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EMERGENCY
MEDICAL
TECHNICIAN
FINAL REVIEW
Barry Barkinsky
EMS-I, Paramedic
Medical Emergencies

Respiratory

Common Problems

Signs and Symptoms

Adequate / Inadequate

Treatment
Obstructive Lung Disease

Types
Emphysema
 Chronic Bronchitis
 Asthma


Causes
Genetic Disposition
 Smoking & Other Risk Factors

Emphysema

Pathophysiology

Exposure to Noxious Substances
Exposure results in the destruction of the walls of the
alveoli.
 Weakens the walls of the small bronchioles and results
in increase residual volume.


Increased Risk of Infection and Dysrhythmia
Emphysema

Assessment

History
Recent weight loss, dyspnea with exertion
 Cigarette and tobacco usage


Lack of Cough
Emphysema

Assessment

Physical Exam
Barrel chest.
 Prolonged
expiration and
rapid rest phase.
 Thin.
 Pink skin due to
extra red cell
production.
 Hypertrophy of
accessory muscles.
 “Pink Puffers.”

RESPIRATORY
Chronic Bronchitis

Pathophysiology
Results from an increase in mucus-secreting cells in
the respiratory tree.
 Alveoli relatively unaffected.
 Decreased alveolar ventilation.


Assessment

History
Frequent respiratory infections.
 Productive cough.

Chronic Bronchitis

Physical Exam
 Often
overweight.
 Rhonchi present
on auscultation.
 Jugular vein
distention.
 Ankle edema.
 Hepatic
congestion.
 “Blue Bloater.”
RESPIRATORY
Bronchitis & Emphysema

Management


Maintain airway.
Support breathing.




Find position of comfort.
Monitor oxygen saturation.
Be prepared to ventilate.
Administer medications.

Bronchodilators.
Asthma

Pathophysiology

Chronic Inflammatory Disorder

Results in widespread but variable air flow
obstruction.

The airway becomes hyperresponsive.

Induced by a trigger, which can vary by individual.

Trigger causes release of histamine, causing
bronchoconstriction and bronchial edema.
Asthma

Assessment

Identify immediate threats.

Obtain history.

SAMPLE & OPQRST History


History of asthma-related hospitalization?
History of respiratory failure/ventilator use?
Asthma

Physical Exam

Presenting signs may include dyspnea, wheezing,
cough.


Wheezing is not present in all asthmatics.
Speech may be limited to 1–2 consecutive words.
Look for hyperinflation of the chest and
accessory muscle use.
 Carefully auscultate breath sounds.

Asthma

Management

Treatment goals:
Correct hypoxia.
 Reverse bronchospasm.
 Reduce inflammation.

Maintain the airway.
 Support breathing.


High-flow oxygen or assisted ventilations as indicated.
RESPIRATORY
(Trauma)
Medical Emergencies

Cardiac Compromise

Cardiac Emergencies

Signs and Symptoms

Treatment
Managing Specific Cardiovascular
Emergencies







Angina Pectoris
Myocardial Infarction
Heart Failure
Hypertensive Emergencies
Cardiogenic Shock
Cardiac Arrest
Peripheral Vascular and Other Cardiovascular
Emergencies
Angina Pectoris

Causes of Chest Pain

Cardiovascular, including acute coronary syndrome, or
thoracic dissection of the aorta

Respiratory, including pulmonary embolism,
pneumothorax or pneumonia.

Gastrointestinal, including pancreatitis, hiatal hernia,
esophageal disease, gastroesophageal reflux, peptic ulcer
disease.

Musculoskeletal, chest wall trauma.
Angina Pectoris

Field Assessment

Signs of Shock

Chest Discomfort
Typically sudden onset, which may radiate or be
localized to the chest.
 Patient often denies chest pain.


Duration
Episodes last 3–5 minutes.
 Pain relieved with rest and/or nitroglycerin.

Angina Pectoris

Breathing

History

Past episodes of angina:

Episodes of angina that are increasing in frequency,
duration, or severity are significant.
Angina Pectoris

Management

Relieve anxiety:

Place the patient in a position of physical and emotional comfort.

Administer oxygen.

Consider medication administration:

Nitroglycerin tablets or spray
Angina Pectoris

Special Considerations
Patients with new-onset often require hospitalization.
 Symptoms not relieved by rest, nitroglycerin, and
oxygen may indicate an overall worsening of the
disease or the early stages of a myocardial infarction.
 Patients may refuse transport after pain is relieved,
even though the underlying problem is not addressed.

Myocardial Infarction

Pathophysiology

Death and necrosis of
heart muscle due to
inadequate oxygen supply.


Causes may include
occlusion, spasm, acute
volume overload,
hypotension, acute
respiratory failure, and
trauma.
Location and size
dependent on the vessel
involved.
Myocardial Infarction

Effects of a Myocardial Infarction
Dysrhythmias
 Heart Failure


Goals of Treatment
Pain Relief
 Reperfusion

Myocardial Infarction

Field Assessment



Breathing
Signs of Shock
Chief Complaint

Typically related to chest pain.

Evaluate using OPQRST:


Discomfort > 30 minutes.
Radiation to arms, neck, back, or epigastric region.

Patients may minimize symptoms.

Feelings of “impending doom.”
Myocardial Infarction

Other Symptoms



Nausea and vomiting
Diaphoresis
Myocardial Infarctions & the ECG

Dysrhythmias:

VF, VT, Asystole, PEA.

Dysrhythmias are the leading cause of death in MI.
Myocardial Infarction

Management
 Transport


Rapid transport indicated when acute MI suspected
Prehospital

Administer oxygen.

Consider medication administration:


Aspirin
Nitroglycerin
Nitroglycerine

Indications

Contraindications

Side effects

Dosage
Heart Failure

Left Ventricular
Failure

Pathophysiology

Results in
increased back
pressure into
the pulmonary
circulation.
Heart Failure

Right Ventricular
Failure

Pathophysiology


Results in
increased back
pressure into the
systemic venous
circulation.
Pulmonary
Embolism
Heart Failure

Congestive Heart Failure

Pathophysiology

Reduction in the heart’s stroke volume causes fluid
overload throughout the body’s other tissues.
Heart Failure

Field Assessment

Pulmonary Edema:



Cough with copious amounts of clear or pink-tinged sputum.
Labored breathing, especially with exertion.
Abnormal breath sounds, including rales, rhonchi, and wheezes.

Paroxysmal Nocturnal Dyspnea (PND)

Medications:



Diuretics.
Medications to increase cardiac contractile force.
Home oxygen.
Heart Failure

Mental Status


Breathing




Mental status changes indicate impending respiratory failure.
Signs of labored breathing.
Tripod positioning.
“Number of pillows.”
Skin


Color changes.
Peripheral and/or sacral edema.
Heart Failure

Management

General management:

Avoid supine positioning.

Avoid exertion such as standing or walking.

Maintain the airway.

Administer oxygen.

Avoid patient refusals if at all possible.
Hypertensive Emergencies

Hypertensive Emergency

Causes
Typically occurs only in patients with a history of
HTN.
 Primary cause is noncompliance with prescribed
antihypertensive medications.
 Also occurs with toxemia of pregnancy.


Risk Factors
Age-related factors
 Race-related factors

Hypertensive Emergencies

Field Assessment

Initial Assessment


Alterations in mental state
Signs & Symptoms





Headache accompanied by nausea and/or vomiting
Blurred vision
Shortness of breath
Epistaxis
Vertigo
Hypertensive Emergencies

History
Known history of hypertension
 Compliance with medications


Exam
BP > 160/90
 Signs of left ventricular failure
 Strong, bounding pulse
 Abnormal skin color, temperature, and condition
 Presence of edema

Hypertensive Emergencies

Management

Maintain airway.

Administer oxygen.
Cardiogenic Shock

Pathophysiology

General





Inability of the heart to meet the body’s metabolic needs.
Often remains after correction of other problems.
Severe form of pump failure.
High mortality rate.
Causes




Tension pneumothorax and cardiac tamponade.
Impaired ventricular emptying.
Impaired myocardial contractility.
Trauma.
Cardiogenic Shock

Field Assessment

Initial Assessment

Chief Complaint
Chief complaint is typically chest pain, shortness of
breath, unconsciousness, or altered mental state.
 Onset may be acute or progressive.


History
History of recent MI or chest pain episode.
 Presence of shock in the absence of trauma.

Cardiogenic Shock

Mental Status


Airway and Breathing



Restlessness progressing to confusion
Dyspnea, labored breathing, and cough
PND, tripod position, accessory muscle retraction, and
adventitious lung sounds
Circulation


Hypotension
Cool, clammy skin
Cardiogenic Shock

Management
Maintain airway.
 Administer oxygen
 Identify and treat underlying problem.

Cardiac Arrest

Sudden Death

Causes









Electrolyte or acid–base imbalances
Electrocution
Drug intoxication
Hypoxia
Hypothermia
Pulmonary embolism
Stroke
Drowning
Trauma
Cardiac Arrest

Field Assessment

Initial Assessment


ECG


Unresponsive, apneic, pulseless patient
Dysrhythmias
History
Prearrest events
 Bystander CPR
 “Down time”

Cardiac Arrest

Management




Resuscitation
Return of Spontaneous Circulation
Role of Basic Life Support
General Guidelines



Manage specific Dysrhythmias.
AED
CPR.
AED
(Automatic External
Defibrillator)
AED
(Automatic External
Defibrillator)
Indications
AED
(Automatic External
Defibrillator)
Contraindications
AED
(Automatic External
Defibrillator)
Joules
AED
(Automatic External
Defibrillator)
# of Shocks
AED
(Automatic External
Defibrillator)
If NO SHOCK
Advised
Peripheral Vascular and Other
Cardiovascular Emergencies

Aneurysm

Pathophysiology


Ballooning of an arterial wall, usually the aorta, that results from
a weakness or defect in the wall
Types



Atherosclerotic
Dissecting
Traumatic
Peripheral Vascular and Other
Cardiovascular Emergencies

Abdominal Aortic
Aneurysm
Often the result of
atherosclerosis
 Signs and symptoms





Abdominal pain
Back/flank pain
Hypotension
Urge to defecate
Peripheral Vascular and Other
Cardiovascular Emergencies

Dissecting Aortic Aneurysm
Caused by degenerative changes in the smooth
muscle and elastic tissue.
 Blood gets between and separates the wall of the
aorta.
 Can extend throughout the aorta and into
associated vessels.

Peripheral Vascular and Other
Cardiovascular Emergencies

Acute Pulmonary Embolism

Pathophysiology
Blockage of a pulmonary artery by a blood clot or
other particle.
 The area served by the pulmonary artery fails.


Signs and Symptoms
Dependent upon size and location of the blockage.
 Onset of severe, unexplained dyspnea.
 History of recent lengthy immobilization.

Medical Emergencies

Altered Mental Status (AMS)

Causes

Treatment
Medical Emergencies

Diabetes

Most common cause

Signs and Symptoms

Treatment
Medical Emergencies
Seizures
Seizures

Generalized Seizures

Tonic-Clonic

Aura

Loss of Consciousness

Tonic Phase

Clonic Phase

Postseizure

Postictal
Seizures

Partial Seizures

Simple Partial Seizures
Involve one body area.
 Can progress to generalized seizure.


Complex Partial Seizures
Characterized by auras.
 Typically 1–2 minutes in length.
 Loss of contact with surroundings.

Seizures

Assessment

Differentiating Between Syncope & Seizure

Bystanders frequently confuse syncope and seizure.
Seizures

Patient History

History of Seizures

History of Head Trauma

Any Alcohol or Drug Abuse

Recent History of Fever, Headache, or Stiff Neck

History of Heart Disease, Diabetes, or Stroke

Current Medications


Phenytoin (Dilantin), phenobarbitol, valproic acid (Depakote), or
carbamazepine (Tegretol)
Physical Exam

Signs of head trauma or injury to tongue, alcohol or drug abuse
Seizures

Management





Scene safety & BSI.
Maintain the airway.
Administer high-flow
oxygen.
Treat hypoglycemia if
present.
Do not restrain the
patient.


Protect the patient
from the environment.
Maintain body
temperature.
Seizures

Management

Position the patient.

Suction if required.

Provide a quiet
atmosphere.

Transport.
Seizures

Status Epilepticus

Two or More Generalized Seizures


Seizures occur without a return of consciousness.
Management


Management of airway and breathing is critical.
Monitor the airway closely.
Medical Emergencies
Stroke (CVA)
Stroke & Intracranial Hemorrhage

Occlusive Strokes


Embolic & Thrombotic Strokes
Hemorrhagic Strokes
Stroke & Intracranial Hemorrhage

Signs
Facial Drooping
 Headache
 Aphasia/Dysphasia
 Hemiparesis
 Paresthesia
 Gait Disturbances
 Incontinence

Symptoms
Confusion
Agitation
Dizziness
Vision Problems
Stroke & Intracranial Hemorrhage

Transient Ischemic Attacks
Indicative of carotid artery disease.
 Symptoms of neurological deficit:

Symptoms resolve in less than 24 hours.
 No long-term effects.


Evaluate through history taking:
History of HTN, prior stroke, or TIA.
 Symptoms and their progression.

Stroke & Intracranial Hemorrhage

Management
Scene safety & BSI
 Maintain the airway.
 Support breathing.
 Obtain a detailed history.
 Position the patient.
 Protect paralyzed extremities.

Medical Emergencies
Allergic Reaction
(Anaphylaxis)
Allergies and Anaphylaxis

Allergic Reaction


An exaggerated response by the immune system
to a foreign substance
Anaphylaxis
An unusual or exaggerated allergic reaction
 A life-threatening emergency

Anaphylaxis

Causes
Assessment Findings
in Anaphylaxis

Focused History & Physical Exam

Focused History

SAMPLE & OPQRST History




Rapid onset, usually 30–60 seconds following exposure.
Speed of reaction is indicative of severity.
Previous allergies and reactions.
Physical Exam

Presence of severe respiratory difficulty is key to
differentiating anaphylaxis from allergic reaction.
Assessment
Findings in
Anaphylaxis

Physical Exam





Facial or laryngeal edema
Abnormal breath sounds
Hives and urticaria
Hyperactive bowel sounds
Vital sign deterioration as
the reaction progresses
Management of Allergic Reactions





Scene safety
Protect the airway.
Support breathing.
Establish IV access.
Administer
medications:

Epinephrine
Epi-Auto Injector
Indications
Epi-Auto Injector
Contraindications
Epi-Auto Injector
Dosage
Epi-Auto Injector
Actions
Epi-Auto Injector
Side Effects
Epi-Auto Injector
Administration
Medical Emergencies

Poisons and Overdose
How they enter the body
 Treatment


Environmental
Heat
 Cold
 Water Emergencies

Trauma Emergencies
Bleeding
Bleeding
External Types,
Treatment ( In order)
Hemorrhage Classification

Capillary

Slow, even flow
Venous
Steady, slow flow
Dark red
Arterial
Spurting blood
Pulsating flow
Bright red color
Bleeding
Internal, S/S,
Treatment
Hemorrhage Control

Internal Hemorrhage

Hematoma

Pocket of blood between muscle and fascia
Humerus or Tibia/Fibula fracture: 500-750mL
 Femur fracture: 1,500mL
 UNEXPLAINED SHOCK is BEST attributed
to abdominal trauma
 General Management


Immobilization, Stabilization, Elevation
Hemorrhage Control

Internal Hemorrhage

Epistaxis: Nose Bleed
Causes: Trauma, Hypertension
 Treatment: Lean forward, pinch nostrils

Hemoptysis
 Esophageal Varices
 Chronic Hemorrhage


Anemia
Trauma Emergencies
Shock
In a Nutshell…..
SHOCK is…
INADEQUATE
TISSUE
PERFUSION
Stages of Shock

Compensated Shock


Decompensated Shock


Minimal Change
System beginning to fail
Irreversible Shock

Ischemia and death imminent
Etiology of Shock

Hypovolemic Shock


Loss of blood volume
Distributive Shock

Prevent appropriate
distribution of nutrients and
removal of wastes




Anaphylactic
Septic
Hypoglycemia
Obstructive Shock

Interference with the blood
flowing through the
cardiovascular system



Tension Pneumothorax
Cardiac Tamponade
Pulmonary Emboli
Cardiogenic Shock
Pump failure
Respiratory Shock
Respiratory system not able to
bring oxygen into the alveoli
Airway obstruction
Pneumothorax
Neurogenic Shock
Loss of nervous control from
CNS to peripheral vasculature
Trauma Emergencies
Soft Tissue
Introduction to
Soft-Tissue Injury



Skin is the largest, most important organ
16% of total body weight
Function
Protection
 Sensation
 Temperature Regulation


AKA: Integumentary System
Introduction to
Soft-Tissue Injury

Epidemiology

Open Wounds

Over 10 million wounds present to ED



Most require simple care and some suturing
Up to 6.5% may become infected
Closed Wounds
More Common
 Contusions, Sprains, Strains

A&P of Soft Tissue Injuries

Skin Layers

Epidermis



Outermost layer
Helps prevent infection
Dermis

Upper Layer (Papillary Layer)


Lower Layer (Reticular Layer)


Integrates dermis with SQ layer
Blood vessels, nerve endings, glands


Loose connective tissue, capillaries and nerves
Sebaceous & Sudoriferous Glands
Subcutaneous


Adipose tissue
Heat retention
Pathophysiology of
Soft-Tissue Injury

Closed Wounds

Contusions

Ecchymosis
Hematomas
 Crush Injuries

Open Wounds
Abrasions
Lacerations
Incisions
Punctures
Impaled Objects
Avulsions
Amputations
Trauma Emergencies
Penetrating Injuries
Trauma Emergencies
Evisceration
Trauma Emergencies
Impaled Object
Trauma Emergencies
Amputation
Management of
Soft-Tissue Injury

Objectives of Wound Dressing & Bandaging
 Hemorrhage Control
Direct Pressure
 Elevation
 Pressure Points
 Consider





Ice
Constricting Band
Tourniquet
USE ALL COMPONENTS TOGETHER
Management of
Soft-Tissue Injury

Objectives of Wound Dressing & Bandaging
 Sterility
Keep the wound as clean as possible
 If wound is grossly contaminated consider cleansing


Immobilization
Prevents movement and aggravation of wound
 Do not use an elastic bandage: TQ effect
 Monitor distal pulse, motor, and sensation
(continued)

Management of
Soft-Tissue Injury

Pain & Edema Control
Cold packs
 Moderate pressure over wound

Dressing & Bandage Materials

Sterile & Non-sterile Dressings




Occlusive/Non-occlusive Dressings
Adherent/Non-adherent Dressings


Adherent: stick to blood or fluid
Absorbent/Non-absorbent


Sterile: Direct wound contact
Non-sterile: Bulk dressing above sterile
Absorbent: soak up blood or fluids
Wet/Dry Dressings


Wet: Burns, postoperative wounds (Sterile NS)
Dry: Most common
Trauma Emergencies

Burns

Classification
Superficial
 Partial-Thickness
 Full-Thickness


Severity
Depth
 Body Surface Area (BSA)

Burn Depth

Superficial Burn:
1st Degree Burn

Signs & Symptoms
Reddened skin
 Pain at burn site
 Involves only
epidermis

Burn Depth

Partial-Thickness
Burn: 2nd Degree
Burn

Signs & Symptoms
Intense pain
 White to red skin
 Blisters
 Involves epidermis &
dermis

Burn Depth

Full-Thickness Burn:
3rd Degree Burn

Signs & Symptoms
Dry, leathery skin
(white, dark brown, or
charred)
 Loss of sensation (little
pain)
 All dermal layers/tissue
may be involved

Trauma Emergencies (Burns)

Rule of Nines (Adult)
Head and Neck:
9%
Each Upper Ext:
 Anterior Trunk:
 Posterior Trunk:
 Each Lower Ext:
9%
18 %
18 %
18 %



Genitalia:
1%
Trauma Emergencies (Burns)

Rule of Nines
(Child)
Head and Neck:
18 %
Each Upper Ext:
 Anterior Trunk:
 Posterior Trunk:
 Each Lower Ext:
 Genitalia:
9%
18 %
18 %
14 %
1%


Trauma Emergencies

Burns
Rule of Palm
 Location
 Preexisting Medical Problems
 Age


5 – 55
Source
 Treatment

Rule of Palms

A burn equivalent to the size of the patient’s
hand is equal to 1% body surface area (BSA)
Pathophysiology of Burns

Types of Burns
Thermal
 Electrical
 Chemical
 Radiation

Thermal Burns

Heat changes the molecular structure of
tissue


Denaturing (of proteins)
Extent of burn damage depends on
Temperature of agent
 Concentration of heat
 Duration of contact

Systemic Complications

Hypothermia


Hypovolemia



Disruption of skin and its ability to thermoregulate
Shift in proteins, fluids, and electrolytes to the burned
tissue
General electrolyte imbalance
Eschar


Hard, leathery product of a deep full thickness burn
Dead and denatured skin
Systemic Complications

Infection



Organ Failure
Special Factors


Greatest risk of burn is infection
Age & Health
Physical Abuse

Elderly, Infirm or Young
Assessment of Thermal Burns
General Signs & Symptoms






Pain
Changes in skin condition at
affected site
Adventitious sounds
Blisters
Sloughing of skin
Hoarseness
Burnt hair
Edema
Paresthesia
Hemorrhage
Other soft tissue injury
Musculoskeletal injury
Dyspnea
Chest pain
Assessment of Thermal Burns
Burn Severity
Minor
Superficial
Partial Thickness
Full Thickness
<50% BSA
<15% BSA
<2% BSA
Moderate
Superficial
Partial Thickness
Full Thickness
>50% BSA
>15% BSA
>2% BSA
Critical
Partial Thickness
>30% BSA
Full Thickness
Inhalation Injury
>10% BSA
Any partial or full thickness burn involving hands, feet, joints,
face, or genitalia
Management of
Thermal Burns

Local & Minor Burns

Local cooling
Partial thickness: <15% of BSA
 Full thickness: <2% BSA

Remove clothing
 Cool or Cold water immersion

Management of
Thermal Burns

Moderate to Severe Burns

Dry sterile dressings
Partial thickness: >15% BSA
 Full thickness: >5% BSA


Maintain warmth


Prevent hypothermia
Consider aggressive fluid therapy

Moderate to severe burns
Management of
Thermal Burns

Moderate to Severe Burns

Caution for fluid overload


Frequent auscultation of breath sounds
Prevent infection
Management of
Thermal Burns

Inhalation Injury

Provide high-flow O2 by NRB

Consider intubation if swelling

Consider hyperbaric oxygen therapy
Assessment & Management of Electrical,
Chemical & Radiation Burns

Electrical Injuries

Safety
Turn off power
 Energized lines act as whips
 Establish a safety zone


Lightning Strikes
High voltage, high current, high energy
 Lasts fraction of a second
 No danger of electrical shock to EMS

Assessment & Management of Electrical,
Chemical & Radiation Burns

Chemical Burns

Scene size-up
Hazardous materials team
 Establish hot, warm and cold zones
 Prevent personnel exposure from chemical


Specific Chemicals
Phenol
 Dry Lime
 Sodium
 Riot Control Agents

Assessment & Management of Electrical,
Chemical & Radiation Burns

Specific Chemicals

Phenol
Industrial cleaner
 Alcohol dissolves Phenol
 Irrigate with copious amounts of water


Dry Lime
Strong corrosive that reacts with water
 Brush off dry substance
 Irrigate with copious amounts of cool water


Prevents reaction with patient tissues
Assessment & Management of Electrical,
Chemical & Radiation Burns

Riot Control Agents

Agents




Irritation of the eyes, mucous membranes, and respiratory
tract.
No permanent damage
General Signs & Symptoms



CS, CN (Mace), Oleoresin, Capsicum (OC, pepper spray)
Coughing, gagging, and vomiting
Eye pain, tearing, temporary blindness
Management

Irrigate eyes with normal saline
Assessment & Management of Electrical,
Chemical & Radiation Burns

Radiation Burns
Notify Hazardous Materials Team
 Establish Safety Zones


Hot, Warm, & Cold
Personnel positioned Upwind and Uphill
 Decontaminate ALL rescuers, equipment and
patients

Musculoskeleta
l System
Pathophysiology of the
Musculoskeletal System

Joint Injury
Sprain
 Subluxation
 Dislocation


Bone Injury
Open Fracture
 Closed Fracture
 Hairline Fracture
 Impacted Fracture

Musculoskeletal
Ligament
Musculoskeletal
Tendon
Pathophysiology of the
Musculoskeletal System

Pediatric Considerations


Geriatric Considerations


Flexible nature
Osteoporosis
Pathological Fractures

Pathological diseases
Pathophysiology of the
Musculoskeletal System

General Considerations with musculoskeletal
injuries
Neurological compromise
 Decreased stability
 Muscle spasm


Bone Repair Cycle
Osteocytes produce osteoblasts
 Deposition of salts
 Increasing strength of matrix

Musculoskeletal Injury
Management

General Principles
Protecting Open Wounds
 Positioning the limb
 Immobilizing the injury
 Checking Neurovascular Function

Trauma Emergencies

Injuries
Painful, swollen, deformed extremities
 Assessment

Signs and Symptoms
 Splinting




Upper Extremities
Lower Extremities
Hip / Pelvis
Musculoskeletal Injury
Management

Splinting Devices





Rigid splints
Formable Splints
Soft Splints
Traction Splints
Other Splinting Aids






Vacuum Splints
Air Sprints
Cravats or Velcro Splints
Fracture Care
Joint Care
Muscular & Connective Tissue Care
Trauma Emergencies

Injuries to Head
Nervous System
 Brain Injuries

Direct
 Indirect


Patient Assessment
Signs and Symptoms
 Neurological Assessment

Trauma Emergencies

Injuries to Spine
MOI
 Assessment

Signs and Symptoms
 Treatment
 Immobilization





Helmets
Collars
LSB
Seated Patient
Musculoskeletal Injury
Management

Care for Specific Joint Injuries
Hip
 Knee
 Ankle
 Foot
 Shoulder
 Elbow
 Wrist/Hand
 Finger

Joint Injuries
Alert for
neurological
Compromise
Triage
Command at
Mass-Casualty
Incidents
Incident Commander (IC)


Coordinates all scene activities
Also called Incident Manager (IM) or
Officer in Charge (OIC)
The first on-scene unit must assume command
and direct all rescue efforts at a mass-casualty
incident (MCI)
Singular vs. Unified Command

Singular command
One person coordinates the incident.
 Most useful in smaller, single-jurisdictional incidents.


Unified command

Managers from different jurisdictions share
command.

Fire, EMS, law enforcement
Establishing Command



First arriving unit establishes command.
Assign command early in an incident.
Establish a command post.
EMS Branch Functions



Triage
Treatment
Transport
Triage



Sorting of patients based upon the severity of
their injuries
Primary triage
Secondary triage
Triage Tags



Alerts care providers to patient priority
Prevents re-triage of the same patient
Serves as a tracking system
The METTAG
Treatment



Red treatment unit
Yellow treatment unit
Green treatment unit
Triage
Priority 1
(RED)
Triage
Priority 2
(Yellow)
Triage
Priority 3
(Green)
OB / GYN
OB / GYN




Labor
Bloody Show
Crowning
Predelivery Emergencies
Labor



Stage One
(Dilation)
Stage Two
(Expulsion)
Stage Three
(Placental Stage)
Management of a Patient
in Labor



Transport the patient in labor unless delivery is
imminent.
Maternal urge to push or the presence of
crowning indicates imminent delivery.
Delivery at the scene or in the ambulance will be
necessary.
Field Delivery





Set up delivery area.
Give oxygen to mother and
start
Drape mother with toweling
from OB kit.
Monitor fetal heart rate.
As head crowns, apply gentle
pressure.
Suction the mouth and then
the nose.
Clamp and cut the cord.
Dry the infant and keep it
warm.
Deliver the placenta and
save for transport with the
mother.
OB / GYN ( Normal Delivery)
OB / GYN ( Normal Delivery)
OB / GYN ( Normal Delivery)
OB / GYN ( Normal Delivery)
OB / GYN ( Normal Delivery)
OB / GYN ( Normal Delivery)
Apgar Scoring
OB / GYN ( Normal Delivery)
Care of Newborn
OB / GYN
(Resuscitation)
HR Less than 100
OB / GYN
(Resuscitation)
HR less than 80
OB / GYN
(Resuscitation)
HR less than 60
Neonatal Resuscitation



If the infant’s respirations are below 30 per minute
and tactile stimulation does not increase rate to
normal range, assist ventilations using bag valve
mask with high-flow oxygen.
If the heart rate is below 80 and does not respond to
ventilations, initiate chest compressions.
Transport to a facility with neonatal intensive care
capabilities.
Causes of Bleeding
During Pregnancy




Abortion
Ectopic pregnancy
Placenta previa
Abruptio placentae
Abortion





Termination of pregnancy before the 20th
week of gestation.
Different classifications.
Signs and symptoms include cramping,
abdominal pain, backache, and vaginal
bleeding.
Treat for shock.
Provide emotional support.
Ectopic Pregnancy


Assume that any female of childbearing age
with lower abdominal pain is experiencing an
ectopic pregnancy.
Ectopic pregnancy is life-threatening.
Transport the patient immediately.
Placenta Previa




Usually presents with
painless bleeding.
Never attempt vaginal
exam.
Treat for shock.
Transport
immediately—
treatment is delivery
by
c-section.
Abruptio Placentae





Signs and symptoms
vary.
Classified as partial,
severe, or complete.
Life-threatening.
Treat for shock, fluid
resuscitation.
Transport left lateral
recumbent position.
Abnormal Delivery Situations
OB / GYN (Abnormal
Deliveries)
Breech
Breech Presentation


The buttocks or both feet present first.
If the infant starts to breath with its face
pressed against the vaginal wall, form a “V”
and push the vaginal wall away from infant’s
face. Continue during transport.
OB / GYN (Abnormal
Deliveries)
Prolapsed Cord
Prolapsed Cord





The umbilical cord precedes the fetal presenting part.
Elevate the hips, administer oxygen, and keep warm.
If the umbilical cord is seen in the vagina, insert two
gloved fingers to raise the fetus off the cord. Do not
push cord back.
Wrap cord in sterile moist towel.
Transport immediately; do not attempt delivery.
OB / GYN (Abnormal
Deliveries)
Limb Presentation
Limb Presentation
With limb presentation, place the
mother in knee–chest position,
administer oxygen, and transport
immediately. Do not attempt delivery.
Other Abnormal Presentations




Whenever an abnormal presentation or position of
the fetus makes normal delivery impossible, reassure
the mother.
Administer oxygen.
Transport immediately.
Do not attempt field delivery in these
circumstances.
Other Delivery Complications
OB / GYN (Abnormal
Deliveries)
Multiple Births
Multiple Births



Follow normal guidelines, but have additional
personnel and equipment.
In twin births, labor starts earlier and babies
are smaller.
Prevent hypothermia.
OB / GYN (Abnormal
Deliveries)
Meconium
Meconium Staining


Fetus passes feces into the amniotic fluid.
If meconium is thick, suction the
hypopharynx and trachea using an
endotracheal tube until all meconium has
been cleared from the airway.
Maternal Complications of
Labor and Delivery
Postpartum Hemorrhage



Defined as a loss of more than
500 cc of blood following delivery.
Treat for shock as necessary.
Follow protocols if applying antishock
trousers.
Uterine Rupture






Tearing, or rupture, of the uterus.
Patient complains of severe abdominal pain and will
often be in shock. Abdomen is often tender and
rigid.
Fetal heart tones are absent.
Treat for shock.
Give high-flow oxygen.
Transport patient rapidly.
Infants and Children

Airway

Maneuvers

FBAO

Adjuncts
Infants and Children

Trauma
Common Causes
 Types


Shock
Causes
 Assessment
 Treatment

Anatomical and physiological considerations
in the infant and child.
a. In the supine position, an infant’s or child’s
larger head tips forward, causing airway
obstruction.
b. Placing padding under the patient’s back and
shoulders will bring the airway to a neutral or
slightly extended position.
General Approach to
Pediatric Assessment
Basic Considerations



Much of the initial patient assessment can be
done during visual examination of the scene.
Involve the caregiver or parent as much as
possible.
Allow to stay with child during treatment and
transport.
Scene Size-Up





Conduct a quick scene size-up.
Take BSI precautions.
Look for clues to mechanism of injury or nature
of illness.
Allow child time to adjust to you before
approaching.
Speak softly, simply, at eye level.
Suctioning




Decrease suction pressure to less than 100
mm/Hg in infants.
Avoid excessive suctioning time—less than 15
seconds per attempt.
Avoid stimulation of the vagus nerve.
Check the pulse frequently.
Inserting an oropharyngeal airway in a
child with the use of a tongue blade.
Ventilation







Avoid excessive bag pressure and volume.
Obtain chest rise and fall.
Allow time for exhalation.
Flow-restricted, oxygen-powered devices are
contraindicated.
Do not use BVMs with pop-off valves.
Apply cricoid pressure.
Avoid hyperextension of the neck.
Circulation
Two problems lead to cardiopulmonary
arrest in children:


Shock
Respiratory failure
Signs and symptoms of shock
(hypoperfusion) in a child.
Respiratory Emergencies


Infections
Upper airway distress
Croup
 Epiglottitis


Lower airway distress
Asthma
 Bronchiolitis

a. Croup and
b. Epiglottitis
Positioning of the child with epiglottitis.
Often there will be excessive drooling.
The child with epiglottitis should be
administered humidified oxygen and
transported in a comfortable position.
Poisoning and Toxic Exposure


Accidental poisoning is a common childhood
emergency.
Leading cause of preventable death in
children.
Medical Emergencies
Seizures
Trauma Emergencies







Falls
Motor vehicle crashes
Car vs. pedestrian injuries
Drowning and near drowning
Penetrating injuries
Burns
Physical abuse
Falls are the most common cause of
injury in young children.
A deploying airbag can propel a child safety seat
back into the vehicle’s seat, seriously injuring
the child secured in it.
Medical Emergencies
SIDS
Sudden Infant Death Syndrome
(SIDS)
SIDS is the sudden death of an
infant during the first year of life
from an illness of unknown etiology.
Child Abuse and
Neglect
The stigmata of child abuse.
Infants and Children with
Special Needs

Common home-care devices
Tracheostomy tubes
 Apnea monitors
 Home artificial ventilators
 Central intravenous lines
 Gastric feeding and gastrostomy tubes
 Shunts

Medical Emergencies
Meningitis
Summary
Questions ?