbances is called a normal sinus
rhythm or NSR

 In NSR, the impulse is initiated in the SA
node and transmitted to the atria. The
stimulus from the electrical impulse causes
the atria to contract and expel blood to the
ventricles. Meanwhile the electrical current
continues to travel through the atria and the
AV node to the ventricles.

 When the ventricles receive the impulse they
contract to expel the blood throughout the
bodies vessels.
 This process normally takes place 60 to 100
times per minute while at rest, more when the
body is exerted

 Heart rhythms
 The healthy heart usually displays on an
ECG a normal sinus rhythm.
 Disturbances or variations to that are called
dysrhythmias
 Dysrhythmias can be benign or have serious
consequences

 Three dysrhythmias or major conduction
disturbances that are life threatening are
asystole, ventricular tachycardia (VT) and
ventricular fibrillation (VF)
 Asystole is the absence of electricle activity in
the heart
 Ventricular Tachycardia (VT) is a rhythm of
fast-paced contractions of the heart’s
ventricles.

 The contractions are too fast to allow the
ventricles to fill with blood to pump an
adequate supply of blood to the body. A
pulse may be still found in this dysrhythmia

 Ventricular Fibrillation (VF) is a chaotic
discharge of electrical activity that causes the
heart muscle to vibrate or shake
uncontrollably. No pulse can be found. VF if
not reversed quickly will deteriorate into
asystole very quickly.

Can cardiac arrest be reversed?
Brain death and permanent death start to
occur in just 4 to 6 minutes after someone
experiences cardiac arrest. Cardiac arrest
can be reversed if it's treated within a few
minutes with an electric shock to the heart to
restore a normal heartbeat.

This process is called defibrillation. A victim's
chances of survival are reduced by 7 to 10
percent with every minute that passes without
defibrillation. Few attempts at resuscitation
succeed after 10 minutes.

Defibrillation
Defibrillation is a medical technique used to
counter the onset of ventricular fibrillation.

In simple terms, the process uses an electric
shock to stop the heart, in the hope that the
heart will restart with rhythmic contractions.

Automated External Defibrillation

AED
An Automated External Defibrillator (AED) is a
machine that analyses and looks for shockable
heart rhythms, advises the rescuer of the need for
defibrillation and delivers that shock, if needed.
Its purpose is to reset a heart that has stopped
beating effectively, usually caused by an abnormal
heart rhythm called ventricular fibrillation (VF).

The AED is applied to the victim of sudden
cardiac arrest.
Adhesive pads attached to wires that connect
to the AED are placed on the patient's chest,
and the machine delivers an electrical shock
through the body to the heart.

 Special Resuscitation Situations
 Special situations require EMRs to pay
special attention when using an AED.
 Hypothermia:
 Check the pulse of a person suffering from
severe hypothermia for up to 45 seconds. If
AED is indicated, give only one shock.
Following the shock, continue the CPR
sequence

 Infants
 Babies under one year old should not be
defibrillated by an EMR

 Transdermal Medications:
 AED electrodes should not be placed directly
over transdermal medications

 Implanted Pacemakers and Implanted
Cardioverter-defibrillaters:
 Position the electrodes a minimum of 2.5 cm
(1 Inch) away from these devices.
 If an AICD is already in shock sequence,
allow 30 to 60 seconds for the AICD to
complete the treatment cycle before
delivering a shock from the AED

 Other precautions:
 Avoid using alcohol pads to clean the chest
before applying the AED pads.
 Stand clear of the patient while AED is
analyzing and shocking
 Do not analyze the heart rhythm in a moving
ambulance
 Do not attempt to defibrillate a patient in the
presence of flammable materials

 Avoid radio transmissions, cell phone activity
within two meters (six feet) while defibrillating
a patient
 Keep breathing devices with free-flowing
oxygen away from the patient while
defibrillating
 Avoid the use of supplemental free-flowing
oxygen while using an AED in a confined
space

 A trained operator who uses the AED
correctly cannot be hurt.
 A serious injury to an AED operator has
never been reported.

Stroke

A stroke is an interruption of the blood supply
to any part of the brain. A stroke is
sometimes called a "brain attack." A stroke
involves loss of brain functions caused by a
loss of blood circulation to areas of the brain.

The blockage usually occurs when a clot or
piece of atherosclerotic plaque breaks away
from another area of the body and lodges
within the vasculature of the brain.

Left cerebral hemisphere - function

The left cerebral hemisphere controls
movement of the right side of the body.
Depending on the severity, a stroke affecting
the left cerebral hemisphere may result in
functional loss or motor skill impairment of
the right side of the body, and may also
cause loss of speech.

Right cerebral hemisphere - function

The right cerebral hemisphere controls
movement of the left side of the body.
Depending on the severity, a stroke affecting
the right cerebral hemisphere may result in
functional loss or motor skill impairment of
the left side of the body. In addition, there
may be impairment of the normal attention to
the left side of the body and its surroundings.

ISCHEMIC STROKE
This is the most common type of stroke. Usually this
type of stroke results from clogged arteries, a
condition called atherosclerosis. Fatty deposits and
blood platelets collect on the wall of the arteries,
forming a sticky substance called plaque. Over time,
the plaque builds up. Often, the plaque causes the
blood to flow abnormally, which can cause the blood
to clot.

There are two types of clots:
A clot that breaks loose and moves through the
bloodstream to the brain is called an cerebral
embolism. Another important cause of cerebral
embolisms is a type of arrhythmia called atrial
fibrillation. Other causes of ischemic stroke include
endocarditis and the use of a mechanical heart
valve. A clot can form on the artificial valve, break
off, and travel to the brain.

HEMORRHAGIC STROKE
A second major cause of stroke is bleeding in
the brain hemorrhagic stroke. This can occur
when small blood vessels in the brain
become weak and burst. Some people have
defects in the blood vessels of the brain that
make this more likely. The flow of blood after
the blood vessel ruptures damages brain
cells.

STROKE RISKS
 High blood pressure is the number one reason that
a patient might have a stroke. The risk of stroke is
also increased by age, family history of stroke,
smoking, diabetes, high cholesterol, and heart
disease.
 Certain medications increase the chances of clot
formation, and therefore the patient’s chances for a
stroke. Birth control pills can cause blood clots,
especially in woman who smoke and who are older
than 35.

 Men have more strokes than women. But,
women have a risk of stroke during
pregnancy and the weeks immediately after
pregnancy.
 Cocaine use, alcohol abuse, head injury, and
bleeding disorders increase the risk of
bleeding into the brain.

Symptoms
The symptoms of stroke depend on what part of the
brain is damaged. In some cases, a person may not
even be aware that he or she has had a stroke.
Usually, a SUDDEN development of one or more of
the following indicates a stroke:
 Weakness or paralysis of an arm, leg, side of the
face, or any part of the body
 Numbness, tingling, decreased sensation

 Vision changes
 Slurred speech, inability to speak or
understand speech, difficulty reading or
writing
 Swallowing difficulties or drooling
 Loss of memory

 Vertigo (spinning sensation)
 Loss of balance or coordination
 Personality changes
 Mood changes (depression, apathy)
 Drowsiness, lethargy, or loss of consciousness
 Uncontrollable eye movements or eyelid drooping

 Remember FAST:
 Face -- Facial numbness or weakness, especially
one one side
 Arm -- Arm numbness ore weakness, especially on
one side
 Speech -- Slurred speech or difficulty speaking or
understanding
 Time -- Time is critically important - do not delay
transport

 Treatment for Stroke Patient:
 Ensure a patent airway for all patients
 Care for any life-threatening conditions
 Position patient on unaffected side for
clearing oral cavity or if putting patient in a
recovery position
 High flow oxygen administrated
 Transport to advanced care

 Summary
 The primary sign or symptom for heart attack
is chest pain
 Transport patients you suspect as suffering
from any cardiovascular attack to advanced
care rapidly but carefully

 Congestive heart failure occurs when the
pumping action of the heart is inadequate,
causing fluid to back up into the lungs and
extremities
 The risk factors for stroke are the same as for
cardiovascular disease

Question
You arrive to find a 48 year old male complaining that
his chest feels heavy. The patient is awake and talking
to you. During your assessment you note that his skin
is pale, cool and clammy. Your first step is to.
A. Apply an AED
B. Administer supplemental oxygen
C. Obtain a past medical history
D. Assist the pt. in taking his neighbor’s nitroglycerine

Answer
(B) Your first step is to administer supplemental
oxygen. When treating chest pain it is important to
get oxygen to the pt. as soon as possible to help
alleviate damage to the heart muscle

Question
The electrical impulse generated in the right atrium is
called the:
A. Atrioventricular node
B. Purkinje fibers
C. Sinoatrial node
D. Bundle of his

Answer
(C) Sinoatrial node

Which of the following arrhythmias should be
shocked using an AED?
A. Asystole
B. Ventricular tachycardia
C. Pulseless electrical activity
D. Atrial fibrillation

Answer
(B) Ventricular tachycardia without a pulse
should be shocked by an AED.
Pulseless electrical activity or PEA has an
organized electrical activity

Question
You are treating a 45 year old male who has a
history of heart problems. The patient tells you
that he has chest pain after exerting himself,
however it relieves itself by rest. You would
suspect this patient has:
A. Angina pectoris
B. Myocardial infarction
C. Congestive heart failure
D. Muscular skeletal pain

Answer
(A) This patient has the signs and symptoms of angina
pectoris. Chest pain brought upon by exertion and
relieved by rest is indicative of angina.

Question
The patient in the previous question may also have is
chest pain relieved by:
A. Albuteral
B. Lasix
C. Epinephrine
D. nitroglycerine

Answer
(D) Patients suffering from angina and who have this
condition in the past will typically have nitro
prescribed to them by their physician.

Question
Your are treating a 62 year old female patient who is
complaining of shortness of breath, chest pain and
is coughing up pink frothy sputum. You would
suspect this patient has:
A. Right sided congestive heart failure
B. Left sided congestive heart failure
C. Emphysema
D. pneumonia

Answer
(B) This patient is suffering from Congestive heart
failure. In order to know if it is right or left depends
on the patient’s symptoms. In this case the pt has
pink frothy sputum which is indicative of oxygenated
blood. Essentially the left side of the heart is not
able to keep up and the blood backs up into the
lungs and causes the pink frothy sputum. Right
sided would be JVD.

UNIT 9
BLEEDING

BLEEDING CONT
 Bleeding the loss of blood from arteries, veins
or capillaries.
 A large amount of bleeding occurring in a
short time is called a hemorrhage
 Bleeding is either internal or external
 Internal bleeding is often difficult to recognize

BLEEDING CONT
 External bleeding is obvious because it is
typically visible
 Uncontrolled bleeding whether internal or
external is a life-threatening emergency
 Checking for and controlling bleeding in the
primary survey is very important.

BLEEDING CONT
BLOOD COMPONENTS
Normally 7-8% of human body weight is from
blood. This essential fluid carries out the
critical functions of transporting oxygen and
nutrients to our cells and getting rid of carbon
dioxide and other waste products.

BLEEDING CONT
In addition, it plays a vital role in our immune
system and in maintaining a relatively
constant body temperature. Blood is a highly
specialized tissue composed of many
different kinds of components.

BLEEDING CONT
Four of the most important ones are red cells, white
cells, platelets, and plasma.
The liquid part of the blood is called the plasma.
The solid components are the red cells and white
cells
Cell fragments are called platelets and also contains
blood clotting factors, sugars, lipids, vitamins,
minerals, hormones, enzymes, antibodies, and other
proteins.

BLEEDING CONT
The red cells are produced continuously in our bone
marrow from stem cells. Hemoglobin is the gas
transporting protein molecule that makes up 95% of
a red cell. Each red cell has about 270,000,000
iron-rich hemoglobin molecules. People who are
anemic generally have a deficiency in red cells. The
red color of blood is primarily due to oxygenated red
cells.

BLEEDING CONT
White Cells
White cells, or leukocytes, exist in variable
numbers and types but make up a very small part of
blood's volume--normally only about 1%.
Leukocytes are not limited to blood. They occur
elsewhere in the body as well, most notably in the
spleen, liver, and lymph glands. Most are produced
in our bone marrow from the same kind of stem cells
that produce red blood cells.

BLEEDING CONT
It is likely that plasma contains some of every
protein produced by the body--approximately
500 have been identified in human plasma so
far

BLEEDING CONT
Platelets
Platelets, or thrombocytes, are cells that clot
blood at the site of wounds. They do this by
adhering to the walls of blood vessels,
thereby plugging the rupture in the vascular
wall. They also can release coagulating
chemicals which cause clots to form in the
blood that can plug up narrowed blood
vessels.

BLEEDING CONT
There are more than a dozen types of blood
clotting factors and platelets that need to
interact in the blood clotting process. Recent
research has shown that platelets help fight
infections by releasing proteins that kill
invading bacteria and some other
microorganisms. In addition, platelets
stimulate the immune system.

BLEEDING CONT
Individual platelets are about 1/3 the size of
red cells. They have a lifespan of 9-10 days.
Like the red and white blood cells, platelets
are produced in bone marrow from stem
cells.

BLEEDING CONT
Functions of blood
Blood functions in:
 Transportation
 oxygen, carbon dioxide, water, nutrients,
heat, wastes, hormones
 Regulation
 pH – buffers

BLEEDING CONT
 Body temperature
 Cell water content
 osmotic pressure of blood

BLEEDING CONT
They also have the function of getting rid of
dead or dieing blood cells as well as foreign
matter such as dust and asbestos. Red cells
remain viable for only about 120 days before
they are removed from the blood and their
components recycled in the spleen.
Individual white cells usually only last 18-36
hours before they also are removed, though
some types live as much as a year.

BLEEDING CONT
BLOOD VESSELS

BLEEDING CONT
 Blood is channeled through the blood
vessels. There are three major types of
blood vessels:
 Arteries
 Veins
 Capillaries

BLEEDING CONT
Arteries
Arteries are elastic vessels that transport
blood away from the heart. The largest artery
of the body is the aorta. The aorta originates
from the heart and branches out into smaller
arteries. The smallest arteries are called
arterioles which branch into capillaries.

BLEEDING CONT
 Major Arteries

BLEEDING CONT
Veins
Veins are elastic vessels that transport blood to the
heart. The smallest veins in the body are called
venules. They receive blood from the arteries via the
arterioles and capillaries. The venules branch into
larger veins which eventually carry the blood to the
largest veins in the body, the vena cava. The blood
is then transported from the vena cava to the right
atrium of the heart.

BLEEDING CONT
 Major Veins

BLEEDING CONT
Capillaries
Capillaries are extremely small vessels located
within the tissues of the body that transport blood
from the arteries to the veins. Capillary walls are
thin and are composed of endothelium (a single
layer of overlapping flat cells). Oxygen, carbon
dioxide, nutrients and wastes are exchanged
through the thin walls of the capillaries.

BLEEDING CONT
The flow of blood is controlled by structures
called precapillary sphincters. These
structures are located between arterioles and
capillaries and contain muscle fibers that
allow them to contract.

BLEEDING CONT
When the sphincters are open, blood flows
freely to the capillary beds of body tissue.
When the sphincters are closed, blood is not
allowed to flow through the capillary beds.

BLEEDING CONT
Capillary Size
Capillaries are so small that red blood cells
can only travel through them in single file.
5-10 microns in diameter.

BLEEDING CONT

BLEEDING CONT
Bleeding from most injuries can be stopped
by applying direct pressure to the injury. This
keeps from cutting off the blood supply to the
affected limb. When there is severe bleeding,
where a major artery has been severed,
pressure may be insufficient and a tourniquet
may be necessary

BLEEDING

BLEEDING CONT

BLEEDING CONT
Considerations
Direct pressure will stop most external bleeding, and
is the most important initial first aid.
Blood loss can cause bruises, which usually result
from a blow or a fall. They are dark, discolored
areas on the skin. Apply a cool compress to the
area as soon as possible to reduce SWELLING.
Wrap the ice in a towel and place the towel over the
injury. Do not place ice directly on the skin.

BLEEDING CONT
Serious injuries do not always bleed heavily, and
some relatively minor injuries (for example, scalp
wounds) can bleed profusely. People who take
blood-thinning medication or who have a bleeding
disorder, such as hemophilia, may bleed
excessively and quickly because their blood cannot
clot properly. Bleeding in such people requires
immediate medical attention.

BLEEDING CONT
Always wash your hands before (if possible)
and after giving first aid to someone who is
bleeding to avoid infections. Try to use latex
gloves when treating a bleeding victim. Latex
gloves should be in every first aid kit.

BLEEDING CONT
People allergic to latex can use a non-latex,
synthetic glove. Viral hepatitis can be
transmitted by skin contact with infected
blood, and HIV can be contracted if infected
blood gets into an open wound -- even a
small one.

BLEEDING CONT
Although puncture wounds usually don't
bleed very much, they carry a high risk of
infection. Seek medical care to prevent
tetanus or other infection.

BLEEDING CONT
Abdominal wounds can be very serious
because of the possibility of severe internal
bleeding, which may not be obvious from
looking at a person, but which may result in
shock

BLEEDING CONT
EXTERNAL BLEEDING
The causes of external bleeding can come
from numerous sources. Any type of cut,
scrape or fall where blood is coming from an
open wound is considered external bleeding.

BLEEDING CONT
There are three types of external bleeding.
Capillary bleeding is the most common type
of external bleeding. This type of bleeding
occurs when blood oozes from capillaries. It
is usually not serious and the easiest form of
external bleeding to control.

BLEEDING CONT
The second more serious type of bleeding is
venous bleeding. This is when a vein has
been severed and blood flows or gushes
steadily. Most veins collapse when cut, which
aids in controlling this type of external
bleeding until medical attention can be
received.

BLEEDING CONT
The third and most serious type of external
bleeding is arterial bleeding. This type of
injury can lead to a large amount of blood
loss, as the blood flows at a faster rate is less
likely to clot. Even so, with the quick
response and by administering the proper
first aid method of controlling external
bleeding, it is unlikely a person will bleed to
death.

BLEEDING CONT
INTERNAL BLEEDING
Internal bleeding is classified as either visible,
in that the bleeding can be seen, or
concealed, where no direct evidence of
bleeding is obvious. Internal bleeding is
always to be considered as a very serious
matter, and urgent medical aid is necessary.

BLEEDING CONT
In most instances, obtaining an adequate
history of the incident or illness will give the
first aid provider the necessary clue as to
whether internal bleeding may be present.
Remember that current signs and symptoms,
or the lack of them, do not necessarily
indicate the casualty’s condition.

BLEEDING CONT
Certain critical signs and symptoms may not
appear until well after the incident due to the
stealth of the bleed, and may only be
detected by the fact that the casualty’s
observations worsen despite there being no
obvious cause.

BLEEDING CONT
Visible internal bleeding
Visible internal bleeding is referred to this
way because the results can be seen:
 Bleeding in the Lungs - frothy, bright red
blood coughed up by the casualty
 Anal or Vaginal Bleeding - usually red blood
mixed with mucus

BLEEDING CONT
 Bleeding in the Stomach - dark ‘coffee
grounds’, or red blood, in vomitus
 Bowel or Intestinal Bleeding - dark, loose,
foul smelling stools
 Bleeding in the Urinary Tract - dark or red
colored urine

BLEEDING CONT
 Bleeding from the Ears - bright, sticky blood
or blood mixed with clear fluid
Bruising - the tissues look dark due to the
blood under the skin. Caused by blows from
blunt instruments or by crushing

BLEEDING CONT
Concealed internal bleeding
In these cases, the EMR is heavily reliant on
history, signs and symptoms. Judgment and
experience play a part, but it may come down
to the EMR’s ‘gut feeling’. If you are unsure,
assume the worst and treat for internal
bleeding.

BLEEDING CONT
The detection of internal bleeding relies upon good
observations and an appreciation of the physical
forces that have affected the casualty. Remember to
look at the important observations that may indicate
internal bleeding, which include:
 Skin appearance
 Conscious state
 Pulse
 Respiration

BLEEDING CONT
SIGNS AND SYMPTOMS
 pale, cool, clammy skin
 thirst
 rapid, weak pulse
 rapid, shallow breathing
 ‘guarding’ of the abdomen, with fetal position
if lying down
 pain or discomfort

BLEEDING CONT
 nausea and/or vomiting
 visible swelling of the abdomen
 gradually lapsing into shock
 anxiety or restlessness
 soft tissue that are tender, swollen or firm

BLEEDING CONT
CARE AND TREATMENT
 position the casualty supine, with legs
elevated and bent at the knees (only if
conscious)
 if unconscious, side position with support
under the legs to elevate them
 reassurance
 treat any injuries
 give nothing by mouth

BLEEDING CONT
 Monitor vitals
 Transport to advanced medical care

BLEEDING CONT
 Control of External Bleeding
 There are four basic procedures for
controlling external bleeding:
 Direct pressure
 Pressure bandages
 Point pressure
 Touriquets

BLEEDING CONT
 Tourniquets
 The application of the tourniquet is the last
alternative to control external bleeding
 Tourniquets should be made with a wide
material such as a cravat or a large BP cuff
 Assess the distal pulse and neurovascular
status before and after application

BLEEDING CONT
 Apply the tourniquet 5 -- 10 cm (2 -- 5 inches)
above the injury and above any joint in this
range
 If using a BP cuff, inflate to approximately 30
mmHg above the systolic pressure

BLEEDING CONT
 After the tourniquet has been in place for two
hours, release it for three to five minutes
every half hour using direct pressure and
pressure points to control bleeding during
release.
 Application and release times must be
documented

BLEEDING CONT
Question
You are applying direct pressure to a 12 year old female’s lower
leg which was lacerated by a large piece of glass. The
bleeding continues to soak through the bandages even while
applying direct pressure. Your next step would be to:
A. Elevate the extremity
B. Apply pressure at the femoral artery
C. Apply a tourniquet
D. Remove the blood soaked bandages and replace with clean
ones

BLEEDING CONT
Answer
(A)
If the blood continues to soak through your pressure
dressing, your next step would be to elevate the
extremity. If the bleeding still does not stop, apply
pressure to her pulse point, which in this case would
be the femoral artery.

BLEEDING CONT
Question
Your patient is complaining of abdominal pain. He
tells you that his stools have been dark and tarry.
His abdomen is tender on palpation. You would
suspect this patient is suffering from.
A. Upper abdominal internal bleeding
B. Lower abdominal internal bleeding
C. Abdominal evisceration
D. Bleeding from the colon

BLEEDING CONT
Answer
(A) You would suspect that this patient is having upper
abdominal internal bleeding. Typically bright red
colored blood in the stool is indicative of lower GI
bleeding. And dark colored blood is indicative of
upper GI bleeding

UNIT 10
CARDIOVASCULAR SHOCK

CARDIOVASCULAR SHOCK
Shock is a severe life threatening condition
that occurs when not enough blood flows
through the body, causing very low blood
pressure, a lack of urine, and cell and tissue
damage.
This can damage multiple organs. Shock
requires IMMEDIATE medical treatment and
can get worse very rapidly

CARDIOVASCULAR SHOCK CONT
Major classes of shock include:
Cardiogenic shock:
Failure of the heart to effectively pump blood
to all parts of the body, occurs with heart
attack, cardiac arrest, angina etc

Psychogenic shock:
Factors such as emotional stress cause blood
to pool in the body in areas away fro the
brain, occurs with brain or nerve injuries

Hypovolemic shock:
Caused by severe bleeding depleting the
blood volume and the ability to oxygenate the
cells.

Anaphylactic shock:
Caused by life-threatening allergic reactions
to a substance like medications, food and
insect bites

Septic shock:
Poisons cause by severe infections that
cause blood vessels to dilate or break down
to allow fluids to pass through the blood
vessel wall.

Respiratory:
Caused by the failure of the lungs to transfer
sufficient oxygen into the bloodstream. This
occurs with breathing emergencies or
respiratory arrest

Neurogenic shock:
The is caused by the failure of the nervous
system to control the size of the blood
vessels, causing them to dilate. This
happens with brain injury or nerve injuries.

Symptoms
A person in shock has extremely low blood
pressure. Depending on the specific cause and type
of shock, symptoms will include one or more of the
following:
 Anxiety or agitation
 Confusion
 Pale, cool, clammy skin
 Low output or no output of urine
 Bluish lips and fingernails

 Dizziness, light-headedness, or faintness
 Profuse sweating, moist skin
 Rapid but weak pulse
 Shallow breathing
 Chest pain, unconsciousness

TREATMENT
 Check the person's airway, breathing, and
circulation. If necessary, begin rescue
breathing and CPR
 Even if the patient is able to breathe on his or
her own, continue to check rate of breathing
at least every 5 minutes while in transport

 If the person is conscious and DOES NOT
have an injury to the head, leg, neck, or
spine, place the person in the shock position.
Lay the person on the cot in the supine
position and elevate the legs about 12
inches. DO NOT elevate the head. If raising
the legs will cause pain or potential harm,
leave the person lying flat.

 Give appropriate care for any wounds,
injuries, or illnesses.
 Keep the person warm and comfortable.
Loosen tight clothing.

 Control external bleeding
 Administer supplemental oxygen

Summary
do not wait for shock to develop before
providing for care to a patient with injury or
illness.
The key to managing CV shock effectively
begins with recognizing the situations that CV
shock may develop

 Care for life-threatening conditions in the
primary survey
 CV shock is a factor not to be overlooked in
illness and injury
 You can not effectively manage CV shock in
the field therefore rapid transport to advanced
care is imperative

Question
A patient who is suffering from a severe allergic
reaction.
A. Asthma
B. Syncope
C. Anaphylactic shock
D. Hayfever

Answer
(C) Anaphylactic shock

Question
Which of the following are the signs and symptoms of shock in
the early stages?
A. Tachycardia, anxious, restless, skin pale, cool and clammy
B. Bradycardia, anxious, restless, skin pale, cool and clammy
C. Tachycardia, hypotension, increased breathing
D. Bradycardia, hypotension, skin pale, cool and clammy

Answer
(A) Early signs of shock include an increased heart
rate, increased respirations, and pale, cool and
clammy skin. The patient is restless anxious due to
hypoxia.

Question
You are treating a patient who has a possible spinal
injury after falling app. 18 feet. The pt is warm and
dry. The pt’s vitals are: pulse – 80, respirations –
20, and BP – 118/76. When you reassess the pt’s
vitals signs 5 minutes later, the pulse and
respirations are the same, but the BP has dropped
to 80/40. You would suspect this pt is suffering
from:

A. Cardiogenic shock
B. Vasogenic shock
C. Neurogenic shock
D. Hypovolemic shock

Answer
(C) Pts who have spinal injuries may suddenly drop
the BP although other vital signs remain the same.
Also called relative hypovolemia do to the blood
vessels ganging in size (dilating or constricting)

Question
You are called to the scene of a pt in his early fifties
and being treated for an illness that has been
ongoing for the past three weeks. The pt is febrile,
diaphoretic, and pale. His BP - 88/40, pulse – 120.
You would suspect this patient is suffering from:

A. Neurogenic shock
B. Psychogenic shock
C. Septic shock
D. Anaphylactic shock

Answer
(C) Pts who have been sick for periods of time are
susceptible to septic shock as a result of infection in
the body causing vasodilation of the blood vessels.

Mid Term Evaluation
 Candidates will write the mid term exam and
achieve a minimum mark of 80%
 You will have 60 minutes to write the exam

UNIT 11
SOFT TISSUE INJURIES

SOFT TISSUE INJURY
Soft tissue injury is damage of the soft tissue
of the body. These types of injuries are a
major source of pain and disability. The four
fundamental tissues that are affected are the
epithelial, muscular, nervous and connective
tissues.
Soft tissue injuries include sprains, strains,
subluxation, repetitive stress injury, carpal
tunnel syndrome, etc.

SOFT TISSUE INJURY CONT
Soft Tissue
The term soft tissue refers to tissues that
connect, support, or surround other
structures and organs of the body. Soft tissue
includes muscles, tendons, fibrous tissues,
fat, blood vessels, nerves, and synovial
tissues.

Often soft tissue injuries are some of the
most chronically painful and difficult to treat
because it is very difficult to see what is going
on under the skin with the soft connective
tissues, joints, muscles, cartilage and
tendons.

Cartilage is found primarily in joints, where it
provides cushioning. The extracellular matrix
of cartilage is composed primarily of collagen.

SPRAIN
A sprain is an injury which occurs to
ligaments caused by a sudden overstretching
. The ligament is usually only stretched, but
sometimes it can be snapped, slightly torn or
ruptured, all of which are more serious and
require longer to heal

Strain
A strain is an injury which occurs to a muscle in
which the muscle fibers tear as a result of over
stretching. Strains are also known as pulled
muscles. The equivalent injury to a ligament is a
sprain.
Typical symptoms of a strain include localized pain,
stiffness, swelling, inflammation and bruising around
the strained muscle.

If you have ever been in a car crash and
experienced pain in your neck, you have
most likely had whiplash. Whiplash, also
called neck sprain or neck strain, is an injury
to the soft tissues of the neck. It is usually
caused by sudden extension (backward
movement of the neck) and flexion (forward
movement of the neck).

This type of injury is often the result of rear-
end car crashes. Severe whiplash can also
include injury to the intervertebral joints,
discs, ligaments, cervical muscles and nerve
roots.

Symptoms of Whiplash
Most people experience neck pain either
immediately after the injury or several days later.
Other symptoms of whiplash may include the
following:
 Neck stiffness
 Injuries to the muscles and ligaments (myofascial
injuries)
 Headache and dizziness (symptoms of a
concussion)

 Difficulty swallowing and chewing and
hoarseness (could indicate injury to the
esophagus and larynx)
 Abnormal sensations such as burning or
prickling (this is called paresthesias)
 Shoulder pain
 Back pain

Subluxation
A subluxation is an incomplete or partial
dislocation of a joint or organ. A dislocation of
any joint will usually need medical attention to
help relocate the joint, however with a
subluxation the patient will often report the
joint relocating by itself.

Subluxation

Management of Soft Tissue Injuries
Management of soft tissue injuries consists of
protecting the injured tissue; resting it with
splints, braces, or tape; ice; compression;
and elevation. An easy mnemonic for
remembering these steps is PRICE –
Protection, Rest, Ice, Compression,
Elevation.

Lacerations
 Are produced by forceful impact with a sharp
object that breaks the skin to varying depths
 The damage to the skin is through all layers (full
thickness)
 Larger blood vessels are involved and bleeding
may be extensive
 Blood loss must be controlled and the wound
protected from further damage

Avulsions
 Flaps of skin or tissue may be torn loose or
pulled completely off
 Often serious and commonly caused by large
amounts of force being transferred to the
patient’s body
 Separated tissue is cut off from oxygen and
nutrients and will rapidly die

Penetrating/puncture wounds
 Are caused by sharp, pointed objects that
puncture the skin
 Most common - gunshot or knife stab
 May also occur during blunt trauma (car
crash) if a piece of the vehicle punctures the
body
 Little or no external bleeding may occur
 Secondary exit wounds may be present

Puncture wound

Amputations
 May involve extremities or other body parts
 The limb or tissue is completely severed from its
attachments to the body
 Bleeding may be severe, but often the divided blood
vessel will constrict limiting the amount
 Keep the severed body part cool and transport with
the patient as quickly as possible

Preserving tissue
 No amputated body part is too small to be salvaged.
Debris or other contaminating material should be
removed, but the tissue should not be allowed to get
wet.
 An amputated body part should be wrapped in
bandages, towels, or other clean, protective material
and sealed in a plastic bag. Placing the sealed bag
in a cooler or in a container that is inside a second
container filled with cold water or ice will help
prevent tissue deterioration

Evisceration
 Is a situation where organs protrude an abdominal
wound
 The organs must be covered with a sterile dressing
as soon as possible
 The dressing should be moistened with sterile saline
to prevent drying
 The rescuer should not touch the organ & never try
to push the organ back in the abdomen

 Penetrating Injuries Involving Weapons
 Low velocity injuries are usually caused by
hand-powered weapons such as knives,
arrows, etc
 Medium and high velocity injuries are usually
caused by another source such as bullets

 In all cases, it is essential to ensure that the
scene is safe and preserve any evidence
possible
 The entry point and the type of weapon may
give clues as to the possible injuries
 It is not always possible to tell the extent of
the injury just by looking at the entry point.

 Crush Injuries
 Crush injuries occur when a part of the body
receives a crushing force.
 These injuries can be severe and cause
internal bleeding, fractures, and organ
damage with the skin still intact
 This force can be over a short period of time
or a long period of time

Treatment
 Maintain the ABC’s, control any external
bleeding and minimize shock
 Immobilize the injury before moving the
patient

 Crush Syndrome is a condition that occurs
after a crushing pressure has been released.
While under the crushing pressure, the
damaged skeletal muscle begins to break
down, which results in a build up of toxic
substances. When pressure is released, the
toxins flow throughout the bloodstream and
can lead to shock and renal failure.

Acute Compartment Syndrome
 ACS results when pressure within the muscle
builds to dangerous levels most often caused
from bleeding or swelling
 This prevents nourishment from reaching
nerve and muscle cells

 If pressure within the compartment, blood
vessels and nerves in a membrane, gets too
high, the capillaries collapse. This disrupts
blood flow, which leads to blood vessel,
nerve, and muscle damage.
 Without the pressure being relieved,
permanent muscle, nerve and vessel damage
or patient death can occur.

Treatment
 Control the airway
 High flow oxygen
 Assess and control any bleeding
 Immobilize any fractures
 Monitor vitals

Blast Injuries
 These injuries are produced from pressure
waves generated by an explosion and striking
the body surface
 Blasts release large amounts of energy in the
form of pressure and heat

 As a result, injuries can include loss of
hearing, pulmonary hemorrhage, pulmonary
edema, abdominal hemorrhage, and bowel
perforation
 Thermal burns may also occur from the
release of energy in the form of heat

There are three mechanisms of injury
resulting from blasts:
 Injuries from the blast itself
 Injuries from the flying debris, shrapnel, from
the blast
 Trauma from being thrown by the blast

Myocardial Contusions
 The heart muscle may be bruised after brunt
force to the chest by the chest hitting a
steering wheel during an MVC, CPR, a fall
etc.
 There may be pain in the chest or experience
some tachycardia

Treatment
 Maintain an open and patent airway
 Monitor ABC’s
 Administer high volume oxygen

Burns
 Burns are soft tissue injuries caused by heat,
certain chemicals, electricity, and solar
radiation and other forms of radiation.
 Burns are classified as superficial, partial
thickness or full thickness

 The severity of the burn depends on the:
 Temperature of the object that causes the
burn
 Location on the body of the burn
 Extent to which the body has been burnt
 patients age, and medical condition

A critical burn:
 Requires transport to advanced medical care
 Is potentially life-threatening, disfiguring, or
disabling

Some factors that can help you determine
if a burn is critical include:
 Burns that are accompanied by difficult
breathing
 Burns covering more than one body part
 Burns to the head, neck, hands, feet or
genitals

 Any partial-thickness burn to a child or an
older adult
 Using the Rule of Nines and adding up the
percentage of the body affected
 Burns resulting from chemicals, explosions,
or electricity

First degree burn or Superficial Thickness

First degree or Superficial burns affect only
the outer layer of the skin. They cause pain,
redness, and swelling.

Second degree or Partial Thickness burn

Second-degree (partial thickness) burns
affect both the outer and underlying layer of
skin. They cause pain, redness, swelling, and
blistering.

Third degree or Full Thickness burn

Third-degree (full thickness) burns extend
into deeper tissues. They cause white or
blackened, charred skin that may be numb.

Body Surface Area (BSA)
• Usually measured using the “Rule of nine”
• An adult’s hand will also cover about 1%
BSA on an adult patient
• An area that can be covered by four adult
hands would equal approximately 4% of
the entire BSA

Airway burn

Burns to the airway can be caused by
inhaling smoke, steam, superheated air, or
toxic fumes, often in a poorly ventilated
space. Airway burns can be very serious
since the rapid swelling of burned tissue in
the airway can quickly block the flow of air to
the lungs.

Considerations
Before treating, evaluate how extensively
burned the person is and try to determine the
depth of the most serious part of the burn.
Then treat the entire burn accordingly. If in
doubt, treat it as a severe burn.

By giving immediate treatment, you can help
lessen the severity of the burn. Prompt
medical attention to serious burns can help
prevent scarring, disability, and deformity.
Burns on the face, hands, feet, and genitals
can be particularly serious.

Children under age 4 and adults over age 60
have a higher chance of complications and
death from severe burns.
In case of a fire, you and the others there are
at risk for carbon monoxide poisoning.
Anyone with symptoms of headache,
numbness, weakness, or chest pain should
be tested.

Causes
Burns can be caused by dry heat (like fire),
wet heat (such as steam or hot liquids),
radiation, friction, heated objects, the sun,
electricity, or chemicals

Burns to your airways can be caused by
inhaling smoke, steam, superheated air, or
toxic fumes, often in a poorly ventilated
space.
Burns in children are sometimes traced to
parental abuse.

Thermal burns are the most common type.
Thermal burns occur when hot metals,
scalding liquids, steam, or flames come in
contact with your skin. These are frequently
the result of fires, automobile accidents,
playing with matches, improperly stored
gasoline, space heaters, and electrical
malfunctions.

Other causes include unsafe handling of
firecrackers and kitchen accidents (such as a
child climbing on top of a stove or grabbing a
hot iron).

Symptoms
 Blisters
 Pain (the degree of pain is not related to the
severity of the burn -- the most serious burns
can be painless)
 Peeling skin
 Red skin

 Shock (watch for pale and clammy skin,
weakness, bluish lips and fingernails, and a
drop in alertness)
 Swelling
 White or charred skin

Symptoms of an airway burn:
 Charred mouth; burned lips
 Burns on the head, face, or neck
 Wheezing
 Change in voice
 Difficulty breathing; coughing
 Singed nose hairs or eyebrows
 Dark, carbon-stained mucus

FOR MINOR BURNS
If the skin is unbroken, run cool water over the
area of the burn or soak it in a cool water bath (not
ice water). Keep the area submerged for at least 5
minutes. A clean, cold, wet towel will also help
reduce pain.
 Calm and reassure the person.
 After flushing or soaking, cover the burn with a dry,
sterile bandage or clean dressing.

 Protect the burn from pressure and friction.
 Minor burns will usually heal without further
treatment. However, if a second-degree burn covers
an area more than 2 to 3 inches in diameter, or if it
is located on the hands, feet, face, groin, buttocks,
or a major joint, treat the burn as a major burn.
 Make sure the person is up-to-date on tetanus
immobilization

FOR MAJOR BURNS
 if someone is on fire, tell the person to STOP,
DROP, and ROLL. Wrap the person in thick material
to smother the flames (a wool or cotton coat, rug, or
blanket). Douse the person with water.
 Make sure that the person is no longer in contact
with smoldering materials. However, DO NOT
remove burnt clothing that is stuck to the skin.

 Make sure the person is breathing. If breathing has
stopped, or if the person's airway is blocked, open
the airway. If necessary, begin rescue breathing and
CPR.
 Cover the burn area with a dry sterile bandage (if
available) or clean cloth. A sheet will do if the
burned area is large. DO NOT apply any ointments.
Avoid breaking burn blisters.

 If fingers or toes have been burned, separate
them with dry, sterile, non-adhesive
dressings.
 elevate the body part that is burned above
the level of the heart. Protect the burnt area
from pressure and friction.

 Take steps to prevent shock. Lay the person supine,
elevate the feet about 12 inches, and cover him or
her with a blanket. However, DO NOT place the
person in this shock position if a head, neck, back,
or leg injury is suspected or if it makes the person
uncomfortable.
 Continue to monitor the person's vital signs. This
means pulse, rate of breathing, and blood pressure

Electrical injury

An electrical current is very damaging to the
human body since the body is a very good
conductor of electricity. An electrical current
can cause damage to the body in several
ways: Cardiac arrest due to the electrical
effect on the heart massive muscle
destruction from a current passing through
the body. Thermal burns from contact with
the electrical source

Symptoms
Symptoms may include:
 Skin burns
 numbness,
 tingling
 Weakness
 Muscle contraction

 Muscular pain
 Bone fractures
 Headache
 Hearing impairment
 Seizures

 Heart arrhythmias
 Cardiac arrest
 Respiratory failure
 Unconsciousness

TREATMENT
 If safely possible, shut off the electrical
current. Unplug the cord, remove the fuse
from the fuse box, or turn off the circuit
breakers if possible. Often, simply turning off
the appliance itself will not stop the flow of
electricity.

 Once the victim is free from the source of
electricity, check the victim's airway,
breathing, and pulse. If either has stopped or
seems dangerously slow or shallow, initiate
CPR.
 If the victim has a burn, remove any clothing
that comes off easily, and rinse the burned
area in cool running water until the pain
subsides. Give first aid for burns.

 If the victim is faint, pale, or shows other
signs of shock, lay the victim down, with the
head slightly lower than the trunk of the body
and the legs elevated, and cover the person
with a warm blanket.

 Electrical injury is frequently associated with
explosions or falls that can cause additional
traumatic injuries, including both obvious
external injuries and concealed internal
injuries. Avoid moving the victim's head or
neck if a spinal injury is suspected.

DRESSINGS AND BANDAGES
Dressings cover wounds
Bandages cover and secure dressings

Fingertip Bandage

Fingertip Bandage The fingertip bandage has a
narrow center with wide adhesive flaps. The narrow
"waist" allows it to cover a curved surface without
wrinkling. Some uses for this bandage are:
 protecting a shallow laceration of the fingertip or
thumb tip
 covering a cut or abrasion between the fingers or
toes

 protecting a loose fingernail or toenail (partial
nail avulsion)
 covering a small chin or nose abrasion

Knuckle Bandage

Knuckle Bandage The knuckle bandage has four
adhesive flaps. The flaps allow the bandage to
remain secure on a curved or moving area.
Some uses for this bandage are:
 protecting a shallow laceration on a knuckle
 covering an abrasion on a "curve" like the heel or
chin

 covering an abrasion or cut on the back of
the elbow
 covering any area where the skin stretches
or moves

Butterfly Bandage

Butterfly Bandage
A butterfly bandage is used to pull the edges
of a short laceration together. Typically, a
butterfly is used for a small cut that tends to
gape a bit. The edges of the cut must be
sharp, not rough or irregular.

Wound Closure Tape

Wound Closure Tape
Steri-Strips are wound closure tapes. They
are ideal for partial thickness cuts. Steris are
more flexible than a butterfly bandage, and
can close longer lacerations.

Non-adherent Pad

Non-adherent Pad
Non-adherent pads are useful to cover open
wounds such as burns and abrasions. The
brand known best is Telfa. The pad keeps the
dressing from sticking to the wound.

Gauze Pads

Gauze Pads
Gauze pads cushion and protect wounds.
They also prevent dryness in an open wound.
(The gauze pad shouldn't be placed directly
on an open wound, because it will stick.) The
gauze pads have a loose weave, so blood
and fluids can ooze pass through to be
absorbed.

To construct a dressing, first place a non-stick
pad. Put the gauze directly over top. Bind it
down with a roller gauze (kling wrap). If you
need compression (either to prevent swelling
or bleeding, or to keep the bandage in place),
add an elastic wrap or Coban wrap.
Otherwise, apply just enough tape to keep
the dressing in place.

Padding Roll Gauze

Padding Roll Gauze
Padding roll gauze is very useful to cushion
large wounds. It's often called "Kerlix," which
is a specific brand. It can be used in place of
a kling wrap in the dressing, and for many
wounds provides enough padding that gauze
pads are not required. It absorbs ooze or
blood, and prevents dryness in an open
wound.

Trauma Dressing

Trauma Dressing
The multi-trauma dressing can be used as
padding, or as coverage. Coming in various
sizes, these dressings unfold to cover (for
example) the entire chest or abdomen.

The large size makes it useful for covering
large areas of burn or abrasion while you
travel to a medical facility. It can be used to
cover exposed viscera. The dressing can be
used to pad an injured arm or leg inside a
splint.

Eye Pads

Eye Pads
Eye pads are padded dressings for the eye.
Eye pads are used to keep the eye shut
following minor eye injuries such as a corneal
abrasion. Depending on the depth of the eye
socket, you may have to fold a pad in half to
get the right amount of pressure.

The eye pad is taped in place. Run the bands of tape
in an oblique direction: aim the top end for the
middle of the front hairline and the bottom end for
the angle of the jaw.
You should NOT tape an eye pad over an eye that
may have been punctured, or that has an impaled
object. Instead, tape a paper drinking cup (with the
open end facing the eye) over the eye.

Roll Gauze

Roll Gauze
Roller gauze is used to secure dressings.
This type of bandage is called a kling wrap.
Pick a size appropriate to the wound, and to
the body part you'll be bandaging. For
example, a 1 inch roll is appropriate for
fingers, while a 3 inch roll is about right for
the upper arm.

To construct a dressing, first place a non-
stick pad. Put the gauze pad directly over top.
Bind it down with your roller gauze. If you
need compression (either to prevent swelling
or bleeding, or to keep the bandage in place),
add an elastic wrap or Coban wrap.
Otherwise, apply just enough tape to keep
the dressing in place.

Padding Roll Gauze

Padding Roll Gauze
Padding roll gauze is very useful to cushion
large wounds. It's often called "Kerlix," which
is a specific brand. It can be used in place of
a kling wrap in the dressing. It absorbs ooze
or blood, and prevents dryness in an open
wound.

Self-adherent Compression Bandage

Self-adherent Compression Bandage
Coban is a sample brand of self-adherent
compression wrap. It sticks to itself, but does
NOT stick to you. It can be used in many of
the situations where you would use an elastic
bandage (ace wrap). It's lighter and more
conforming to your shape.

Example uses for Coban wrap would be:
 compression of a healing shin muscle strain
during sports
 support for a healing wrist sprain at work
 placement over a kling wrap to compress an
injury

Triangular Bandage

Triangular Bandage
The triangular bandage's primary use is as a
sling. But it can be surprisingly handy. The
triangular bandage can also be used as a tie
for a splint on the arm or leg. It can be used
as a wrap to secure a dressing. In a pinch, it
can even replace a broken helmet strap.

Care for Wounds
Minor cuts and scrapes usually don't require
a trip to the emergency room. Yet proper care
is essential to avoid infection or other
complications. These guidelines can help you
care for simple wounds:

Stop the bleeding. Minor cuts and scrapes
usually stop bleeding on their own. If they
don't, apply gentle pressure with a clean cloth
or bandage. Hold the pressure continuously
for 20 to 30 minutes. Don't keep checking to
see if the bleeding has stopped because this
may damage or dislodge the fresh clot that's
forming and cause bleeding to resume

If the blood spurts or continues to flow after
continuous pressure, seek medical
assistance.

Clean the wound. Rinse out the wound with
clear water. Soap can irritate the wound, so
try to keep it out of the actual wound. If dirt or
debris remains in the wound after washing,
use tweezers cleaned with alcohol to remove
the particles. If debris remains embedded in
the wound after cleaning, see your doctor.

Thorough wound cleaning reduces the risk of
tetanus. To clean the area around the wound,
use soap and a washcloth. There's no need
to use hydrogen peroxide, iodine or an
iodine-containing cleanser.

Cover the wound. Bandages can help keep
the wound clean and keep harmful bacteria
out. After the wound has healed enough to
make infection unlikely, exposure to the air
will speed wound healing.

Summary
Care for external and internal bleeding,
and CV shock are similar:
> control the bleeding
> position the person supine
> maintain normal body temperature
> administer high volume oxygen
> transport to advanced medical care

 Even though there are different types of wounds, the
care is generally the same, stop the bleeding.
 Four steps of controlling external bleeding are:
> Direct pressure
> Pressure bandage
> Pressure points
> Tourniquets

 Blast injuries may produce few external
injuries but inflict severe internal injuries:
> pulmonary edema
> hearing loss
> gastrointestinal
> bowel perforation
> organ damage

 Acute compartment syndrome results when
pressure within the muscle builds to
dangerous levels most often caused from
bleeding or swelling

 The Rules of Nines method of estimating
burns in a baby is slightly different from the
method used for adults
 The three steps of burn care are:
> cool the burned area to stop the burning
> cover the area to minimize infection
> minimize shock

Question
An early complication of direct heat transfer and
burns to the respiratory tract is:
A. Pulmonary fibrosis
B. Bronchitis from mucus production
C. Airway obstruction
D. Pulmonary embolus

Answer
(C) Airway Obstruction

Question
When air escapes into the soft tissue of the chest
wall or neck, the condition is called:
A. Rhonchi
B. Subcutaneous emphysema
C. Ischemia
D. Parenchyma

Answer
(B) Subcutaneous emphysema is a collection of air in
the soft tissue. This is often associated with some
type of disruption of the tracheobronchial tree and is
a serious finding. Rhonchi refers to abnormal lung
sounds, parenchyma is the substance of a gland or
organ, and ischemia involves inadequate blood flow
to tissue.

Question
When bruising is noted over the area of a vital
organ:
A. A superficial injury should be suspected
B. Direct pressure should be applied to the area
C. Damage to the underlying organ and internal
bleeding should be suspected
D. It is of concern only if it is noted on the abdomen
and not the chest

Answer
(C) When bruising is noted over the area of a vital
organ, suspect damage to the underlying organ and
possible internal bleeding.

UNIT 12
MUSCULOSKELETAL INJURIES

MUSCULOSKELETAL INJURIES
If more pressure is put on a bone than it can
stand, it will split or break. A break of any size
is called a fracture. If the broken bone
punctures the skin, it is called an open
fracture (compound fracture).
A stress fracture is a hairline crack in the
bone that develops because of repeated or
prolonged forces against the bone.

MUSCULOSKELETAL INJURIES CONT
There are several types of bone fracture,
including: Oblique - a fracture which goes at
an angle to the axis. Comminuted - a fracture
of many relatively small fragments. Spiral - a
fracture which runs around the axis of the
bone. Compound - a fracture (also called
open) which breaks the skin

Greenstick - an incomplete fracture in which
the bone bends. Transverse - a fracture that
goes across the bone's axis. Simple - a
fracture which does not break the skin

MUSCULOSKELETAL INJURIES cont
Fracture Types

Fracture Types

Considerations
It is hard to tell a dislocated bone from a
broken bone. However, both are emergency
situations, and the basic treatment steps are
the same.

Causes
The following are common causes of broken bones:
 Fall from a height
 Motor vehicle accidents
 Direct blow
 Child abuse
 Repetitive forces, such as those caused by running,
can cause stress fractures of the foot, ankle, tibia, or
hip

Signs and Symptoms
 A visibly out-of-place or misshapen limb or
joint
 Swelling, bruising, or bleeding
 Intense pain
 Numbness and tingling
 Broken skin with bone protruding
 Limited mobility or inability to move a limb

Treatment
 Check the person's airway and breathing. If
necessary assist breathing, perform CPR or
control bleeding
 Keep the person still and calm.
 Examine the person closely for other injuries.

 If the skin is broken, it should be treated
immediately to prevent infection. Don't
breathe on the wound or probe it. If possible,
lightly rinse the wound to remove visible dirt
or other contamination, but do not vigorously
scrub or flush the wound. Cover with sterile
dressings.

 If needed, immobilize the broken bone with a
splint or sling. Immobilize the area both
above and below the injured bone.
 Apply ice packs to reduce pain and swelling.
 Take steps to prevent shock. To transport lay
the person flat on the cot, elevate the feet
about 12 inches above the head, and cover
the person with a blanket.

CHECK BLOOD CIRCULATION
Check the person's blood circulation. Press
firmly over the skin beyond the fracture site.
(For example, if the fracture is in the leg,
press on the foot). It should first blanch white
and then "pink up" in about two seconds.

Other signs that circulation is inadequate
include pale or blue skin, numbness or
tingling, and loss of pulse. If circulation is
poor, try to realign the limb into a normal
resting position. This will reduce swelling,
pain, and damage to the tissues from lack of
blood.

TREAT BLEEDING
Place a dry, clean cloth over the wound to
dress it.
If the bleeding continues, apply direct
pressure peripherally to the site of bleeding.

Treatment for leg strain

Leg strain is also known as a pulled muscle.
It results from damage to a muscle from
excessive physical activity. Proper treatment
of a pulled muscle includes a cold
compress, rest, and elevation of the
damaged muscle above the level of the
heart.

Radial Head Injury

Radial dislocation may be caused by a
sudden pull on a child's arm or hand.

Dislocation of the Hip

A dislocation is an injury in which a bone is
displaced from its proper position. Unless
there are accompanying fractures or tissue
damage, a simple dislocation may be
manipulated back into place by a physician.

Shoulder joint

The shoulder joint is a ball-and-socket joint
and is the most freely moving joint of the
body. The shoulder joint can move in multiple
directions therefore it is less stable than other
joints and is more susceptible to injury.
Dislocation of the shoulder joint is common
and occurs when the top part of arm bone
slips out of its socket.

Definition
A dislocation is a separation of a bone where
it meets a joint. (Joints are areas where two
or more bones come together.) A dislocated
bone is no longer in its normal position. A
dislocation may also cause ligament and
nerve damage.

Considerations
It may be hard to tell a dislocated bone from a
broken bone. Both are emergency situations
and require the same treatment. Injuries to
the surrounding ligaments generally take 3 to
6 weeks to heal.

Causes
Dislocations are usually caused by a sudden
impact to the joint. This usually occurs
following a blow, fall, or other trauma.

Symptoms
A dislocated joint may be:
 Visibly out-of-place, discolored, or misshapen
 Limited in movement
 Swollen or bruised

 Intensely painful, especially if you try to use
the joint or bear weight on it
 Nursemaid's elbow is a partial dislocation
common in toddlers. The main symptom is
refusal to use the arm.

Treatment
 If there has been a serious injury, check the
person's airway, breathing, and circulation. If
necessary, begin rescue breathing, CPR, or
bleeding control.
 Do not move the person unnecessarily if you
think that his head, back, or leg has been
injured. Make one move to the
backboard.Provide reassurance.

 If the skin is broken, take steps to prevent infection.
Do not blow on the wound. Rinse the area gently to
remove obvious dirt, but do not scrub or probe.
Cover the area with sterile dressings before
immobilizing the injury.
 Splint or sling the injury in the position in which you
found it. Do not move the joint. Be sure to
immobilize the area above and below the injured
joint.

 Check the person's blood circulation around the
injury by pressing firmly on the skin in the affected
area. It should blanch white, then regain color within
a couple of seconds.
 Apply ice packs to ease pain and swelling.
 Take steps to prevent shock. Unless there is a
head, leg, or back injury, lay the victim flat on the
cot, elevate the feet about 12 inches, and cover the
person with a blanket.

Ankle sprain

Definition
A sprain is an injury to the ligaments around a
joint. Ligaments are strong, flexible fibers that
hold bones together. When a ligament is
stretched too far or tears, the joint will
become painful and swell.

Early treatment of injury

Minor injuries like sprains may be treated at
home if broken bones are not suspected. The
acronym RICE is helpful in remembering how
to treat minor injuries: "R" stands for rest, "I"
is for ice, "C" is for compression, and "E" is
for elevation.

Symptoms:
 Joint pain or muscle pain
 Swelling
 Joint stiffness
 Discoloration of the skin, especially bruising

Muscle strain

A muscle strain is the stretching or tearing of
muscle fibers. A muscle strain can be caused
by sports, exercise, a sudden movement, or
trying to lift something that is too heavy.

Causes
 Excessive physical activity or effort
 Improperly warming up before a physical
activity
 Poor flexibility

Symptoms of a muscle strain
 pain
 tightness
 swelling
 tenderness
 and the inability to move the muscle very
well.

Treatment
 Apply ice immediately to reduce swelling.
Wrap the ice in cloth -- avoid using ice
directly on the skin. Apply ice for 10 to 15
minutes every 1 hour for the first day. Then,
every 3 to 4 hours.
 Use ice for the first 3 days. After that, either
heat or ice may be helpful.

 Rest the pulled muscle for at least a day. If
possible, keep the pulled muscle elevated
above the level of the heart.
 Avoid using a strained muscle while it is still
painful. When the pain subsides, start activity
slowly and in moderation.

A splint is a device used for holding a part of
the body stable and motionless to prevent
pain and further injury.

Splinting
 Treat the area of all wounds before creating
the splint.
 The injured limb should be left in the position
that it was found in.
 for support a limb can also be taped to an
uninjured body (Anatomical Splint) part to
prevent it from moving.

 extend the splint above and below the injured
area to prevent it from moving. Splinting
beyond the closest two joints is ideal.
 Secure the splint with ties and be sure not to
knot the injured area. Avoid tying too tight as
it may cut off circulation
 Check the area often for swelling or paleness

Open Fractures
 Are those in which the integrity of the skin
has been interrupted
 Usually caused by the bone ends breaking
through the skin
 The bone ends may still be sticking out
 The bone ends may have been pulled back in
due to muscle contractions and spasm

Closed Fractures
 Are fractures in which the skin integrity
has not been compromised
 The bone is broken, however the skin
around the break is not
 Hemorrhage into the skin tissue
surrounding the fracture site is a
significant complication

Deformity
 Breaks in the bone or dislocations of the
joint produce an extra bending point or
extra angulation
 Any kind of deformity that does not
show in- line positioning (normal linear
position) of the extremity should raise
the rescuer’s suspicion

Crepitus
 Is a sound and the feeling bones can make
when they are fractured
 Caused by the grating of the bone ends against
each other
 Can be felt by palpating the site of the injury
 Will cause great pain, therefore the rescuer
should not attempt to produce it

Swelling
 Acute swelling of an extremity indicates
hemorrhage and inflammation in the
area
 Can result from either a fracture or
sprain
 Swelling may impede circulation at an
injury sight

Splinting
There are a number of manufactured splints on
the market
- Sager traction splint
- SAM splint
- Vacuum splints
- Rigid
(board) splints
There are also a number of improvised splints
- Blanket
splint
- Anatomical splint
- Pillow splint

Sager Traction Splint
 Easy to apply without moving injured limb
 For a fracture below the top 1/3 of the femur and
above the bottom 1/3 of the tib-fib apply 10%
of the body weight to a maximum of 10 Lbs.
traction
 For a fracture at the knee joint or an open
fracture apply a maximum of 5 Lbs. of traction
 Not to be used for fractures of the hip or ankle

Sager Splint

SAM Splints
 A disposable soft metal splint that is coated with a
thin foam layer
 Can be formed into any shape for almost any injury
site
 Requires double thickness for appropriately stability
 Must be held in place with a bandage of some kind

Vacuum splintsVacuum splints

Summary
 The signs and symptoms of various
musculoskeletal injuries and the treatment for
each are very similar.
 Since you cannot diagnose the degree of
damage, care for all such injuries initially as if
they are possible fractures

Question
When moving a patient with a suspected pelvic
injury, do not:
A. Tighten the backboard straps
B. Use a ROS
C. Place the pt on his/her back
D. Log-roll the patient

Answer
(D) Patients with suspected pelvic injuries should not
be log rolled. The ROS or a backboard can be
used, and straps should always be used to secure
the patient. Pelvic injuries are associated with
serious blood loss and shock

Question
A patient with a humerus fracture who is
experiencing an inability to raise the wrist should
be suspected of having:
A. A radial nerve injury
B. An accompanying cervical fracture
C. An accompanying radius or ulna fracture
D. A dislocated elbow

Answer
(A) A radial nerve injury should be suspected if a
patient with a humerus fracture is unable to raise the
wrist.

Question
Serious blood loss may often accompany:
A. A clavicle injury
B. An elbow injury
C. A tibia injury
D. A femur injury

Answer
(D) A femur injury may be accompanied by serious
blood loss into the surrounding tissues. The
situation is even more serious if both femurs are
injured

UNIT 13
INJURIES TO THE HEAD AND SPINE

Brain Anatomy
917Head Trauma -
Intracranial volume
• Brain
• CSF
• Blood vessel volume
 Dilatation with high pCO2
 Constriction with low pCO2
 Slight effect on volume

HEAD AND SPINE INJURIES
Head injuries can range from a minor bump
on the head to a devastating brain injury.
Learning to recognize a serious head injury,
and implementing basic first aid, can make
the difference in saving someone's life.

HEAD AND SPINE INJURIES CONT
Considerations
Every year, millions of people sustain a head injury.
Most of these injuries are minor because the skull
provides the brain with considerable protection. The
symptoms of minor head injuries usually go away on
their own. More than half a million head injuries a
year, however, are severe enough to require
hospitalization.

Learning to recognize a serious head injury,
and implementing basic first aid, can make
the difference in saving someone's life.
In patients who have suffered a severe head
injury, there is often one or more other organ
systems injured. For example, a head injury
is sometimes accompanied by a spinal injury.

Accidents are the leading cause of death or
disability in men under age 35, and over 70%
of accidents involve head injuries and/or
spinal cord injuries.
Common causes of head injury include traffic
accidents, falls, physical assault, and
accidents at home, work, outdoors, or while
playing sports.

Head injury

Indications of head injury

Closed Head Injuries

Head injury can be classified as either closed
or penetrating. In closed head injury, the
head sustains a blunt force by striking against
an object.

In penetrating head injuries, a high velocity
object breaks through the skull and enters the
brain. The signs and symptoms of a head
injury may occur immediately or develop
slowly over several hours.

Some head injuries result in prolonged or non-reversible brain
damage. This can occur as a result of bleeding inside the brain
or forces that damage the brain directly. These more serious
head injuries may cause:
 Changes in personality, emotions, or mental abilities
 Speech and language problems
 Loss of sensation, hearing, vision, taste, or smell
 Seizures
 Paralysis
 Coma

Head Injury
 It is important to ask the patient if he/she has
ever lost consciousness after the injury
 When the brain rebounds, the opposite side
of the brain hits the skull, and the resulting
contusion is called a contre-coup injury

 Various signs and symptoms will appear,
depending on what area of the brain was
injured and how large the area is.
 Over time, or in a severe head injury,
Cushing’s Triad may be present

Cushing’s Triad
The Cushing’s Reflex or Cushing’s Triad (usually
seen in the terminal stages of acute head injury), is
an increase in systolic BP (or widening of the pulse
pressure) in response to low blood supply to the
brain, while at the same time there is attempt to slow
the heart rate. Irregular breathing patterns are often
present as well.

Symptoms
 The signs of a head injury can occur
immediately or develop slowly over several
hours. Even if the skull is not fractured, the
brain can bang against the inside of the skull
and be bruised. (This is called a concussion.)
The head may look fine, but complications
could result from bleeding inside the skull.

 When encountering a person who just had a
head injury, try to find out what happened. If
the patient cannot tell you, look for clues and
ask witnesses. In any serious head trauma,
always assume the spinal cord is also
injured.
 The following symptoms suggest a more
serious head injury that requires emergency
medical treatment:

 Loss of consciousness, confusion, or
drowsiness
 Low breathing rate or drop in blood pressure
 Convulsions
 Fracture in the skull or face, facial bruising,
swelling at the site of the injury, or scalp
wound

 Fluid drainage from nose, mouth, or ears
(may be clear or bloody)
 Severe headache
 Initial improvement followed by worsening
symptoms
 Irritability (especially in children), personality
changes, or unusual behavior Restlessness,
clumsiness, lack of coordination

 Slurred speech or blurred vision
 Inability to move one or more limbs
 Stiff neck or vomiting
 Pupil changes
 Inability to hear, see, taste, or smell

Treatment
 Check the person's airway, breathing, and
circulation. If necessary, begin rescue breathing and
CPR
 If the person's breathing and heart rate are normal
but the person is unconscious, treat as if there is a
spinal injury. Stabilize the head and neck by placing
your hands on both sides of the person's head,
keeping the head in line with the spine and
preventing movement.

 Stop any bleeding by firmly pressing a clean cloth
on the wound. If the injury is serious, be careful not
to move the person's head. If blood soaks through
the cloth, DO NOT remove it. Place another cloth
over the first one.
 If you suspect a skull fracture, DO NOT apply direct
pressure to the bleeding site, and DO NOT remove
any debris from the wound. Cover the wound with
sterile gauze dressing.

 If the person is vomiting, roll the head, neck,
and body as one unit to prevent choking. This
still protects the spine, which you must
always assume is injured in the case of a
head injury. (Children often vomit ONCE after
a head injury.
 Apply ice packs to swollen areas.

 Maintain patient’s
airway ensure
adequate ventilation
 Control serious
bleeding
 Most importantly,
splint before you
move them

Major goals of
emergency care
Prevent further injury
and transport the
patient to a hospital
without further
movement

Concussion

A concussion may result when the head
strikes against an object or is struck by an
object. Concussions may produce
unconsciousness or bleeding in or around the
brain.

A blow to the head may cause a bruise, a cut
on the scalp, concussion or, sometimes,
dangerous internal brain injuries. Fortunately,
most falls or blows to the head result in injury
to the scalp only, which is usually more
frightening than threatening. A scalp injury
can bleed extensively, since the scalp is rich
with blood vessels.

The "goose egg" or swelling that may appear
on the scalp after a head blow results from
the scalp's veins leaking fluid or blood into
(and under) the scalp. It may take days or
even weeks to disappear.

Cheek Injury:
 Bleeding may occur both on the inside
and the outside of the cheek
 Several folded dressings may be used
in the mouth. The victim will hold the
dressings in place.

 External bleeding is treated in the
normal manner.
 It is ok to remove embedded objects
from the cheek, but it is not advisable
unless the object is making breathing
difficult or choking is a possibility.

How to remove:
 Pull object out in the same direction it entered.
 If this is overly painful, leave in place and stabilize
with bulky dressings.
 Once object is removed treat both the inner and
outside injuries to the cheek.
 Have victim hold dressings in place if possible
 Have the victim sit while leaning slightly forward if
possible. This will minimize the swallowing of blood

Nasal
fracture

Nose Injury
To control a nosebleed
 Place the victim in a seated position with the
head slightly forward
 Instruct the victim to pinch the nostrils
together

 An icepack to the bridge of the nose may also
help
 If the bleeding is persistent, recurring, or the
result of high blood pressure, seek medical
assistance.
 If the victim loses consciousness, place
him/her on their side.

Eye Injury:
 Injuries to the eye can involve the bone and
the soft tissue surrounding the eye.
 Injuries around the eye are treated normally
.

Care for objects embedded in the eye as follows:
 Place the victim on his / her back
 DO NOT remove objects from the eye.
 Place sterile dressings around the object
 Stabilize the object as best you can. (a paper cup
with a hole in it works well, see picture in text)
 Apply a bandage to hold dressings in place

Particulate matter in the eye:
 Can cause significant damage
 To remove:
 Tell the victim to blink several times.
 If blinking is nonproductive, flush the eye with water
(cool water)
 If the object remains, the victim should receive
professional medical attention. Attempting to "swab
-out " particles by untrained people is dangerous to
the eye

Ear Injury:
 Injuries to the outer ear are treated normally.
 Injuries resulting in bleeding from the ear
canal should NOT have direct pressure
applied. Instead they are covered lightly with
absorbent dressings and allowed to drain.

Mouth, Jaw, and Neck Injuries:
 Primary concern is to ensure an open airway.
 If a spinal injury is not suspected, allow the
person to sit with the head slightly forward to
minimize swallowed blood.
 Alternately the victim may be placed on his or
her side to allow drainage from the mouth.

 lip injuries may be treated with a dressing
inside the lip and outside, with direct pressure
and cold application.
 If teeth are knocked out, control bleeding and
save the teeth for explanation
 Put the tooth in milk if possible, if not, put the
tooth in water. Try not to damage the roots of
the tooth.

 Injuries serious enough to dislocate or
fracture the jaw can also indicate head, neck
and back injury. In these cases–
 Maintain an open airway
 Check mouth for and control bleeding
 Minimize movement of the head and neck

Skeletal spine

The spine is divided into several sections.
The cervical vertebrae make up the neck.
The thoracic vertebrae comprise the chest
section and have ribs attached. The lumbar
vertebrae are the remaining vertebrae below
the last thoracic bone and the top of the
sacrum.

The sacral vertebrae are caged within the
bones of the pelvis, and the coccyx
represents the terminal vertebrae or vestigial
tail.

Spinal cord injury

A severe spinal cord injury often causes loss of
feeling and paralysis, the loss of movement and
voluntary control over the muscles in the body.
Spinal cord damage also causes loss of reflex
function below the point of injury interrupting bodily
functions such as breathing, bowel control, and
bladder control. In the event of a spinal injury prompt
medical attention can help to minimize further spinal
cord damage.

Considerations
When someone has a spinal injury, additional
movement may cause further damage to the nerves
in the cord and can sometimes mean the difference
between life and death.
If you think someone could possibly have a spinal
injury, DO NOT move the injured person even a little
bit, unless it is absolutely necessary (like getting
someone out of a burning car).

If you are in doubt about whether a person
has a spinal injury, assume that he or she
DOES have one.

Causes
 Bullet or stab wound
 Direct trauma to the face, neck, head, or back
(e.g., car accidents)
 Diving accident
 Electric shock
 Extreme twisting of the trunk
 Sports injury (landing on head)

Symptoms
 Major blow to the head or chest, car accident,
fall from a great height
 Head held in unusual position
 Numbness or tingling that radiates down an
arm or leg
 Weakness
 Difficulty walking

 Paralysis of arms or legs
 No bladder or bowel control
 Shock (pale, clammy skin; bluish lips and
fingernails; acting dazed or semi-conscious)
 Unconscious
 Stiff neck, headache, or neck pain

Treatment for Spinal Injuries
Remember: Head, neck, and spinal injuries can
become life-threatening or severely disabling
emergencies.
 Minimize movement of the head, neck, and back.
 Maintain an open airway

 Monitor consciousness and breathing
 Control any external bleeding
 Keep the patient from getting chilled or
overheated (body's temp regulation
mechanisms may be damaged)

 Use in-line stabilization for the head and neck
(Put hands on both sides of head and
straighten the head in-line with the body)
Can be done on victims lying down, sitting, or
standing.
Don’t perform when:
Victim complains of pain, pressure, or muscle
spasms on initial movement of the head.

When the rescuer feels resistance when
attempting to move the head. (support head in
position in which it is found).
Remember: You don't always need to roll the
victim on their back to check for breathing (only
when it's the only way to tell if they are breathing).

A victim of serious head, neck, or back injury will
experience fluctuations in consciousness. They
may not answer questions correctly or
appropriately. They may appear drowsy or lapse
into sudden sleep. Breathing may also be erratic
or stop completely.

Summary
 Care for injuries to the eye requires slow,
precise movement to avoid further injury
while bandaging
 In some circumstances, proper care for head
and spine injuries may involve helmet
removal

 Kendrick Extrication Device (KED) is a useful
piece of equipment to immobilize the head,
neck and spine of a person in an MVC, or
confined space unable to be immobilized on
a spine board
 Proper care for head and spinal injuries
requires fully immobilizing a patient using a
spine board.

Question
Which of the following signs of Cushing’s Triad?
A. Increased pulse, increased BP, change in
respiratory rate
B. Decreased pulse, increased BP, change in
respiration
C. Increased pulse, decreased BP, change in
respiratory rate
D. decreased pulse, decreased BP, change in
respiratory rate

Answer
(B) Cushing’s Triad is indicative of a closed head injury
with increased intracranial pressure. Therefore, the
signs would be an increase in BP, a decrease in
pulse and a change in breathing rate. When ICP
increases, the vagus nerve is stimulated and
reduces the pulse rate. These are also late signs in
a patient with head injury.

Question
If only two EMR’s are available to perform a log roll,
one EMR should be positioned:
A. At the pt’s head and the other at the pat’s torso
B. At the pt’s shoulders and the other at the pt’s hips
C. At the pt’s head and the other at the pt’s legs
D. At the pt’s torso and the other slides the board
under the patient

Answer
(A) If only 2 EMR’s are available tp perform a log-roll,
one EMR controls the head and neck and the other
should be positioned at the torso and control the
hips.

Question
A pt. with a head injury may quickly develop:
A. An increased level of consciousness
B. Chest pain
C. Nausea and vomiting
D. hyperglycemia

Answer
(C) Increasing pressure inside the head can cause
nausea and vomiting.

Question
A patient who is an alcoholic is more prone to
develop:
A. A spontaneous pneumothorax
B. Hemophilia
C. A kidney stone
D. Intercranial bleeding

Answer
(D) Alcoholics are prone to developing ICB. This due
to impaired clotting mechanisms caused by liver
damage and because of frequent falls.

Question
The blood pressure of a patient with a severe head
injury and increased intracranial pressure will:
A. Decrease
B. Increase
C. Remain the same
D. Increase or decrease directly proportional to the
pulse

Answer
(B) As the ICP increases, the BP increases. This to
overcome the resistance to blood flow created by
the swelling of brain tissue. At the same time, the
pulse rate will normally decrease.

UNIT 14
INJURIES TO THE CHEST, ABDOMEN AND
PELVIS

INJURIES TO THE CHEST,
ABDOMEN AND PELVIS CONT
Chest

ABDOMEN AND PELVIS
Chest injury
May include both open and closed wounds
Sign and Symptoms of serious chest include:
> the patient is coughing up blood
> penetrating object in the chest
> sounds of a sucking chest wound

> Deformity of the rib cage
> Bruising at the site of injury
> When using a stethoscope, there may be a
decreased or absent breath sounds on the
side of the injury
> There may be also sounds of congestion,
wheezing, or crackles in the chest

Hemothorax
> Hemothorax results from blood entering the
pleural space
> It is caused by blunt trauma, penetrating
trauma, a lacerated lung, or laceration of a
blood vessel in the chest
> As the affected side fills up with blood,
breathing will be impaired

 This increased volume of fluid and pressure
put pressure on the heart
 Signs of shock will be evident due to the loss
of blood
 Hemothorax can occur with closed chest
wounds as well as open ones

Pneumothorax
> Pneumothorax results from air entering the
pleural space
> It can be caused by blunt tgrauma,
penetrating trauma, or no trauma at all
> Pneumothorax is a one-time entry into the
pleural space, as opposed to tension
pneumothorax, which has continual air entry

> The lung may be totally collapsed, depending on
how much air entered the pleural space
> The patient’s signs and symptoms will depend on
how much air has entered the pleural space
> A pneumothorax can progress to a tension
pneumothorax in some situations
> A pneumothorax is most commonly secondary to rib
fractures

 Pneumothorax can occur in otherwise healthy
people without any associated trauma.
Pneumothorax occurring in these patients is called
spontaneous pneumothorax and is frequently seen
in young, tall, thin males.

Typically the patient complains of a sudden,
sharp chest pain and sudden shortness of
breath followed by strenuous exertion,
coughing or recent air travel. Physical
findings are the same as for any
pneumothorax. Treatment is the same

Tension Pneumothorax
> Tension pneumothorax is the continual flow
of air into the pleural space, which becomes
trapped

> This usually occurs as a result of lung tissue
having been torn
> If untreated, the lung will eventually collapse,
thereby diminishing the amount of air the
person can inhale

 As conditions worsen, signs of hypoxia
ensue, and a breathing emergency is evident
 The patient’s condition may range from
complete absence of symptoms to severe
dyspnea
 When assessing for chest injury, assess the
neck for jugular vein distension (JVD)

Caring for Serious Chest Injury:
 Position the victim to aid breathing
 If ribs are broken, binding the victim's arm to
the injured side can help support the injured
area and make breathing easier.
 If a sucking chest sound is evident, cover the
wound with an airtight dressing such as
plastic wrap. Tape it in place, leaving only
one corner uncovered.

Abdominal Injury
Signs and Symptoms
 External bleeding.
 Nausea and Vomiting
 Thirst
 Pain, tenderness, or a tight feeling in the
abdomen

Abdomen

 Weakness
 Organs protruding from the abdomen.
 To care for a serious abdominal injury
 Position the victim on their back

 If the injury involves an open wound
 Remove clothing from around the wound
 Do not put pressure on organs or try to put them
back in the abdomen.
 Cover the wound loosely with moist clean
dressings.
 Place plastic wrap over the dressings
 Lightly cover the wound with a towel to maintain
warmth.

 If the injury involves a closed wound
 Position the patient on his/her back
 Try bending the patient's knees slightly, placing
pillows or blankets under the legs for support.
 Whether they are open or closed wounds,
abdominal injuries should be considered a load and
go and treated at an advanced care facility, since
shock is likely to occur with a serious injury.
 Even if shock occurs, you have already taken the
steps to minimize it by properly positioning the
victim.

Abdominal Aortic Aneurysm
 In an abdominal aortic aneurysm (AAA), the
walls of the aorta weakens and bulges until
the vessel thins and ruptures. The risk
factors are similar to those of heart disease
and stroke

Signs and Symptoms
> Abdominal pain
> abdominal rigidity
> Back pain
> pulsating mass in the abdomen
> Nausea and vomiting
> Tingling or numbness in the lower extremities

 A person with an abdominal aortic aneurysm
(AAA) may have absent or decreased
femoral or pedal pulse on both sides of the
body.
 If you suspect an AAA, do not put pressure
on the abdomen
 Many elderly people may mistake AAA as
renal colic as the pain pattern is quite similar

Pelvis

Pelvic Injury
Signs and Symptoms are the same as those
of abdominal injury, with the addition of:
 Loss of sensation or movement in the legs
(sometimes occurs).

 To care for pelvic injury:
 Minimize movement of the victim.
 When the injury involves the genitals, pain can be severe.
 If an open wound to the genital area is present, control any
bleeding with direct pressure.
 If any parts are severed, wrap them appropriately (and put
on ice) and make sure they are transported with the victim.
 Consider using a full body vacuum splint for immobilization
or transfer via a ROS (Clam Stretcher)

Summary
 Hemothorax, pneumothorax, and tension
pneumothorax are respiratory emergencies
 The general signs and symptoms and care
for chest, abdominal, and pelvic injuries are
similar. Immobilize the affected area and
transport to advanced medical care

UNIT 15
INJURIES TO THE EXTREMITIES

INJURIES TO THE EXTREMITIES CONT
Open wounds
• Remove contamination
 Gross: remove
 Smaller: irrigate with normal saline
• Sterile dressing and bandage
 Pressure dressing, if necessary
 Pressure point
 Tourniquet rare
 Hemostatic agent
1014Extremity Trauma -
Courtesy of Roy Alson, MD

Amputations
• Disabling and sometimes life-threatening
• Potential for massive hemorrhage
 Most often, bleeding controlled with ordinary pressure
1015Extremity Trauma -

Treatment
 Checking the patient's airway and breathing. If
necessary, begin rescue breathing and CPR.
 Loosening tight clothing around the neck.
 Keeping the affected patient lying down for at least
10 - 15 minutes, preferably in a cool and quiet
space. If the patient cannot lie down, have the
patient sit forward and lower his/her head below the
levels of the shoulders, between the knees.

 If vomiting has occurred, turning the patient
onto one side to prevent choking
 Elevating the feet above the level of the heart
(about 12 inches).

Consider other treatment if:
 Fall from a height, especially if injured or
bleeding.
 Does not regain consciousness quickly
(within a couple of minutes).
 Is pregnant or over 50 years old.
 Has diabetes (check medical identification
bracelets).

 Feels chest pain, pressure, or discomfort;
pounding or irregular heartbeat; or has loss of
speech, visual disturbances, or inability to
move one or more limbs.
 Has convulsions, tongue trauma, or loss of
bowel control.

TREATMENT
 Treat injury and consider MOI for other
injuries
 Monitor ABC’s
 Check distal pulses
 Splint with appropriate splinting apparatus

UNIT 16
SUDDEN ILLNESS

SUDDEN ILLNESSES
Fainting/Syncope
Fainting or Syncope is a common sudden illness
characterized by partial or complete loss of
consciousness, caused by a reduction in blood flow
to the brain due to a variety of factors that include:
> A blood vessel in the neck being impinged
> Other reasons the patient may faint include
hyperventilation, use of alcohol or drugs, or low
blood sugar.

SUDDEN ILLNESSES CONT
> Fainting may occur while the patient is urinating,
having a bowel movement (especially if straining),
coughing strenuously, or when he/she has been
standing in one place too long. Fainting can also be
related to fear, severe pain, or emotional distress.
> A sudden drop in blood pressure can cause the
patient to faint. This may happen if he/she is
bleeding or severely dehydrated. It can also happen
if the patient stands up very suddenly from a lying
position.

> Certain medications may lead to fainting by
causing a drop in the patient’s blood pressure
or for another reason. Common drugs that
contribute to fainting include those used for
anxiety, high blood pressure, nasal
congestion, and allergies.
> Less common but more serious reasons
include heart disease (like abnormal heart
rhythm or heart attack) and stroke.

 Since syncope is actually one type of shock,
the patient will commonly display shock-like
signs and symptoms -- dizziness, nausea and
pale, cool and diaphoretic skin

 Syncope usually resolves itself when normal
blood flow to the brain is restored, for
example, when the person is in a supine
position and blood can more freely to the
head.

 Fainting/syncope by itself does not usually
harm the patient, but the possible secondary
injury from the subsequent fall may.
 A good primary assessment is essential to
find any injuries caused by the subsequent
fall

 Care for fainting/syncope includes positioning
the patient supine, checking the ABC’s, and
loosening any restrictive clothing. Do not
allow the patient anything to eat or drink.
 Patient should be transported to an advanced
care facility

Diabetic Emergencies
 Insulin is a hormone that forces the liver and
muscles cells to store sugar. When insulin
levels decrease, the cells release the sugar
into the bloodstream
 The condition in which the body does not
produce enough insulin is called diabetes
mellitus. A patient in this condition is referred
to as a diabetic

 Anyone with diabetes must carefully monitor
their diet and exercise. A patient with insulin-
dependent diabetes must also regulate their
use of insulin as insulin keeps the sugar level
in the blood controlled

 When the patient with diabetes fails to control
these factors, one of two emergencies occur
-- too much or too little sugar in the
bloodstream. This imbalance causes the
medical emergency

Hyperglycemia means to much sugar. With too
much sugar in the blood, the insulin level is too low.
Without insulin, the body cells can not get the sugar
they need, even though the abundant sugar is
present.

To meet its energy demands, the body will
break down other food sources. This results
in a person becoming ill over a period of time
as excess waste products build up in the
body. This condition can result in a serious
form of a diabetic emergency called diabetic
coma

Hypoglycemia is too little sugar in the blood.
Consequently, the insulin level is too high.
The small amount of sugar is used rapidly.
When the brain gets too little sugar to
function, it results in an acute condition called
insulin reaction or insulin shock

 Either too much sugar or too little sugar can
result in a diabetic emergency

Pancreas

Islets of Langerhans

There are three major types of diabetes:
Type 1 diabetes is usually diagnosed in
childhood. The body makes little or no
insulin, and daily injections of insulin are
required to sustain life. Without proper daily
management, medical emergencies can
arise.

Type I diabetes

Type 2 diabetes is far more common than
type 1 and makes up 90% or more of all
cases of diabetes. It usually occurs in
adulthood. Here, the pancreas does not
make enough insulin to keep blood glucose
levels normal, often because the body does
not respond well to the insulin.

Many people with type 2 diabetes do not
know they have it, although it is a serious
condition. Type 2 diabetes is becoming more
common due to the growing number of older
people, increasing obesity, and failure to
exercise.

Gestational diabetes
Some women may develop gestational
diabetes during pregnancy. These women
are non-symptomatic before the pregnancy.
Generally, glucose levels will return to normal
after the pregnancy, although there is a
higher risk of developing diabetes later in life

There are many risk factors for diabetes,
including:
 A parent, brother, or sister with diabetes
 obesity
 Age greater than 45 years
 Some ethnic groups (particularly African-
Americans and Hispanic Americans, First
Nation)

 Gestational diabetes or delivering a baby
weighing more than 9 pounds
 High blood levels of triglycerides (a type of fat
molecule)
 High blood cholesterol level

Symptoms
High blood levels of glucose can cause
several problems, including frequent
urination, excessive thirst, hunger, fatigue,
weight loss, and blurry vision. However,
because type 2 Diabetes develops slowly,
some people with high blood sugar
experience no symptoms at all.

 Symptoms of type 1 diabetes:
 Increased thirst
 Increased urination
 Weight loss in spite of increased appetite
 Fatigue
 Nausea
 Vomiting

Symptoms of type 2 Diabetes:
 Increased thirst
 Increased urination
 Increased appetite
 Fatigue
 Blurred vision
 Slow-healing infections
 Impotence in men

Patients with type 1 Diabetes usually develop
symptoms over a short period of time, and
the condition is often diagnosed in an
emergency setting. In addition to having high
glucose levels, acutely ill type 1 Diabetics
have high levels of ketones.

Ketones are produced by the breakdown of
fat and muscle, and they are toxic at high
levels. Ketones in the blood cause a
condition called "acidosis" (low blood pH).
Urine testing detects both glucose and
ketones in the urine. Blood glucose levels are
also high.

Treatment
> Care for any life-threatening conditions you
find
> If a person is conscious and there is no life-
threatening conditions, do a secondary
survey, ask the person SAMPLE Hx
questions
> Look for medical alert identification

> If the patient is conscious and able to swallow, give
him/her sugar in the form of fruit juice or instagel or
glucogel. If the patient’s condition is caused by low
sugar, the sugar will give help quickly, if the
condition is caused by too much sugar, the excess
sugar will do no further harm. Provide high volume
oxygen, monitor vitals, take a blood glucose reading
during assessment and document, transport to
advanced medical care

> If the patient is unresponsive, do not give
anything by mouth (NPO). Monitor the ABC’s
and maintain normal body temperature.
Provide high volume oxygen, monitor vitals,
take a blood glucose reading during
assessment and document, transport to
advanced medical care

Measuring Glucose Level
Blood Glucose Level (BGL) is measured in
millimoles per litre (mmol/l), and a normal
BGL ranges from 4 mmol/l to 7 mmol/l.
Hypoglycemia is most often defined as a BGL
of less than 4 mmol/l, whereas hyperglycemia
is defined as a BGL of greater than 7 mmol/l.

To accurately check someone’s BGL, use a
device called a glucometer. Use this reading,
along with a patient’s history and any signs
and symptoms found during assessment, to
determine whether to treat the situation as a
diabetic emergency.

How to use the Glucometer
> Prepare the lancet and lancet device
> Let the patient’s arm hang to the side if
possible
> Remove a new test strip from the vial and
insert it into the device
> Match the code number on the screen to that
of the test strip vial

> Cleanse the finger and force blood to the finger by
squeezing the finger
> Prick the side of the finger and gently squeeze out a
drop of blood
> Drop the blood onto the test strip in the appropriate
place, cover lancet site with a Band-Aid
> Record the BGL reading
> Remove the test strip and dispose into a biohazard
bag

SEIZURES
When normal electrophysiologic functions of
brain are disrupted by injury, disease, fever,
or infection, the electrical activity of the brain
becomes irregular. This irregularity can
cause sudden loss of body control known as
a seizure.

Seizures

Brain

The chronic form of seizure is known as
epilepsy. Although epilepsy is usually
controlled with medications, some people
with epilepsy have seizures from time to time

Before a seizure occurs, the patient may
experience a “warning” called an aura. This
is an unusual sensation or feeling, such as a
visual hallucination: a strange sound, taste,
or smell: or an urgent need to get to safety.

Seizures may range from mild blackouts that
others mistake for daydreaming to sudden
uncontrolled muscular contractions lasting
several minutes.
When the seizure is over, the patient will be
drowsy and disorientated. Do a secondary
assessment to check if there are any injuries.
Be reassuring and comforting.

Do not try to stop or restrain the patient while
seizing is occurring. Protect the patient from
injuring his/herself. If there is saliva, blood or
vomitus in the patient’s mouth, position the
patient on their side so that the fluid drains
from the mouth
Do not place anything between the teeth

Because the brain uses all of its energy
(sugar) during the seizure, as an EMR, you
will need to constantly reorient the patient as
to what happened for an extended period of
time after the patient regains consciousness.

Pay attention to which arms or legs are
shaking, whether there is any change in
consciousness, whether there is loss of urine
or stool, and whether the eyes deviate in any
direction.

When a seizure occurs, the main goal is to
protect the person from injury. Try to prevent
a fall by laying the person on the ground in a
safe area. The area should be cleared of
furniture or other sharp objects.
Cushion the person's head.
Loosen tight clothing, especially around the
neck

 Make sure the patient has a patent airway
 provide high volume oxygen
 monitor the ABC’s
 Obtain a BGL
 Transport patient to an advanced care facility

Generalized seizures go through phases:
> Aura phase -- The patient becomes aware a seizure
is coming, usually within seconds prior to the seizure
> Tonic Phase -- The patient becomes unconscious;
then the muscles contract
> Clonic Phase -- The patients muscles alternate
between contractions and relaxation
> Postictal Phase -- The patient regains
consciousness gradually

Be Aware When
> The seizure lasts more than a few minutes
> The patient appears to be injured
> When the cause is unknown
> The patient is pregnant
> The patient is a diabetic
> The patient is a baby or child
> the seizure takes place in water
> The patient fails to regain consciousness

Causes
 Epilepsy
 Alcohol use
 Barbiturates, intoxication or withdrawal Brain
illness or injury
 Brain tumor (rare)
 Choking

 Drug abuse
 Electric shock
 Fever (particularly in young children)
 Head injury
 Heart disease
 Heat illness

 Malignant hypertension (very high blood
pressure)
 Meningitis
 Poisoning
 Stroke
 Toxemia of pregnancy

 Uremia related to kidney
 Venomous bites and stings
 Withdrawal from benzodiazepines (such as
Valium)
 Low blood sugar

Symptoms
 Brief blackout followed by period of confusion
 sudden falling
 Drooling or frothing at the mouth
 Grunting and snorting

 Breathing stops temporarily
 Uncontrollable muscle spasms with twitching
and jerking limbs
 Loss of bladder or bowel control
 Eye movements

Appendicitis
> Appendicitis is an acute inflammation of the
appendix
> It occurs when the channel or cavity in the appendix
becomes blocked as a result of inflammation from a
viral or bacterial infection
> If the appendicitis goes untreated, the appendix will
eventually become gangrenous and rupture

> This will lead to inflammation of the membrane that
lines the abdominal wall (peritoneum)
> The pain complaint will initially be located near the
umbilicus area and diffuse, later becoming intense
and localized to the right lower quadrant.
> The pain becomes worse when moving, taking deep
breath coughing and being touched in the area.

Bowel Obstruction
 Bowel obstruction is an occlusion of the intestinal
cavity that results in a blockage of normal flow of the
intestinal contents
 Bowel obstruction can be caused by:
> Adhesions
> Hernias
> Fecal blockage
> Tumors

 Bowel obstruction in the small intestines is
usually from adhesions or hernias
 Bowel obstruction in the large intestines is
usually from the tumors or fecal obstruction.
 The danger of bowel obstruction is
perforation with generalized inflammation of
the peritoneum and infection (sepsis)

Treatment
 Maintain a patent airway
 Administer high volume oxygen
 Monitor vitals
 Transport carefully to advanced medical care

UNIT 17
POISONING

Poisoning
Carbon Monoxide Poisoning
Carbon monoxide is an odorless,
colorless gas that is produced by the
incomplete combustion of carbon-
containing substances

Poisoning CONT

Poisoning CONT
carbon monoxide

Poisoning CONT
Carbon monoxide binds with the hemoglobin
in blood and prevents oxygen from being
transported
It can happen where stoves are used with
poor ventilation

Poisoning CONT
Carbon Monoxide Poisoning
Signs and Symptoms
 dizziness, confused, headache
 partial or complete unresponsiveness
 sudden respiratory arrest
 skin may be pale, blue or pink

Poisoning CONT
Carbon Monoxide Poisoning -
Emergency Care
 remove patient from the contaminated area
 pay attention to your own safety
 give oxygen at high flow rate
 support breathing and give care for
unresponsiveness if necessary

Poisoning CONT
Substance Abuse
 the use of mind altering chemicals without a
legitimate medical purpose
 usually self prescribed and self administered

Poisoning CONT
 alters the perception of
the environment
 use of these chemicals
can cause exhilaration,
tranquility or
disorientation
Substance
Abuse

Poisoning CONT
 can cause addiction or
dependence
 the users life revolves
around obtaining and
using the drug

Poisoning CONT
 the altered state and
diminished judgment
make the individual a
risk to him/herself and
others

Poisoning CONT
Drug - a substance
that alters physical
and or mental
function when taken
into the body

Poisoning CONT
Tolerance-
increasing amounts of
a drug are required to
produce the same
result in the body

Poisoning CONT
Assessment of Patient
First Impression -First Impression - Look at the surroundings. Is
the person sick or injured? Use universal
precautions.
Initial Assessment -Initial Assessment - Is patient responsive?
What is the level of responsiveness? Open and
maintain airway. Check pulse, assess chest, pulse,
abdomen. Check neck and head if unresponsive.

Poisoning CONT
Initial Assessment-Initial Assessment- This is the stage where
you will determine if substance abuse is the
cause. Talk to the patient or their
companions. Get a medical history.
 Ask the patient what happened. Ask about
drugs being taken. Assess vital signs.
 Look for signs of substance abuse.

Poisoning CONT
 treat for shock if it develops
 treat for hypothermia or hypothermia
 calm an agitated patient
 treat for convulsions if possible
 stay with patient.
 preserve vomitus, bottles, pills, to send with
the patient

Poisoning CONT
Poisons are introduced into the body in one
of four ways:
 ingestion
 Injection
 Inhalation
 absorption (contact)

Poisoning CONT
Ingested Poisons
 approximately 80% of all poisoning is by mouth;
ingested products include household products, food,
plants and in the majority of cases... drugs.
 children are poisoned most frequently and the most
common products they are poisoned with are
household products.

Poisoning CONT
 if an ingested poison is suspected the EMR’s
job is to first assess Airway, Breathing,
Circulation and Disability (ABCD).

Poisoning CONT
Inhaled Poisons
 Inhaled poisons include several substances
including natural gas -- the most common accidental
inhaled poison -- pesticides, chlorine, smoke and
others.
 all patients should be moved into an environment
where there is fresh air. Supplemental oxygen
should also be provided for those suspected of
inhaling a poison. .

Poisoning CONT
 signs and symptoms may include burning or watery
eyes, sore throat, cough, hoarseness, respiratory
distress, stridor, pulmonary edema, seizures and
altered mental status. Remember, signs and
symptoms need not be immediate... therefore, if an
inhaled poison is suspected, ALL patients require
transport to the hospital.
 EMR’s should be prepared to use Basic Life Support
(BLS) skills.

Poisoning CONT
Injected poisonings
 Injected poisons are almost always the result
of substance abuse. Heroin and cocaine top
the list... but injected poisons can also be the
result of bites and stings.
 signs and symptoms (s/s) vary in every
patient but common s/s include weakness,
dizziness, altered mental status, excitability,
or unresponsiveness.

Poisoning CONT
 injected poisons are difficult for EMR’s to
treat since dilution is difficult. Some
medications can be given in certain
circumstances that counteract the effects of
some drug-induced poisoning but quick
transport to the hospital is the key to effective
treatment.
 EMR’s should be prepared to use Basic Life
Support (BLS) skills.

Poisoning CONT
Absorbed or Contact Poisons
chemicals that contact the skin, mucus membranes
or eyes have the potential to cause severe damage.
Alkalis, acids and hydrocarbons are some of the
most destructive.
signs and symptoms (s/s) of such poisonings
include a history suggestive of this, irritated skin,
erythema of the skin or bullae (blisters) present on
the skin.

Poisoning CONT
 emergency treatment involves removing the
offending chemical by first, preventing self-
contamination and secondly diluting with copious
amounts of water. If the patient is wearing clothing --
REMOVE IT. Flush with water for 10 minutes if
contact is on the skin.
 if the patient has chemical exposure in the eyes
irrigation should be at least 10 minutes for acid
substances and 20 minutes for alkali substances. If
you are unsure, irrigate for 20 minutes.

Poisoning CONT
 the only time irrigation is contraindicated is if
a potential harmful reaction may occur from
contact with water. Examples include
phosphorous and elemental sodium.
 provide prompt transport to the emergency
department. Irrigate while in route if
necessary.

Poisoning CONT
Emergency Medical Care
"the solution to pollution is dilution.
Hercules, 5000 bn
 the key to emergency medical care is diluting
the poisoned substance so much that it lacks
the ability to cause harm.
 treatment then focuses on support i.e.
assessing and maintaining ABCD.

Poisoning CONT
SPECIFIC POISONS
 EtOH is the most commonly abused drug in
the Canada contributing to more than 20,000
deaths each year.
 EtOH is a powerful CNS depressant that
sedates (to decrease the activity of) and is a
hypnotic (induces sleep).

Poisoning CONT
 EtOH dulls the senses, slows reflexes,
reduces reaction time, and reduces
coordination.
 signs and symptoms include any of the above
and CNS depression. Periods of CNS
depression may result in a patient vomiting
without even knowing s/he has vomited... so
ALWAYS PROTECT THE AIRWAY in these
patients.

Poisoning CONT
 a patient with EtOH withdrawl may
experience delirium tremors (DT's) --
syndrome characterized by restlessness,
fevers, sweating, chills, delusions,
hallucinations, agitation and seizure activity.

Poisoning CONT
Opioids
named so due to its origin from the poppy
seed. Include such drugs and medicines as
heroin, codeine, and morphine, demerol,
dilaudid, percocet, vicodin and methadone.
these substances are CNS depressants and
result in severe CNS depression.

Poisoning CONT
s/s include "sedated" patients, occasionally they are
cyanotic and have pinpoint pupils.
treatment includes supporting ABC, administering
supplemental oxygen, being prepared for vomiting
and dilution with IV fluids.
an antidote for narcotics include a powerful narcotic-
antagonist called Narcan -- usually administered by
paramedics -- that will reverse the "high" in as little
as two-minutes.

Poisoning CONT
Sedative Hypnotic Drugs
 includes a category of drugs and medicines
categorically known as barbiturates and
benzodiazepines.
 these substances are CNS depressants and
alter level of conscious.

Poisoning CONT
 s/s are similar to EtOH intoxication.
 these substances are lethal when used in
combination with alcohol (EtOH).
 these drugs are also touted to be given to
people as "knock-out" drugs or "date rape
drugs." Rohypnol is one such example.

Poisoning CONT
 general treatment for such individuals is
airway support, ventilatory assistance, and
transport to the emergency department for
continued ventilatory support. Always
administer supplemental oxygen.

Poisoning CONT
Inhalants
s/s are similar to the CNS effects seen with
sedative-hypnotic but the route is via
inhalation vs. ingestion or infection.
common inhalants include acetone, hexane
(found in glues), paint thinner, hydrocarbons
(found in gasoline or other petroleum
products), propellants found in aerosol
sprays.

Poisoning CONT
drowsiness is a common finding, but seizures
can also occur with the use of this substance.
patients that inhale hydrocarbons can make
the heart sensitive to the patients own
adrenaline putting them a risk for sudden
cardiac death; try to keep such patients from
struggling or exerting themselves.

Poisoning CONT
treatment should always include
supplemental high-flow oxygen and use
stretches to move these patients.
transport to a hospital is always
recommended.

Poisoning CONT
Sympathomimetics
These are CNS stimulants (substances that produce
an excited state) causing hypertension (HTN),
tachycardia and dilate the pupils. examples include
amphetamines, methamphetamines, phentermine,
caffeine, phenylpropanolamine (nasal
decongestants), and pseudoephedrine (nasal
decongestants).

Poisoning CONT
cocaine and crack are the classic sympathomimetics
though recently ecstasy -- a so-called "designer
drug" -- has become increasingly abused in certain
areas of the United States.
designer drugs can be ingested, inhaled and
injected.
s/s include disorganized behavior, restlessness,
delusions, paranoia. Effects of the medication last
less than one hour usually.

Poisoning CONT
the risk of cardiac arrhythmia and stroke is
also high -- particularly with cocaine or crack.
EMR's may see extremes of HTN and
seizures.
treatment includes oxygen, be prepared to
suction and protect the airway.

Poisoning CONT
Marijuana
It is estimated that as many as 20 million people use
marijuana daily in the United States and Canada.
s/s normally include euphoria, drowsiness,
hallucinations and relaxation.
marijuana normally impairs short-term memory and
complex thinking, but usually doesn't result in a
hospital admission or an ambulance transport.

Poisoning CONT
exceptions include the patient who is
hallucinating and is paranoid or anxious.
marijuana is a "gateway drug" -- a drugs that
is used as vehicle for additional and
oftentimes more harmful drugs.

Poisoning CONT
Hallucinogens
Hallucinogens alter one's sense of perception.
Two common hallucinogens include LSD and PCP.
s/s include visual hallucinations and intensify
auditory and visual senses.
many of the hallucinogens have sympathomimetic
properties therefore treatment usually invokes a
calm manner and providing emotional support.

Poisoning CONT
Anticholinergics
These drugs block the parasympathetic
nervous system.
common medications include benadryl and
tricyclic antidepressants.
s/s include tachycardia, agitation and pupil
dilation.

Poisoning CONT
Serious side effects include cardiac
arrhythmia's and seizures.
treatment for such serious side effects is
necessary in a hospital environment.

Poisoning CONT
Cholinergics
Cholinergic agents are the "nerve gases"
used in chemical warfare. the mechanism by
which they act up regulate the
parasympathetic nervous system.
normally found in insecticides or some wild
mushrooms.

Poisoning CONT
s/s are easily remembered by the acronym
SLUDGE
- salivation
- lacrimation
- urination
- defecation
- GI irritation
- eye constriction

Poisoning CONT
patients exposed to cholinergic actions
frequently require decontamination by
HAZMAT units.
treatment include ALCS intervention
bypractitioners and aggressive airway
support

Poisoning CONT
Others
Two of the more common medications that can lead
to lethal conditions include aspirin (ASA) and
Tylenol (acetaminophen - APAP).
over-ingestion of ASA can result in nausea and
vomiting and tinnitus (ringing in the ears). Serious
side effects include lowering the pH of the body to
lethal levels resulting in tachyarrhythmia or kidney
failure.

Poisoning CONT
 over-ingestion of APAP leads to liver failure...
the problem is, it may not be apparent for
over a week and the patient may be symptom
free until that time. If information about the
overdose is obtained early enough, a antidote
may minimize and in some cases prevent
liver failure.

Poisoning CONT
Food Poisoning
There are two main types. In one type, the
organism is responsible for the disease
process; in the other type, the organism
produces a toxin which then causes the
disease.

Poisoning CONT
Salmonella is one example in which the
organism causes the disease process.
s/s of salmonellas is characterized by
nausea, vomiting, abdominal pain, diarrhea,
fever and generalized weakness. It occurs
within 72 hours of eating and is common
when eating improperly cooked poultry.

Poisoning CONT
Staphylococcus is an example where the
organism produces a toxin that causes the
disease process.
s/s include nausea, vomiting, and diarrhea
starting within 2-3 hours after ingestion of the
offending organism.

Poisoning CONT
This type of poisoning commonly occurs
when eating food that are prepared in
advance and kept unrefrigerated.
treatment includes supportive care until IV
fluids and medications can be administered.

Poisoning CONT
Plant Poisoning
Thousands of cases each year due to contact
or ingestion.
Though it is impossible to memorize all plants
that can cause harm, two common offending
organisms are listed below -- poison ivy and
poison oak.

Poisoning CONT
Treatment include maintaining an open
airway and monitor vital signs, notifying the
regional Poison Control Center (PCC) below
to identify the plant, taking the patient and the
plant to the Emergency Department and
transporting the patient to the hospital.

UNIT 18
HEAT AND COLD EMERGENCIES

Thermoregulation is the ability of an
organism to keep its body temperature within
certain boundaries, even when temperature
surrounding is very different. This process is
known as homeostasis: a dynamic state of
stability between an human’s internal
environment and its external environment.

CONT
If the body is unable to maintain a normal
temperature and it increases significantly
above normal, a condition known as
hyperthermia occurs. The opposite condition,
when body temperature decreases below
normal levels, is known as hypothermia

CONT
Types of thermoregulation
There are two types of thermoregulation that
are used by humans:
Physiological regulation: This is when an
organism changes its physiology to regulate
body temperature.

CONT
For example, humans tend to sweat in order
to lower temperature. Another example is
when humans get cold, muscles may shiver
in order to produce heat.

CONT
Behavioral regulation
This is when an organism changes its
behavior to change its body temperature. For
example, when humans warm up out in the
sun, they may wish to find shade to cool
down.

CONT
Human Temperature Variation Effects
Heat
Fevers are not to be confused with heat
stroke. In fever the person can feel cold at
high body temperatures since the body is
fooled into thinking it is cold by the infectant
microbe affecting the point that the body
thermostat is set at. It is literally set higher
than usual.

CONT
37°C (98.6°F) - Normal body temperature (which
varies between about 36-37.5°C (96.8-99.5°F)
38°C (100.4°F) - Sweating, feeling very
uncomfortable, slightly hungry. 39°C (102.2°F)
(Pyrexia) - Severe sweating, flushed and very red.
Fast heart rate and breathlessness. There may be
exhaustion accompanying this. Children and
epileptics may be very likely to get convulsions at
this point.

CONT
40°C (104°F) - Fainting, dehydration, weakness,
vomiting, headache and dizziness may occur as well
as profuse sweating.
41°C (105.8°F) - (Medical emergency) - Fainting,
vomiting, severe headache, dizziness, confusion,
hallucinations, delirium and drowsiness can occur.
There may also be palpitations and breathlessness.

CONT
42°C (107.6°F) - Subject may turn pale or remain
flushed and red. They may become comatose, be in
severe delirium, vomiting, and convulsions can
occur. Blood pressure may be high or low and heart
rate will be very fast.
43°C (109.4°F) - Normally death, or there may be
serious brain damage, continuous convulsions and
shock. Cardio-respiratory collapse will occur.
44°C (111.2°F) or more - Almost certainly death will
occur. However patients have been know to survive
up to 46°C (114.8°F).

CONT
Cold
37°C (98.6°F) - Normal body temperature (which
varies between about 36-37.5°C (96.8-99.5°F)
36°C (96.8°F) - Mild to moderate shivering (this
drops this low during sleep). May be a normal body
temperature.
35°C (95.0°F) - (Hypothermia) is less than 35°C
(95.0°F) - Intense shivering, numbness and
blueish/greyness of the skin. There is the possibility
of heart irritability.

CONT
34°C (93.2°F) - Severe shivering, loss of movement
of fingers, blueness and confusion. Some behavioral
changes may take place.
33°C (91.4°F) - Moderate to severe confusion,
sleepiness, depressed reflexes, progressive loss of
shivering, slow heart beat, shallow breathing.
Shivering may stop. Subject may be unresponsive
to certain stimuli.

CONT
32°C (89.6°F) - (Medical emergency) Hallucinations,
delirium, complete confusion, extreme sleepiness
that is progressively becoming comatose. Shivering
is absent (subject may even think they are hot).
Reflex may be absent or very slight.
31°C (87.8°F) - Comatose, very rarely conscious.
No or slight reflexes. Very shallow breathing and
slow heart rate. Possibility of serious heart rhythm
problems.

CONT
28°C (82.4°F) - Severe heart rhythm disturbances
are likely and breathing may stop anytime. Patient
may appear to be dead.
24-26°C (75.2-78.8°F) or less - Death usually
occurs due to irregular heart beat or respiratory
arrest. However, some patients have to been known
to survive much lower body temperature and may
be mistaken for being dead right down to 14°C
(57.2°F)

CONT
How a body loses heat:
Conduction - heat escapes from
your body e.g. when you sit on a
cold rock.
Convection - cooler air currents
remove heat from the surface of
your skin.

CONT
Evaporation - evaporative cooling
occurs when water (often from
perspiration) leaves the skin surface as
a vapour, lowering the body
temperature by taking the heat of
evaporation from the body.
Radiation - e.g. acquisition of heat from
solar radiation

CONT
Considerations
People most likely to experience hypothermia
include:
 Very old or very young
 Chronically ill, especially with heart or circulation
problems
 Malnourished
 Overly tired
 Under the influence of alcohol or drugs

CONT
Common causes include:
 Being outside without enough protective
clothing in winter.
 Falling overboard from a boat into cold water.
 Wearing wet clothing in windy or cold
weather.
 Heavy exertion, not drinking enough fluids, or
not eating enough in cold weather.

CONT
Symptoms
As people develop hypothermia, their abilities to
think and move are often lost slowly. In fact, they
may even be unaware that they need emergency
treatment. Someone with hypothermia also is likely
to have frostbite.
The symptoms include:
 Drowsiness
 Weakness and loss of coordination
 Pale and cold skin

CONT
 Confusion
 Uncontrollable shivering (although at
extremely low body temperatures, shivering
may stop)
 Slowed breathing or heart rate
 Lethargy, cardiac arrest, shock, and coma
can set in without prompt treatment.
Hypothermia can be fatal.

CONT
Treatment
 If the person is unconscious, check airway,
breathing, and circulation. If necessary, begin
rescue breathing or CPR. If the victim is
breathing less than 6 breaths per minute,
begin rescue breathing.

CONT
 Take the person inside to room temperature
and cover him or her with warm blankets. If
going indoors is not possible, get the person
out of the wind and use a blanket to provide
insulation from the cold ground. Cover the
person's head and neck to help retain body
heat.

CONT
 Once inside, remove any wet or constricting
clothes and replace them with dry clothing.
 Warm the person. If necessary, use your own
body heat to aid the warming. Apply warm
compresses to the neck, chest wall, and
groin. If the person is alert and can easily
swallow, give warm, sweetened, nonalcoholic
fluids to aid the warming.

CONT
Frostbite - hands

CONT
Frostbite

CONT
Considerations
A person with frostbite on the extremities
may also be subject to hypothermia (lowered
body temperature). Check for hypothermia
and treat those symptoms first.

CONT
Frostbite is distinguishable by the hard, pale,
and cold quality of the skin that has been
exposed to the cold for a length of time. The
area is likely to lack sensitivity to touch,
although there may be an aching pain. As the
area thaws, the flesh becomes red and very
painful.

CONT
Any part of the body may be affected by frostbite;
but hands, feet, nose and ears are the most
vulnerable. If only the skin and underlying tissues
are damaged, recovery may be complete. However,
if blood vessels are affected, the damage is
permanent and gangrene can follow which may
require amputation of the affected part.
Upon warming, it is common to experience intense
pain and tingling or burning in the affected area.

CONT
Frostbite occurs when the skin and body
tissues are exposed to cold temperature for a
prolonged period of time. Hands, feet, noses,
and ears are most likely to be affected.

CONT
If the blood vessels in the frostbite areas are
affected, permanent damage can occur.
Damage to the blood vessels causes death of
the tissue it supplies. Tissue death may
necessitate amputation of the affected area.

CONT
Causes
Frostbite occurs when the skin and body
tissues are exposed to cold temperature for a
prolonged period of time. Hands, feet, noses,
and ears are most likely to be affected.

CONT
Although anyone who is exposed to freezing
cold for a prolonged period of time can get
frostbite, people who are taking beta-
blockers, which decrease the flow of blood to
the skin, are particularly susceptible. So are
people with peripheral vascular
disorder/disease (a disorder of the arteries).

CONT
Other things that may increase the risk of
frostbite include: smoking, windy weather
(which increases the rate of heat loss from
skin), diabetes, peripheral neuropathy, and
Raynaud’s phenomenon.

CONT
Symptoms
 toes or fingers that change color when
exposed to the cold
 toes or fingers that change color upon
pressure
 pain in the fingers or toes when exposed to
the cold
 tingling or pain on warming

CONT
Additional symptoms that may be associated
with this disease:
 Skin redness or inflammation
 Bluish skin
 paleness

CONT
Treatment
 Shelter the victim from the cold and move the
victim to a warmer place. Remove any
constricting jewelry and wet clothing. Look for
signs of hypothermia (lowered body
temperature) and treat accordingly.

CONT
 If immediate medical help is available, it is
usually best to wrap the affected areas in
sterile dressings (remember to separate
affected fingers and toes) and transport the
victim to an emergency department for further
care.

CONT
 If immediate care is not available, re-warming
first aid may be given. Immerse the affected
areas in warm (never HOT) water -- or
repeatedly apply warm cloths to affected
ears, nose, or cheeks -- for 20 to 30 minutes.

CONT
 The recommended water temperature is 104
to 108 degrees Fahrenheit. Keep circulating
the water to aid the warming process. Severe
burning pain, swelling, and color changes
may occur during warming. Warming is
complete when the skin is soft and sensation
returns.

CONT
 Apply dry, sterile dressing to the frostbitten
areas. Put dressings between frostbitten
fingers or toes to keep them separated. Move
thawed areas as little as possible.

CONT
 Re-freezing of thawed extremities can cause
more severe damage. Prevent re-freezing by
wrapping the thawed areas and keeping the
victim warm. If re-freezing cannot be
guaranteed, it may be better to delay the
initial re-warming process until a warm, safe
location is reached.

CONT
 If the frostbite is extensive, give warm drinks
to the victim in order to replace lost fluids.

CONT
Heat emergencies
Heat emergencies are
of three types: heat
cramps (caused by loss
of salt), heat exhaustion
(caused by
dehydration) and heat
stroke (shock).

CONT
Considerations
 Heat illnesses are easily preventable by taking
precautions in hot weather.
 Children, elderly, and obese people have a higher
risk of developing heat illness. People taking certain
medications or drinking alcohol also have a higher
risk. However, even a top athlete in superb condition
can succumb to heat illness if he or she ignores the
warning signs.

CONT
 If the problem isn't addressed, heat cramps
(caused by loss of salt from heavy sweating)
can lead to heat exhaustion (caused by
dehydration), which can progress to
heatstroke. Heatstroke, the most serious of
the three, can cause shock, brain damage,
organ failure, and even death.

CONT
Causes
The following are common causes of heat
emergencies:
 High temperatures or humidity
 Dehydration
 Prolonged or excessive exercise
 Excess clothing
 Alcohol use

CONT
 Medications, such as diuretics, neuroleptics,
phenothiazines, and anticholinergics
 Cardiovascular disease
 Sweat gland dysfunction

CONT
Symptoms
The early symptoms of heat illness include:
 Profuse sweating
 Fatigue
 Thirst
 Muscle cramps

CONT
Later symptoms of heat exhaustion include:
 Headache
 Dizziness and light-headedness
 Weakness
 Nausea and vomiting
 Cool, moist skin
 Dark urine

CONT
The symptoms of heatstroke include:
 Fever (temperature above 104°F)
 Irrational behavior
 Extreme confusion
 Dry, hot, and red skin
 Rapid shallow breathing
 Rapid, weak pulse
 Seizures
 Unconsciousness

CONT
Treatment
 Have the person lie down in a cool place.
Elevate the person's feet about 12 inches.
 Apply cool, wet cloths (or cool water directly)
to the person's skin and use a fan to lower
body temperature. Place cold compresses on
the person's neck, groin, and armpits.

CONT
 If alert, give the person beverages to sip (such as
Gatorade), or make a salted drink by adding a
teaspoon of salt per quart of water. Give a half cup
every 15 minutes. Cool water will do if salt
beverages are not available.
 For muscle cramps, give beverages as above and
massage affected muscles gently, but firmly, until
they relax.

CONT
 Prepare for emergency protocols If the
person shows signs of shock (bluish lips and
fingernails and decreased alertness) starts
having seizures, or loses consciousness

CONT
Prevention
 Wear loose-fitting, lightweight clothing in hot
weather.
 Rest frequently and seek shade when
possible.
 Avoid exercise or strenuous physical activity
outside during hot or humid weather.

CONT
 Drink plenty of fluids every day. Drink more
fluids before, during, and after physical
activity.
 Be especially careful to avoid overheating if
you are taking drugs that impair heat
regulation, or if you are overweight or elderly.
 Be careful of hot cars in the summer. Allow
the car to cool off before getting in.

UNIT 19
SPECIAL POPULATIONS

SPECIAL POPULATIONS CONT
Airway
Potential obstruction
Respiratory system
1198Trauma in Elderly -
 Decreased
• Pulmonary circulation 30%
• Alveolar exchange
• Capacity and work rate
• Chest wall movement
• Inhalation time
• Vital capacity due to
increased residual volume

The Aging Body
Musculoskeletal system
• Postural changes
 Kyphotic deformity of spine
 Slight flexion of knees and hips
 Muscle strength decreased
• Fractures
 Advanced osteoporosis
 Bone density decreased
 Subcutaneous tissue decreased

 Communication skills are critical for all
special populations
 Care is determined by characteristics instead
of chronological age
 As with adults, assessment should begin with
the primary survey

Family-centered care is critical.
• Caregiver not always parent.
• Involve caregivers as much as possible in care.
• Give explanations and careful instructions.
• Inclusion and respect will improve stabilization.
• Keep caregivers in physical and verbal contact.
Demonstrate competence and compassion.
1202Trauma in Children -

 An effective secondary survey that requires
that you respond to the emotional state of
both the child and the parent or guardian as
you gather information. The following
considerations will help you assess an injured
or ill child
> Observe the child before you touch him/her

> Communicate clearly with the parent, or
guardian and the child
> Remain calm
> Do not separate the child from loved ones
unless necessary
> Gain trust through your actions
> Conduct your “head to toe examination” of
the child in reverse order.

 If caring for a baby or child in a car seat,
unless it is damaged, as you do your
assessment. The car sear can be used to
immobilize the baby or child
 A breathing emergency in a child can be the
result of a serious infection, such as croup or
epiglottitis

 The specific causes of SIDS are still
unknown, but there are some factors that put
the baby at a greater risk. Take a history:
Was the baby sleeping face down? Is there a
history of SIDS in the family?

 Child abuse is a very serious situation in our society.
Some general signs include:
> Injuries such as burns or bruises, that are healing
> more injuries than usual for a child of that age
> injuries located in suspect parts of the body, such as
buttocks, back, genitals, upper thighs, torso, head,
upper arms and neck
> An injury that does not fit the description of what
caused the injury

 Child abuse must be reported to your NIC or
next highest care giver.

 ILLNESS IN CHILDREN
 It is sometimes harder to assess a child than
an adult. When doing so, you can ask
yourself, the child, the parents or guardians
the following questions:
> Is the child: confused, unusually sleepy,
unusually irritable or fussy, more active or
subdued than normal

> Does the child: appear pale or flushed, show
signs of pain or anxiety, have bluish lips
> Does the child have: warm and dry or cold
and moist skin, a rash or spots, an unusal
skin color, itchy skin, any bruising or swelling.

> Does the child: rub and scratch his eyes, squint,
have red and inflamed eyes, have discharge in his
eyes, have dull or unusually bright eyes, have
swollen or puffy eyes, have yellow eyes, complain of
seeing spots.
> Does the child have: trouble hearing, swelling,
ringing in the ears, an earache, any discharge, loss
of balance, a tendency to pull, cup, or poke his ears

 Does the child have: rapid shallow breathing,
painful breathing.
 Does the child have: pain, difficult
swallowing, unusual drooling, a red and
inflamed throat, a voice that sounds
differently.
 Does the cough: occur frequently, and is dry,
bring up sputum

 Is the child: unable to keep food or water
down, nauseated, frequent vomiting,
projectile vomiting
 How often has the child voided or had BMs
during the last day

Pediatrics
Pediatrics differs from adult medicine in many
respects. The obvious body size differences
are paralleled by maturational changes. The
smaller body of an infant or neonate is
substantially different physiologically from
that of an adult.

Congenital defects, genetic variance,
immunology, oncology, and a host of other
issues are unique to the realm of pediatrics.
Issues revolving around infectious diseases
and immunizations are also dealt with
primarily by pediatricians.

Anatomy
There are four basic anatomic differences
between a child’s body and an adult’s body
that you need to be aware of that include:
 lower blood volume
 bigger head size
 softer bones
 internal organs are more vulnerable to injury

A child’s blood volume is very small when
compared to that of an adult. A good rule of
thumb is that there is approximately 70 cc
of blood present for every 1kg (2 lbs) of body
weight. That means a 20 lb child has about
700cc of blood--about the same volume as a
large McDonalds soda.

A child’s head size is proportionally larger
than an adult’s. This can make spinal
immobilization and airway management more
difficult. Infants and small children have large
occiputs (base of the back of the head) and
relatively straight cervical spines. When lying
flat a child’s cervical spine becomes slightly
flexed and the airway can become collapsed
and occluded.

A child’s bones are growing and therefore
much softer than an adult’s. They can bend
more easily.
The internal organs of a pediatric patient are
not as well-protected and the relative lack of
fat and softness of bones in the rib cage
make them susceptible to significant internal
injuries with very little mechanism or obvious
outward signs of injury.

Shock in Children
Shock is defined as circulatory failure that
results in the inadequate delivery of blood to
the body’s tissues. This lack of blood flow
inhibits delivery of oxygen and removal of
waste products. Of the several types of
shock, hypovolemic shock secondary to
blood and body fluid loss is most often seen
in children

Signs of Shock
Hypotension
is a late sign in
pediatric
shock.

Shock is defined as circulatory failure that
results in the inadequate delivery of blood to
the body’s tissues. This lack of blood flow
inhibits delivery of oxygen and removal of
waste products. Of the several types of
shock, hypovolemic shock secondary to
blood and body fluid loss is most often seen
in children.

Early Signs of Shock
 Sustained tachycardia
 Delayed capillary refill > 2 seconds
 Tachypnea
 Anxiousness, combativeness, agitation
 Peripheral constriction, cold clammy
extremities

1225
Persistent tachycardia
is most reliable indicator of shock.
Trauma in Children -

Late Signs of Shock
 Weak or absent peripheral pulses
 Decreased LOC – unconsciousness
 Hypotension (a
very late and ominous sign)

SICK/NOT SICK
Make a decision early…
SICK or NOT SICK

Pediatric Triangle
 Appearance
 Work of
Breathing
 Circulation/skin
signs

Appearance
 Alertness
 Distractibility
 Consolability
 Eye contact
 Speech/cry
 Spontaneous motor activity
 Color

Work of Breathing
 Apnea
 Labored respirations
 Retractions (supraclavicular, intercostal,
subcostal)
 Grunting
 Nasal flaring
 Poor tidal volume

Circulation / Skin Signs
 Skin color
 Temperature
 Capillary refill time
 Pulse quality

Circulation/Skin Signs
If you wait for blood pressure
to drop before
treating for shock, you have
…waited too long!

Treatment
 Trendelenberg position
 High flow oxygen
 Keeping patient warm
 Splinting fractures

Spinal Immobilization
A special concern when back boarding an
infant or small child is avoiding over flexion of
the cervical spine. To prevent this problem,
fold a towel several times and place it under
the child’s shoulders. The head should then
rest in a neutral position.

Ill or injured older adults
> All body systems change with age
> These changes may lead to an increase in injury or
illness
> When dealing with an older adult, speak slowly and
calmly if necessary. Assume the person’s
communications skills are normal unless you
observe otherwise. Use the person’s name and try
to avoid raising your voice

> Like child abuse, elder abuse is problem that
should be recognized
> There are multiple types of elder abuse.

Geriatrics
Geriatrics is the branch of medicine that
focuses on health promotion and the
prevention and treatment of disease and
disability in later life. The term itself can be
distinguished from gerontology, which is the
study of the aging process itself.

Elder abuse
Elder abuse is a single or repeated act or lack
of appropriate action, occurring within any
relationship where there is an expectation of
trust, which causes harm or distress to an
older person.

There are six main type of abuse of the
elderly:
Physical: e.g. hitting, punching, slapping,
burning, pushing, restraining or giving too
much medication or the wrong medication

Psychological: e.g. shouting, swearing,
frightening, blaming, ignoring or humiliating a
person, also common is threatening to place
the person in a nursing home even though
the person's physical or mental condition may
not require such

Financial: e.g. illegal or unauthorized use of
a person’s property, money, pension book or
other valuables (including changing the
person's will to name the abuser as heir),
often fraudulently obtaining power of
attorney, followed by deprivation of money or
other property, or by eviction from own home.

Sexual: e.g. forcing a person to take part in
any sexual activity without his or her consent

Neglect: e.g. where a person is deprived of
food, heat, clothing or comfort or essential
medication

Rights abuse, by denying the civil and
constitutional rights of people who are old,
but not declared by court to be mentally
incapable

Within the issue of elder abuse there is a
hidden fact, that approximately 60% of elder
abuse is towards women and that domestic
violence in later life may be a continuation of
long term partner abuse, or it may begin with
retirement or the onset of a health condition.
(Silent and Invisible: A Report on Abuse and
Violence in the Lives of Older Women in
British Columbia and Yukon, 2001)

AGING CHANGES
Normal body temperature does not change
significantly with aging. Temperature regulation,
however, is more difficult.
Because of changes in the heart, the resting heart
rate may become slightly slower. It takes longer for
the pulse to speed up when exercising, and longer
to slow back down after exercise. The maximum
heart rate reached with exercise is lowered.

Blood vessels become less elastic. The average
blood pressure increases from 120/70 mm Hg to
about 150/90 mm Hg and may remain slightly high
even if treated. The blood vessels also respond
more slowly to a change in body position.
Although lung function decreases slightly, changes
are usually only in the reserve function. The rate of
breathing usually does not change.

EFFECT OF CHANGES
 Loss of subcutaneous fat makes it harder to
maintain body heat. Many older people find
that they need to wear layers of clothing in
order to feel warm. Likewise, skin changes
include the reduced ability to sweat.
Therefore, older people find it more difficult to
tell when they are becoming overheated.

 There may be decreased tolerance to
exercise. Some elderly people have a
reduced response to decreased oxygen or
increased carbon dioxide levels (the rate and
depth of breathing does not increase as it
should).

 Many older people find that they become
dizzy if they stand up too suddenly. This is
caused by a drop in blood pressure when
they stand called orthostatic hypotension.

 For example, digitalis (used for heart failure)
and certain blood pressure medications
called beta blockers may cause the pulse to
slow. Pain medications can slow breathing.
Diuretics can cause low blood pressure and
aggravate orthostatic hypotension (a drop in
blood pressure when changing body
position).

COMMON PROBLEMS
 Older people are at greater risk for overheating
(hyperthermia or heat stoke). They are also at risk
for dangerous drops in body temperature
(hypothermia).
 Fever is an important sign of illness in the elderly.
Many times, fever is the only symptom for several
days. Any fever that is not explained by a known
illness should be investigated by a health care
provider.

 Often, older people are unable to create a higher
temperature with infection so very low temperatures
and checking the other vital signs plays an important
role in following these people for signs of infection.
 Heart rate and rhythm problems are fairly common
in the elderly. Excessively slow pulse (bradycardia)
and arrhythmias such as atrial fibrillation are
common.

 High blood pressure (hypertension) and a drop in
blood pressure when changing body position
(orthostatic hypotension) are common blood
pressure problems. High blood pressure should
always be discussed with your health care provider.
 Breathing problems are seldom normal. Although
exercise tolerance may decrease slightly, even a
very elderly person should be able to breathe
without effort under usual circumstances.

Information
Some changes in the heart and blood vessels
normally occur with age, but many others are
modifiable factors that, if not treated, can lead
to heart disease

BACKGROUND
The heart has two sides. The right side pumps blood
to the lungs to receive oxygen and get rid of carbon
dioxide. The left side pumps oxygen-rich blood to
the body.
Blood flows out of the heart through arteries, which
branch out and get smaller and smaller as they go
into the tissues. In the tissues, they become tiny
capillaries.

Capillaries are where the blood gives up oxygen
and nutrients to the tissues, and receives carbon
dioxide and wastes back from the tissues. Then, the
vessels begin to collect together into larger and
larger veins, which return blood to the heart.
Aging causes changes in the heart and in the blood
vessels. Heart and blood vessel diseases are some
of the most common disorders in the elderly.

AGING CHANGES
Heart
 Normal changes in the heart include deposits of the
"aging pigment," lipofuscin. The heart muscle cells
degenerate slightly. The valves inside the heart,
which control the direction of blood flow, thicken and
become stiffer. A heart murmur caused by valve
stiffness is fairly common in the elderly.

 The heart has a natural pacemaker system
that controls heartbeat. Some of the
pathways of this system may develop fibrous
tissue and fat deposits. The natural
pacemaker (the SA node) loses some of its
cells. These changes may result in a slightly
slower heart rate.

 Heart changes cause the ECG of a normal,
healthy aged person to be slightly different
than the ECG of a healthy younger adult.
Abnormal rhythms (arrhythmias) such as
atrial fibrillation are common in older people,
which may be caused by heart disease.

 A slight increase in the size of the heart,
especially the left ventricle, is not uncommon.
The heart wall thickens, so the amount of
blood that the chamber can hold may actually
decrease despite the increased overall heart
size. The heart may fill more slowly

Blood vessels
 The main artery from the heart (aorta) becomes
thicker, stiffer, and less flexible. This is probably
related to changes in the connective tissue of the
blood vessel wall. This makes the blood pressure
higher and makes the heart work harder, which may
lead to hypertrophy (thickening of the heart muscle).
The other arteries also thicken and stiffen. In
general, most elderly people experience a moderate
increase in blood pressure.

 Receptors, called baroreceptors, monitor the blood
pressure and make changes to help maintain a fairly
constant blood pressure when a person changes
positions or activities. The baroreceptors become
less sensitive with aging. This may explain the
relatively common finding of orthostatic hypotension,
a condition in which the blood pressure falls when a
person goes from lying or sitting to standing,
resulting in dizziness.

 The wall of the capillaries thickens slightly.
This may cause a slightly slower rate of
exchange of nutrients and wastes.

Blood
 The blood itself changes slightly with age.
Aging causes a normal reduction in total body
water. As part of this, there is less fluid in the
bloodstream, so blood volume decreases.

 The number of red blood cells (and
correspondingly, the hemoglobin and
hematocrit levels) are reduced. This
contributes to fatigue. Most of the white blood
cells stay at the same levels, although certain
white blood cells important to immunity
(lymphocytes) decrease in number and ability
to fight off bacteria. This reduces the ability to
resist infection

EFFECT OF CHANGES
 Under normal circumstances, the heart continues to
adequately supply all parts of the body. However, an
aging heart may be slightly less able to tolerate
increased workloads, because changes reduce this
extra pumping ability (reserve heart function).
 Some of the things that can increase heart workload
include illness, infections, emotional stress, injuries,
extreme physical exertion, and certain medications.

COMMON PROBLEMS
 Heart and blood vessel diseases are fairly
common in older people. Common disorders
include high blood pressure and orthostatic
hypotension.
 Arteriosclerosis (hardening of the arteries) is
very common. Fatty plaque deposits inside
the blood vessels cause it to narrow and can
totally block blood vessels.

 Coronary artery disease is fairly common.
 Angina (chest pain caused by temporarily
reduced blood flow to the heart muscle),
shortness of breath with exertion and Heart
attack can result from coronary artery
disease.
 Abnormal heart rhythms (arrhythmias) of
various types can occur.

 Heart failure is also very common in the
elderly. In people older than
 At age 75, heart failure occurs 10 times more
often than in younger adults.
 Valve diseases are fairly common. Aortic
stenosis , or narrowing of the aortic valve, is
the most common valve disease in the
elderly.

 Anemia may occur, possibly related to
malnutrition, chronic infections, blood loss
from the gastrointestinal tract, or as a
complication of other diseases or
medications.
 Transient ischemic attacks (TIA) or strokes
can occur if blood flow to the brain is
disrupted

Other problems with the heart and blood
vessels include the following:
 Peripheral vascular disease, resulting in
claudication (intermittent pain in the legs with
walking)
 Varicose veins
 Blood clots
 Thrombophelitis
 Deep vein thrombosis

Changes in lung tissue with age
Lung tissue atrophies and is not as efficient
with age.

AGING CHANGES
 An average person continues to slowly make new
alveoli until about age 20. After this age, the lungs
begin to lose some of their tissue. The number of
alveoli decreases, and there is a corresponding
decrease in lung capillaries. The lungs also become
less elastic due to various factors including the loss
of a tissue protein called elastin.

 Changes in the bones and muscles result in a
slightly increased front-to-back chest
diameter. Loss of bone mass in the ribs and
vertebrae, and mineral deposits in the rib
cartilage, change the spine curvature. There
may be side-to-side curvature (kyphosis) or
increased front-to-back curvature (scoliosis)
or lordosis.

 The maximal force one can generate on
inspiration (breathing in) or expiration
(breathing out) decreases with age, as the
diaphragm and muscles between the ribs
(intercostals) become weaker. The chest is
less able to stretch to breathe, and the
pattern of breathing may change slightly to
compensate for decreased ability to expand
the chest.

EFFECT OF CHANGES
 Maximum lung function decreases with age. The
amount of oxygen diffusing from the air sacs into the
blood decreases, the rate of air flow through the
airways slowly declines after age 30, and the
maximal force one is able to achieve on inspiration
and expiration decreases. Usual breathing should
remain adequate, and even a very old person
should, under most circumstances, be able to
breathe without effort.

 However, when there is a need for increased
breathing, the lungs may not be able to keep
up with the demand. As aging continues,
there may be a decreased capacity for
exercise, and high altitude may cause
problems.

 An important change for many older people is that
the airways close more readily. The airways tend to
collapse when an older person breathes shallowly or
when in bed for a prolonged time. Breathing
shallowly because of pain, illness, or surgery causes
an increased risk for pneumonia or other lung
problems. As a result, it is important for older people
to be out of bed as much as possible, even when ill
or after surgery.

 Normally, breathing is controlled by your brain. It
receives information from various parts of the body
telling it how much oxygen and carbon dioxide are in
the blood. Low oxygen levels or high carbon dioxide
levels trigger an increased rate and depth of
breathing. It is normal for even healthy older people
to have a reduced response to both decreased
oxygen and increased carbon dioxide levels.

 The voice box (larynx) also changes with aging. This
causes the pitch, loudness, and quality of the voice
to change. The voice may become quieter and
slightly hoarse. The pitch may be decreased
(becoming lower) in women and increased
(becoming higher) in men. The voice may sound
"weaker," but most people remain quite capable of
effective communication. Some people may be
emotionally sensitive to the voice's perceived loss of
appeal or effectiveness.

COMMON PROBLEMS
Elderly people are at increased risk for lung
infections. The body has many ways to
protect against lung infections. With aging,
these defenses may weaken.

 The cough reflex may not trigger as readily, and the
cough may be less forceful. The hair like projections
that line the airway (cilia) are less able to move
mucus up and out of the airway. In addition, the
nose and breathing passages secrete less of a
substance called IgA (an antibody that protects
against viruses). Thus, the elderly are more
susceptible to pneumonia and other types of lung
infections.

 Common lung problems in the elderly include
chronically low oxygen levels (reducing
tolerance to illness), decreased exercise
tolerance, abnormal breathing patterns
including sleep apnea (episodes of no
breathing during sleep), increased risk of lung
infections such as pneumonia or bronchitis,
and diseases caused by tobacco damage
such as emphysema or lung cancer

Aging changes in the bones - muscles –
joints
Osteoporosis and aging; Muscle weakness
associated with aging

Osteoarthritis

Osteoarthritis is a chronic disease of the joint
cartilage and bone, often thought to result
from "wear and tear" on a joint, although
there are other causes such as congenital
defects, trauma and metabolic disorders.
Joints appear larger, are stiff and painful and
usually feel worse the more they are used
throughout the day.

Osteoarthritis

Osteoporosis

Information
 Changes in posture and gait are as universally
associated with aging as changes in the skin and
hair.
 The skeleton provides support and structure to the
body. Joints are the areas where bones come
together. They allow the skeleton to be flexible for
movement. In a joint, bones do not directly contact
each other. Instead, they are cushioned by cartilage,
membranes, and fluid.

 Muscles provide the force and strength to
move the body. Coordination, although
directed by the brain, is affected by changes
in the muscles and joints. Changes in the
posture and gait, weakness, and slowed
movement are caused by changes in the
muscles, joints, and bones.

AGING CHANGES
 Bone mass or density is lost as people age,
especially in women after menopause. The bones
lose calcium and other minerals.
 The spine is made up of bones called vertebrae.
Between each bone is a gel-like cushion
(intervertebral disk). The trunk becomes shorter as
the disks gradually lose fluid and become thinner.

 In addition, vertebrae lose some of their mineral
content, making each bone thinner. The spinal
column becomes curved and compressed (packed
together). Bone spurs, caused by aging and overall
use of the spine, may also form on the vertebrae.
 The shoulder blades (scapulae) and other bones
may become porous - on an x-ray they may look
"moth-eaten." The foot arches become less
pronounced, contributing to slight loss of height.

 The long-bones of the arms and legs, although more
brittle because of mineral losses, do not change
length. This makes the arms and legs look longer
when compared to the shortened trunk. The joints
become stiffer and less flexible. Fluid in the joints
may decrease, and the cartilage may begin to rub
together and erode. Minerals may deposit in some
joints (calcification). This is common in the shoulder.

 Hip and knee joints may begin to lose
structure (degenerative changes). The finger
joints lose cartilage and the bones thicken
slightly. Finger joint changes are more
common in women and may be hereditary

 Some joints, such as the ankle, typically
experience little change with aging.
 Lean body mass decreases, caused in part
by loss of muscle tissue (atrophy). The rate
and extent of muscle changes seems to be
genetically determined. Muscle changes
often begin in the 20s in men and the 40s in
women.

 Lipofuscin (an age-related pigment) and fat
are deposited in muscle tissue. The muscle
fibers shrink. Muscle tissue is replaced more
slowly, and lost muscle tissue may be
replaced with a tough fibrous tissue. This is
most noticeable in the hands, which may
appear thin and bony.

 Muscle tissue changes, combined with
normal aging changes in the nervous system,
cause muscles to have reduced tone and
contractility. Muscles may become rigid with
age and may lose tone even if exercised

EFFECT OF CHANGES
 Bones become more brittle and may break more
easily. Height decreases, primarily caused by
shortening of the trunk and spine.
 Inflammation, pain, stiffness and deformity may
result from breakdown of the joint structures. Almost
all elderly people are affected by joint changes,
ranging from minor stiffness to severe arthritis

 The posture may become progressively stooped
(bent) and the knees and hips more flexed. The
neck may become tilted, and the shoulders may
narrow while the pelvis, on the other hand, may
become wider.
 movement slows and may become limited. The
walking pattern (gait) becomes slower and shorter.
Walking may become unsteady, and there is less
arm swinging. Fatigue occurs more readily, and
overall energy may be reduced.

 Strength and endurance change. Loss of
muscle mass reduces strength. However,
endurance may be enhanced by changes in
the muscle fibers. Aging athletes with healthy
hearts and lungs may find that performance
improves in events that require endurance,
and decreases slightly in events that require
short bursts of high-speed performance.

COMMON PROBLEMS
 Osteoporosis is a common problem, especially for
older women. Broken bones occur more readily, and
compression fractures of the vertebrae can cause
pain and reduce mobility.
 Muscle weakness contributes to fatigue, weakness,
and reduced activity tolerance. Joint problems are
extremely common. This may be anything from mild
stiffness to debilitating arthritis.

 Injury risk is greater because of falls related
to gait changes, instability, and loss of
balance
 Some elderly people have reduced reflexes.
This is most often caused by changes in the
muscles and tendons rather than changes in
the nerves. Decreased knee jerk or ankle jerk
is not unexpected.

 Some changes, such as a positive Babinski’s
reflex, are always considered abnormal
 Involuntary movements (muscle tremors and
fine movements called fasciculations are
more common in the elderly. Inactive or
immobile elderly people may experience
weakness or abnormal sensations
(paresthesia).

 Muscle contractures may occur in those
unable to move voluntarily or to have their
muscles stretched through exercise. Restless
leg syndrome may occur.

Loss of vision
Blindness is the lack of vision, or a loss of vision
that cannot be corrected with glasses or contact
lenses. Blindness may be partial, with very limited
vision, or complete, with no perception of light.
People with vision worse than 20/200, or a field of
vision of less than 20 degrees in the better eye, are
considered legally blind.

Common Causes
Blindness has many causes. The leading
causes are diabetes, glaucoma, macular
degeneration, and accidents (such as
chemical burns or injuries from bungee cords,
fishing hooks, fireworks, racket balls, and
similar objects).

 Patients with physical or mental disabilities
> The EMR should be aware of any special
needs of these individuals and be prepared to
provide care for them
> There are many forms of physical and mental
disabilities, for example hearing, visual
developmental and behavioural.

 Behavioral and Psychiatric Emergencies
 Behavioral or psychiatric emergencies are those
disorders that involve mood, thought, or behavior
that is dangerous or disturbing.
 These disorders can be classified into three
categories of causes:
> Situational causes
> Organic causes
> Psychiatric causes

 Situational Causes:
> certain situations can affect anyone if subjected to
sufficient stress
> some individuals are more vulnerable than others
> often when basic needs are threatened, individuals
face a crisis
> the severity of the crisis depends on that patient’s
ability to deal with their own feelings

 Organic disturbances:
> These disturbances can result in significant changes
in behavior
> examples of organic causes are: substance abuse,
trauma, illness (diabetes, electrolyte imbalance,
infections, tumors, dementia
> It is important that the EMR consider the possibilities
of all of the above in behavioral emergencies

Psychiatric problems:
> These are a result of problems within the
mind, by mechanisms we still do not fully
understand
> Conditions that fall into this category include:
psychosis, anxiety and depression

Psychosis
> By definition, psychosis means being out of
touch with reality
> people suffering from psychosis are tuned
into their internal reality of ideals and feelings
> In their mind, these internal ideas and
feelings are a reflection of the world outside

> This internal reality may make them
belligerent and angry towards others
> They may also become mute and withdrawn
as they give all their attention to the voices
and feelings within
> dealing with psychotic patients can be very
difficult

> Safety of the EMR is imperative
> The usual method of reasoning with the
patient will likely be ineffective since a
psychotic patient has their own rules of logic

Anxiety
> The dominant mood of anxiety is fear and
apprehension
> All of us experience anxiety from time to time
> this type of anxiety is helpful in helping adapt
constructively to stress

 The patient with an anxiety disorder
experiences persistent, incapacitating anxiety
in the absence of an external threat
 There are several types of anxiety disorders,
but the two most common the EMR’s will be
exposed to are: panic disorder and phobia

Depression
> Depression or depressive behavior is
characterized by a sad expression, bouts of
crying, and listless or apathetic behavior
> Patients suffering from depression express
feelings of worthlessness, guilt and
pessimism

 Quite often they will want to be left alone
 They may say that no one understands or cares that
their problems are hopeless anyway
 One of the real dangers is that a depressed patient
may commit suicide
 In these cases, the EMR may need the assistance
of a law enforcement officer to allow this person to
be taken to medical help
 Choice of words and tone are important when
communicating with this patient

UNIT 20
CHILDBIRTH

CHILDBIRTH
Emergency Childbirth

CHILDBIRTH CONT
Having a baby is one of the most natural
things the female can do
Always remember –
““Mothers deliver babies”Mothers deliver babies”
The EMR is just there to assist any way
they can

CHILDBIRTH CONT
Childbirth Terminology
 Fetus
 Cervix
 Bloody show
 Placenta (afterbirth)
 Umbilical cord
 Amniotic sac (fluid)
 Birth canal

CHILDBIRTH CONT
Stages of Labour
 During the first stage of labor the cervix
becomes fully dilated. This is described as
contractions.
 Stage one may last longer than 18 hours.
 The women who have had previous babies
may have a very short first stage.
 When contractions are 2 minutes apart, birth
is very near

CHILDBIRTH CONT
First Stage of Labour

CHILDBIRTH CONT
Stages of Labour
 The second stage of labor starts when the
baby moves through the birth canal and ends
when the baby is born.
 During the stage there will most likely be
bloody discharge (bloody show).
 The baby’s head will appear at the opening of
the birth canal (crowning).
 The shoulders and body will follow.

CHILDBIRTH CONT
Second Stage of
Labour

CHILDBIRTH CONT
 As soon as the head is delivered, the airway
must be suctioned.
 Suction the mouth first then the nose.Suction the mouth first then the nose.
 Although babies are nose breathers, they will
aspirate the fluid in their mouth as they are
stimulated to cry.
 Be sure the baby is supported at all times
during the delivery – They are very slippery

CHILDBIRTH CONT

CHILDBIRTH CONT
 Once the baby is delivered and the airway
has been cleared (the baby is crying), the
umbilical cord may be cut.
 Apply one cord clamp half way between the
baby and mom and the second one a couple
inches from the first.
 Once the cord stops pulsating, cut it between
the clamps

CHILDBIRTH CONT

CHILDBIRTH CONT
 Dry the baby and wrap it in a warm blanket
as soon as possible.
 The new born looses body heat within
seconds.
 Place the baby at the mother’s breast to
nurse as soon as it is dry and warm.
 Nursing will stimulate the uterus to shrink and
control any bleeding

CHILDBIRTH CONT

CHILDBIRTH CONT
 During the third stage, the placenta separates
from the uterine wall.
 Usually, it is spontaneously expelled from the
uterus
 Make sure you save it in a plastic bag
provided in most OB kits. It will have to be
examined at the health centre

CHILDBIRTH CONT
Third Stage of
Labour

CHILDBIRTH CONT

CHILDBIRTH CONT
Complications of Delivery
 Prolapsed Cord
 Breech Birth
 Umbilical Cord Around the Neck
 Limb Presentation
 Multiple Births
 Premature Births
 Placenta Previa

CHILDBIRTH CONT
Prolapsed Cord
 When the cord is delivered before the infant,
it is in great danger of suffocating
 The cord is compressed against the birth
canal by the baby’s head
 Emergency care is extremely urgent

CHILDBIRTH CONT
Prolapsed Cord

CHILDBIRTH CONT
Emergency Care
 Have the mother lie on her left side with knees
drawn to her chest
 Administer high-flow oxygen
 With a gloved hand, gently push the baby up the
vagina far enough so their head is off the cord –
this is controversial in some areas – follow local
protocol

CHILDBIRTH CONT
 Cover the cord with a moist sterile towel
 DO NOT PUSH THE CORD BACK INDO NOT PUSH THE CORD BACK IN

CHILDBIRTH CONT
Breech Birth
The baby’s feet or buttocks delivers first
The mother must be transported to the health
facility as soon as possible

CHILDBIRTH CONT
Breech Birth

CHILDBIRTH CONT
Emergency Care
 Prepare the mother for a normal delivery
 Let the buttocks and trunk deliver on their
own
 Support the infant
 Observe the delivery of the head
 If necessary, form an airway for the baby

CHILDBIRTH CONT
Cord Around the Neck
 Try to slip the cord gently over the baby’s
shoulders or head
 If this cannot be done and the cord is
wrapped too tightly around the neck, place
clamps 3 inches apart and quickly but
carefully, cut between them
 Unwrap the cord and deliver the baby,
supporting the head at all times

CHILDBIRTH CONT
Limb Presentation
 If the baby’s arm or leg delivers first, it means that
the infant has shifted so much in the uterus that a
normal delivery is not possible
 This is a medical emergency – the baby must be
delivered by a physician – delay can be fatal
 The mother must be transported immediately to the
health facility

CHILDBIRTH CONT
Multiple Births

CHILDBIRTH CONT
Multiple Births
 Twins are delivered the same way as single
babies
 Identical twins have 2 umbilical cords coming
out of one placenta
 If the twins are fraternal there will be 2
placentas
 The mother may, or may not be aware they
are carrying twins

CHILDBIRTH CONT
Signs of a Multiple Birth
 The abdomen is still large after one baby is
delivered
 The baby’s size is out of proportion with the
mother’s abdomen
 Strong contractions begin again within 10
minutes of delivering the first baby

CHILDBIRTH CONT

CHILDBIRTH CONT
Premature Birth
 When a baby is delivered before the 36th
week of
gestation, or delivery weight is less than 5 ½
pounds, the baby is considered to be premature
 They are much smaller, yet have heads
proportionately larger than full-term babies.
 Special cares is necessary as they are vulnerable to
infection

CHILDBIRTH CONT
Placenta Previa
 This occurs when the placenta is positioned
in the uterus in an abnormally low position
 When the cervix dilates, the fetus moves or
labor begins, the placenta separates from the
uterus
 This puts both the mother and bay in danger

CHILDBIRTH CONT
 Lightening
 A few weeks before the onset of labor (at
approximately 37 to 38 weeks in the first
pregnancy), the abdomen of the woman
undergoes a change in shape. This is called
lightening. The change is described as
“feeling like the baby has dropped”. The
uterus settles down in the pelvic cavity.

CHILDBIRTH CONT
 The fetal head descends to or even through
the pelvic opening in preparation for labor. In
subsequent pregnancies, lightening may not
occur until labor begins.

CHILDBIRTH CONT
 False Labor
 For a period before true or effective labor
begins, a woman may experience false labor.
Labor is considered false when the uterine
contractions are not associated with cervical
dilation.

CHILDBIRTH CONT
 The contractions are irregular and very short
in duration. The discomfort is usually
confined to the lower abdomen and groin. In
contrast, the uterine contractions in true labor
begin first in the fundal region, then radiate
over the uterus through the lower back.

CHILDBIRTH CONT
 False labor often stops spontaneously, but
may convert rapidly to true labor. Therefore,
complaints of infrequent and uncomfortable
uterine contractions cannot be ignored.

CHILDBIRTH CONT
 True Labor
 A dependable sign that labor is approaching
is the presence of show or bloody show,
which is a small amount of blood-tinged
mucus. It reresents the expulsion of the
mucous plug that fills the cervical canal
during pregnancy. Show is a late sign.
Labor usually begins during the next few
hours or days

CHILDBIRTH CONT
 Normally, only a few drops of blood escape
with the mucous plug. More substantial
bleeding suggests an abnormal condition

CHILDBIRTH CONT
 Duration of Labor
 There are wide variations in the duration of
labor. The duration depends on whether the
woman is pregnant for the first time
(primigravida), whether she already ahs
children (multipara), and the time that has
elapsed since the birth of the last child.

CHILDBIRTH CONT
 The longest part of labor is the first stage. In
the primigravida, the second stage is seldom
less than a half hour. In the multiparous
woman, the second stage may be fifteen
minutes or less. The duration of the third
stage is usually between five and twenty
minutes

CHILDBIRTH CONT
 A considerable number of primigravidas have
labors of under twelve hours. A number of
multiparas have labors of six to eight hours
and, in many cases, less than six hours. Any
labor less than three hours is referred to as a
precipitous delivery.

CHILDBIRTH CONT
 A woman who has had a precipitous delivery
in the past will probably deliver precipitously
in the subsequent pregnancies.
 Any woman will have a shorter labor and
delivery with subsequent pregnancies.

CHILDBIRTH CONT
 Assessment and Management
 Use the primary and secondary surveys of
your patient assessment model for the
obstetrical patient. But there are differences
which you must remember. Keep in mind
that the pregnant woman is niether ill or
traumatized. She is experiencing a normal
biological phenomenon.

CHILDBIRTH CONT
 Primary Survey:
 Airway
 Few obstetrical problems affect the woman’s
airway, with exception of an eclamptic patient
who has a seizure.


CHILDBIRTH CONT
 Breathing
 Assess her respirations. Except mild
shortness of breath. Remember that the
pregnant patient will have mild SOB if the
uterus crowds her diaphragm. This is
especially true in late pregancies and with
twins

CHILDBIRTH CONT
 The semi fowler position allows maximum
lung expansion. Rapid breathing may be due
to hemorrhage or anxiety. Determine which
condition is causing the shortness of breath.
If the patient is anxious and hyperventilating,
she may complain of light headedness and
tingling in her extremities.
 Her anxiety may also stress the fetus.

CHILDBIRTH CONT
 Calm her by slowly and gently directing her
attention to her breathing. Help her to slow
down. Provide emotional support and explain
each step as you go.

CHILDBIRTH CONT
 Circulation
 Any compromise to the woman’s circulation
affects the circulation of blood and oxygen to
the fetus.
 The most common cause of hypotension in
the pregnant patient is lying supine. When
lying supine, her uterus compresses her vena
cava against her vertebral column

CHILDBIRTH CONT
 Blood return to the heart decreases, resulting
in hypotension and reduced blood flow to the
fetus. Place the patient on her left side in
order to diplace the uterus away from the
vena cava.
 If the patient’s chief complaint is bleeding,
she must be assessed for signs of shock.

CHILDBIRTH CONT
 The pregnant woman is normally
hypervolemic (has a large amount of fluid in
her circulatory system, which also must be
taken into consideration when assessing the
pulse. The pulse may be up to fifteen beats
faster per minute by full term. She may not
show signs of hypovolemic shock until blood
loss is much greater than a non-pregnant
patient

CHILDBIRTH CONT
 The fetus is compromised as the woman’s
compensatory mechanisms redirect blood
flow to her vital organs, reducing blood flow
to the fetus.

CHILDBIRTH CONT
 Secondary Survey
 Vital signs:
 Temperature: Are there signs of shock, skin
cool, clammy? Are there signs of infection,
elevated temperature?
 Pulse: Expect the pulse rate to be greater tan
normal because of the increased blood
volume.

CHILDBIRTH CONT
 Respirations: The patient may be short of
breath because of the diaphragm is being
crowded by the uterus.
 Blood Pressure: Refer to circulation in the
primary survey. Hypotension is often the
result of a supine position. Blood loss will be
apparent before the B/P shows hypovolemic
changes.

CHILDBIRTH CONT
 Therefore be aware that there has been
significant blood loss if the patient is
hypotensive and bleeding.
 If the B/P is low and bleeding is not apparent,
check the pulse. Hypertension is a
complication of pregnancy referred to has
Pregnancy Induced Hypertension.

CHILDBIRTH CONT
 Level of Consciousness
 A decreased level of consciousness is very
rare in the pregnant patient. It may occur
when advanced hypovolemic shock or
pregnancy induced hypertension is present.
Remember that a patient who is in extreme
pain or preparing to deliver may be unable to
concentrate or interact.

CHILDBIRTH CONT
 Patient History
 Ask the following questions to obtain a history
of the pregnancy:
 Have you been seeing a doctor during your
pregnancy?
 Try to determine if the woman has received
prenatal care.
 Has there been anything unusal about this
pregnancy?

CHILDBIRTH CONT
 Has the doctor told you anything about this
pregnancy?
 Try to determine whether the pregnancy has
progressed normally or whether there is any
risk.

CHILDBIRTH CONT
 Past Obstetrical History
 Ask the following questions to obtain the
woman’s past obstetrical history.
 What was the outcome of your previous
pregnancies?
 How many pregnancies, including
spontaneous or therapeutic abortions?
 How long was the gestation?

CHILDBIRTH CONT
 Was the baby preterm or posterm?
 Did the birth weight correspond to the
gestation period?
 Was the infant’s intrauterine growth retarded
or were the dates incorrect?
 Was the birth weight excessive (this may
indicate latent gestational diabetes)

CHILDBIRTH CONT
 Was the baby born alive?
 Was the baby normally developed?
 Was labor spontaneous or induced?
 Was labor unusually short or long?Was
delivery accomplished spontaneously, with
forceps or by Cesarean section?
 Why was an operative procedure necessary?

CHILDBIRTH CONT
 Was presentation abnormal, breech etc?
 Were there any complications during
pregnancy, labor or in post partum?

CHILDBIRTH CONT
 Past Medical History
 Obtain the woman’s past medical history.
Ask about pertinent illnesses, such as
diabetes mellitus, TB, rheumatic heart
disease any renal, collagen, metabolic, or
hematologic disorders. These could
influence intrauterine development

CHILDBIRTH CONT
 You must judge how much history you should
take prior to transport and what history you
should take on route to the hospital.
 As a rule of thumb, take the history you need
to assess the chief complaint and the
possibility of imminent delivery prior to
transport.

CHILDBIRTH CONT
 Chief Complaint
 If the chief complaint is labor, ask the
following questions.
 When is the baby due?
 Are you having contractions?
 When did they begin?
 How long do they last?
 How far apart are they?

CHILDBIRTH CONT
 How many in ten minutes?
 Describe the intensity of the contractions:
mild, moderate, hard.
 Do you feel that you need to move your
bowels?
 Has your water broken?

CHILDBIRTH CONT
 If the chief complaint is bleeding, ask the
following questions.
 How much blood has been lost?
 When did the bleeding begin?
 Is there pain with the bleeding?

CHILDBIRTH CONT
 Decision to Transport
 A critical decision in imminent childbirth is
whether to transport the mother to the
hospital before or after birth. Once you have
completed your assessment, you must make
that decision based on your findings.

CHILDBIRTH CONT
 As a general rule, if the mother’s labor pains
are longer than 5 minutes apart, she is not
straining, and does not feel the urge to move
her bowels, you should:
ﾔ Instruct the mother to take deep breaths by
mouth during contractions and not bear down
at this time
ﾔ obtain vital signs

CHILDBIRTH CONT
헐 Transport the patient to the hospital. Take
into account the time to the hospital and other
environmental factors or factors that might
delay you.
헐 Ask your partner to notify the
physician/hospital/HC via dispatch
헐 Transport the mother on her left side

CHILDBIRTH CONT
 Imminent Birth
 If the mother’s contractions are less than 5
minutes apart or if she is straining and feels
she has to move her bowels, you should:
ȝ Not transport the patient to the hospital at this
time

CHILDBIRTH CONT
阐 Do not allow the mother to sit on the toilet.
Explain to her that the sensation to move her
bowels is natural and is caused by the baby’s
head pressing against the rectum
阐 Examine the mother for crowning
阐 If crowning prepare for delivery.

CHILDBIRTH CONT
Placenta Previa

CHILDBIRTH CONT
Signs & Symptoms
Severe, usually painless bleeding from the
vagina and shock

CHILDBIRTH CONT
 Miscarriage
> A miscarriage is defined as a termination of
pregnancy from any cause before the first
twenty weeks of gestation
> This is the most common cause of vaginal
bleeding in the first trimester of pregnancy
> This occurs in about 1 in ten pregnancies

CHILDBIRTH CONT
 EMRs need to get a detailed history
including:
> time of onset of pain and bleeding
> amount of blood loss
> whether the patient has passed any tissue
during bleeding, any of which needs to be
collected for analysis

CHILDBIRTH CONT
 Management of all first trimester
emergencies include:
> Closely monitoring the patient’s vital signs
> observing for shock
> positioning the patient in a comfortable
position, unless she is in
> administering high concentration oxygen
> Transport to advanced care facility

CHILDBIRTH CONT
Ectopic Pregnancy
 Ectopic pregnancy occurs when a fertilized
ovum implants anywhere other than the
uterus
 It occurs in about 1 in every 200 pregnancies
 It is the leading cause first trimester death of
the mother that usually results from
hemorrhage

CHILDBIRTH CONT
 There are numerous causes of ectopic
pregnancy; however, most involve factors
that delay or prevent passage of the fertilized
ovum to the uterus.
 The predisposing factors include: previous
surgery, previous ectopic pregnancy, tubes
blocked as a sterilization method

CHILDBIRTH CONT
 The EMR should obtain a detailed history
from the patient
 Most ruptures occur by 2 to 12 weeks of
gestation
 A ruptured ectopic pregnancy is a true
medical emergency
 Management includes: monitoring vitals,
supplemental high concentration oxygen,
rapid transport to advanced facility

CHILDBIRTH CONT
Third Trimester Bleeding
 Third trimester bleeding occurs in a very
small percentage of pregnancies and is never
normal
 Third trimester bleeding is usually as a result
of: abruptio placenta, placenta previa and
uterine rupture

CHILDBIRTH CONT
 Uterine rupture is a spontaneous or traumatic
rupture of the uterus wall. The condition may result
of a previous scar from a Cesarean birth, prolonged
or obstructed labor, or direct trauma
 Management includes: treating for shock, monitoring
vitals, placing the patient in a left lateral recumbent
position, supplemental high concentration oxygen
and rapid transport to a advanced care facility

CHILDBIRTH CONT
Postpartum Complications
 Postpartum bleeding refers to bleeding after the
birth of the new born
 It is characterized by more than 500 ml of blood loss
 It frequently occurs within the first few hours after
delivery but can be delayed for up to 24 hours

CHILDBIRTH CONT
 Causes of postpartum bleeding include the
following: uterine muscles are not contracting fully
after birth, pieces of the placenta or membranes
remain in the uterus, vaginal or cervical tears were
caused during the delivery
 Management includes: Managing any external
bleeding, positioning the patient in antishock
position, monitor vitals, supplemental high
concentration oxygen, transport to advanced care
facility

CHILDBIRTH CONT
Eclampsia and Preeclamsia
Also referred to as toxemia, preeclampsia is a
condition that pregnant women can get. It is marked
by high blood pressure accompanied with a high
level of protein in the urine. Women with
preeclampsia will often also have swelling of the
feet, legs and hands.

CHILDBIRTH CONT
Preeclampsia, when present, usually
appears during the second half of
pregnancy, generally in the latter part of
the second or in the third trimesters,
although it can occur earlier.

CHILDBIRTH CONT
Eclampsia is the final and most severe phase
of preeclampsia and occurs when
preeclampsia is left untreated. In addition to
the previously mentioned symptoms, women
with eclampsia often have seizures.
Eclampsia can cause coma and even death
of the mother and baby and can occur before,
during or after childbirth.

CHILDBIRTH CONT
What Causes Preeclampsia and
Eclampsia?
The exact causes of preeclampsia and
eclampsia are not known, although some
researchers suspect poor nutrition, high body
fat or insufficient blood flow to the uterus as
possible causes.

CHILDBIRTH CONT
Who Is at Risk for Preeclampsia?
Preeclampsia is most often seen in first-time
pregnancies and in pregnant teens and
women over 40. Other risk factors include:
A history of chronic high blood pressure
prior to pregnancy.
Previous history of preeclampsia

CHILDBIRTH CONT
A history of preeclampsia in mother or
sisters.
Obesity prior to pregnancy.
Carrying more than one baby.
History of Diabetes, kidney disease, lupus or
rheumatoid arthritis
Eclampsia

CHILDBIRTH CONT
Signs and Symptoms
In addition to swelling, protein in the urine,
and high blood pressure, symptoms of
preeclampsia can include:
Rapid weight gain caused by a significant
increase in bodily fluid
Abdominal pain
Severe headaches

CHILDBIRTH CONT
Change in reflexes
Reduced output of urine or no urine
Blood in the urine
Dizziness
Excessive vomiting and nausea

CHILDBIRTH CONT
1415Trauma in Pregnancy -

CHILDBIRTH CONT

CHILDBIRTH CONT
Transport position
• Tilt or rotate backboard 20–30o
to patient’s left
• Elevate right hip 4–6 inches with towel
 Manually displace uterus to left

CHILDBIRTH CONT
Gunshot wounds and stabbings
Entry below fundus
 Uterus absorbs force, protects maternal organs
 High fetal mortality rate: 40–70%
 Lower maternal mortality rate: 4–10%
Entry above fundus
 Bowel injury due to displacement

UNIT 21
CRISIS INTERVENTION

CRISIS INTERVENTION
Depression in children

CRISIS INTERVENTION CONT
Children who are depressed may exhibit symptoms
differently than adults. For instance, a depressed
child may seem bored and unusually irritable.
The elderly are at high risk for depression because
they are more likely than younger people to have
experienced illness, death of loved ones, impaired
function and loss of independence. The cumulative
effect of negative life experiences may be
overwhelming to an older person.

Suicide is the act of deliberately taking one's
own life. Suicidal behavior is any deliberate
action with potentially life-threatening
consequences, such as taking a drug
overdose or deliberately crashing a car.

Suicidal behaviors can accompany many
emotional disturbances, including
depression, bipolar disorder, and
schizophrenia. More than 90% of all suicides
are related to a mood disorder or other
psychiatric illness.

Suicidal behaviors often occur as a response
to a situation that the person views as
overwhelming, such as social isolation, death
of a loved one, emotional trauma, serious
physical illness, growing old, unemployment
or financial problems, guilt feelings, and
alcohol or other drug dependence.

In the U.S., suicide accounts for about 1% of
all deaths each year. The highest rate is
among the elderly, but there has been a
steady increase in the rate among
adolescents. Suicide is now the third leading
cause of death for those 15 - 19 years old,
after accidents and homicide.

Suicide attempts that do not result in death
far outnumber completed suicides. Many
unsuccessful suicide attempts are carried out
in a manner that makes rescue possible.
They often represent a desperate cry for help

The method of suicide varies from relatively
nonviolent methods (such as poisoning or
overdose) to violent methods (such as
shooting oneself). Males are more likely to
choose violent methods, which probably
accounts for the fact that suicide attempts by
males are more likely to be completed.

Suicide attempts should always be taken
seriously and mental health care should be
sought immediately. Dismissing them as
attention-seeking can have devastating
consequences.

Relatives of people who seriously attempt or
complete suicide often blame themselves or
become extremely angry, seeing the attempt
or act as selfish. However, when people are
suicidal, they often mistakenly believe that
they are doing their friends and relatives a
favor by taking themselves out of the world.
These irrational beliefs often drive their
behavior.

Symptoms
Early signs:
 Depression
 Statements or expressions of guilt feelings
 Tension or anxiety
 Nervousness
 Impulsiveness

Critical signs:
 Sudden change in behavior, especially
calmness after a period of anxiety
 Giving away belongings, attempts to "get
one's affairs in order"
 Direct or indirect threats to commit suicide
 Direct attempts to commit suicide

Treatment
Emergency measures may be necessary after a
person has attempted suicide. First aid, CPR or
mouth-to-mask resuscitation may be required.
Hospitalization is often needed, both to treat the
recent actions and to prevent future attempts.
Psychiatric intervention is one of the most important
aspects of treatment.

Sexual assault is any undesired physical contact of
a sexual nature perpetrated against another person.
While associated with rape, sexual assault is much
broader and the specifics may vary according to
social, political or legal definition.
Sexual assault includes "inappropriate touching,
vaginal, anal, or oral penetration, sexual intercourse
that [one says] no to, rape, attempted rape, [and]
child molestation

Aggressors may include, but are not limited
to, strangers, acquaintances, superiors, legal
entities (as in the case of torture), or even
family members. Often, the act is
accomplished by force sufficient to cause
physical injury. At other times, even though
no lasting physical injury is sustained, the
psychological damage done by this intimate
violation may be substantial.

Treatment for sexual assault
Render lifesaving care and basic care as
appropriate to physical injuries. Do not touch
items on scene except as necessary to
render patient care.
Due to the sensitive nature of this criminal
offense, EMRs should be scrupulous about
respecting the victim's wishes.

Field care for EMRs
Follow local protocols. Provide supportive
care for other injuries as appropriate. Fully
document any care given and additional
information for use by later investigators.

Grief is a reaction to a significant loss. It is
most frequently an unhappy and painful
emotion triggered by the death of a loved
one. These same emotions can also be
experienced by someone with a terminal
illness who expects to die, or by someone
with a chronic condition who must deal with a
loss of autonomy. The end of a significant
relationship often results in a grieving
process as well.

Everyone experiences grief in their own way,
but generally there are recognized stages to
the process of mourning. It starts at the
recognition of a loss and extends to the
eventual acceptance of it. Responses will
vary depending upon the circumstances
associated with the death.

For example, if the deceased suffered from a
chronic illness, the death may have been
anticipated, and may even come as a relief of
suffering. If the death was accidental or
violent, coming to a stage of acceptance may
take longer.

Symptoms
There are typically 5 stages of grief. These
reactions do not occur in a specific order, and
may (at times) show simultaneously. Not all
of these emotions are necessarily
experienced:

 Denial, disbelief, numbness

 Anger, blaming others

 Bargaining (e.g., "If I am cured of this
cancer, I will never smoke again.")

 Depressed mood, sadness, and crying

 Acceptance, coming to terms
Individuals who are grieving will frequently
report crying spells, some trouble sleeping,
and difficulty being productive at work

Signs and tests
Prolonged symptoms may lead to clinical
depression.
Physiological signs of depression may be
present, such as sleep and appetite
disturbance.

Treatment
Emotional support for the grieving process is
usually provided by family and friends.
Sometimes outside factors can influence the
normal grieving process, and outside help
from clergy, social workers, mental health
specialists, or self-help groups may be
indicated.

The acute phase of grief can usually last up
to 2 months, but some residual milder
symptoms may extend a year or longer.
Psychological counseling may benefit a
person suffering from absent grief reaction, or
from depression associated with grieving.

Critical Incident Stress Syndrome
Critical Incident Stress Syndrome (CISS) is a
very real and potentially fatal danger to EMS
personnel. It can cause the break up of
families, loss of jobs, and other negative
events. That's the bad news; the good news
is that it can be treated with few
complications if recognized and treated early.

CISS is the adverse psychological and/or
physiological reaction to a stressful incident. EMS
personnel are particularly susceptible to this due to
the very nature of their job.
In an incident where a particularly stressful situation
develops, EMS people are at risk. An incident
involving a mutilated or decomposing body, the
death or serious injury of a fellow searcher or a
politically frustrating situation may all lead to CISS.

Stress does have a cumulative effect on the
body. Someone who has been involved in
numerous incidents without any lasting
complications may suddenly develop the
signs and symptoms of a stress reaction.

Another example of the cumulative effect of stress is
an individual who is experiencing other stressors
such as marital problems, problems with children, or
a recent death of a friend or relative, and who then
is called out for a EMS incident. He may develop the
signs and symptoms of a stress reaction in what
may seem a particularly uneventful incident.

Everyone involved in an EMS incident has
the responsibility to be alert for the signs and
symptoms of a stress reaction in him/herself
and in fellow medics. The supervisor must be
alert for signs of a stress reaction in his/her
team members. The team debriefing is an
opportune time to assess the searchers. The
supervisor must pass any suspicions on to
the CISD debriefer.

CISD—CRITICAL INCIDENT STRESS
DEBRIEFING
The most effective way to minimize the
negative effect of C.I.S. is through a C.I.S.
debriefing facilitated by a trained mental
health professional.

UNIT 22
REACHING AND MOVING CASUALTIES

REACHING AND MOVING
CASUALTIES
Gaining Access
As an EMR, you will not usually be
responsible for rescue and extrication.
Rescue involves many different processes
and environments. It also requires training
beyond the level of the EMR.

REACHING AND MOVING
CASUALTIES CONT
Once on sceneOnce on scene
 Assess for immediate danger to rescuers
 Spilled fuel
 Downed electric wires
 Ice or water
 Glass & sharp sheet metal

REACHING AND MOVING
CASUALTIES CONT
Extrication
Extrication is the removal from entrapment or
from a dangerous situation or position.
Entrapment
Entrapment means to be caught within a
closed area with no way out, or to have a
limb or other body part trapped.

REACHING AND MOVING
CASUALTIES CONT
Vehicle Extrication
Vehicle extrication is the process of
removing a person from a vehicle that has
been involved in a motor vehicle accident
when conventional means of exit are
impossible or unadvisable. This is typically
accomplished by utilizing hydraulic tools,
including the Jaws of Life.

REACHING AND MOVING
CASUALTIES CONT
The basic extrication process consists of five
steps:
 The fire department creates the protection of
the zone, to avoid a risk of collision (marking
out the zone, lighting) and of fire (switching
off the ignition, disconnecting the battery,
absorbing powder on oil and gasoline pools,
fire extinguisher and fire hose ready to use) ;

REACHING AND MOVING
CASUALTIES CONT
 The fire department stabilizes the vehicle, to
avoid the movements of the vehicle itself
(e.g. falling in a ditch), and the movements of
the suspension (risk of worsening of an
unstable trauma) ;

REACHING AND MOVING
CASUALTIES CONT
 The fire department opens the vehicle and
the deformation of the structure (such as
"popping a window) to allow the intervention
of a EMR inside the vehicle and also to
release a possible pressure on the casualty;

REACHING AND MOVING
CASUALTIES CONT
 The fire fighters remove the section of the
cabin (usually removal of the roof or door) to
allow an extrication in good conditions,
especially respecting the head-neck-back
axis (rectitude of the spine).
 removal of the patient from the vehicle is the
responsibility of the EMR

REACHING AND MOVING
CASUALTIES CONT
In less complicated cases, it is possible to
extricate the casualty from the side door such
as removing a patient from another part other
vehicle without actually "cutting" the car.

REACHING AND MOVING
CASUALTIES CONT
As soon as possible, best before beginning
the mechanical operation, a rescuer enters
the cabin to perform the first aid to the
casualty: assessment, stopping the bleeding,
putting a cervical collar (these operation are
likely to provoke vibrations), providing oxygen

REACHING AND MOVING
CASUALTIES CONT
Jaws of Life

REACHING AND MOVING
CASUALTIES CONT
The deformation of the structure and the
section of the roof take several minutes; this
de-extrication time can be used for medical or
paramedical acts such as intubation or
placing an intravenous drip.

REACHING AND MOVING
CASUALTIES CONT
When the casualty is in cardiac arrest, CPR
can be performed during the freeing, the
casualty being seated. The use of this
incompressible duration is sometimes called
play and run, as a compromise between
scoop and run (fast evacuation to a trauma
center) and stay and play (maximum medical
care onsite).

REACHING AND MOVING
CASUALTIES CONT
HAZMAT INCIDENT

REACHING AND MOVING
CASUALTIES CONT
General Approach to a Hazmat Incident
Hazmat incidents occur under a wide variety
of conditions. For some of these situations
there are special considerations and
concerns.

REACHING AND MOVING
CASUALTIES CONT
Listed below are some of these
considerations and concerns for Hazmat
incidents involving highway transport, rail
transport, marine transport, fixed facilities,
pipelines, radioactive materials, cryogenic
tanks, chemical and biological terrorism and
illegal or clandestine drug laboratories.

REACHING AND MOVING
CASUALTIES CONT
Drowning
Drowning is death caused by the filling of the
lungs by a liquid, rendering breathing
ineffective and leading to death due to
asphyxia.

REACHING AND MOVING
CASUALTIES CONT
Near drowning is initial survival of a
drowning event, and can lead to serious
secondary complications including death later
on. Cases of near drowning therefore also
require attention by medical professionals.

REACHING AND MOVING
CASUALTIES CONT
Secondary drowning is death due to
chemical and biological changes in the lungs
after a near drowning incident or exposure to
chemicals. In many countries, drowning is
one of the leading causes of death for
children under 14 years old.

REACHING AND MOVING
CASUALTIES CONT
No person should attempt a rescue that is
beyond his or her ability or level of
training!

REACHING AND MOVING
CASUALTIES CONT

REACHING AND MOVING
CASUALTIES CONT
Drowning may occur wherever there is water,
whether it is only a few inches in the bottom
of the tub, or thousands of feet in the ocean.
People should be aware of life-saving
techniques from rescue to resuscitation.

REACHING AND MOVING
CASUALTIES CONT
Drowning rescue on ice, board assist

REACHING AND MOVING
CASUALTIES CONT
Drowning rescue,
reaching assist

REACHING AND MOVING
CASUALTIES CONT
Drowning rescue on the ice, human chain

REACHING AND MOVING
CASUALTIES CONT
Walking assist

REACHING AND MOVING
CASUALTIES CONT
One-person
walking assist

REACHING AND MOVING
CASUALTIES CONT
Two handed seat carry

REACHING AND MOVING
CASUALTIES CONT
 Clothes Drag
 Blanket Drag

Unit 22
MULTIPLE CASUALTY INCIDENTS

Multiple Casualty Incident
Definitions vary from one community to
another, it may be described as an incident
that reduces the effectiveness of the
traditional EMS response because of number
of patients, special hazards, or difficult rescue

MULTIPLE CASUALTY INCIDENT
CONT
Incident
Commander
 first arriving unit assumes command until they
delegate the authority to another person
 Establish communications and request additional
resources
 Stabilize the incident and provide for life safety,
accountability, and welfare of personnel
 Ensure that all patients are extricated, triage/treated,
and transported to medical facilities

CONT
Triage
Unit
 Triage Means, “To Sort”
 A process for sorting injured people into groups based on
their need for immediate medical treatment and transport
 Clear and assemble the walking wounded using verbal
instructions
 Primary triage assesses respiration, perfusion, and mental
status RPM
 Secondary triage is a more in-depth assessment usually
conducted in the Treatment Unit

CONT
Triage
Unit
 Determine location of triage areas
 Conduct Primary triage, ensure all patients
are assessed and sorted using appropriate
triage protocol
 Communicate resource requirements

CONT

CONT
Triage Tag
Alerts care providers to patient priority
Prevents re-triage of the same patient
Serves as a tracking system

CONT

CONT
Triage Categories
Immediate:
Life-threatening but treatable injuries
requiring rapid medical attention
Delayed:
Potentially serious injuries, but are stable
enough to wait a short while for medical
treatment

CONT
Minimum:
Minor injuries that can wait for longer
period of time prior to treatment
Expectant:
Death or lack of spontaneous respirations
after airway is opened

CONT
START
Triage method
Simple Triage and Rapid Transport
Triage assessment based on
three criteria
RPM

CONT
RPM
 Respiratory effort
 Pulses / Perfusion
 Mental status
Uses the universally
recognized triage categories

CONT
Treatment
Unit
 Determine location for treatment area
 Coordinate with the Triage unit to move patients
from the triage area to treatment areas
 Establish communication
with Incident Command

CONT
 Reassess patients, conduct
secondary triage to match
patient with resources
 Direct movement to
ambulance loading area

CONT
Transportation
Unit
 Management of patient movement from the
scene to the receiving Hospitals
 Works with Treatment unit to establish
adequately sized, easily identifiable patient
loading area

CONT
 Designates an ambulance staging area
 Maintain communication with Incident
Command

CONT
Staging
Area
 Location designated to collect available
resources near incident area
 Several staging areas may be required
 Should be easy for arriving resources to
locate
 Staging area may need to be relocated as the
situation dictates

CONT
 Regardless of the definition, Multiple Casualty
Incidents stress emergency resources and
responders
 The Incident Command System is a standardized,
on-scene, all-hazard incident management concept.
Early implementation will help bring order to a
chaotic situation
 Incident Command is assumed by the first unit on
scene and may be delegated to another person

DROWNING AND NEAR
DROWNING
Every year, more than 140,000 deaths occur
worldwide by drowning. More than half of these
deaths occur in pools and bathtubs. Drowning is the
leading cause of death in children between one and
five years of age. The age group between fifteen
and nineteen years of age has the highest number
of drownings and near drowning episodes. Of these,
males are involved five times more frequently than
females.

DROWNING AND NEAR
DROWNING cont
There have been a number of drownings and
near drownings involving children immersed
in water. Some victims, immersed longer
than 70 minutes have survived with little or no
brain damage. The patient’s prognosis is
related directly to the handling of the patient
prior to the patients arrival at the emergency
ward.

DROWNING AND NEAR
DROWNING cont
Drowning is death as caused by suffocation
when a liquid causes interruption of the
body's absorption of oxygen from the air
leading to asphyxia. The primary cause of
death is hypoxia and acidosis leading to
cardiac arrest.
Drowning is death within 24 hours from
suffocation by submersion in a liquid,
normally fresh water or sea water.

DROWNING AND NEAR
DROWNING cont
Near drowning is the survival of a drowning event
involving unconsciousness or water inhalation and
can lead to serious secondary complications,
including death, after the event.
Near drowning is survival for more than 24 hours
from suffocation by submersion.

DROWNING AND NEAR
DROWNING cont
Secondary drowning is death due to
chemical or biological changes in the lungs
after a near drowning incident.
Secondary drowning is a non-specific term for
death after 24 hours from complications of
submersion.

DROWNING AND NEAR
DROWNING cont
Risk Factors
 Inability to swim or overestimation of
swimming capabilities
 Risk-taking behavior, including the use of
alcohol and illicit drugs
 Inadequate adult supervision of children
 Trauma (such as a physical injury),
seizures, stroke, heart attack or heart
arrhythmia

DROWNING AND NEAR
DROWNING cont
 Immersion Syndrome is sudden cardiac
arrest on cold immersion. It may be vagal
response coupled with vasoconstriction.
 Recovery syncope is syncope immediately
following removal from cold water. May be
due to cold diuresis and loss of external
water pressure leading to reduced central
perfusion.

DROWNING AND NEAR
DROWNING cont
 "Shallow water blackout" in which swimmers
hyperventilate in order to swim longer under
water. This can lead to a lack of oxygen in
the brain and loss of consciousness.
 Hypothermia, or lowered body temperature.
This can lead to heart arrhythmia and rapid
exhaustion.

DROWNING AND NEAR
DROWNING cont
Prehospital Care
 Success or failure of initial basic life support
provided at the scene of the accident is the most
important determinant of outcome.
 As in any rescue initiative, initial treatment should be
geared toward ensuring adequacy of the airway,
breathing, and circulation, with attention given to
cervical spine stabilization if the scenario suggests
spinal trauma.

DROWNING AND NEAR
DROWNING cont
 The patient should be removed from water as
soon as possible.
 Initiate rescue breathing immediately, even while
the patient is still in the water, if necessary and
feasible.
 Chest compressions are not effective in the water
and waste valuable time.
 The Heimlich maneuver has not been shown to
be effective in removing aspirated water.

DROWNING AND NEAR
DROWNING cont
 Debris visible in the oropharynx should be
removed with a finger-sweep maneuver.
 Higher pressures may be required for ventilation
because of the poor compliance resulting from
pulmonary edema.
 Supplemental oxygen, 100%, should be
administered as soon as available. The degree of
hypoxemia may be difficult to determine on clinical
observation.

DROWNING AND NEAR
DROWNING cont
Pathophysiology
Submersion injury occurs when a person is
submerged in water, attempts to breathe, and either
aspirates water (wet drowning) or has laryngospasm
without aspiration (dry drowning). Although most
patients with submersion injury have aspirated a
small amount of water or gastric contents into their
lungs, approximately 10-15% of patients have
become asphyxiated without evidence of aspiration.

DROWNING AND NEAR
DROWNING cont
The most important contributory factors to
morbidity and mortality from near drowning
are hypoxemia and a decrease in oxygen
delivery to vital tissues. The pathophysiology
of near drowning is intimately related to the
multiorgan effects of hypoxemia.

DROWNING AND NEAR
DROWNING cont
CNS damage may occur because of
hypoxemia sustained during the drowning
episode (primary injury) or may result from
ongoing pulmonary injury, reperfusion injury,
or multiorgan dysfunction (secondary injury),
particularly with prolonged tissue hypoxia.

DROWNING AND NEAR
DROWNING cont
Factors associated with high mortality following
submersion
 submersion > 25 minutes100%
 CPR > 25minutes100%
 Pulseless in 100%
 VF or VT when 1st monitored 93%
 Fixed pupils 89%
 Severe acidosis 89%
 Respiratory Arrest 87%

DROWNING AND NEAR
DROWNING cont
 Dry drowning is when a person's lungs become
unable to extract oxygen from the air, due primarily
to:
 Muscular paralysis
 Puncture wound to the torso (affecting ability of
diaphragm to create respiratory movement)
 Changes to the oxygen-absorbing tissues
 Persistence of laryngospasm when immersed in
fluid

DROWNING AND NEAR
DROWNING cont
 Overdose of free water (solute free) which leads to
decreased sodium in the blood hyponatremia which
leads to massive swelling in the brain.
 The person may effectively own without any sort of
liquid. In cases of dry drowning in which the victim
was immersed, very little fluid is aspirated into the
lungs. The laryngospasm reflex essentially causes
asphyxiation and neurogenic pulmonary edema.
 Dry drowning can occur clinically, or due to illness or
accident.

DROWNING AND NEAR
DROWNING cont
Signs or behaviors associated with
drowning or near-drowning:
 Head low in the water, mouth at water level
 Head tilted back with mouth open
 Eyes glassy and empty, unable to focus
 Eyes open, with fear evident on the face
 Hair over forehead or eyes

DROWNING AND NEAR
DROWNING cont
 Hyperventilating or gasping
 Trying to swim in a particular direction but not
making headway
 Trying to roll over on the back to float
 Uncontrollable movement of arms and legs,
rarely out of the water.

DROWNING AND NEAR
DROWNING cont
Medical Treatment
Someone with no symptoms after a drowning will be
observed in the emergency department. Further
evaluation will depend upon the clinical
presentation.
 CPR if the patient is not breathing and there is no
heartbeat.
 Oxygen for patients with low oxygenation in their
blood.

DROWNING AND NEAR
DROWNING cont
 Airway control and an positive pressure ventilation
should the patient be unable to breath adequately
 Immobilization of neck with a collar for suspected
neck injury

Treatment for shock and hypothermia

DROWNING AND NEAR
DROWNING cont
• Minimize abrupt handling as this may cause
vomiting, dydrhythmias, or further injury.
• Cover patient to maintain body heat.
• Have suction and O2 ready at all times
• Notify receiving emergency department of your
patient’s status
• Ensure rapid but gentle transport

DROWNING AND NEAR
DROWNING cont
Complications of Drowning
 Hypoxemia causing brain damage is the major complication in
drowning victims who do not die.
 Direct lung tissue damage because of water aspirated into the
lung can also occur and lead to pneumonia and acute respiratory
distress syndrome (ARDS)
 If the drowning occurs in colder water risks include hypothermia
or a drop in body temperature. (
 Cervical spine fractures may occur in diving injuries associated
with drowning.

Orientation to the Ambulance
 Equipment
 The ambulance and equipment carried on
board should be examined on a daily basis
 The ambulance and equipment must be
maintained in a safe and working condition
 A checklist must be used for routine
inspections

Orientation to the Ambulance cont.
Stretcher Use
 It is important to identify all stretcher handles
and release devices
 Grab areas indicated by the manufacturer
should be identified and used, avoiding pich
areas for personal safety

Emergency Vehicles
 An EMR’s responsibilities are not necessarily
completed after providing care and treatment
 EMRs are required to prepare and transport
the patient(s) to a medical facility or hospital

 Ambulances are well equipped and efficiently
organized vehicles, aircrafts and watercrafts
 Ambulances, with their advanced
communications and technology, can bring
medical supplies, personnel, and advanced
life-support care to the scene.

Checking Emergency Vehicles
 Completing an emergency equipment and
supply checklist at the beginning of each
work shift is important for: safety, care for the
ill or injured patient, risk management issues,
proper functioning of the vehicle, identifying
potential problems that requiring servicing

 Some equipment on the vehicle may require
routine maintenance and testing to ensure
proper functioning when needed
 EMRs should be familiar with the
requirements and operational guidelines.
 All checks need to be documented and all
problems or deficiencies brought to the
attention of the supervisor

 EMRs must take any vehicle or piece of equipment
out of service if any immediate safety issues arise
 A driver’s duties at the start of the shift include:
check with your partner and discuss expectations
and roles for the shift, check outgoing shift for the
status of the emergency vehicle and equipment,
check communication equipment such as radios,
portable radios, cell phones and batteries, perform a
vehicle check.

 Driver’s duties during a call: receive the call and
confirm the location, check a map if required to
confirm the location, confirm the location with your
partner, drive to the scene, assess the scene for
hazards, communicate with dispatch your arrival,
anticipate your partner’s needs, prepare equipment,
assist as required, obtain information from family,
bystanders, assist in loading the ill or injured patient,
communicate with dispatch your departure,

 drive to the medical facility, assist unloading the
patient, transfer the patient over to the hospital bed,
gather and clean up equipment and the inside of the
ambulance, ready the vehicle for the next call.

 Driver’s duties after the call: refuel the ambulance,
restock all kits as required, replenish used supplies
with fresh supplies, clean the interior and exterior of
the ambulance, claen or replace any soiled
equipment, complete all forms or records, discuss
the call with your partner what went well, what could
have gone better

Safe Vehicle Operations
 Safe vehicle operations are important for the
safety of the ill or injured patient, the crew
and the public
 All Emergency Medical Services should have
a requirement that personnel receive
emergency driving training and ongoing
training as a part of their job

When operating an emergency vehicle, the EMR
should follow these guidelines:
> fuel the vehicle if required
> follow all the laws and acts with respect to the
operation of an emergency vehicle in this jurisdiction
> follow all operational guidelines
> be tolerant and observant of other motorists and
pedestrians

> Always use the seat belt and restraints
> be familiar with the characteristics of the emergency
vehicle
> be alert to changes in weather, road conditions, and
terrain
> exercise caution in the use of audible and visible
warning devices
> drive within the speed limit, except in circumstances
allowed by law

> Select the fastest and most appropriate route to and
from the scene
> maintain a safe following distance
> drive with due regard for the safety of others
> always drive in a manner consistent with managing
acceptable levels of risk

Appropriate Use of Warning Devices
 Emergency calls require the driver to use both
audible and visual warning devices
 Drivers must follow the laws and guidelines set out
by the jurisdiction
 Use of audible and visible warning devices while
transporting an ill or injured person will be based on
the assessment of the person

 When responding with audible and visual
warning devices, keep in mind that some
motorists may not hear or see you due to
rolled up widows, loud music, and air
conditioning or heating fans
 Always proceed with caution
 Never assume that warning devices provide
an absolute right-of-way to proceed

Proceeding Safely Through Intersections
 Most territories and provinces require emergency
vehicles to come to a complete stop at all controlled
intersections that require you to stop. Only than are
you allowed to proceed through the intersection
when safe to do so.
 Gain motorists attention by changing the mode of
the siren

Parking at the Emergency Scene
 When approaching the scene, hazards such as
leaking fuel, hazardous materials, and leaking gas
must be taken into consideration
 Position the emergency vehicle upwind from the
scene
 Position the vehicle for ease of leaving, back into
the desired location with the aid of your partner
 Position the vehicle so that it protects the
emergency crews and the patient

Other hazards to be aware of when
positioning the vehicle include:
> vehicle exhaust fumes
> downed electrical lines
> poor lighting
> blocking extrication and equipment
> collapse of surrounding structures due to fire
or explosion

Air Ambulance Support
Air Ambulance Transportation
 Transport time, the location of the patient,
and rough ground terrain have made air
ambulance service more effective
 There are generally two types of air
ambulance transportation: fixed wing and
rotary wing

Air Ambulance Support cont
 Fixed wing aircraft are generally not as high
profile as rotary wing aircraft
 Quite often fixed wing aircraft are used for
long distance, greater than 200 km, for
interhospital transfers
 Rotary wing aircraft have proven themselves
as an effective and timely way to get ill or
injured patients to a medical facility.

Landing Site Preparations
 A helicopter landing zone should be approximately
30 meters by 30 meters or 100 feet by 100 feet
 A landing zone should:
> have no vertical structures
> be relatively flat
> be free of high grass, crops, or other factors that can
reveal uneven land, hinder access and be free of
debris

 Rescue personnel close to the landing site
should wear protective eyewear and helmets
 Depending on the time of day, a landing site
may need to be lit
 Around the perimeter of the landing zone,
use portable lights or traffic cones with
reflectors or position the emergency vehicles
with warning lights on

 If white lights are used, they should be pointing to
the center of the landing zone, not up at the aircraft,
so as not to blind the pilot
 Radio communications should be used between the
ground crew and the helicopter to advise of any
concerns such as wind direction, rough terrain or
other hazards
 Hand signals can also be used as the helicopter
approaches the landing site

Ground Safety Precautions
 Everyone should be clear of the landing zone
during landing and take-off when a distance
of 30 - 6- meters or 100 - 200 ft should be
maintained
 Never allow ground personnel to approach
the helicopter unless requested by the pilot

 Allow only necessary personnel to help load or
unload the ill or injured patient
 Secure any loose objects or clothing that could blow
by the rotor or downwash
 Do not permit smoking around the landing zone or
aircraft
 Approach from the front of the helicopter in a
crouched position always within the sight of the pilot

 Never approach the rear of the aircraft from
any direction; the tail rotors on most aircraft
are near the ground and spin at a high rpm,
making them virtually invisible. Tail rotors
often inflict fatal injuries
 Carry long objects horizontally and no more
than waist high
 Depart the helicopter from the front and
within the view of the pilot

Final Practical Evaluation and Exams
 EMR candidates will participate in two
scenarios, a trauma and an illness
 EMR candidates will write a final exam
consisting of 100 questions. A candidate
must achieve a minimum of 80% to pass the
exam.
 You will have 120 minutes to write the exam.

Emergency Medical Responder

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