lsti emt-b manual

Emergency Medical

Technician – Basic

Course Manual

Life Support Training International

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Emergency Medical Technician - Basic (EMT-B) Course Manual

This work is protected by copyright in The Philippines and internationally. No part of

this course may be reproduced without the written permission of Life Support Training

International (LSTI). All rights reserved.

This first edition produced 2010.

Edited by Craig Barrett, BA, PG Dip Ed, EMT-B

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Editor’s Note

Welcome to the first edition of the Emergency Medical Technician-Basic manual published by

Life Support Training International. The manual aims to help you on your journey to becoming a

competent EMT-B by providing you as much information as possible to supplement the lectures

provided by LSTI.

As you proceed through the manual, please note that all information was current at the time of

publishing. As new treatments and protocols are released, your lecturers will update you to keep

you current with worldwide standards.

For the Philippines, the prehospital care system is about to undergo significant changes with the

passing of the EMS Bill by the Philippine Senate.

This book is dedicated to Aidan and Joann Tasker-Lynch, without whom the EMS industry in the

Philippines would still be poorly developed. It is their vision and dedication to prehospital care

and the Filipino EMT that gives us all hope for nation-wide professional EMS services, with

world-class Filipino EMTs providing the best possible care for the Filipino people.

On a final note, as a graduate of LSTI Batch 67, I congratulate you on your decision to become

an EMT. It is a difficult but immensely rewarding course you are to undertake, and hopefully it is

the beginning of a career you will be passionate about.

Craig Barrett, EMT-B

LSTI-Batch 67

Quezon City 2010

Contents

Chapter Page

1 EMS In The Philippines 1

2 Roles and Responsibilities of the EMT 10

3 Medico-Legal and Ethical Issues in EMS 20

4 Ambulance Vehicles and Equipment 28

5 Medical Terminology in EMS 37

6 Infection Control and the EMT 48

7 Anatomy for EMTs 57

8 Health, Hygiene, Fitness and Safety of the EMT 71

9 Patient Assessment 75

10 Communication and Documentation 110

11 Airway Management 123

12 The Basic ECG 155

13 The Automated External Defibrillator 164

Appendices

Appendix 1 ERC Guidelines (2010)

Chapter 1: EMS In The Philippines

Page 1

Emergency Medical Technician – Basic

Outline


Philippine Society of Emergency Medical Technicians

PSEMT Affiliations

PSEMT Membership Grades

LSTI Academic Policies and Procedures


ife Support Training International is the Philippines’ industry leader in all

levels of instruction in pre-hospital emergency medical care and is

dedicated to the spread of knowledge in handling all traumatic and

medical emergencies.

Our consultants have been involved in developing Emergency Medical Services

Systems (EMSS) in various parts of the world, ranging from the United Kingdom

to the Middle East, the Western Pacific Region and, indeed, here in The

Philippines. In the Philippines, we work closely with Emergency Medicine

Consultants from the University of the Philippines, Philippines General Hospital,

Department of Emergency Medicine. Life Support Training International is

heavily involved with the Philippine Heart Association, being active members of

both the Expanded Council on Resuscitation and the National Emergency

Medical Services Council. We are also the founding executive members of the

Philippine Society of Emergency Medical Technicians, which is a society

dedicated to developing a National Emergency Medical Services System

throughout The Philippines.

Our faculty is composed of only the most qualified and experienced instructors

ranging from trained Trauma Surgeons and fully registered Emergency Medical

Chapter 1:

EMS In The Philippines

L


Page 2


Technicians and Paramedics - WE GIVE YOU ONLY THE VERY BEST. Our

standards of training meet with the highest of international standards and

great care is taken to mould the courses to meet your specific requirements.

We will help students to develop the essential knowledge, skills and

confidence in order to be able to provide essential Emergency Life Support in

times of crisis.

Life Support Training International is currently The Philippines only fully

certified training and assessment center for the Philippine Society of

Emergency Medical Technicians and, internationally, the Australasian Registry

of Emergency Medical Technicians (AREMT) and the Technical Education and

Skills Development Authority (TESDA).

WHEN THEY DEPEND ON YOU

YOU CAN ALWAYS DEPEND ON US!

Philippine Society of Emergency Medical Technicians

The Philippine Society of Emergency Medical Technicians (PSEMT) is a non-

profit, non-political, non-union body which is dedicated to the cause of

pushing for the introduction of an effective National Ambulance System for all

citizens of The Philippines, irrespective of social status, cultural background,

religious beliefs or political affiliations.

The development of a first-class Emergency Medical Services System in The

Philippines is our prime objective, as this is absolutely essential in order to

form an integral link in the chain of delivering quality care to the ill and

injured. We must accept, however, that any chain is only as strong as its

weakest link, and with this in mind, the Philippine Society of Emergency

Medical Technicians has recognized that excellence can only be achieved

through education, training and maintenance of the highest standards. Our

National Training, Research and Development Council, has developed

comprehensive training guidelines which clearly outline the standards required

of all those seeking the implementation of truly professional standards of Pre-

Hospital Emergency Medical Care, and these standards will be required of

anyone seeking membership of the Society.


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It is clearly recognized that any Pre-Hospital Care System involving EMTs

requires the support and clinical supervision of physicians. The Society has

established a National Executive Council composed of some of the foremost

physicians and experts in the field of Pre-Hospital Emergency Care. This

council will formulate the legal framework for pre-hospital care professionals

to carry out their vital role. As outline above, the Society has established a

National Training, Research and Development Council, which is tasked with,

not only setting the Society’s Training Standards, but also establishing a

National Examination System to ensure that these standards are achieved and

maintained. This council has also been tasked to carry out continuing research

and development in the field of Pre-Hospital Emergency Care to ensure that

members are keep abreast of advances in equipment and techniques.

We are pleased to announce that, due to our adherence to the highest of

international standards and practice, the Philippine Society of Emergency

Medical Technicians was, in March 2007, awarded direct and complete

reciprocity with the Australasian Registry of Emergency Medical Technicians

(AREMT). The AREMT is an Australian-based pre-hospital professional body,

which bases its standards on both the US Department of Transport and

European models of pre-hospital care. Due to this recognition, the Filipino

EMT is justifiably and proudly acknowledged as a world-standard professional.

PSEMT Affiliations

American College of Emergency Physicians


Page 4


Emergency Care and Safety

Institute

Australasian Registry of

Emergency Medical Technicians

International Liaison Committee

on Resuscitation

Philippine Heart Association


Page 5


PSEMT Membership Grades

The following are the grades of membership for the PSEMT:

ASSOCIATE MEMBER

BASIC EMERGENCY MEDICAL TECHNICIAN - EMT (B)

EMERGENCY MEDICAL TECHNICIAN, DEFIBRILLATOR TRAINED - EMT (D)

EMERGENCY MEDICAL TECHNICIAN, INFUSION & INTUBATION TRAINED -

EMT (I & I)

ADVANCED EMERGENCY MEDICAL TECHNICIAN - EMT (A)

REGISTERED EMERGENCY MEDICAL TECHNICIAN, PARAMEDIC - REMT (P)

REGISTERED EMERGENCY MEDICAL SERVICES INSTRUCTOR - REMSI

Associate Membership

This level will allow entry to all that hold current First Aid and Basic Life Support

Provider certificates from a Recognized Training Agency. The minimum requirement

will be thirty-two hours of instruction in First Aid, with a further eight hours in Basic

Life Support.

Basic Emergency Medical Technician - EMT (B) “Certification”

This is the initial entry grade for all professional pre-hospital care providers. This

grade is inclusive of ambulance staff and nursing personnel who can demonstrate

appropriate training and experience in line with PSEMT/PBEMT published standards.

Entry may be afforded to applicants who are outside the full time professional

sector on achievement of the following requirements:

Completion of a PSEMT/PBEMT approved 280 hour training course and the

achievement of the required pass mark in all sections of the National Final

Examination.

Proof of a minimum of 250 hands-on patient management in the preceding

twelve months. This must be confirmed by the applicant’s Officer-In-Charge

and duly approved by the Society’s National Executive Committee.

Completion of a minimum of 40 hours continuous medical education.

Submission of a personal log of experience gained.

Successful completion of National Examinations.


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The minimum age shall be 20 years.

Emergency Medical Technician, Defibrillator - EMT (D) “Certification”

All applicants must be a certified Emergency Medical Technician (EMT) with a

minimum of three (3) months full-time post-EMT (B) certification experience,

which must include emergency response duties. They must have successfully

completed the prescribed defibrillation module, and examinations thereof,

which will include all the content as outlined in the Society’s National Syllabus.

Re-registration will be required on an annual basis and all applications thereof

must be accompanied by a competency certificate duly countersigned by an

Emergency Medical Practitioner who has been approved by PSEMT/PBEMT.

Emergency Medical Technician Advanced - EMT (A) “Registration”

Entry requirement must be that of EMT (I & I) with not less than six (6) months

post-certification experience. In addition to this, all applicants must have

successfully completed two hundred hours instruction in Advanced Cardiac

Life Support and Advanced Trauma Management and the examinations

thereof.




Registered Emergency Medical Technician Paramedic - EMT (P)

“Registration”

The minimum entry criteria for Paramedic training is EMT Advanced (A), in

accordance with the standards set out by the PSEMT/PBEMT, with at least six

(6) months post-certification experience. All applicants must have successfully

completed the three hundred and sixty (360) hour Advanced Clinical Training

modules. This level will only be available to those who complete a minimum of

seven hundred and fifty (750) hours actual operational experience per year.


Page 7





Registered Emergency Medical Services Instructor - REMSI

This level has yet to be defined.

Exemptions

Exemptions from some requirements may be considered based on

alternative qualifications and experience. Requests for exemption will be

reviewed by the PSEMT National Training, Research and Development

Council and the PBEMT. Their decision will be considered final.

LSTI Academic Policies and Procedures

Course Performance Rating

Students’ overall performances are evaluated via the following:

Weekly Examinations 10%

Attendance and Timekeeping 10%

Final Written Examination 45%

Final Practical Examination 35%

Passing grade is set at 75% in all written and practical examinations. In

accordance with the Philippine Heart Association (PHA), a minimum passing

grade of 80% is required for the Basic Life Support (BLS) written examination.

BLS certification is a mandatory requirement for the issuance of EMT

certification.

Payment of Tuition Fees

Training fees may be paid on an instalment basis, but must be paid in full,

whether or not the candidate chooses to complete the course - in other words,

all students who start the course are obliged to pay in full, irrespective of the

outcome thereof.


Page 8


Reservation fee - PHP5000 (Non-refundable)

Weekly payment - PHP3000 (Week 2-6 inclusive)

LSTI meticulously enforces the payment schedule given to students on the first

day of the class. Students should follow the schedule diligently.

Life Support Training International reserves the right to terminate the training

of any student who fails to honor the set payment schedule.

Weekly Assessment

Every Monday morning, starting week 2, an assessment/examination shall be

conducted to gauge the student’s performance and knowledge. All policies

regarding examinations, payment of fees etc. are applicable.

Final Examinations

The final examination is done under the strict supervision of the Philippine

Society of Emergency Medical Technicians (PSEMT) and the Australasian

Registry of Emergency Medical Technicians (AREMT).

The high standards of training shall not be compromised in any way, and as

such:

Any cheating, or perceived attempt to cheat, in the Final Examinations will

be subject to immediate disqualification, and those involved will forfeit

any chance to re-sit the exam.

Students must settle all outstanding accounts before the Final Examination.

Non-payment or incomplete payment of tuition fees will result in forfeiture of

the student’s chance to take the examination.

Re-Sit/Re-Examination

In the case of failures, re-sit/re-examination shall be done at a time and date

designated by the PSEMT/AREMT. All students are obliged to follow the

scheduled examination date.


Page 9


For the EMT Final Written Examination PSEMT/AREMT policy allows for a

maximum of two (2) sits only (1 exam and 1 re-sit).

For the Basic Life Support Written Examination, a maximum of three (3) sits are

allowed (1 exam and 2 re-sits). No EMT certification can be awarded to a

candidate without successful completion of both practical and theoretical

examinations in Basic Life Support.

Validity of the re-sit/re-examination is limited to within one (1) year from the

time the student finishes the course. If a student fails to re-sit or take the Final

Examination within this grace period, he/she shall forfeit their right to retake

said Final Examination.

Under no circumstances will a candidate who has failed the final examinations

and re-sit be accepted for retraining at LSTI.

Students who fail all the re-sits/re-examinations shall not be awarded any

certificate of proficiency.

In accordance with PSEMT/AREMT policies, repetition of the EMT-Basic Course

is also not permitted.

Smoking is strictly

prohibited in and

around the

training facility at

all times.

Please put all your litter in the

numerous garbage receptacles

provided around the training

facility for student use.

Chapter 2: Roles and Responsibilities of the EMT

Page 10

Emergency Medical Technician - Basic

Outline

The Star of Life

The Emergency Medical Services System

Components of the Emergency Medical Services System

Roles and Responsibilities of the EMT

Professional Attributes

The Star of Life

ust as physicians have the caduceus, and pharmacists the mortar and

pestle, Emergency Medical Services have the ‘Star of Life’, a symbol

whose use is encouraged by both the American Medical Association

and the Advisory Council within the Department of Health and Human

Services. On road maps and highway signs, the Star of Life indicates the

location or access to qualified emergency care services.

The Star of Life was designed by Leo Schwartz, EMS Branch Chief at the

National Highway Traffic Safety Administration (NHTSA) USA. The star of life

was created in 1973 as a common symbol to be used by US emergency

medical services (EMS) and medical goods pertaining to EMS.

CChhaapptteerr 22::

RRoolleess aanndd

RReessppoonnssiibbiilliittiieess ooff tthhee

EEMMTT

J


Page 11

Sample Manual Template

The symbol’s six-barred cross represents the six-system function of

Emergency Medical Services. The staff in the center of the symbol

represents medicine and healing. According to Greek mythology, the staff

belonged to Asclepius, the son of Apollo (god of light, truth and

prophesy), who learned the art of healing.

The Emergency Medical Services S

Regulation and Policy

Laws that allow the system to exist.

Resource Management

Centralized coordination of resources (i.e. hospitals) to have equal access to basic

emergency care and transport by certified personnel in a licenced and equipped

ambulance, to an appropriate facility.


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Human Resources and Training

All personnel who ride ambulances should be trained at the minimum level

using a standardized curriculum.

Transportation

Safe, reliable ambulance transportation is a critical component.

Communications

There must be an effective ccommunications system, beginning with a

universal access number

Public Information and Education

Efforts to educate the public about their role in the EMS system and

prevention of injuries.

Medical Direction

Involvement of EMS physicians in all aspects of pre-hospital emergency

medical care practice.

Trauma Systems

Development of more than one trauma center. Triage and transfer guidelines

for trauma patients, rehabilitation programs, data collection and means for

managing and assuring the quality of the system.

Evaluation

Program for improving the EMS system.


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Roles and Responsibilities of the EMT

Personal Safety

An EMT is no good if he or she becomes another victim.

Safety of the Crew, Patient and Bystanders

Patient Assessment

Finding out what is wrong with your patient to be able to undertake

emergency medical care.

Patient Care

Preparation for action or a series of actions to take that will help the

patient deal with and survive illness or injury.

Lifting and Moving

Effective and safe application of patient handling procedures to avoid

self-inflicted and career-ending injuries.

Transport

A serious responsibility in ambulance operations, even more so with a

patient on board.

Patient Advocacy

Moral responsibility to speak on behalf of the patient’s need of attention

for a particular cause. Must develop a rapport that will give understanding

of the patient’s condition.

Professional Attributes of the EMT

Appearance

Excellent personal grooming and a neat clean appearance to instil confidence

in patients.


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Knowledge and Skills

A successful completion of EMT-B training and the knowledge to know:

The use and the maintenance of common emergency

equipment.

How and when to assist the administration of medications

approved by medical direction or protocol.

How to clean, disinfect and sterilize non-disposable equipment.

Personal safety and security measures, as well as for other

rescuers, the patient and bystanders.

The territory and terrain within the service area.

Traffic laws and ordinances concerning emergency

transportation of the sick and injured.

Physical Demands

Good physical health and good eyesight to properly assess the patient and drive

safely.

Temperament and Abilities

A pleasant personality

Leadership ability

Good judgement

Good moral character

Stability and adaptability


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Components of Emergency Medical Services Systems – In Depth

The following 15 components have been identified as essential to an EMS system:

Communication

Training

Manpower

Mutual Aid

Transportation

Accessibility

Facilities

Critical Care Units

Transfer of Care

Consumer Participation

Public Education

Public Safety Agencies

Standard Medical Records

Independent Review and Evaluation

Disaster Linkages

The above design has proved proficient in many aspects, including medical direction and

accountability, prevention, rehabilitation, financing and operational and patient care

protocols. EMS systems continued to be refined in the 1980s and 1990s.

Successful EMS systems are designed to meet the needs of the communities they serve.

The state provides laws that broadly outline what is prudent, safe and acceptable. To be

effective, EMS systems must be planned and operated at the local level.


Page 16


Communities need to identify their individual needs and resources, develop funding

mechanisms, and become involved at all levels in structuring the system. A governing

body or council should be established to organize, direct and coordinate all system

components. The council consists of representatives from the local medical, EMS,

consumer and public safety agencies to ensure consensus in developing policies and

settling disputes. The EMS system must provide equal access to all, and remain

protected from forces that serve the interests of only one group.

Medical Direction

Physician input, leadership and oversight in ensuring that medical care provided is safe,

effective and in accordance with accepted standards. Physicians must be empowered and

imvolved in planning, implementing, overseeing and evaluating all components of the

system. Medical direction is characterized as either immediate (on-line) or organisational

(off-line).

On-line medical direction provides EMTs with consultation in the field, either in person or,

more commonly, via radio or telephone communication. This responsibility is delegated

medical director to physicians who staff local Emergency Departments. The base station

facility providing on-line control is required to monitor all advanced life support (ALS)

communications, provide field consultations, and notify receiving facilities of incoming

patients. Physicians providing on-line direction should be appropriately trained and

familiar with the operations and limitations of the system.

The medical director assumes authority and responsibility for off-line medical direction. In

cooperation with the local medical community, the medical director is responsible for

developing standards, protocols, policies and procedures; developing training programs;

issuing credentials and providing evaluations; and implementing a process for continuous

quality improvement.

Communications

A comprehensive communications plan is essential to provide the community access to

system dispatch and to provide the EMT access to medical direction and additional

resources. The establishment of a universal access number (911 in the US and Canada or

999 in the UK for example) has greatly improved the system’s accessibility. Additional

advancements have been made with enhanced systems, such as the enhanced 911


Page 17


system, which automatically provide the dispatcher with the caller’s address and

telephone number. Using enhanced systems, callers can obtain services even if they are

unable to communicate with dispatch. Emergency medicine dispatch includes assessment

of patient location and status, as well as the provision of pre-arrival instructions.

Ground vehicles provide most EMS transportation. Ambulances should be constructed

according to federal or national standards, and be appropriately equipped to provide

basic or advanced level of care. Air transport, such as a helicopter or airplane, may also be

either BLS or ALS. Air transport is used to transport patients over greater distances,

decrease total pre-hospital time or to reach patients in poorly accessible locations.

Operational standards are established to delineate the equipment needed, the number of

personnel and the level of certification required, as well as the response-time criteria and

the destination for each transport.

On-line medical direction should be obtained in all calls that result in transport. This

includes:

Decision to transport;

Patient refusal of care; and

Triage to a lower level of care.

Otherwise, the provider may be perceived as practicing without a licence, and could be

charged with an offence.

Transportation

Inter-facility transportation occurs once the patient has been examined and stabilized.

Patients are transported in compliance with regional protocols and federal, national or

state laws (e.g. Consolidated Omnibus Budget Reconciliation Act [COBRA] and Emergency

Medical Treatment and Active Labor Act [EMTALA] in the US). Legislation dictates that

medically unstable patients be transferred only when the transfer is expected to have a

positive effect on outcome.

Patients should be transported to the closest, most appropriate facility. Receiving facilities

are required to have the capabilities to treat the patients, stabilize their condition, and

improve their outcome. Stable patients may be transported to the hospital of their choice,

as long as the transport meets regional point-of-entry protocols, has the approval of on-

line medical control, and does not necessarily overburden the system.


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Specialized resources to care for the severely injured are not available in every hospital.

Local communities need to establish regional protocols to provide clear guidance for the

transport of unstable patients to categorized facilities. Unstable patients with special

problems, such as burns or trauma, can be transported to regionally designated hospitals,

bypassing closer facilities.

Training Standards

Providers must be trained to meet the expectations and requirements in programs that

comply with regional and national standards. Training includes didactic, clinical and field

components. Most states require that candidates pass written and practical examinations

prior to certification. Additionally, EMTs are required to receive continuing didactic and

clinical education to maintain certification.

Education is also used to reinforce proper patient care, update standards and protocols,

and remedy perceived deficiencies in patient care. Physician involvement is essential to

assure appropriate utilizations of skills and equipment. The EMS system also provides

community education, such as public courses in CPR, first aid, child safety and EMS access.

Protocols

Protocols are developed to deal with operational, administrative and patient care issues.

They define a standardized, acceptable approach to commonly encountered problems.

Protocols should reflect regional and national standards, as well as the uniqueness and

limitations of the local environment. The medical director has the responsibility to address

protocols dealing with patient care, such as triage and treatment.

Triage assesses the condition of each patient, sorts patients into treatment categories, and

optimizes use of field resources for treatment and transport. In addition, triage addresses

the level of provider during multiple casualty incidents to facilitate the screening,

prioritization, treatment and transport of patients.

Treatment protocols describe the authority and responsibilities of providers and offer

guidance for medical evaluation and care. Optimal care and medical accountability require

standardized protocols, algorithms and standing orders that outline specific actions

providers can take without contacting a physician for orders. Any deviation from these

standing orders must be considered a breach of duty and must result in an audit. On-line

medical direction is crucial in systems, requiring decision-making to provide guidance and

assume some of the patient-care responsibilities.


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Continuous Quality Improvement

Continuous quality improvement (CQI) is the sum of all activities undertaken to assess

and improve the products and services EMS provides. The goal is to influence patient

outcomes positively by delivering products timely, consistent, appropriate,

compassionate and cost-effective systems. CQI ensures that the field staff provides the

highest quality of care and that the system supports this goal. Quality should be

monitored from within the EMS system and by an external, independent and unbiased

body that involves the consumer, government and medical communities. Standardized

protocols, policies, performance and documentation are invaluable in constructing a

successful CQI process.

Quality evaluation is prospective, concurrent and retrospective. Prospective evaluation

is most effective process to ensure quality in EMS, because it has the potential to

prevent mistakes. The system must be scrutinized constantly to determine areas

requiring refinement and improvement. When goals and standards are not met, CQI

staff members must identify the problem, establish and implement a corrective course

of action, and measure the outcome. Concurrent evaluation occurs on scene or on-

line. Staff members observe performance, encourage positive behavior and correct

problems before bad habits develop. Retrospective evaluation is the least valuable and

most time-consuming. It includes critique sessions and reviews of patient encounter

tapes and charts.

Disaster Preparedness

The EMS system is an integral part of disaster preparedness and planning. It plays an

important role in initial response and transportation, and is essential in establishing a

regional disaster preparedness plan in coordination with public safety agencies,

government and the medical community. The plan should address disaster

management, communication, treatment and designation of casualties. Periodic

disaster drills serve to assess performance, refine management and educate personnel

and the community.

Public support is invaluable in constructing a successful EMS system; involvement is

required to plan a system that works for everyone. Consumers need to be well

informed of the benefits of having an EMS system and how to gain access to it.

Chapter 3: Medico-Legal and Ethical Issues in EMS

Page 20


Outline

Definitions

Patient Bill of Rights

Ethical Implications

Right of Refusal

Legal Aspects

Crime Scenes

EMS Code of Ethics

Definitions

ETHICS - The science of right and wrong, of moral duties and of ideal behaviour.

MEDICAL ETHICS - The part of ethics that deals with the health care of human

beings.

Patient Bill of Rights

The patient has the right to considerate and respectful care.

The patient has the right to refuse treatment to the extent permitted by law

and to be informed of the medical consequences of his or her action.

The patient has the right to expect that all communications and records

pertaining to his or her care should be treated as confidential.

The patient has the right to expect continuity of care.

Chapter 3:

Medico-Legal and Ethical

Issues in EMS


Page 21


In the Philippines, the Patient Bill of Rights is known as Title 111: Declaration of Rights.

Good Samaritan Law

Protects a person from liability for acts performed in good faith, unless those

acts constitute gross negligence.

Does not prevent one from being sued, although it may provide some

protection against losing a lawsuit if one has performed to the standard of

care for an EMT-B.

Different standards may be held in different legal jurisdictions.

Medical Direction

The legal right to function as an EMT-B is contingent upon medical direction.

The EMT-B must:

Follow standing orders and protocols

Establish telephone and radio communications

Communicate clearly and completely and follow orders given

in response

Consult medical direction for any question about the scope

and direction of care

Duty to Act

The obligation to provide care. May be implied or formal.

IF ON-DUTY:

legally obligated

IF OFF-DUTY:

may stop and help; or

may pass the scene and call for help; or

may pass the scene and make no attempt to call for help.


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Ethical Responsibilities

Serve the needs of the patients with respect for human dignity, without

regard to nationality, race, gender, creed or status.

Maintain skill mastery.

Keep abreast of changes in EMS which affect patient care.

Critically review performances.

Report with honesty.

Work harmoniously with others.

Patient Consent and Refusal

Types of Consent

Expressed consent

Implied consent

Consent to treat a minor or mentally incompetent adult

Advance Directives

“Living Will”, DNR/DNAR

Instructions written in advance documenting the wish of the chronically or

terminally ill patient not to be resuscitated and legally allows the EMT-B to

withhold resuscitation.

Usually accompanied by a doctor’s written orders.

Associated problems:

More useful in an institutional setting.

More than one physician may be required to verify the patient’s

condition.

Scrutiny of an advance directive may be time consuming.


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Remember:

A competent adult is

defined as one who is lucid

and capable of making an

informed decision.

Refusal of Treatment

Competency

A competent adult is defined as one who is lucid and capable of making

an informed decision.

Protecting yourself:

Do the following before you leave the scene:

Try to persuade the patient to accept treatment or

transport to a hospital.

Make sure that the patient is able to make a

rational informed decision.

Consult medical direction as required by local

protocol.

If the patient still refuses, have them sign a refusal form.

Before you leave, encourage the patient to seek help if certain

symptoms develop.

Other Legal Aspects

Abandonment and Negligence

Abandonment One stopped providing care for the patient without ensuring that

equivalent or better care would be provided

Negligence The care one provides deviates from the accepted standard of care

and this results in further injury to the patient

In order to establish negligence, it must be proved that:

The EMT-B had a duty to act;

The patient was injured, either physically or psychologically;

The EMT-B violated the standard of care expected.

The EMT-B’s action or lack thereof caused or contributed to the

patient’s injury.


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Confidentiality

Do not speak to the press, your family, friends or other members of the public about

details of the emergency care you provided to a patient.

Releasing confidential information requires a written release form signed by the

patient or a legal guardian.

Instances when an EMT-B is allowed to release confidential information:

Another health care provider needs to know the information to continue medical

care;

As requested by the police as part of a potential criminal investigation;

As required on a third-party billing form;

As required by legal subpoena;

When a patient signs a release form.

Special Situations

Donors and Organ Harvesting

A legal signed document is required, such as a signed donor care sticker affixed to a

driver’s licence or an organ donor card.

To provide assistance in organ harvesting:

1. Identify the patient as a potential donor.

2. Communicate with medical direction regarding the possibility of organ

donation.

3. Provide emergency care that will maintain the vital organs.

Dying and Deceased Patients

If the person is obviously dead, you may be required to leave the body at the scene if

there is any possibility that the police will have to investigate.

In other situations, you may be required to arrange for transport of the body so that a

physician can officially pronounce the patient dead.


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Medical Identification Insignia

A patient with a serious medical condition may be wearing a medical identification

tag (bracelet, necklace or card).

Crime Scenes

General guidelines - a potential crime scene is any scene that may require police

support.

If you suspect a crime is in progress or a criminal is still active at a scene, do not

attempt to provide care to any patient. Try to avoid any item at the scene that may

be considered evidence.

Basic Guidelines for the EMT at a Crime Scene

Touch only what you need to touch.

Move only what you need to move.

Do not use the phone unless authorised by the police.

Observe and document anything unusual at the scene.

If possible, do not cut through holes in the patient’s clothing.

Do not cut through any knot in a rope or tie.

If the crime is rape, do not wash the patient or allow the patient to wash,

change their clothing, use the bathroom or take anything by mouth.


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The EMT Code of Ethics

Professional status as an Emergency Medical Technician and Emergency Medical

Technician-Paramedic is maintained and enriched by the willingness of the individual

practitioner to accept and fulfil obligations to society, other medical professionals, and

the profession of Emergency Medical Technician. As an Emergency Medical Technician-

Paramedic, I solemnly pledge myself to the following code of professional ethics:

A fundamental responsibility of the Emergency Medical Technician is to conserve life, to

alleviate suffering, to promote health, to do no harm, and to encourage the quality and

equal availability of emergency medical care.

The Emergency Medical Technician provides services based on human need, with

respect for human dignity, unrestricted by consideration of nationality, race creed, color,

or status.

The Emergency Medical Technician does not use professional knowledge and skills in

any enterprise detrimental to the public wellbeing.

The Emergency Medical Technician respects and holds in confidence all information of a

confidential nature obtained in the course of professional work unless required by law

to divulge such information.

The Emergency Medical Technician, as a citizen, understands and upholds the law and

performs the duties of citizenship; as a professional, the Emergency Medical Technician

has the never-ending responsibility to work with concerned citizens and other health

care professionals in promoting a high standard of emergency medical care to all

people.

The Emergency Medical Technician shall maintain professional competence and

demonstrate concern for the competence of other members of the Emergency Medical

Services health care team.

An Emergency Medical Technician assumes responsibility in defining and upholding

standards of professional practice and education.


Page 27


The Emergency Medical Technician assumes responsibility for individual professional

actions and judgment, both in dependent and independent emergency functions, and

knows and upholds the laws which affect the practice of the Emergency Medical

Technician.

An Emergency Medical Technician has the responsibility to be aware of and participate

in matters of legislation affecting the Emergency Medical Service System.

The Emergency Medical Technician, or groups of Emergency Medical Technicians, who

advertise professional service, do so in conformity with the dignity of the profession.

The Emergency Medical Technician has an obligation to protect the public by not

delegating to a person less qualified, any service which requires the professional

competence of an Emergency Medical Technician.

The Emergency Medical Technician will work harmoniously with and sustain confidence

in Emergency Medical Technician associates, the nurses, the physicians, and other

members of the Emergency Medical Services health care team.

The Emergency Medical Technician refuses to participate in unethical procedures, and

assumes the responsibility to expose incompetence or unethical conduct of others to

the appropriate authority in a proper and professional manner.

The EMT Code of Ethics was written by Dr. Charles Gillespie and adopted by the

National Association of EMTs in 1978.

Chapter 4: Ambulance Vehicles and Equipment

Page 28


Outline

Introduction

North American Ambulance Designs

European Ambulance Designs

Paramedic Fast Response Vehicles

Helicopter Emergency Medical Services (HEMS)

Standard Ambulance Equipment

Daily Checks of Ambulance Equipment

Cleanliness

Phases of an Ambulance Call

Emergency Driving

Ambulance Hygiene

Chapter 4:

Ambulance Vehicles and

Equipment


Page 29


Introduction

odern ambulances have evolved into sophisticated vehicles, with modern

safety features such as ABS brakes and airbags. Many newer ambulances

look similar to older vehicles, with changes related to the use of new

lightweight materials and increased safety features. Ambulances now are often

equipped with GPS and computer dispatch systems. Ambulances are equipped

according to their role - basic transport, Intermediate Life Support (ILS), Advanced Life

Support (ALS), or Mobile Intensive Care Unit (MICU).

North American Ambulance Designs

Ambulance vehicle designations in the USA are governed by federal laws and

standards.

In America, an ambulance is defined as a vehicle used for emergency medical care

that provides:

A driver’s compartment.

A patient compartment to accommodate an emergency medical services provider

(EMSP) and one patient located on the primary cot so positioned that the primary

patient can be given intensive life-support during transit.

Equipment and supplies for emergency care at the scene as well as during

transport.

Safety, comfort, and avoidance of aggravation of the patient’s injury or illness.

Two-way radio communication.

Audible and Visual Traffic warning devices

M


Page 30


There are three basic ambulance specifications in North America:

TYPE I AMBULANCE - a cab chassis furnished with a modular ambulance body.

TYPE II AMBULANCE - a long wheelbase van, with integral cab-body.

TYPE III AMBULANCE - a cutaway van with integrated modular ambulance body.

European Ambulance Designs

European ambulances are generally manufactured on an individual service

requirement basis. The general cab-chassis is similar to the North American Type II

vehicle but the interior is generally built to the customer’s specific requirements.

Fibreglass is used extensively in the manufacture of European vehicles - this promotes

vehicle handling characteristics as well as reducing overall weight and fuel

consumption.

Paramedic Fast Response Vehicles

These vehicles are utilized to deliver Advanced Life Support quickly and efficiently at

the scene of any emergency. The vehicle is either dispatched at the same time as an

ambulance unit or in advance of the ambulance unit when resources are limited and

demands on the service are high. Paramedic Fast Response Units are mobilized to

achieve early stabilization of the patient and rely heavily on ambulance follow-up for

transportation of the victim/s to the receiving medical facility.

Helicopter Emergency Medical Services (HEMS)

Helicopter Emergency Medical Services (HEMS) units are basically used for trauma and

high-dependency transfers. HEMS are particularly useful for the pickup of patients in

isolated areas where access by other forms of air, sea or road transport is difficult or just

not possible at all. It should be said that HEMS units are extremely costly to set up and


Page 31


run. Due to the high cost factor, HEMS units are usually run on a regional or national

basis as opposed to local operations.

Standard Ambulance Equipment

Monitoring Equipment:

BP Cuff / NIBP, Stethoscope, ECG Monitor Defibrillator, Vital Signs Monitor, Pulse

Oximeter, Thermometer.

Airway Equipment:

Oxygen Cylinder, Regulator, Flowmeter, Automated Transport Ventilator / Resuscitator,

Bag Valve Mask, Suction unit, Guedal Airways, Combitubes, Laryngeal Mask Airway,

Endotracheal Tubes.

Immobilisation / Splinting Equipment:

Scoop Stretcher, Vacuum Mattress, Extrication Device (KED), Cervical Collars, Head

Immobilizer, Extremity Splints, Traction Splint, Straps and harnesses.

Others:

Stretcher

Carry chair

Entonox

Medical Bag

Medical disposables according to checklist


Page 32


Daily Checks of Ambulance Equipment

It is the duty of the driver and assistant to check the vehicle and equipment according to the

checklist when reporting for duty. As emergency care professionals, we are dealing with

people’s lives each time we respond to a call, and a faulty vehicle or equipment could result in

the loss of a life that could have been saved. When checking equipment it is also vital to ensure

that all the equipment on the ambulance is clinically clean. The safety of the crew also depends

on any faults with the vehicle being noted and corrected.

Duties of Driver

Check all fluid levels – fuel, engine oil, radiator coolant, automatic transmission fluid,

battery water levels before starting the vehicle. Also check for leaks under the vehicle.

Check lights – headlights, taillights, direction indicators, rotators, flashers, sirens, etc.

Check communications equipment – vehicle radio and handheld radio

Check tyres for pressure, wear and damage.

Check brakes – both foot and handbrakes

Check all windows and mirrors

Check all door latches and handles

Check all seatbelts / passenger restraints

When checking the vehicle it is important to remember that the most engine wear occurs

during the first 30 seconds after start up, before the oil is circulated through the engine. DO

NOT rev the engine immediately on or after start up.

It is also important to remember that diesel engines with a turbo need to idle before shut

down. NEVER rev a turbo engine before turning off the ignition, as it can cause damage to

the turbo bearings, loss of power and shorten the life of the engine.


Page 33


Duties of Attendant

Check equipment according to the checklist, making sure that all the equipment is

complete and in good working order.

Check medical disposables according to checklist, noting expiry dates.

Check oxygen cylinders are full, and that gauges and flowmeters are working.

Make sure batteries are charged for any battery powered equipment such as ECG

monitors, pulse oximeters, etc.

Make sure that the patient compartment, equipment and supplies are clinically

clean and thoroughly hygienic.

Make sure that you know exactly how each item of equipment works, and the

trouble-shooting procedures for that item of equipment.

Cleanliness

Cleanliness of the vehicle, both inside and out serves two purposes. The first is that a

clean vehicle portrays a professional image. The second and more important function is

to ensure that both the crew and patients are protected from the transmission of

infection and communicable diseases by contaminated surfaces, linen, equipment, etc. It

is vitally important to clean the interior surfaces with approved disinfectants, as a surface

which appears clean, can harbour bacteria and viruses.

Phases of an Ambulance Call

1. Daily pre-run vehicle and equipment preparation

Ambulance maintenance benefits:

• decreases vehicle downtime


Page 34


• improves response times to the scene

• safer emergency and non-emergency responses

• improves transport times to a medical facility

• safer patient transports to a medical facility

Daily inspection of the vehicle

Ambulance equipment

Personnel

2. Dispatch

Location of call.

Nature of call.

Name, location and callback number of the caller.

Location of the patient.

The number of patients and severity of the problem.

Any other special problems or circumstances that may be pertinent.

3. En route to the scene.

4. At the scene.

5. En route to the receiving facility.

6. At the receiving facility.

7. En route to the station.


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8. Post run.

Emergency Driving

Emergency Driving Privileges

Exceed the posted speed limit for the area as long as you are not

endangering lives or propery.

Drive the wrong way down a one-way street or drive down the opposite side

of the road.

Turn in any direction at an intersection.

Park anywhere as long as you do not endanger lives or property.

Leave the ambulance standing in the middle of a street or intersection.

Cautiously proceed through a red flashing signal.

Pass other vehicles in a no-passing zones.

Warning and Emergency Lights

Warning lights must be activated at all times when responding to an

emergency call.

Lights should be used even when you are not using the siren.

Ambulance emergency lights should be high enough to cast a beam above the

traffic.

Ambulance Hygiene

After every call

Strip used linens from the stretcher and place them in a plastic bag or designated

receptacle.


Page 36


In an appropriate receptacle, dispose of all disposable equipment used for

patient care.

Disinfect all non-disposable equipment used for patient care.

Clean the stretcher with germicidal solution.

If there is any spoilage or contamination in the ambulance, clean it up.

Air out the ambulance with all doors and windows open for 15 minutes.

At least once a day:

Empty the ambulance of the stretcher and equipment boxes.

Disinfect the oxygen humidifier and refill with clean water.

Scrub all the interior surfaces with soap and water.

Scrub again with germicidal solution, then air out again to let everything dry.

Chapter 5: Medical Terminology in EMS

Page 37


Outline

Words describing location

Words describing position

Medical terms by body systems

Common medical abbreviations

Words Describing Location

Midline Imaginary vertical line down the middle of the front surface of the body

Anterior Toward the front

Posterior Toward the back

Superior Above; toward the head

Inferior Below; toward the feet

Medial Nearer the midline of the body

Lateral Farther from the midline of the body

Proximal Nearer the point of attachment to the body

Distal Farther from the point of attachment to the body (or the heart)

Internal Inside

External Outside

Chapter 5:

Medical Terminology in

EMS


Page 38


Superficial Near the surface

Deep Remote from the surface

Words Describing Position

Erect Standing upright

Recumbent Lying down

Supine Lying face up

Prone Lying face down

Lateral Lying on the side


Page 39


Medical Terms By Body Systems

HEENT – Head, Ears, Eyes, Nose & Throat

Occipital - back of the head

Photophobia - intolerant of light

Phonophobia - intolerant of sounds

Diplopia - double vision

Epistasis - nosebleed

Rhinorrhea - runny nose or nasal discharge

Otorrhea - discharge from the ear

Tinnitus - ringing noise in the ear

NCAT - normocephalic, atraumatic

PERRL - Pupils Equal Round and Reactive to Light

Erythema - redness

Purulent - consisting of pus

Injected - blood vessel congestion, such as red eye


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Coronary & Pulmonary

Cor - Coronary (the heart)

Pulm - Pulmonary (respiratory system)

CTAB no rrw - Clear to auscultation bilaterally, no rales, ronchi or

wheezes

SOB - Shortness of Breath (dyspnea)

Productive cough - phlegm producing

Wheezing - high pitched sounds

Hemoptysis - coughing up blood

Pleuritic - worse with deep inspiration

Rales - crackles

Ronchi - wheezes/whistling sounds

Retractions - visible skin retractions with inspiration

Tachypnea - rapid breathing

Abdomen (Abd) or Gastrointestinal (GI)

Anorexia - loss or lack of appetite

Post-prandial - after eating

Emesis - vomiting

NBNB - non-bloody, non-bilious

Hematemesis - bloody emesis

Hematochezia - bloody stool

BRBPR - Bright Red Blood per Rectum

Melena - tarry black stool


Page 41


BS - bowel sounds (normoactive, hyperactive, hypoactive, absent)

TTP - tender to palpation, often more so in a single quadrant

Guarding - hard abdomen when palpated

Rebound - worse pain as examining hand is quickly pulled away

Genitourinary (GU)

Dysuria - painful urination

Hematuria - blood in the urine

Musculoskeletal & Extremities

MS - Musculoskeletal

Ext - Extremities

Myalgias - muscle aches

Arthralgias - joint aches

Edema - swelling

Skin

Pruritic - itchy

Macule - flat discoloration <10mm in diameter

Bumps:

Papule - bump 5mm or less

Nodule - well defined bump >5mm

Plaque - raised area

Sacs:

Vesicle - fluid filled sac <5mm

Bulla - fluid filled sac >5mm


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Pustule - sac filled with pus

Erythema - redness

Common Medical Abbreviations

A

AED Automated External Defibrillator

a.c. Before meals

ASA Aspirin

AMA Against medical advice

AMI Acute myocardial infarction

ASHD Arteriosclerotic heart disease

B

b.i.d. Twice a day

BP Blood pressure

BS Breath sounds, bowel sounds, or blood sugar

BVM Bag-valve-mask

C

c/o Complaining of

Ca Cancer/carcinoma

cc Cubic centimeter

CC Chief Complaint

CHF Congestive heart failure

CO Carbon monoxide


Page 43


COPD Chronic obstructive pulmonary disease (emphysema,

chronic bronchitis)

CPR Cardiopulmonary resuscitation

CSF Cerebrospinal fluid

CVA Cerebrovascular accident

CXR Chest X-ray

D

d/c Discontinue

DM Diabetes mellitus

DOA Dead on arrival

DOB Date of birth

Dx Diagnosis

E

ECG, EKG Electrocardiogram

e.g. For example

ETA Estimated time of arrival

ETOH Alcohol (ethanol)

F

Fx Fracture

G

GI Gastrointestinal

GSW Gun shot wound

gtt. Drop


Page 44


GU Genitourinary

GYN Gynecologic

H

h, hr. Hour

H/A Headache

HEENT Head, ears, eyes, nose, throat

Hg Mercury

h/o History of

hs At bedtime

HTN Hypertension

Hx History

I

ICP Intracranial pressure

ICU Intensive Care Unit

IM Intramuscular

IO Intraosseous

J

JVD Jugular venous distension

K

KVO Keep vein open


Page 45


L

L Left or Liter

LAC Laceration

LOC Level of consciousness

LR Lactated Ringers solution

M

mcg Micrograms

MS Morphine sulphate, multiple sclerosis

N

NAD No apparent distress

NC Nasal cannula

NKA No known allergies

npo Nothing by mouth

NRB Non-rebreather mask

NS Normal saline

NSR Normal sinus rhythm

NTG Nitroglycerin

N/V Nausea / vomiting

O

O2 Oxygen

OB Obstetrics

OD Overdose

OR Operating room


Page 46


P

PCN Penicillin

PEA Pulseless electrical activity

PERL Pupils equal and reactive to light

PID Pelvic inflammatory disease

PND Paroxysmal nocturnal dyspnea

po By mouth

PRN As needed

PSVT Paroxysmal supraventricular tachycardia

Pt Patient

PTA Prior to arrival

PVC Premature ventricular contraction

Q

q.h. Every hour

q.i.d. Four times a day

R

R Right

r/o Rule out

Rx or Tx Treatment

S

SIDS Sudden Infant Death Syndrome

SOB Shortness of breath


Page 47


stat. immediately

SVT Supraventricular tachycardia

T

TIA Transient ischemic attack

t.i.d. Three times a day

TKO To keep open

V

V.S. Vital signs

X

x Times

W

w/o or s without

WNL Within normal limits

Y

y/o or y.o. Years old

Symbols

Δ change

+ Positive

- Negative

Chapter 6: Infection Control and the EMT

Page 48


Outline

Overview

The Chain of Infection

Stages of Infection

Methods of Transmission

Defenses against Infection

Diseases That Pose A Threat To EMS Workers

Body Substances Isolation (BSI)

Exposure Control Plan

Reservoirs – Portals of Exit

Susceptible Defenses of a Susceptible Host

Hand Washing

Recommended Use of Personal Protective Equipment by Situation

Overview

Infection Control

Procedures to reduce infection in patients and health care personnel.

Infection

The growth of an organism in a susceptible host with or without signs and

symptoms of illness.

Chapter 6:

Infection Control and the

EMT


Page 49


Communicable Disease

Any disease that can be spread from one person to another or to a person

from contaminated objects.

The Chain of Infection

1. Etiologic Agent/Causative Agent

2. Reservoir

3. Portal of exit from reservoir

4. Method of transmission

5. Portal of entry to the susceptible host

6. Susceptible host

Stages of Infection

Incubation Period

Interval between entrance of pathogen into body and appearance of first symptoms (e.g.,

chickenpox, 2-3 weeks; common cold, 1-2 days; influenza, 1-3 days; mumps, 15-18 days).

Prodromal Stage

Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to

more specific symptoms (during this time, microorganisms grow and multiply, and client may

be more capable of spreading disease to others).


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Illness Stage

Interval when client manifests signs and symptoms specific to type of infection (e.g., common

cold manifested by sore throat, sinus congestion, rhinitis; mumps manifested by earache, high

fever, parotid and salivary gland swelling).

Convalescence

Interval when acute symptoms of infection disappear (length of recovery depends on severity of

infection and client’s general state of health; recovery may take several days to months).

Methods of Transmission

Direct contact

Contact with contaminated materials

Inhalation of infected droplets (TB, Meningitis)

The bite of an infected animal, human or insect

Puncture by contaminated needle

Transfusion of contaminated blood products

Defenses against Infection

Normal flora

Body system defenses

Inflammation

Immune response (acquired immunity)

Diseases that pose a threat to Health Care Providers

HIV

Hepatitis B and C

Tuberculosis

Syphilis

Meningitis

Rabies (Philippines)


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Rabies

Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is

caused by a virus. Rabies infects domestic and wild animals, and is spread to people through

close contact with infected saliva (via bites or scratches). The disease is present on nearly every

continent of the world but most human deaths occur in Asia and Africa (more than 95%). Once

symptoms of the disease develop, rabies is fatal.

Rabies is widely distributed across the globe. More than 55 000 people die of rabies each year.

About 95% of human deaths occur in Asia and Africa.

Wound cleansing and immunizations, done as soon as possible after suspect contact with an

animal and following WHO recommendations, can prevent the onset of rabies in virtually 100%

of exposures. Once the signs and symptoms of rabies start to appear, there is no treatment and

the disease is almost always fatal.

Hepatitis B

Hepatitis B is the most common serious liver infection in the world. It is caused by the hepatitis

B virus (HBV) that attacks the liver. This disease is more infectious than AIDS because it is very

easily transmitted by blood, a single virus particle can cause disease. It is transmitted through

infected blood and other body fluids like seminal fluid, vaginal secretions, breast milk, tears,

saliva and open sores. Once infected with the hepatitis B virus, approximately 10% of the people

develop a chronic permanent infection. It is very common in Asia, Africa and the Middle East.

The overall incidence of reported Hepatitis B is 2 per 10,000 individuals, but the true incidence

may be higher, because many cases do not cause symptoms and go undiagnosed and

unreported.

Tuberculosis

Left untreated, each person with active TB disease will infect on average between 10 and 15

people every year. But people infected with TB bacilli will not necessarily become sick with the

disease. The immune system “walls off” the TB bacilli which, protected by a thick waxy coat, can

lie dormant for years. When someone’s immune system is weakened, the chances of becoming

sick are greater.

• Someone in the world is newly infected with TB bacilli every second.

• Overall, one-third of the world’s population is currently infected with the TB bacillus.

Globally, the Philippines’ rate of TB infection is ninth among 22 high burden countries and ranks

third in the Western Pacific region (WHO, 2004).


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Meningitis

Meningitis is inflammation of the thin tissue that surrounds the brain and spinal cord, called

the meninges. There are several types of meningitis. The most common is viral meningitis,

which you get when a virus enters the body through the nose or mouth and travels to the

brain. Bacterial meningitis is rare, but can be deadly. It usually starts with bacteria that cause a

cold-like infection. It can block blood vessels in the brain and lead to stroke and brain

damage. It can also harm other organs.

Meningitis is more common in people whose bodies have trouble fighting infections.

Meningitis can progress rapidly. Symptoms include:

• sudden fever

• severe headache

• stiff neck

Body Substances Isolation

Wear mask and protective eyewear in situations where droplets of body fluids may spray

onto mucus membranes.

Wear gloves when in contact with blood or bodily fluids.

Wear a gown in situations where it is likely that droplets of blood or body fluids will be

sprayed on your working clothes.

Immediately and thoroughly wash or other skin surfaces that come into contact with blood or

body fluids.

To prevent needle stick injuries, dispose of all use needles in a puncture-resistant container

with a secured lid.

Use mouthpieces, resuscitation bags or ventilation equipment when providing resuscitation.

Do not provide direct patient care when you have open and oxidative skin lesions.

Exposure Control Plan

A comprehensive plan that helps employees reduce their risk of exposure or acquisition

of communicable diseases.


Page 53


Determination of Exposure - this area should define who is at risk at comining in contact with

blood or body fluids.

Education and Training - this area should explain why a qualified individual has to answer

questions about CD and why infection control is required

Hepatitis Vaccination Program - outlines the immunization schedules for EMT personnel.

Personal Protective Equipment - should list the PPE and should be of good quality.

Changing and Disinfection Practices - should describe how to care for and maintain vehicle

and equipment.

Post-Exposure Management - should identify who to notify when you believe you have been

exposed.

Body Fluids and the Risk of Hepatitis B/C or HIV

Primary Risk

Blood

Semen

Vaginal Secretions

Secondary Risk

Synovial Fluid

CSF Fluid

Amniotic Fluid

No Risk

Sweat

Tears

Saliva


Page 54


Feces

Vomitus

Nasal Secretions

Sputum

Reservoirs – Portals of Exit

Respiratory Tract

nose, mouth, through sneezing, coughing, breathing, talking, ET tubes

and tracheostomies.

Gastro-Intestinal Tract

mouth, saliva, vomitus, feces, anus, drainage tubes, ostomies

Urinary Tract

urethral meatus, urine, urinary diversion, ostomies

Reproductive Tract

vaginal discharges, vagine, semen, urine

Blood

open wound, needle puncture site, any disruption of intact skin or

mucous membrane

Susceptible Defenses of a Susceptible Host

Hygiene

Good personal hygiene and maintaining the intactness of the skin and mucus

membrane retains a barrier against microorganisms entering the body.


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Immunization

The immunologic system is a major defense against infection.

Nutrition

Adequate nutrition enhances the health of all body tissues, helps keep the skin intact

and promotes the skin’s ability to repel microorganisms.

Fluid

Adequate fluid intake flushes the bladder and urethra

Rest and Sleep

Adequate rest and sleep are essential to health and preserving energy.

Stress

Predisposes people to infection.

Personnel Protective Equipment

Vinyl latex gloves

Heavy duty gloves for cleansing

Protective eyewear

Mask - including pocket mask for CPR

Cover gown

Ventilatory equipment

Handwashing

Purposes:

1. To reduce the number of microorganisms onto the hands.

2. To reduce the risk of transmission of infectious organisms to one’s self.

3. To reduce the risk of transmission of microorganisms and cross-contamination

to patients


Page 56


Recommended Use of Personal Protective Equipment by Situation

Task or Activity Disposable

Gloves

Gown Mask Protective

Eyewear

Bleeding control

with spurting

blood

Yes Yes Yes Yes

Bleeding control

with minimal

blood

Yes No No No

Emergency

childbirth

Yes Yes Yes, if splashing

is likely

Yes, if splashing

is likely

Blood drawing At certain times No No No

Starting an IV

line

Yes No No No

Endotracheal

intubation

Yes No No, unless

splashing is

likely

No, unless

splashing is

likely

Oral/nasal

suctioning,

manually

clearing airway

Yes No No, unless

splashing is

likely

No, unless

splashing is

likely

Handling and

cleaning

instruments with

microbial

contamination

Yes No, unless

soiling is likely

No No

Measuring blood

pressure

No No No No

Measuring

temperature

No No No No

Giving an

injection

No No No No

Chapter 7: Anatomy for EMTs

Page 57


Outline

Body Organization

Anatomical Planes and Directions

Metabolism

Skeletal System

Circulatory System

Respiratory System

Nervous System

Muscular System

Body Cavities

The Abdomen

Body Organization

Chapter 7:

Anatomy for EMTs


Page 58


Anatomical Planes and Directions

Metabolism

Metabolism refers to the chemical and energy transformations which occur in the body.

In the human body, carbohydrates, proteins and fats are oxidised to produce CO2, H2O

and form available energy (adenosine triphosphate - ATP) which is essential for life

processes.

At the cellular level, the production of energy takes place in the mitochondria when

oxygen and pyruvate are combined.


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Aerobic Metabolism

In aerobic metabolism, there is sufficient oxygen entering the cell to react with and convert the

available pyruvate into ATP.

Anaerobic Metabolism

In anaerobic metabolism, there is no oxygen or insufficient oxygen entering the cell and little or

no utilisation of pyruvate. The remaining pyruvate converts into lactic acid and cellular acidosis

occurs, invariably leading to cell damage or death. As little as 10% of ATP is produced during

anaerobic metabolism.

Skeletal System

Gives form to the body

Protects vital organs

Consists of 206 bones

Acts as a framework for attachment of muscles

Designed to permit motion of the body

The skeletal system can be divided into two parts: the axial skeleton and the

appendicular skeleton

The Spine

The spine supports the skull and gives attachment to the ribs. It is a column of 33 irregular

bones called vertebrae.

Discs of cartilage between the vertebrae:

allow limited movement

prevent friction

act as shock absorbers.


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The Skeletal System

The Circulatory System

The circulatory system is a closed system which transports essential food, oxygen and

water to the cells of the body and removes the waste products they produce.

The circulatory system consists of three parts:

The heart

Blood vessels

Blood

These three parts are sometimes referred to as:

Pump

Pipes

Fluid


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Normal Heart Rates

Adults 60 to 100 bpm

Children 70 to 150 bpm

Infants 100 to 160 bpm

Electrical Control Mechanism

Heart contraction is controlled by nerve stimuli which originate in the sino-atrial node (the

‘pacemaker’), passing down the Bundle of His and radiating throughput the heart muscle.


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Physiology of the Circulatory System

Pulse

The wave of blood through the arteries formed when the left ventricle contracts.

Can be felt where an artery passes near the skin surface and over a bone.

Blood Pressure

Amount of force exerted against walls of arteries.

Systole: Left ventricle contracts.

Diastole: Left ventricle relaxes.

Perfusion

Circulation of blood within an organ or tissue.

If inadequate, the patient goes into shock.

Blood Vessels

There are five types of blood vessels:

Arteries

Arterioles


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Veins

Venules

Capillaries

Arteries carry blood away from the heart. The blood is moved along by the heartbeat and

the artery walls. Arteries have a strong outer wall and a thick muscle layer to withstand

high pressure.

Veins carry blood to the heart by the action of the surrounding muscles and by the suction

of the heart. Veins have thinner walls and are provided with valves, to stop the blood

flowing in the wrong direction.

Arterioles and venules dilate or contract to control the blood flow into and out of the

capillary bed.

Capillaries allow for the interchange of gases and the transfer of nutrients and waste

products. Capillaries have very thin walls consisting of a single layer of cells only. They are

semi-permeable to permit the passage of substances between the blood and the tissues.

Respiratory System

Extracts oxygen from the atmosphere and transfer it to the bloodstream in the lungs

Excretes water vapour and CO2

Maintains the normal acid-base status of the blood

Ventilates the lungs

Normal Breathing Rates

Adults 12 to 20 breaths/min

Children 15 to 30 breaths/min

Infants 25 to 50 breaths/min

Inspired Air

The air we breathe in contains approximately:

79% nitrogen

20% oxygen


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0.04% carbon dioxide

1% inert gases

water vapour - variable

Expired Air

The air we breathe out contains approximately:

79% nitrogen

16% oxygen

4% carbon dioxide

1% inert gases

water vapour to saturation


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Exchange of Gases

External respiration

takes place in the lungs. Oxygen from inhaled air is absorbed into the blood via the

capillaries of the lung. Carbon dioxide is released from the blood into the lungs and

is exhaled.

Internal respiration

takes place in the tissues.

The Diaphragm

Has characteristics of both voluntary and involuntary muscles

Dome-shaped muscle

Divides thorax from abdomen

Contracts during inhalation

Relaxes during exhalation

Mechanisms of Breathing

Inhalation

Diaphragm and intercostal muscles contract, increasing the size of the thoracic

cavity.

Pressure in the lungs decreases.

Air travels to the lungs.

Exhalation

Diaphragm and intercostal muscles relax.

As the muscles relax, all dimensions of the thorax decrease.

Pressure in the lungs increases.

Air flows out of the lungs.


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Normal Breathing Characteristics

Normal rate and depth

Regular rhythm

Good breath sounds in both lungs

Regular rise and fall movements in the chest

Easy, not labored

Infant and Child Anatomy

Structures less rigid

Airway smaller

Tongue proportionally larger

Dependent on diaphragm for breathing

The Nervous System

The nervous system controls the body’s voluntary and involuntary actions.

Somatic nervous system - regulates voluntary actions

Autonomic nervous system - controls involuntary body functions


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The Brain

The brain is the highest level of the nervous system and is continuous with the spinal

cord. It is divided into three main parts:

Cerebrum

motor centres control all the voluntary muscles.

sensory centres receive sensory signals from the skin, muscles, bones and joints.

control of the autonomic nervous system is buried deep in the cerebrum, in the

thalamus and hypothalamus

regulates the central nervous system, and is pivotal in maintaining consciousness

and regulating the sleep cycle.

Cerebellum

responsible for the maintenance of balance, muscle coordination and muscle tone.

Brainstem

the nerve connections of the motor and sensory systems from the main part of the

brain to the rest of the body pass through the brain stem.

regulation of cardiac and respiratory function.


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Divisions of the Nervous System

Central Nervous System

Consists of the brain and the spinal cord

Peripheral Nervous System

Links the organs of the body to the central nervous system.

Sensory nerves carry information from the body to the central nervous system.

Motor nerves carry information from the central nervous system to the muscles of

the body.

Nerves

There are four types of nerves:

1. Cranial nerves connect the sense organs (eyes, ears, nose, mouth) to the brain.

2. Central nerves connect areas within the brain and spinal cord.

3. Peripheral nerves connect the spinal cord with the limbs.

4. Autonomic nerves connect the brain and spinal cord with the organs (heart, stomach, intestines,

blood vessels, etc.).

Muscular System

Gives the body shape

Protects internal organs

Provides for movement

Consists of more than 600 muscles

Three Types of Muscles

1. Skeletal (voluntary) muscle

Attached to the bones of the body.

2. Smooth (involuntary) muscle

Carries out the automatic muscular functions of the body.

3. Cardiac muscle

Involuntary muscle.


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Has own blood supply and electrical system.

Can tolerate interruptions of blood supply for only very short periods.

Body Cavities

The Abdomen


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Chapter 8: Health, Hygiene, Fitness and Safety of the EMT

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Outline

Traits of a Good EMT

Healthy Lifestyle of an EMT

The Food Pyramid for Filipino Adults

Body Mechanics

Guidelines for Preventing Back Injuries

EMS and Back Injuries

Traits of a Good EMT

Neat and clean - to promote confidence in both patients and

bystanders and to reduce the possibility of contamination.

Physically fit - should be in good health and fit to carry out duties.

Emotionally and mentally fit - should be able to cope with stress at

work and able to overcome unpleasant aspects of any emergencies.

Healthy Lifestyle of an EMT

Nutrition - to perform efficiently, an EMT should eat nutritious food to fuel the

body and make it run. Physical exertion and stress are part of an EMT‟s job and

require high energy output.

Exercise and relaxation - a regular program of exercise will enhance the benefits of

maintaining nutrition and adequate hydration.

Balancing work, family and health - as an EMT you will often be called to assist the

sick and the injured any time of the day or night. Shift work may be required to be

apart from loved ones for long periods of time. Never let the job interfere

Chapter 8:

Health, Hygiene, Fitness

and Safety of the EMT


Page 72


excessively with your own needs. Find a balance between work and family. Make sure that you

have the time that you need to relax with family and friends.

The Food Pyramid for Filipino Adults


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Body Mechanics

The efficient coordinated and safe use of the body to produce motion and maintain

balance during activity.

Proper movement promotes body musculoskeletal functioning, reduces the energy

required for a task, and maintains balance, thereby reducing fatigue and decreasing the

risk of injury.

Three Basic Elements of Body Mechanics

1. Body Alignment (Posture) - when the body is well-aligned, balance is achieved

without undue strain on the joints, muscles, tendons or ligaments. Proper body

alignment also enhances lung expansion and promotes efficient circulatory,

renal and gastrointestinal function.

2. Balance (Stability) - good body alignment is essential to body balance. A person

maintains balance as long as the line of gravity passes through the centre of

gravity and the base of support.

3. Coordinated Body Movement - body mechanics involves the integrated

functioning of the musculoskeletal and nervous system as well as joint mobility.

Guidelines for Preventing Back Injuries

1. Be consciously aware of your posture and body mechanics.

2. Minimize lumbar lordosis as much as possible:

when standing for a period of time, periodically flex one hip

and knee and rest your foot on an object if possible.

when sitting, keep your knees slightly higher than your hips.

unless you have a pillow or other support beneath your

abdomen, avoid sleeping in the prone position.

3. Exercise regularly to maintain overall physical condition, including

exercises that strengthen the pelvic, abdominal and lumbar muscles.

4. Apply principles of body mechanics when moving objects:

Spread your feet apart to provide a wide base of support.

Place your feet appropriately in the direction in which the

movement will occur.

Push, pull, roll or slide objects rather than lifting them

whenever possible.


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Avoid twisting the spine by pushing or pulling an object, directly away from or

toward the body and squarely facing the direction of movement.

When lifting objects, distribute the weight between the large muscles of the

arms and legs.

5. Wear clothing that allows you to use good body mechanics and wear comfortable

low-heeled shoes that provide good foot support and will not cause you to slip,

stumble and turn your ankle.

EMS and Back Injuries

“One in four EMS workers will suffer a career ending back injury within the first 4

years of service. The number one physical reason for leaving EMS,” (mytactical.com,

EMS Back Injury Facts, 2007).

“Back injury from improper lifting is the number one injury suffered by pre-hospital

care providers,” according to New Mexico‟s EMT training manual.

“Almost one in two workers(47%) have sustained a back injury while performing

EMS duties,” (National Association of Emergency Medical Technicians, 2005).

“Average cost for a „simple‟ sprain or strain of the lumbar spine is approximately

US$18,365 in direct costs per occurrence,” (Mitterre D., “Back Injuries in EMS,” EMS

Magazine, 1999).

Lifting caused just over 62% of back injuries for EMT‟s, and low back strain was the

cause of 78% of the compensation days in a 3.5 year period, (Hogya PT, Ellis L.,

University of Pittsburgh Affiliated Residency in Emergency Medicine, PA, 1990).

Chapter 9: Patient Assessment

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Outline

Overview

Purpose of Patient Assessment

Scene Size-Up


Scene Safety

Number of Patients

Additional Resources

Mechanism of Injury (MOI)

Nature of Illness (NOI)

Cervical-Spine Immobilization

Initial Assessment

Baseline Vital Signs

Priority Patients

Transport Decisions

Trauma Assessment

Focused Physical Examination

Significant Mechanism of Injury

Patient Assessment Definitions

OPQRST

The Full Assessment

Overview

Scene size-up

Initial assessment

Focused history and physical exam

Chapter 9:

Patient Assessment


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Vital signs

History

Detailed physical exam

Ongoing assessment

Purpose of Patient Assessment

Your total patient care and transport decisions will be based on your assessment of

the patient’s condition as follows:

To determine whether the patient has suffered trauma or has a medical complaint.

To identify and manage immediately life threatening injuries or conditions.

To determine further assessment and care on the scene vs immediate transport with

assessment and care continuing en route.

To provide further emergency care.

To examine the patient and gather a patient medical history.

To monitor the patient’s condition, assessing and adjusting care as required.

To communicate patient information to the medical facility to ensure continuity of care.

Scene Size-Up

Review dispatch information

Inspection of scene

Scene hazards

Safety concerns

Mechanism of injury

Nature of illness/chief complaint

Number of patients

Additional resources needed


Assumes all body fluids present a possible risk for infection

Protective equipment:

Latex or vinyl gloves should always be worn

Eye protection

Mask

Gown


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Scene Safety

Park in a safe area.

Speak with law enforcement first if present.

The safety of you and your partner comes first!

Next concern is the safety of patient(s) and bystanders.

Request additional resources if needed to make scene safe.

Potential hazards

Oncoming traffic

Unstable surfaces

Leaking gasoline

Downed electrical lines

Potential for violence

Fire or smoke

Hazardous materials

Other dangers at crash or rescue scenes

Crime scenes

Number of Patients

Determine the number of patients and their condition.

Assess what additional resources will be needed.

Triage to identify severity of each patient’s condition.

Additional Resources

Medical resources

Additional units

Advanced life support

Nonmedical resources

Fire suppression

Rescue


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Law enforcement

Mechanism of Injury (MOI)

Helps determine the possible extent of injuries on trauma patients

Evaluate:

Amount of force applied to body

Length of time force was applied

Area of the body involved

Nature of Illness (NOI)

Search for clues to determine the nature of illness.

Often described by the patient’s chief complaint

Gather information from the patient and people on scene.

Observe the scene.

The Importance of MOI/NOI

Guides preparation for care of the patient

Suggests equipment that will be needed

Prepares for further assessment

Fundamentals of assessment are the same whether the emergency appears to be

related to trauma or a medical cause.

Cervical-Spine Immobilization

Consider early during assessment.

Do not move without immobilization.

Err on the side of caution


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Initial Assessment

1. Develop a general impression.

2. Assess mental status.

3. Assess airway.

4. Assess the adequacy of breathing.

5. Assess circulation.

6. Identify patient priority.

Forming a General Impression

Occurs as you approach the scene and the patient

Assessment of the environment

Patient’s chief complaint

Presenting signs and symptoms of patient

Assessing Mental Status/Level of Consciousness

A Alert - awake and oriented

V Verbal - responds to verbal stimuli

P Painful: responds to painful stimuli

U Unresponsive: does not respond to stimuli

Assessing the ABCs

A Airway

B Breathing

C Circulation

Airway

Look for signs of airway compromise:

Two- to three-word dyspnea

Use of accessory muscles

Nasal flaring and use of accessory muscles in children


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Labored breathing

Breathing

Look for:

Choking

Rate

Depth

Cyanosis

Lung sounds

Air movement

Circulation

Assessing the pulse:

Presence

Rate

Rhythm

Strength

Assessing and controlling external bleeding

Assess after clearing the airway and stabilizing breathing

Look for blood flow or blood on floor/clothes

Controlling bleeding

Direct pressure

Elevation

Pressure points

Assessing perfusion:

Color

Temperature

Skin condition

Capillary refill


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Check:

Breathing

Pulse

Skin

Pupils

Blood Pressure

Pulse Oximetry

Respirations

Normal ranges for respiration:

Adult 12-20 breaths/min

Children 15-30 breaths/min

Infants 25-50 breaths/min

Breathing checklist:

Normal Shallow Laboured Noisy

Equal chest rise Shallow chest rise Increased breathing

effort. Use of

accessory muscles;

gasping, nasal flaring

Snoring, wheezing,

gurgling and

grunting noises

Rhythm

Regular

Irregular


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Effort

Effortless - Talks normally

Difficulty breathing - Can only speak few words at a time

Depth

Shallow

Normal

Deep

Pulse checklist:

Normal ranges for pulse rates:

Adult 60-100 60 – 100 beats/min

Children 80-120 80-120 beats/min

Toddlers 90-150 beats/min

Newborn 120-160 beats/min

Tachycardia >100 beats/min

Bradycardia <60 beats/min

Strength

Weak

Normal

Strong

Quality

Slow

Normal

Rapid


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Rhythm

Regular

Irregular

Skin

Color

Pale/grey/waxy Blue/grey Red/flushed

Poor peripheral perfusion;

Abnormally cold/frozen

Blood not properly

saturated with oxygen

Fever, poisoning, sunburn,

heatstroke, high blood

pressure

Temperature

Cold Cool Normal Hot

Shock, hypothermia

Early shock, mild

hypothermia,

inadequate

perfusion

Hyperthermia, fever,

sunburn

Moisture

Dry/Normal Moist Wet

Early Shock Shock

Capillary Refill in Children

CRT=2 secs Normal

CRT>2 secs Poor peripheral circulation

Blood Pressure

Blood pressure is a vital sign.

Pressure of circulating blood against the walls of the arteries.

A drop in blood pressure may indicate:

Loss of blood

Loss of vascular tone


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Cardiac pumping problem

Blood pressure should be measured in all patients older than 3 years of age.

Normal ranges for blood pressure:

Adults 90 to 140 mmHg (s)

60 to 90 mmHg (d)

Children (1-8) 80 to 110 mmHg (s)

Infants (up to 1 yr) 50 to 90 mmHg (s)

Systolic pressure The amount of pressure exerted against the walls

of the arteries when the left ventricle contracts.

Diastolic pressure The pressure exerted against the wall of the

arteries when the left ventricle is at rest.

Pulse pressure Systolic pressure minus diastolic pressure.

BP by Auscultation BP by Palpation


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Level of Responsiveness

A Alert - awake and oriented

V Verbal - responds to verbal stimuli

P Painful: responds to painful stimuli

U Unresponsive: does not respond to stimuli

Pupil Response

P - Pupils

E - Equal

A - And

R - Round

R - Regular in size

L - React to Light

Abnormal pupil reaction


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Priority Patients

‘Stay and Play’ vs. ‘Scoop and Run’

Difficulty breathing

Poor general impression

Unresponsive with no gag reflex

Severe chest pain

Signs of poor perfusion

Complicated childbirth

Uncontrolled bleeding

Responsive but unable to follow commands

Severe pain

Inability to move any part of the body

Transport Decisions

Patient condition

Availability of advanced care

Distance to transport

Local protocols

Rapid Trauma Assessment

A 60-90 second head-to-toe exam that is quickly conducted on a patient who has

suffered or may have suffered severe injuries


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During the Rapid Trauma Assessment, the EMT is looking for signs of:

D Deformities

C Contusions

A Abrasions

P Punctures/Penetrations

B Burns

T Tenderness

L Lacerations

S Swelling

Stages of the Rapid Trauma Assessment

1. Maintain spinal immobilization while checking patient’s ABCs.

2. Inspect and palpate the head and face, including the ears, pupils, nose and mouth.

3. Assess the neck.

4. Apply a cervical spine immobilization collar.

5. Expose and assess the chest. Perform a four-point auscultation of the chest to listen

for breath sounds.

6. Assess the abdomen. If the patient complains of pain or there is obvious trauma, do

not palpate.

7. Assess the pelvis, checking for stability and crepitus.

8. Assess all four extremities, including pulses, motor function and sensation (PMS).

9. Roll the patient with spinal precautions.

Remember:

DCAP - BTLS


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Focused Physical Exam

Used to evaluate patient’s chief complaint.

Performed on:

• Trauma patients without significant MOI

• Responsive medical patients

SAMPLE History

S Signs and Symptoms

A Allergies

M Medications

P Pertinent past history

L Last oral intake

E Events leading to injury or illness

Stages of the Focused Physical Exam

Head, Neck, and Cervical Spine

Feel head and neck for deformity, tenderness, or crepitation.

Check for bleeding.

Ask about pain or tenderness.

Chest

Watch chest rise and fall with breathing.

Feel for grating bones as patient breathes.

Listen to breath sounds.

Abdomen

Look for obvious injury, bruises, or bleeding.

Evaluate for tenderness and any bleeding.

Remember:

SAMPLE


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Do not palpate too hard.

Pelvis

Look for any signs of obvious injury, bleeding, or deformity.

Press gently inward and downward on pelvic bones.

Extremities

Look for obvious injuries.

Feel for deformities.

Assess PMS:

Pulse

Motor function

Sensory function

Posterior Body

Feel for tenderness, deformity, and open wounds.

Carefully palpate from neck to pelvis.

Look for obvious injuries.

Significant Mechanism of Injury

Ejection from vehicle

Death in passenger compartment

Fall greater than 15’-20’

Vehicle rollover

High-speed collision

Vehicle-pedestrian collision

Motorcycle crash

Unresponsiveness or altered mental status

Penetrating trauma to the head, chest, or abdomen


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Assessment Summary

Assessment Steps for Significant MOI

• Rapid trauma assessment

• Baseline vital signs

• SAMPLE history

• Re-evaluate transport decision

Assessment Steps for Trauma Patients

Without Significant MOI

• Focused assessment


• SAMPLE history


Responsive Medical Patients

• History of illness

• SAMPLE history

• Focused assessment

• Vital signs


Unresponsive Medical Patients

• Rapid medical assessment


• SAMPLE history


Ongoing Assessment

• Is treatment improving the patient’s

condition?

• Has an already identified problem gotten

better? Worse?

• What is the nature of any newly

identified problems?

Steps of the Ongoing Assessment

• Repeat the initial assessment.

• Reassess and record vital signs.

• Repeat focused assessment.

• Check interventions.


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Patient Assessment Definitions

Scene Size-Up

Steps taken by EMS providers when approaching the

scene of an emergency call; determining scene

safety, taking BSI precautions, noting the mechanism

of injury or patient’s nature of illness, determining

the number of patients, and deciding what, if any

additional resources are needed including Advanced

Life Support.

Initial Assessment

The process used to identify and treat life-

threatening problems, concentrating on Level of

Consciousness, Cervical Spinal Stabilization, Airway,

Breathing, and Circulation. You will also be forming a

General Impression of the patient to determine the

priority of care based on your immediate assessment

and determining if the patient is a medical or trauma

patient. The components of the initial assessment

may be altered based on the patient presentation.

Focused History

and Physical

Exam

In this step you will reconsider the mechanism of

injury, determine if a Rapid Trauma Assessment or a

Focused Assessment is needed, assess the patient’s

chief complaint, assess medical patients complaints

and signs and symptoms using OPQRST, obtain a

baseline set of vital signs, and perform a SAMPLE

history. The components of this step may be altered

based on the patient’s presentation.

Rapid Trauma

Assessment

This is performed on patients with significant

mechanism of injury to determine potential life

threatening injuries. In the conscious patient,

symptoms should be sought before and during the

Rapid Trauma assessment. You will estimate the

severity of the injuries, re-consider your transport

decision, reconsider Advanced Life Support, consider

the platinum 10 minutes and the Golden Hour,

rapidly assess the patient from head to toe using

DCAP-BTLS, obtain a baseline set of vital signs, and

perform a SAMPLE history.


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Rapid Medical

History

This is performed on medical patients who are

unconscious, confused, or unable to adequately

relate their chief complaint. This assessment is used

to quickly identify existing or potentially life-

threatening conditions. You will perform a head to

toe rapid assessment using DACP-BTLS, obtain a

baseline set of vital signs, and perform a SAMPLE

history

Focused History

and Physical

Exam - Trauma

This is used for patients, with no significant

mechanism of injury, that have been determined to

have no life-threatening injuries. This assessment

would be used in place of your Rapid Trauma

Assessment. You should focus on the patient’s chief

complaint. An example of a patient requiring this

assessment would be a patient who has sustained a

fractured arm with no other injuries and no life-

threatening conditions.

Focused History

and Physical

Exam - Medical

This is used for patients with a medical complaint

who are conscious, able to adequately relate their

chief complaint to you, and have no life-threatening

conditions. This assessment would be used in place

of your Rapid Medical Assessment. You should focus

on the patient’s chief complaint using OPQRST,

obtain a baseline set of vital signs, and perform a

SAMPLE history.


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Detailed Physical

Exam

This is a more in-depth assessment that builds on the

Focused Physical Exam. Many of your patients may

not require a Detailed Physical Exam because it is

either irrelevant or there is not enough time to

complete it. This assessment will only be performed

while en route to the hospital or if there is time on

scene while waiting for an ambulance to arrive.

Patients who will have this assessment completed are

patients with significant mechanism of injury,

unconscious, confused, or unable to adequately relate

their chief complaint. In the Detailed Physical Exam

you will perform a head to toe assessment using

DCAP-BTLS to find isolated and non-life-threatening

problems that were not found in the Rapid

Assessment and also to further explore what you

learned during the Rapid Assessment.

Ongoing

Assessment

This assessment is performed during transport on all

patients.

The Ongoing Assessment will be repeated every 15

minutes for the stable patient and every 5 minutes for

the unstable patient.

This assessment is used to answer the following

questions:

1. Is the treatment improving the patient’s condition?

2. Are any known problems getting better or worse?

3. What is the nature of any newly identified

problems?

You will continue to reassess mental status, ABCs, re-

establish patient priorities, reassess vital signs, repeat

the focused assessment, and continually recheck your

interventions.


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OPQRST

Used to assess a patient’s chief complaint during a medical exam.

O Onset

P Provocation

Q Quality

R Radiation/Region

S Severity

T Time

OPQRST Explained

Onset

The word “onset” should trigger questions regarding what the patient was doing just

prior to and during the onset of the specific symptom(s) or chief complaint.

• What were you doing when the symptoms started?

• Was the onset sudden or gradual?

It may be helpful to know if the patient was at rest when the symptoms began or if they

were involved in some form of activity. This is especially true with patients presenting

with suspected cardiac signs & symptoms.

Provocation

The word “provocation” should trigger questions regarding what makes the symptoms

better or worse.

• Does anything you do make the symptoms better or relieve them in any way?

• Does anything you do make the symptoms worse in any way?

This is sometimes helpful in ruling in or out a possible musculoskeletal cause. A patient

with a broken rib or pulled muscle will most likely have pain that is easily provoked by

palpation and/or movement. This is often in contrast to the patient having chest pain of


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a cardiac origin whose pain is not made any better or worse with movement or

palpation.

Quality

The word “quality” should trigger questions regarding the character of the symptoms

and how they feel to the patient.

• Can you describe the symptom (pain/discomfort) that you are having right now?

• What does it feel like?

• Is it sharp or dull?

• Is it steady or does it come and go?

• Has it changed since it began?

This if often the most difficult question for the patient to understand and to articulate.

The key here is to allow the patient to use their own words and not try to feed the

patient with suggestions that they may choose simply because you have made it easy. It

is sometime helpful to offer the patient choices and allow them to decide which is most

appropriate for their situation. For instance, “is your pain sharp or is it dull” or “is your

pain steady or does it come and go”?

Region/Radiation

The words “region and radiation” should trigger questions regarding the exact location

of the symptoms.

• Can you point with one finger where it hurts the most?

• Does the pain radiate or move anywhere else?

Although it is not always easy for a patient to identify the exact point of pain, especially

with pediatric patients, it is important to ask. Asking if they can point with one finger to

where it hurts the most is a good start. From there you will want to know if the pain

“moves” or “radiates” anywhere from the point of origin. The patient may need you to

offer some suggestions such as, “does the pain radiate anywhere else such as your back,

neck, jaw or shoulders”? Always give them two or three choices and allow them to select

from the options that you give.


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Severity

The word “severity” should trigger questions relating to the severity of the symptoms.

• On a scale of 1 to 10, how would you rate your level of discomfort right now?

• Using the same scale, how would you rate your discomfort when it first began?

It’s not always just about how bad the pain or discomfort is when you arrive - this is a

common mistake made by many new EMTs. Once you have established the level of

discomfort that the patient is experiencing at that moment, you must follow this up with

how severe the discomfort was at onset. This will help you establish whether the

discomfort is getting better, worse or staying the same over time. You will want to

follow these two checkpoints up with an additional check once the patient has received

some of your care and reassurance. Often times with a little oxygen and reassurance the

symptoms may subside. Ask the patient a few minutes later how the discomfort is and if

it has changed at all since your arrival.

Time

The word “time” should trigger questions relating to the when the symptoms began.

• When did the symptoms first begin?

• Have you ever experienced these symptoms before? If so, when?

Establishing an accurate duration of the symptoms will be very helpful to the hospital

staff that will be caring for the patient. This question has special importance when caring

for patients presenting with suspected cardiac signs and symptoms.

The Full Assessment

SCENE SIZE-UP

Steps taken when approaching the scene.

Ensure BSI (Body Substance Isolation) procedures and & personal protective gear is

being used.

Observe scene for safety of crew, patient, bystanders. Identify the mechanism of injury

or nature of illness.

Identify the number of patients involved.

Determine the need for additional resources including Advanced Life Support.


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Consider C-Spine stabilization

INITIAL ASSESSMENT

Assessment & treatment (life-threats)

General Impression

Mechanism of injury or nature of illness

Age, sex, race

Find and treat life threatening conditions (any obvious problems that may

kill the patient within seconds). Problems with Airway, Breathing, or

Circulation

Verbalize general impression of patient

Mental Status

If the pt. appears to be unconscious, check for responsiveness, (“Hey! Are

you OK”?)

Evaluate mental status using AVPU.

Obtain a chief complaint, if possible.

Airway

Is the pt. talking or crying?

Do you hear any noise?

Will the airway stay open on its own?

Does anything endanger it?

Open the airway - head-tilt-chin-lift or jaw thrust – as needed

Clear the airway – as needed

Suction - as needed

Insert an OPA/NPA - as needed

Breathing

Do you see any signs of inadequate respirations?

Is the rate and quality of breathing adequate to sustain life?

Is the patient complaining of difficulty breathing?

Quickly inspect the chest for impaled objects, open chest wounds, and

bruising (trauma).


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Quickly palpate the chest for unstable segments, crepitation (trauma), and equal

expansion of the chest.

Check pulse oximetry - if below 94% administer oxygen.

If the pt. is unresponsive and breathing is inadequate, use a BVM to maintain pulse

oximetry at 94% or above.

Circulation

If the pt. is unresponsive, assess for presence and quality of the carotid pulse.

If the pt. is responsive, assess the rate and quality of the radial pulse.

If radial pulse is weak or absent, compare it to the carotid pulse.

For patients 1 year old or less, assess the brachial pulse.

Is there life threatening hemorrhage?

Control life threatening hemorrhage

Assess the patient’s perfusion by evaluating skin for color, temperature and condition

(CTC);

can also check the conjunctiva and lips

Assess capillary refill in infant or child < 6 yrs. old

Cover with blanket and elevate the legs as needed for shock (hypoperfusion)

Identify Priority Patients

Is the patient:

Critical?

Unstable?

Potentially Unstable?

Stable?

Consider the need for Advanced Life Support

If the patient is CRITICAL, UNSTABLE or POTENTIALLY UNSTABLE , begin packaging the

patient during the rapid assessment while treating life threats and transport as soon as

possible.

In addition, perform the rapid trauma assessment for the trauma patient if he/she has

significant mechanism of injury and apply spinal immobilization as needed.

For the unresponsive medical patient perform the rapid medical assessment.

If the patient is or STABLE, perform the appropriate focused physical exam (for the

medical pt. perform the focused physical exam; for trauma patient perform the focused

trauma assessment.)


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FOCUSED HISTORY AND PHYSICAL EXAM - TRAUMA

Re-consider the mechanism of injury. If there is significant mechanism of injury, perform a Rapid

Trauma Assessment on-scene while preparing for transport and then a Detailed Assessment

during transport. If there is no significant mechanism of injury, perform the Focused Trauma

Assessment. Direct the focused trauma assessment to the patient’s chief complaint and the

mechanism of injury (perform it instead of the rapid trauma assessment).

Rapid Trauma Assessment

Performed on patients with significant MOI.

Continue spinal stabilization

Re-consider ALS back-up

Inspect and palpate the body for injuries to the following:

HEAD

DCAP-BTLS

Blood & fluids from the head, including cerebrospinal fluid

NECK

DCAP-BTLS

JVD (Jugular Vein Distention)

Crepitation

Apply CSIC (Cervical Spinal Immobilization Collar) - if not already done

CHEST

DCAP-BTLS

Paradoxical movement

Crepitation

Breath sounds - bilateral assessment of the apices, mid-clavicular line;

midaxillary at the nipple line; and at the bases

ABDOMEN

DCAP-BTLS

Pain

Firm


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Soft

Distended

PELVIS

DCAP-BTLS

If no pain is noted, gently compress the pelvis to determine tenderness or unstable

movement.

EXTREMITIES

DCAP-BTLS

Crepitation

Distal pulses

Sensory function

Motor function

POSTERIOR

Logroll the patient. Maintain c-spine stabilization.

Inspect and palpate for injuries or signs of injury.

DCAP-BTLS

FOCUSED TRAUMA ASSESSMENT

Performed on patients with no significant MOI.

Assess the patient’s chief complaint

The specific injury they are complaining about – why they called EMS

Assess and treat injuries not found during your Initial Assessment

Reconsider your transport decision

Consider ALS intercept

Focused Assessment

Follow order of the Rapid Assessment

Focus assessment on the specific area of injury or complaint


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Obtain a full set of vital signs including:

Respirations

Pulse

Blood Pressure

Level of Consciousness

Skin

Pupils

Assess SAMPLE History

Signs & Symptoms

Pertinent Past Medical History

Allergies

Last oral intake

Medications

Events leading up to the injury/illness

Respirations

RATE:

Watch the chest/abdomen and count for no less than 30 seconds.

If abnormal respirations are present count for a full 60 seconds.

QUALITY:

Normal

Shallow

Any unusual pattern?

Labored?

Deep

Noisy breathing?

Pulse

RATE:

Check the radial pulse. If pulse is regular, count for 30 seconds and multiply x 2. If it is irregular,

count for a full 60 seconds.


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QUALITY:

Regular

Strong

Irregular

Weak

Skin (CTC)

COLOUR:

Normal (unremarkable)

Cyanotic

Pale

Flushed

Jaundice

TEMPERATURE:

Warm

Hot

Cool

Cold

CONDITION:

Wet

Dry

Blood Pressure

Blood pressure should be measured in all patients over the age of 3.

Auscultate the blood pressure. In a high noise environment, palpate (only the systolic

reading can be obtained).

Pupils

Use a penlight to check reactivity of the pupils; also assess for size

equal or unequal

normal, dilated, or constricted


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reactive - change when exposed to light

non-reactive - do not change when exposed to light

equally or unequally reactive when exposed to light

FOCUSED HISTORY AND PHYSICAL EXAM - MEDICAL

During this phase of the patient assessment, the mnemonic OPQRST and SAMPLE will be used

to gather information about the chief complaint and history of the present illness. Baseline vital

signs and a focused physical exam or a rapid medical assessment will be performed. The order

in which you perform the steps of this focused history and physical exam varies depending on

whether the patient is responsive or unresponsive.

RAPID MEDICAL ASSESSMENT

Performed on patients who are unconscious, confused, or unable to adequately relate their chief

complaint.

Perform a rapid assessment using DCAP-BTLS following the order of the Rapid Trauma

Assessment:

Assess the head

Assess the neck

Assess the chest

Assess the abdomen

Assess the pelvis

Assess the extremities

Assess the posterior

Obtain baseline set of vital signs

Position patient to protect the airway

Obtain the SAMPLE history from bystander, family, or friends.

FOCUSED MEDICAL ASSESSMENT

Performed on the conscious, alert patient who can adequately relate their chief complaint.

Obtain the history of the present illness

Onset - “What were you doing when the symptoms started?”

Provocation - “Is there anything that makes the symptoms better or worse?”

Quality - “What does the pain/discomfort feel like?”


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Radiation - “Where do you feel the pain/discomfort?” “Does the pain/discomfort

travel anywhere else?”

Severity - “How bad is the pain?” “How would you rate the pain on a scale of 1-10,

with 10 being the worst pain you’ve felt in your life?”

Time - “How long has the problem been going on?”

Assess SAMPLE

Examples of questions to ask a conscious medical patient and assessment elements

according to the patient’s chief complaint

Altered Mental Status

o Description of episode

o Duration

o Onset

o Associated symptoms

o Evidence of trauma

o Interventions

o Seizures

o Fever

Allergic Reaction

o History of allergies

o Exposed to what?

o How exposed

o Effects

o Progression

o Interventions

Cardiac/Respiratory

o Onset

o Provocation

o Quality

o Radiation

o Severity

o Time

o Interventions

Poisoning & OD

o Substance

o When exposed/ingested

o Amount

o Time period

o Interventions

o Estimated weight

Environmental

o Source

o Environment

o Duration

o Loss of consciousness

o Effects-general or local

Behavioral

o How do you feel?

o Determine if suicidal:

“Were you trying to hurt yourself?”

“Have you been feeling that life is not

worth living?”

“Have you been feeling like killing

yourself?”

o Threat to self or others

o Medical problem

o Interventions


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Obstetrics

o Are you pregnant?

o How long have you been pregnant?

o Pain or contraction

o Bleeding or discharge

o Has your water broke?

o Do you want to push?

o Last menstrual period?

Acute Abdomen

o Location of pain

o Any vomiting? If so,

color/substance

o Taking birth control

o Vaginal bleeding or discharge

o Abnormal vital signs

Loss of Consciousness

o Length of time unconscious

o Position

o History

o Blood in vomit or stool

o Trauma

o Incontinence

o Abnormal vital signs


Obtain a full set of vital signs including:

- Respirations

- Pulse

- Blood Pressure

- Level of Consciousness

- Skin

- Pupils

Provide Treatment

Provide emergency medical care based on signs and symptoms.

DETAILED PHYSICAL EXAM

The Detailed Physical Exam is used to gather additional information regarding the patient’s

condition only after you have provided interventions for life threats and serious conditions. Not

all patients will require a Detailed Physical Exam. It is performed in a systematic head-to-toe

order. You will examine the same body areas that you examined during your rapid assessment.

During the detailed physical exam, you will look more closely at each area to search for findings


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of lesser priority than life threats and/or signs of injury that have worsened. Do not delay

transport to perform a detailed physical exam; it is only performed while en route to the

hospital or while waiting for transport to arrive.

Detailed Physical Exam – Trauma or Medical

The Detailed Physical Exam is used to gather additional information regarding the patient’s

condition only after you have provided interventions for life threats and serious conditions.

Not all patients will require a Detailed Physical Exam. It is performed in a systematic head-to-

toe order. You will examine the same body areas that you examined during your rapid

assessment. During the detailed physical exam, you will look more closely at each area to

search for findings of lesser priority than life threats and/or signs of injury that have

worsened. Do not delay transport to perform a detailed physical exam; it is only performed

while en route to the hospital or while waiting for transport to arrive.

HEAD - inspect and palpate for signs of injury.

• DCAP-BTLS

• Blood & fluids from the head

FACE - inspect and palpate for signs of injury.

• DCAP-BTLS

EARS - inspect and palpate for signs of injury.

• DCAP-BTLS

• Drainage (blood or any other fluid)

EYES - inspect for signs of injury.

• DCAP-BTLS

• Discoloration

• Unequal Pupils

• Foreign Bodies

• Blood in Anterior Chamber


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NOSE - inspect and palpate for signs of injury.

• DCAP-BTLS

• Drainage

• Bleeding

MOUTH - inspect for signs of injury.

• DCAP-BTLS

• Damaged/Missing Teeth

• Obstructions

• Swollen or Lacerated Tongue

• Discoloration

• Unusual Odors

NECK - inspect and palpate for signs of injury.

• DCAP-BTLS

• JVD

• Tracheal deviation

• Crepitation

CHEST - inspect and palpate for signs of injury.

• DCAP-BTLS

• Paradoxical movement

• Crepitation

• Breath sounds - bilateral assessment of the apices, midclavicular line; mid-axillary at the

nipple line; and at the bases

• Present

• Absent

• Equal


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ABDOMEN - inspect and palpate for signs of injury.

• DCAP-BTLS

• Pain/Tenderness

• Firm

• Soft

• Distended

PELVIS - inspect and palpate for signs of injury.

• DCAP-BTLS

• If no pain is noted, gently compress the pelvis to determine tenderness or

unstable movement.

EXTREMITIES - inspect and palpate the lower and upper extremities for signs of injury.

• DCAP-BTLS

• Crepitation

• Distal pulses

• Sensory function

• Motor function

POSTERIOR

• Log roll the patient. Maintain c-spine stabilization.

• Inspect and palpate for injuries or signs of injury.

• DCAP-BTLS


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ON-GOING ASSESSMENT

The On-Going Assessment will be performed on all patients while the patient is being

transported to the hospital. It is designed to reassess the patient for changes that may require

new intervention. You will also evaluate the effectiveness of earlier interventions, and reassess

earlier significant findings. You should be prepared to modify treatment as appropriate and

begin new treatment on the basis of your findings during the On-Going Assessment.

Repeat Initial Assessment

• Reassess mental status.

• Maintain an open airway.

• Monitor breathing for rate and quality.

• Reassess pulse for rate and quality.

• Monitor skin color and temperature (CTC).

• Re-establish patient priorities.

Reassess and Record Vital Signs

Repeat Focused Assessment

Check Interventions

• Assure adequacy of oxygen delivery/artificial ventilation.

• Assure management of bleeding.

• Assure adequacy of other interventions

UNSTABLE PATIENTS – repeat On-Going

Assessment at least every 5 minutes.

STABLE PATIENTS – repeat On-Going

Assessment at least every 15 minutes.

Chapter 10: Communication and Documentation

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Outline

Overview

Types of Communication in EMS

Emergency Medical Dispatch

Response Times

Dispatch Life Support

EMT Communication

Triage

Verbal Communication

Communicating with Patients

Documentation

The Pre-hospital Care Report/Patient Care Report

Documenting Refusal

Special Reporting Situations

Overview

Essential components of pre-hospital care:

• Verbal communications are vital.

• Adequate reporting and accurate records ensure continuity of patient care.

• Reporting and record keeping are essential aspects of patient care.

Chapter 10:

Communication and

Documentation


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Types of Communication in EMS

Base Station Radios

• Transmitter and receiver located in a fixed place

• Power of 100 watts or more

• A dedicated line (hot line) is always open.

• Immediately “on” when you lift up the receiver

Mobile and Portable Radios

• Mobile radios installed in vehicle

- Range of 10 to 15 miles

• Portable radios hand-held

- Operate at 1 to 5 watts of power

Repeater-Based Systems

• Receives radio messages and retransmits

• A repeater is a base station able to receive low-power signals.

Digital Systems

• Some EMS systems use telemetry to send an ECG from the unit to the hospital.

• Telemetry is the process of converting electronic signals into coded, audible signals.

• Signals can be decoded by the hospital.

Cellular Telephones

• Low-powered portable radios that communicate through interconnected repeater stations

• Cellular telephones can be easily scanned.


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Others

• Simplex

- Push-to-talk communication

• Duplex

- Simultaneous talk-listen

• MED channels

- Reserved for EMS

Emergency Medical Dispatch

Responsibilities

• Screen and assign priorities

• Select and alert appropriate units to respond

• Dispatch and direct units to the location

• Coordinate response with other agencies

• Provide pre-arrival instructions to the caller

Information Received From Dispatch

• Nature and severity of injury, illness, or incident

• Location of incident

• Number of patients

• Responses by other agencies

• Special information

• Time dispatched


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Advanced Medical Priority Dispatch System (AMPDS)

The Advanced Medical Priority Dispatch System (AMPDS), is a medically-approved,

unified system used to dispatch appropriate aid to medical emergencies including

systematized caller interrogation and pre-arrival instructions. AMPDS is developed and

marketed by Priority Dispatch Corporation which also has similar products for police and

fire.

The output gives a main response category - A (Immediately Life Threatening), B (Urgent

Call), C (Routine Call). This may well be linked to a performance targeting system such as

ORCON where calls must be responded to within a given time period. For example, in

the United Kingdom, calls rated as „A‟ on AMPDS are targeted with getting a responder

on scene within 8 minutes.

Positive Benefits of AMPDS

Decreased EMV accidents

Decreased burn-out of field personnel

Decreased lights-and-siren runs

Improved medical control at dispatch

Improved medical dispatcher professionalism

Improved standardization of care, interrogation and decision making

Increased appropriateness of medical care through correct response

Increased resource availability, especially ALS

Increased safety of response personnel in the field

Increased knowledge at arrival of response personnel

Increased cooperation with associated public safety systems, law enforcement

and fire departments

Response Times

Most countries have adopted a response time of 8 to 10 minutes for the most critical

cases, and a longer response time for non-acute calls.

Toronto, Canada

Within 9 minutes in 90% of critical, life-threatening and serious cases; and within 21

minutes in 90% of non-acute cases.


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London, UK

Within 8 minutes in 75% of immediately life-threatening cases; no target set for

cases that are not serious or life-threatening.

Queensland, Australia

Within 10 minutes in 68% of Emergency Transport cases; no target set for non-

urgent cases.

Dispatch Life Support

An Emergency Medical Dispatcher (EMD) is trained to dispatch EMTs based on

the information given during the initial emergency call. They are trained to

mobilise resources based on these essential guidelines:

A seizure or convulsion may be a sympton of the onset of cardiac arrest.

Any person 35 years or older who presents with a seizure as a chief

complaint should be assumed to be in cardiac arrest until proven

otherwise.

Cardiac arrest in a previously healthy child should be considered to be

caused by a foreign body obstructing the airway until proven otherwise.

Dispatchers should be trained to identify obvious death situations (as

defined by medical control), mobilize response accordingly and give

limited pre-arrival instructions.

If the caller is a third-party who cannot identify if the victim is

unconscious and not breathing, the victim should be assumed to be in

cardiac arrest until proven otherwise.

EMDs should assume that bystanders have inappropriately placed a pillow

under the head of an unconscious victim, until proven otherwise, and

ensure it is removed.

BLS protocol for a choking victim should be modified to reflect EMDs

recommend a specific number of thrusts, rather than stating a range of

thrusts.

The Heimlich manoeuvre should be the primary treatment of infants,

children and adults who are choking.


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Remember that Emergency Medical Dispatchers are not usually EMT-trained.

They are trained to ask specific questions and give basic life support advice over

the telephone. Because people calling emergency services rarely have medical

training, EMDs are trained to err on the side of caution and cater for the worst

case scenario.

EMT Communication

EMT Communication with Dispatch

Report any problems during run.

Advise of arrival.

Communicate scene size-up.

Keep communications brief.

EMT Communication with Medical Control

Radio communications facilitate contact between providers and medical

control.

Consult with medical control to:

- Notify hospital of incoming patient.

- Request advice or orders.

- Advise hospital of special circumstances.

Organize your thoughts before transmitting.

Calling Medical Control

The physician bases his or her instructions on the report received from the

EMT-B.

Never use codes while communicating.

Repeat all orders received.

Do not blindly follow an order that does not make sense to you - ask the

physician to clarify his or her orders.

Notify as early as possible.

Estimate the potential number of patients.

Identify special needs of patient.


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Reporting Requirements

Acknowledge dispatch information.

Notify arrival at scene.

Notify departure from scene.

Notify arrival at hospital or facility.

Notify you are clear of the incident.

Notify arrival back in quarters.

Patient Report

Identification and level of services

Receiving hospital and ETA

Patient‟s age and gender

Chief complaint

History of current problem

Other medical history

Physical findings

Summary of care given and patient response

Triage

Triage Priorities

Triage is the sorting of patients according to the urgency of their need for care.

It occurs both in the field and at the hospital.

Priority One (Highest)

Airway or breathing difficulties

Uncontrolled or severe bleeding

Decreased or altered mental status

Severe medical problems

Signs and symptoms of shock

Severe burns with airway compromise


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Priority Two

Burns without airway compromise

Multiple or major bone or joint injuries

Back injuries with or without spinal cord damage

Priority 3 (Lowest)

Minor bone or joint injuries

Minor soft-tissue injuries

Prolonged cardiac arrest

Cardiopulmonary arrest

Death

Verbal Communication

Essential part of quality patient care.

You must be able to find out what the patient needs and then tell others.

You are a vital link between the patient and the health care team.

Components of an Oral Report

Patient‟s name, chief complaint, nature of illness, mechanism of injury

Summary of information from radio report

Any important history not given earlier

Patient‟s response to treatment

The vital signs assessed

Any other helpful information

Communicating with Patients

Make and keep eye contact.

Use the patient‟s proper name.

Tell the patient the truth.

Use language the patient can understand.

Be careful of what you say about the patient to others.

Be aware of your body language.

Always speak slowly, clearly, and distinctly.


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If the patient is hearing impaired, speak clearly and face him or her.

Allow time for the patient to answer questions.

Act and speak in a calm, confident manner.

Communicating With Geriatric Patients

Determine the person‟s functional age.

Do not assume that an older patient is senile or confused.

Allow patient ample time to respond.

Watch for confusion, anxiety, or impaired hearing or vision.

Explain what is being done and why.

Communicating With Hearing-Impaired Patients

Always assume that the patient has normal intelligence.

Make sure you have a paper and pen.

Face the patient and speak slowly, clearly and distinctly.

Never shout!

Learn simple phrases used in sign language.

Communicating With Children

Children are aware of what is going on.

Allow people or objects that provide comfort to remain close.

Explain procedures to children truthfully.

Position yourself on their level.

Communicating With Vision-Impaired Patients

Ask the patient if he or she can see at all.

Explain all procedures as they are being performed.

If a guide dog is present, transport it also, if possible.


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Communicating With Non-English-Speaking Patients

Use short, simple questions and answers.

Point to specific parts of the body as you ask questions.

Learn common words and phrases in the non-English languages

used in your area.

Documentation

Minimum Data Set for Written Documentation

Patient information:

Chief complaint

Mental status

Systolic BP (patients older than 3 years)

Capillary refill (patients younger than 6 years)

Skin color and temperature

Pulse

Respirations and effort

Time incident was reported

Time that EMS unit was notified

Time EMS unit arrived on scene

Time EMS unit left scene

Time EMS unit arrived at facility

Time that patient care was transferred

The Pre-hospital Care Report (PCR)

The Pre-hospital Care Report (or Patient Care Report) serves six functions:

Continuity of care

Legal documentation

Education

Administrative

Research

Evaluation and quality improvement


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Types of PCR Forms

Written forms

Computerized versions

Narrative sections of the form:

Use only standard abbreviations.

Spell correctly.

Record time with assessment findings.

Report is considered confidential.

Reporting Errors

Do not write false statements on report.

If error made on report then:

Draw a single horizontal line through error.

Initial and date error.

Write the correct information.

Remember:

A PCR is a legal document.

If you didn‟t do something - don‟t write it down.

If you don‟t write it down - it didn‟t happen.

Documenting Right of Refusal

Document assessment findings and care given.

Have the patient sign the form.

Have a witness sign the form.

Include a statement that you explained the possible consequences of

refusing care to the patient

Special Reporting Situations

Be familiar with required reporting in your jurisdiction, including:

Gunshot wounds

Animal bites


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Certain infectious diseases

Suspected physical, sexual, or substance abuse

Multiple-casualty incidents (MCI)


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Chapter 11: Airway Management

Page 123


Outline

Anatomy Review


Recognizing Adequate Breathing

The Patent Airway

Recognizing Inadequate Breathing

Hypoxia

Different Types of Abnormal Respirations

Abnormal Lung Sounds

Conditions Resulting in Hypoxia

Opening the Airway

Assessing the Airway

Suctioning

Basic Airway Adjuncts

Ventilation Devices

Oxygen Therapy

Article: 10 Things Every Paramedic Should Know About

Capnography

Reading a Capnograph Wave

Oxygen Delivery Equipment

Pressure Regulation Devices

Article: The Oxygen Myth

Chapter 11:

Airway Management


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Anatomy Review


Adult 12-20 breaths per minute

Child 15-30 breaths per minute

Infant 25-50 breaths per minute


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Recognizing Adequate Breathing

• Normal rate and depth

• Regular pattern

• Regular and equal chest rise and fall

• Adequate depth

The Patent Airway

0-1 minute without oxygen Cardiac irritability

0-4 minutes without oxygen Brain damage not likely

4-6 minutes without oxygen Brain damage possible

6-10 minutes without oxygen Brain damage very likely

More than 10 minutes without oxygen Irreversible brain damage

Recognizing Inadequate Breathing

• Fast or slow rate

• Irregular rhythm

• Abnormal lung sounds

• Reduced tidal volumes

• Use of accessory muscles

• Cool, damp, pale or cyanotic skin

Hypoxia

• Not enough oxygen for metabolic needs

• Develops when patient is:

- Breathing inadequately

- Not breathing


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Signs of Hypoxia

• Nervousness, irritability, and fear

• Tachycardia

• Mental status changes

• Use of accessory muscles for breathing

• Difficulty breathing, possible chest pain

Different Types of Abnormal Respirations

• BRADYPNEA - rate of breathing is abnormally slow < 10 bpm.

• TACHYPNEA - rate of breathing is abnormally rapid > 24 bpm.

• HYPERNEA - respirations are increased in depth and rate (occurs normally with

exercise).

• APNEA - respirations cease for several seconds.

• HYPERVENTILATION - rate of ventilation exceeds normal metabolic requirements

for exchange of respiratory gases. Rate and depth of respiration is increased.

• HYPOVENTILATION - rate of ventilation is insufficient for metabolic requirements.

Respiratory rate is below normal and depth of ventilations is depressed.

• CHEYNE-STOKES RESPIRATION - respiratory rhythm is irregular, characterised by

alternating periods of apnoea and hyperventilation. The respiratory cycle begins

with slow and shallow respiration and gradually increases to abnormal depth and

rapidity.

• KUSSMAUL RESPIRATION - respirations are abnormally deep but regular. Similar

to hyper ventilation.

• ORTHOPNEA - respiratory condition in which the person must sit or stand to

breathe deeply and comfortably.

• BIOT’S RESPIRATION - condition of the central nervous system which causes

shallow breathing interrupted by irregular periods of apnoea.

Abnormal Lung Sounds

Crackles

Crackles (or rales) are caused by fluid in the small airways or atelectasis. Crackles

are referred to as discontinuous sounds; they are intermittent, nonmusical and

brief. Crackles may be heard on inspiration or expiration. The popping sounds


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produced are created when air is forced through respiratory passages that are

narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation

or infection of the small bronchi, bronchioles, and alveoli. Crackles that don’t clear

after a cough may indicate pulmonary edema or fluid in the alveoli due to heart

failure or adult respiratory distress syndrome (ARDS).

• Crackles are often described as fine, medium, and coarse.

• Fine crackles are soft, high-pitched, and very brief. You can simulate this

sound by rolling a strand of hair between your fingers near your ear, or by

moistening your thumb and index finger and separating them near your

ear.

• Coarse crackles are somewhat louder, lower in pitch, and last longer than

fine crackles. They have been described as sounding like opening a Velcro

fastener.

Wheezes

Wheezes are sounds that are heard continuously during inspiration or expiration,

or during both inspiration and expiration. They are caused by air moving through

airways narrowed by constriction or swelling of airway or partial airway

obstruction.

• Wheezes that are relatively high pitched and have a shrill or squeaking

quality may be referred to as sibilant rhonchi. They are often heard

continuously through both inspiration and expiration and have a musical

quality. These wheezes occur when airways are narrowed, such as may

occur during an acute asthmatic attack.

• Wheezes that are lower-pitched sounds with a snoring or moaning quality

may be referred to as sonorous rhonchi. Secretions in large airways, such

as occurs with bronchitis, may produce these sounds; they may clear

somewhat with coughing.

Stridor

Stridor refers to a high-pitched harsh sound heard during inspiration. Stridor is

caused by obstruction of the upper airway, is a sign of respiratory distress and

thus requires immediate attention.

If abnormal lungs sounds are heard, it is important to assess:

• their loudness.


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• timing in the respiratory cycle.

• location on the chest wall.

• persistence of the pattern from breath to breath, and.

• whether or not the sounds clear after a cough or a few deep breaths:

- secretions from bronchitis may cause wheezes, (or rhonchi), that clear with

coughing.

- crackles may be heard when atelectatic alveoli pop open after a few deep

breaths.

Conditions Resulting In Hypoxia

• Myocardial infarction

• Pulmonary edema

• Acute narcotic overdose

• Smoke inhalation

• Stroke

• Chest injury

• Shock

• Lung disease

• Asthma

• Premature birth

Opening the Airway

Head Tilt-Chin Lift Method

Used when cervical spine injury is not suspected.

1. Kneel beside patient’s head.

2. Place one hand on forehead.

3. Apply backward pressure.

4. Place tips of finger under lower jaw.

5. Lift chin.


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Jaw Thrust Maneuver

Used when cervical spine injury is suspected.

1. Kneel above patient’s head.

2. Place fingers behind angle of jaw.

3. Use thumbs to keep mouth open

Assessment of the Airway

1. Look

2. Listen

3. Feel


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Suctioning

Suctioning of a patient’s airway may be necessary when:

• Blood, other liquids and food particles block the airway.

• A gurgling sound is heard when performing artificial ventilation.

Suctioning Technique

• Check the unit and turn it on.

• Select and measure proper catheter to be used.

• Open the patient’s mouth and insert tip.

• Suction as you withdraw the catheter.

• Never suction adults for more than 15 seconds.

Basic Airway Adjuncts

Oropharyngeal airways

• Keep the tongue from blocking the upper airway

• Allow for easier suctioning of the airway

• Used in conjunction with BVM device

• Used on unconscious patients without a gag reflex

Inserting an oropharyngeal airway

1. Select the proper size airway.

2. Open the patient’s mouth.

3. Hold the airway upside down and insert it in the patient’s mouth.

4. Rotate the airway 180° until the flange rests on the patient’s lips.


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Nasopharyngeal Airways

• Used on conscious patients who cannot maintain airway

• Can be used with intact gag reflex

• Should not be used with head injuries or nosebleeds

Inserting a nasopharyngeal airway

1. Select the proper size airway.

2. Lubricate the airway.

3. Gently push the nostril open.

4. With the bevel turned toward the septum, insert the airway.

Airway Kits

Basic airways

Advanced airways

A typical EMS airway kit


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Ventilation Devices

The EMT is equipped with a range of devices to assist ventilation. Some of these

devices are not authorized for use by EMT-Bs, but the EMT-B may be called upon to

assist with the use of these devices.

Pocket Mask

A pocket mask may be used to provide artificial ventilations when no other equipment

is available. Pocket masks may be disposable or reusable. Some pocket masks have a

nozzle for the attachment of oxygen tubing. A pocket mask should be equipped with a

one-way valve to prevent body fluids from transferring from the patient to the EMT.

Bag-Valve Mask

The bag-valve mask should be the EMTs primary method of delivering ventilations.

Supplemental oxygen may be attached to the bag-valve if needed. Bag-valve masks

can also be used in conjunction with airway adjuncts and advanced airways such as the

endotracheal tube. Three different sizes are available - adult, child and infant. The child

and infant BVM have a pressure valve to prevent overinflation of the lungs.

Ventilation Techniques

Mouth to Mask Technique

1. Kneel at patient’s head and open airway.

2. Place the mask on the patient’s face.

3. Take a deep breath and breathe into the patient for 1 1/2 to 2 seconds.

4. Remove your mouth and watch for patient’s chest to fall.


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1 Person BVM Technique

1. Insert an oral airway.

2. Establish and maintain an adequate seal with one hand while using the other

hand to delivers ventilations.

3. Place mask on patient’s face.

4. Squeeze bag to deliver ventilations.

2 Person BVM Technique

1. Insert an oral airway.

2. One caregiver maintains seal while the other delivers ventilations.

3. Place mask on patient’s face.

4. Squeeze bag to deliver ventilations.


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Oxygen Therapy

Medical Oxygen

Oxygen is a colourless, odourless gas normally present in the atmosphere at

concentrations of approximately 21%.

The chemical symbol for the element oxygen is O. As a medicinal gas, oxygen contains

not less than 99.0% by volume of O2.

Whereas previously oxygen tended to be given to a majority of patients, research has led

to the prescription of oxygen when and as needed, using pulse oximetry and end-tidal

CO2 capnography to guide the EMT.

Pulse Oximeters

• Used to measure the oxygen saturation of hemoglobin.

• May give false readings with CO absorption because it cannot distinguish between

O2 and CO.

• Takes several minutes to give an accurate reading.

A pulse oximetry of 94% O2 saturation or

above means the patient is receiving

adequate oxygen for metabolism.


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Capnography

Capnography is increasingly being used by paramedics to aid in their assessment and

treatment of patients in the prehospital environment. These uses include verifying and

monitoring the position of an endotracheal tube. A properly positioned tube in the trachea

guards the patient’s airway and enables the paramedic to breathe for the patient. A

misplaced tube in the esophagus can lead to death.

A study in the March 2005 Annals of Emergency Medicine, comparing field intubations that

used continuous capnography to confirm intubations versus non-

use showed zero unrecognized misplaced intubations in the

monitoring group versus 23% misplaced tubes in the

unmonitored group. The American Heart Association (AHA)

affirmed the importance of using capnography to verify tube

placement in their 2005 CPR and ECG Guidelines.

The AHA also notes in their new guidelines that capnography,

which indirectly measures cardiac output, can also be used to

monitor the effectiveness of CPR and as an early indication of

return of spontaneous circulation (ROSC). Studies have shown

that when a person doing CPR tires, the patient’s end-tidal CO2

(ETCO2, the level of carbon dioxide released at the end of

expiration) falls, and then rises when a fresh rescuer takes over.

Other studies have shown when a patient experiences return of

spontaneous circulation, the first indication is often a sudden rise in the ETCO2 as the rush

of circulation washes untransported CO2 from the tissues. Likewise, a sudden drop in

ETCO2 may indicate the patient has lost pulses and CPR may need to be initiated.

Paramedics are also now beginning to monitor the ETCO2 status of nonintubated patients

by using a special nasal cannula that collects the carbon dioxide. A high ETCO2 reading in a

patient with altered mental status or severe difficulty breathing may indicate

hypoventilation and a possible need for the patient to be intubated.

Capnography, because it provides a breath by breath measurement of a patient’s

ventilation, can quickly reveal a worsening trend in a patient’s condition by providing

paramedics with an early warning system into a patient’s respiratory status. As more clinical

studies are conducted into the uses of capnography in asthma, congestive heart failure,

diabetes, circulatory shock, pulmonary embolus, acidosis, and other conditions, the

prehospital use of capnography will greatly expand.


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Article: 10 Things Every Paramedic Should Know About Capnography

Adapted from an Article from JEMS (Journey of Emergency Medical Services), by Peter Canning,

EMT-P, December 29, 2007

10 Things Every Paramedic Should Know About Capnography

Capnography is the vital sign of ventilation.

By tracking the carbon dioxide in a patient’s exhaled breath, capnography enables paramedics

to objectively evaluate a patient’s ventilatory status (and indirectly circulatory and metabolic

status), as the medics utilize their clinical judgement to assess and treat their patients.

Part One: The Science

Definitions:

Capnography – the measurement of carbon dioxide (CO2) in exhaled breath.

Capnometer – the numeric measurement of CO2.

Capnogram – the wave form.

End Tidal CO2 (ETCO2 or PetCO2) – the level of (partial pressure of) carbon dioxide released at

end of expiration.

Oxygenation Versus Ventilation

Oxygenation is how we get oxygen to the tissue. Oxygen is inhaled into the lungs where gas

exchange occurs at the capillary-alveolar membrane. Oxygen is transported to the tissues

through the blood stream. Pulse oximetry measures oxygenation.

At the cellular level, oxygen and glucose combine to produce energy. Carbon dioxide, a waste

product of this process (The Krebs cycle), diffuses into the blood.

Ventilation (the movement of air) is how we get rid of carbon dioxide. Carbon dioxide is carried

back through the blood and exhaled by the lungs through the alveoli. Capnography measures

ventilation.

Capnography versus Pulse Oximetry

Capnography provides an immediate picture of patient condition. Pulse oximetry is delayed.

Hold your breath. Capnography will show immediate apnea, while pulse oximetry will show a

high saturation for several minutes.


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Circulation and Metabolism

While capnography is a direct measurement of ventilation in the lungs, it also indirectly

measures metabolism and circulation. For example, an increased metabolism will

increase the production of carbon dioxide increasing the ETCO2. A decrease in cardiac

output will lower the delivery of carbon dioxide to the lungs decreasing the ETCO2.

Normal Capnography Values

ETCO2 35-45 mm Hg is the normal value for capnography. However, some experts say

30 mm HG – 43 mm Hg can be considered normal.

Cautions: Imperfect positioning of nasal cannula capnofilters may cause distorted

readings. Unique nasal anatomy, obstructed nares and mouth breathers may skew

results and/or require repositioning of cannula. Also, oxygen by mask may lower the

reading by 10% or more.

Capnography Wave Form

The normal wave form appears as straight boxes on the monitor screen but the wave

form appears more drawn out on the print out because the monitor screen is

compressed time while the print out is in real time.

The capnogram wave form begins before exhalation and ends with inspiration. Breathing

out comes before breathing in.

Abnormal Values and Wave Forms

ETCO2 Less Than 35 mmHg = “Hyperventilation/Hypocapnia”

ETC02 Greater Than 45 mmHg = “Hypoventilation/Hypercapnia”

Part Two: Clinical Uses of Capnography

1. Monitoring Ventilation

Capnography monitors patient ventilation, providing a breath by breath trend of

respirations and an early warning system of impending respiratory crisis.

Hyperventilation

When a person hyperventilates, their CO2 goes down.

Hyperventilation can be caused by many factors from anxiety to bronchospasm to

pulmonary embolus. Other reasons C02 may be low: cardiac arrest, decreased cardiac

output, hypotension, cold, severe pulmonary edema.


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Note: Ventilation equals tidal volume X respiratory rate. A patient taking in a large tidal

volume can still hyperventilate with a normal respiratory rate just as a person with a small

tidal volume can hypoventilate with a normal respiratory rate.

Hypoventilation

When a person hypoventilates, their CO2 goes up.

Hypoventilation can be caused by altered mental status such as overdose, sedation,

intoxication, postictal states, head trauma, or stroke, or by a tiring CHF patient. Other

reasons CO2 may be high: Increased cardiac output with increased breathing, fever, sepsis,

pain, severe difficulty breathing, depressed respirations, chronic hypercapnia.

Some diseases may cause the CO2 to go down, then up, then down. (See asthma below).

Pay more attention to the ETCO2 trend than the actual number.

A steadily rising ETCO2 (as the patient begins to hypoventilate) can help a paramedic

anticipate when a patient may soon require assisted ventilations or intubation.

Heroin Overdoses – Some EMS systems permit medics to administer narcan only to

unresponsive patients with suspected opiate overdoses with respiratory rates less than 10.

Monitoring ETCO2 provides a better gauge of ventilatory status than respiratory rate.

ETCO2 will show a heroin overdose with a respiratory rate of 24 (with many shallow

ineffective breaths) and an ETCO2 of 60 is more in need of arousal than a patient with a

respiratory rate of 8, but an ETCO2 of 35.

2. Confirming, Maintaining , and Assisting Intubation

Continuous end-tidal CO2 monitoring can confirm a tracheal intubation. A good wave

form indicating the presence of CO2 ensures the ET tube is in the trachea.

A 2005 study comparing field intubations that used continuous capnography to confirm

intubations versus non-use showed zero unrecognized misplaced intubations in the

monitoring group versus 23% misplaced tubes in the unmonitored group. -Silverstir,

Annals of Emergency Medicine, May 2005

Paramedics can attach the capnography filter to the ET tube prior to intubation and, in

cases where it is difficult to visualize the chords, use the monitor to assist placement. This

includes cases of nasal tracheal intubation.


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Continuous Wave Form Capnography Versus Colorimetric Capnography

In colorimetric capnography a filter attached to an ET tube changes color from purple

to yellow when it detects carbon dioxide. This device has several drawbacks when

compared to waveform capnography. It is not continuous, has no waveform, no

number, no alarms, is easily contaminated, is hard to read in dark, and can give false

readings.

Paramedics should encourage their services to equip them with continuous wave form

capnography.

3. Measuring Cardiac Output During CPR

Monitoring ETC02 measures cardiac output, thus monitoring ETCO2 is a good way to

measure the effectiveness of CPR.

In 1978, Kalenda “reported a decrease in ETC02 as the person performing CPR

fatigued, followed by an increase in ETCO2 as a new rescuer took over, presumably

providing better chest compressions.” –Gravenstein, Capnography: Clinical Aspects,

Cambridge Press, 2004

With the new American Heart Association Guidelines calling for quality compressions

(”push hard, push fast, push deep”), rescuers should switch places every two minutes.

Set the monitor up so the compressors can view the ETCO2 readings as well as the ECG

wave form generated by their compressions. Encourage them to keep the ETCO2

number up as high as possible.

“Reductions in ETCO2 during CPR are associated with comparable reductions in cardiac

output….The extent to which resuscitation maneuvers, especially precordial

compression, maintain cardiac output may be more readily assessed by measurements

of ETCO2 than palpation of arterial pulses.” -Max Weil, M.D., Cardiac Output and End-

Tidal carbon dioxide, Critical Care Medicine, November 1985

Note: Patients with extended down times may have ETCO2 readings so low that quality

of compressions will show little difference in the number.

Return of Spontaneous Circulation (ROSC)

ETCO2 can be the first sign of return of spontaneous circulation (ROSC). During a

cardiac arrest, if you see the CO2 number shoot up, stop CPR and check for pulses.

End-tidal CO2 will often overshoot baseline values when circulation is restored due to

carbon dioxide washout from the tissues.


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A recent study found the ETCO2 shot up on average 13.5 mmHg with sudden ROSC before

settling into a normal range

.-Grmec S, Krizmaric M, Mally S, Kozelj A, Spindler M, Lesnik B.,Resuscitation. 2006 Dec 8

Loss of Spontaneous Circulation

In a resuscitated patient, if you see the stabilized ETCO2 number significantly drop in a

person with ROSC, immediately check pulses. You may have to restart CPR.

4. End Tidal CO2 As Predictor of Resuscitation Outcome

End tidal CO2 monitoring can confirm the futility of resuscitation as well as forecast the

likelihood of resuscitation.

“An end-tidal carbon dioxide level of 10 mmHg or less measured 20 minutes after the

initiation of advanced cardiac life support accurately predicts death in patients with cardiac

arrest associated with electrical activity but no pulse. Cardiopulmonary resuscitation may

reasonably be terminated in such patients.” -Levine R, End-tidal Carbon Dioxide and

Outcome of Out-of-Hospital Cardiac Arrest, New England Journal of Medicine, July 1997

Likewise, case studies have shown that patients with a high initial end tidal CO2 reading

were more likely to be resuscitated than those who didn’t. The greater the initial value, the

likelier the chance of a successful resuscitation.

“No patient who had an end-tidal carbon dioxide of level of less than 10 mm Hg survived.

Conversely, in all 35 patients in whom spontaneous circulation was restored, end-tidal

carbon dioxide rose to at least 18 mm Hg before the clinically detectable return of vital

signs….The difference between survivors and nonsurvivors in 20 minute end-tidal carbon

dioxide levels is dramatic and obvious.” – ibid.

“An ETCO2 value of 16 torr or less successfully discriminated between the survivors and

the nonsurvivors in our study because no patient survived with an ETCO2 less than 16 torr.

Our logistic regression model further showed that for every increase of 1 torr in ETCO2,

the odds of surviving increased by 16%.” –Salen, Can Cardiac Sonography and

Capnography Be Used Independently and in Combination to Predict Resuscitation

Outcomes?, Academic Emergency Medicine, June 2001

Caution: While a low initial ETCO2 makes resuscitation less likely than a higher initial

ETCO2, patients have been successfully resuscitated with an initial ETCO2 >10 mmHg.


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Asphyxic Cardiac Arrest versus Primary Cardiac Arrest

Capnography can also be utilized to differentiate the nature of the cardiac arrest.

A 2003 study found that patients suffering from asphyxic arrest as opposed to primary

cardiac arrest had significantly increased initial ETCO2 reading that came down within a

minute. These high initial readings, caused by the buildup of carbon dioxide in the lungs

while the nonbreathing/nonventilating patient’s heart continued pump carbon dioxide to

the lungs before the heart bradyed down to asystole, should come down within a minute.

The ETCO2 values of asphyxic arrest patients then become prognostic of ROSC

.-Grmec S, Lah K, Tusek-Bunc K,Crit Care. 2003 Dec

5. Monitoring Sedated Patients

Capnography should be used to monitor any patients receiving pain management or

sedation (enough to alter their mental status) for evidence of hypoventilation and/or

apnea.

In a 2006 published study of 60 patients undergoing sedation, in 14 of 17 patients who

suffered acute respiratory events, ETCO2 monitoring flagged a problem before changes in

SPO2 or observed changes in respiratory rate.

“End-tidal carbon dioxide monitoring of patients undergoing PSA detected many clinically

significant acute respiratory events before standard ED monitoring practice did so. The

majority of acute respiratory events noted in this trial occurred before changes in SP02 or

observed hypoventilation and apnea.” – -Burton, Does End-Tidal Carbon Dioxide

Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices,

Academic Emergency Medicine, May 2006

Sedated, Intubated Patients

Capnography is also essential in sedated, intubated patients. A small notch in the wave

form indicates the patient is beginning to arouse from sedation, starting to breathe on

their own, and will need additional medication to prevent them from “bucking” the tube.

6. ETCO2 in Asthma, COPD, and CHF

End-tidal CO2 monitoring on non-intubated patients is an excellent way to assess the

severity of Asthma/COPD, and the effectiveness of treatment. Bronchospasm will produce

a characteristic “shark fin” wave form, as the patient has to struggle to exhale, creating a

sloping “B-C” upstroke. The shape is caused by uneven alveolar emptying.


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Hypoxic Drive

Capnography will show the hypoxic drive in COPD “retainers.” ETCO2 readings will steadily

rise, alerting you to cut back on the oxygen before the patient becomes obtunded. Since it

has been estimated that only 5% of COPDers have a hypoxic drive, monitoring capnography

will also allow you to maintain sufficient oxygen levels in the majority of tachypneic COPDers

without worry that they will hypoventilate.

CHF: Cardiac Asthma

It has been suggested that in wheezing patients with CHF (because the alveoli are still, for

the most part, emptying equally), the wave form should be upright. This can help assist your

clinical judgement when attempting to differentiate between obstructive airway wheezing

such as COPD and the “cardiac asthma” of CHF.

7. Ventilating Head Injured Patients

Capnography can help paramedics avoid hyperventilation in intubated head injured patients.

“Recent evidence suggests hyperventilation leads to ischemia almost immediately…current

models of both ischemic and TBI suggest an immediate period during which the brain is

especially vulnerable to secondary insults. This underscores the importance of avoiding

hyperventilation in the prehospital environment.” –Capnography as a Guide to Ventilation in

the Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004

Hyperventilation decreases intracranial pressure by decreasing intracranial blood flow. The

decreased cerebral blood flow may result in cerebral ischemia.

In a study of 291 intubated head injured patients, 144 had ETCO2 monitoring. Patients with

ETCO2 monitoring had lower incidence of inadvertant severe hyperventilation (5.6%) than

those without ETCO2 monitoring (13.4%). Patients in both groups with severe

hyperventilation had significantly higher mortality (56%) than those without (30%). –Davis,

The Use of Quantitative End-Tidal Capnometry to Avoid Inadvertant Severe Hyperventilation

in Patients with Head Injury After Paramedic Rapid Sequence Intubation, Journal of Trauma,

April 2004

8. Perfusion Warning Sign

“A target value of 35 mmHg is recommended…The propensity of prehospital personnel to

use excessively high respiratory rates suggests that the number of breaths per minute

should be decreased. On the other hand, the mounting evidence against tidal volumes in

excessive of 10cc/kg especially in the absence of peep, would suggest the hypocapnia be

addressed by lower volume ventilation.” – –Capnography as a Guide to Ventilation in the

Field, D.P. Davis, Gravenstein, Capnography: Clinical Perspectives, Cambridge Press, 2004


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End tidal CO2 monitoring can provide an early warning sign of shock. A patient with a

sudden drop in cardiac output will show a drop in ETCO2 numbers that may be regardless

of any change in breathing. This has implications for trauma patients, cardiac patients –

any patient at risk for shock.

9. Other Issues

DKA – Patients with DKA hyperventilate to lessen their acidosis. The hyperventilation

causes their PAC02 to go down.

“End-tidal C02 is linearly related to HC03 and is significantly lower in children with DKA. If

confirmed by larger trials, cut-points of 29 torr and 36 torr, in conjunction with clinical

assessment, may help discriminate between patients with and without DKA, respectively.”

–Fearon, End-tidal carbon dioxide predicts the presence and severity of acidosis in

children with diabetes, Academic Emergency Medicine, December 2002

Pulmonary Embolus – Pulmonary embolus will cause an increase in the dead space in the

lungs decreasing the alveoli available to offload carbon dioxide. The ETCO2 will go down.

Hyperthermia – Metabolism is on overdrive in fever, which may cause ETCO2 to rise.

Observing this phenomena can be live-saving in patients with malignant hyperthermia, a

rare side effect of RSI (Rapid Sequence Induction).

Trauma – A 2004 study of blunt trauma patients requiring RSI showed that only 5 percent

of patients with ETCO2 below 26.25 mm Hg after 20 minutes survived to discharge. The

median ETCO2 for survivors was 30.75. - Deakin CD, Sado DM, Coats TJ, Davies G.

“Prehospital end-tidal carbon dioxide concentration and outcome in major trauma.”

Journal of Trauma. 2004;57:65-68.

Field Disaster Triage – It has been suggested that capnography is an excellent triage tool

to assess respiratory status in patients in mass casualty chemical incidents, such as those

that might be caused by terrorism.

“Capnography…can serve as an effective, rapid assessment and triage tool for critically

injured patients and victims of chemical exposure. It provides the ABCs in less than 15

seconds and identifies the common complications of chemical terrorism. EMS systems

should consider adding capnography to their triage and patient assessment toolbox and

emphasize its use during educational programs and MCI drills.”- Krauss, Heightman, 15

Second Triage Tool, JEMS, September 2006

Anxiety- ETCO2 is being used on an ambulatory basis to teach patients with anxiety

disorders as well as asthmatics how to better control their breathing. Try (it may not

always be possible) to get your anxious patient to focus on the monitor, telling them that


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as they slow their breathing, their ETCO2 number will rise, their respiratory rate number will fall

and they will feel better.

Anaphylaxis- Some patients who suffer anaphylactic reactions to food they have ingested (nuts,

seafood, etc.) may experience a second attack after initial treatment because the allergens

remain in their stomach. Monitoring ETCO2 may provide early warning to a reoccurrence. The

wave form may start to slope before wheezing is noticed.

Accurate Respiratory Rate – Studies have shown that many medical professionals do a poor job

of recording a patient’s respiratory rate. Capnography not only provides an accurate respiratory

rate, it provides an accurate trend or respirations.

10. The Future

Capnography should be the prehospital standard of care for confirmation and continuous

monitoring of intubation, as well as for monitoring ventilation in sedated patients. Additionally,

it should see increasing use in the monitoring of unstable patients of many etiologies. As more

research is done, the role of capnography in prehospital medicine will continue to grow and

evolve.

The normal range for exhaled CO2 is 35-45mmHg

Reading a Capnograph Wave

Segment I (A to B) of the wave represents post inspiration / dead space expiration.


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Segment II (B to C) of the wave represents exhalation upstroke where dead space gas

mixes with alveolar gas.

Segment III (C to D) of the wave represents a continuance of exhalation and is also called

the plateau.

Segment IV (D to E) of the wave represents inspiration washout.


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The height of the wave should be compared to the scale on the page/screen to determine

ETCO2 levels.

• The number of wave forms per minute can be counted to get an accurate respiratory rate.

• The waves should be analyzed to see if there is any difference from the expected squared-

off wave form.

• Changes in the height of the waves during monitoring should also be evaluated.

Oxygen Delivery Devices

Nasal Cannula

An oxygen tube that provides only a very limited oxygen concentration.

Adult or Pediatric Simple Face Mask

No reservoir and can only deliver up to 60% oxygen.

Adult Nonrebreather Mask

Has an oxygen reservoir bag attached to the mask with a one-way valve between them that

prevents the patient’s exhaled air from mixing with the oxygen in the reservoir bag. Oxygen

requirement = 15 LPM.


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Pediatric Nonrebreather Mask

Has an oxygen reservoir bag attached to the mask with a one-way valve between them

that prevents the patient’s exhaled air from mixing with the oxygen in the reservoir bag.

Oxygen requirement = 8 LPM.

Partial Rebreather Mask

Similar to a nonrebreather mask but is equipped with a two-way valve that allows the

patient to rebreathe about 1/3 of their exhaled air. Can provide an oxygen concentration

of about 35% to 60%.

Venturi Mask

A low flow oxygen system that provides precise concentrations of oxygen through an

entertainment valve connected to the face mask.

Ventilatory Devices and Oxygen Concentration

Device Liter Flow (LPM) Oxygen Delivered

Nasal Cannulae 1-6 24-26%

Mouth-to-Mask 10 50%

Simple face mask 8-10 40-60%

BVM without reservoir 8-10 40-60%

Partial rebreather mask 6 60%

Simple mask with reservoir 6 60%

BVM with reservoir 15 100%

Nonrebreathing mask with

reservoir

15 90-100%


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Oxygen Cylinders

In emergency medical care, the following sizes of

oxygen cylinders are commonly used:

D cylinder 350 liters

E Cylinder 625 liters

M Cylinder 3000 liters

G cylinder 5300 liters

H cylinder 6900 liters

Safety Precautions

Oxygen is a gas that acts as an accelerant for combustion, and oxygen cylinders are under

high pressure.

Never allow combustible materials, such as oil and grease, touch the cylinder, regulator

fittings, valves or hoses.

Never smoke or allow others to smoke in any area where oxygen cylinders are in use or on

standby.

Calculation of Oxygen Cylinder Contents in Liters

D cylinder - Lbs per in2 x 0.16 = contents in liters

E cylinder - Lbs per in2 x 0.28 = contents in liters

G cylinder - Lbs per in2 x 2.41 = contents in liters


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H cylinder - Lbs per in2 x 3.14 = contents in liters

M cylinder - Lbs per in2 x 1.56= contents in liters

Calculation of Oxygen Required for Transport

Breaths per minute x tidal volume x travel time = ɵ

ɵ + ɵ/2 = total requirement of oxygen for transport

(Note: 50% of the estimated need is added in order to cater for emergencies or unforeseen

circumstances)

Minimum Volume Requirements for Pediatrics

Age in Years Minimum Volume Required

1 120ml

2 156ml

3-4 170ml

5-6 200ml

7-10 270ml

11-12 380ml

13-14 420ml

15 as adult

Safety with Oxygen Cylinders

• Store cylinders below 50 degrees Celsius.

• Never use an oxygen cylinder without a safe, properly fitting

regulator valve.

• Keep all valves closed when the cylinder is not in use, even if the

tank is empty.

• Keep oxygen cylinders secured to prevent them from toppling

over.


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• When you are working with oxygen cylinders, never put any body parts over

the cylinder valve.

Pressure Regulators

Pressure regulators are devices that control gas flow and reduce the high pressure in the

cylinder to a safe range (from 2000psi to around 50psi), and controls the flow of oxygen

from 1-15 liters per minute.

There are two types of regulators:

High-pressure regulator

This type of regulator has one gauge that registers the content of the cylinder and that,

through a step-down regulator, can provide 50psi to power a flow restricted oxygen

powered automatic transport ventilator (ATV).

Therapy regulator

This type of regulator has two gauges, one indicating the pressure in the tank and a

flowmeter indicating the measured flow of oxygen being delivered to the patient (0-15

LPM).


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Article: The Oxygen Myth?

The Oxygen Myth?

An article by Bryan E. Bledsoe, DO, FACEP, Mar 5 2009, JEMS

(http://www.jems.com/news_and_articles/columns/Bledsoe/the_oxygen_myth.html)

In EMS, we’ve always emphasized two things: airway and oxygenation. In reality, we should

be emphasizing ventilation. Without an airway, your patient cannot ventilate. Without

ventilation, you cannot assess the airway. They’re inseparably linked.

Likewise, without ventilation, oxygenation is impossible. But ventilation involves much more

than oxygenation. It involves the elimination of carbon dioxide and toxins and plays a role in

other important biological processes.

We’ve always taught that a little oxygen is good and a lot of oxygen is better. We adopted

pulse oximeters and really only use them to document oxygen saturations -- especially low

thresholds. The closer to 100%, the better -- or so we thought. But is doing this in the best

interest of the patients?

Several years ago we saw a change in practice in the neonatology community to limit

supplemental oxygenation given to newborns and neonates. We had always known that

high-concentration oxygen was associated with the development of retinopathy of

prematurity (ROP), formerly called retrolental fibroplasia, in premature infants. Later,

clinicians found that neonates resuscitated with high-concentration oxygen had worse

outcomes than those resuscitated with room air. For example, infants resuscitated with 100%

oxygen have a greater delay to first cry and a greater delay to first respiration.(1) In one

study of depressed infants, mortality was 13% for those resuscitated with 100% oxygen and

only 8% for those resuscitated with room air.(2) Further, neonates resuscitated with room air

had a lower mortality at one week compared to those resuscitated with 100% oxygen.(3) The

American Heart Association now recommends starting with room air and increasing oxygen

concentration as needed to maintain an adequate oxygen saturation.(4)

Next, the phenomenon of reperfusion injury was noted. Reperfusion injury occurs when

oxygen is reintroduced to ischemic tissues. Stated another way, the injury does not occur

during periods of hypoxia. It occurs after oxygen is restored to the affected tissues.

The primary mechanism is thought to be the development of toxic chemicals called “reactive

oxygen species” or “free radicals.” These chemicals have an unpaired electron in their outer

shell and are very unstable. They occur normally, to a limited degree, but the body has

enzyme systems that process the free radicals into less toxic substances, thus avoiding

significant cellular damage. But following a period of hypoxia, a large number of free radicals


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are produced that overwhelm the protective enzyme systems (antioxidants) and cellular

damage occurs. This damage is called “oxidative stress . “

The effects of aging are often due to oxidative stress. Also, some diseases such as

atherosclerosis, Alzheimer’s disease, Parkinson’s disease, and others have been linked to

oxidative stress and free radical induction. Thus, the evolving thought is that, in some

conditions, high concentrations of oxygen can be harmful.

So, what does this mean to the future evolution of EMS practice? Well, there are several

disease processes we must consider.

Stroke: The brain is very vulnerable to the effects of oxidative stress. The brain has fewer

antioxidants than other tissues. Thus, should we give oxygen to non-hypoxic stroke patients?

Studies have shown that patients with mild-moderate strokes have improved mortality when

they receive room air instead of high-concentration oxygen.

The data on patients with severe strokes is less clear.(5) Current research indicates that

supplemental oxygen should not be routinely given to patients with stroke and can, in some

cases, be detrimental.(6)

Acute Coronary Syndrome: The myocardium is highly oxygen dependent and vulnerable to

the effects of oxidative stress. Thus far, there’s no evidence that giving supplemental oxygen

to acute coronary syndrome patients is helpful, but there’s no evidence it’s harmful.(7)

Post-Cardiac Arrest: Here, too, the evidence is too scant to tell. We do know that virtually all

current therapies for cardiac arrest (drugs, airway) are of little, if any, benefit. The primary

therapies remain CPR (often with limited ventilation initially) and defibrillation followed by

induced hypothermia. The whole purpose of induced hypothermia is to prevent the

detrimental effects of oxidative stress and the other harmful effects of reperfusion injury.

Trauma: What role should oxygen play in non-hypoxic trauma patients? Little research exists,

but an interesting study out of New Orleans demonstrated that there was no survival benefit

to the use of supplemental oxygen in the prehospital setting in traumatized patients who do

not require mechanical ventilation or airway protection.(8)

Carbon Monoxide (CO) Poisoning: We have learned a lot about carbon monoxide poisoning

in the past few years. We know that the mechanism of CO poisoning is a lot more complex

than once thought. We also know that there’s no reliable evidence that hyperbaric oxygen

(HBO) therapy improves outcome (although it’s still widely used).(9) But when you think

about it, the goal of treatment in CO poisoning is to eliminate CO through ventilation -- not

hyperoxygenation. Although oxygen can displace some CO from hemoglobin, the induction

of free-radicals may be worse than the effects of CO. Again, the science here is in a state of

flux.


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Neonates: The science is clear in regard to supplemental oxygen in neonates. It should be

used only when room air ventilation fails.

Again, this is a discussion of the changing science. Always continue to follow the direction of

your medical director and local protocols. That said, it’s clear that we need to use every tool

possible to support, but not replace, our physical exam skills. We should use pulse oximetry

and waveform capnography. Although, individually, each technology has its limitations,

together they provide important information about the patient.

The goal of therapy is to avoid hypoxia and hyperoxia. If the patient’s oxygen saturation and

ventilation are adequate, supplemental oxygen is probably not required. If the patient is

hypoxic or hypercapnic, then you must determine whether the problem can be remedied

through increased ventilation, increased oxygenation, or both. Thus, you have to assess the

problem, recognize and understand the pathophysiological processes involved, plan an

appropriate therapy (within the scope of your protocols), and provide the needed therapy.

That is what prehospital care is all about.

References

1. Martin RJ, Bookatz GB, Gelfand SL, et al: “Consequences of neonatal resuscitation with

supplemental oxygen.” Semin Perinatol. 32:355-366, 2008.

2. Davis PG, Tan A, O’Donnell CP, et al: “Resuscitation of newborn infants with 100% oxygen

or air: A systematic review and meta-analysis.” Lancet. 364:1329-1333, 2004.

3. Rabi Y, Rabi D, Yee W: “Room air resuscitation of the depressed newborn: A systematic

review and meta-analysis.” Resuscitation. 72:353-363, 2007.

4. American Heart Association: “2005 American Heart Association guidelines for

cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric

and neonatal patients: Pediatric basic life support.” Circulation.13:IV1-203, 2005.

5. Ronning OM, Guldvog B: “Should stroke victims routinely receive supplemental oxygen? A

quasi-randomized controlled trial.” Stroke. 30:2033-2037, 1999.

6. Pancioli AM, Bullard MJ, Grulee ME, et al: “Supplemental oxygen use in ischemic stroke

patients: Does utilization correspond to need for oxygen therapy.” Archives of Internal

Medicine. 162:49-52, 2002.

7. Mackway-Jones K: “Oxygen in uncomplicated myocardial infarction.” Emergency Medicine

Journal. 21:75-81, 2004.

8. Stockinger ZT, McSwain NE: “Prehospital supplemental oxygen in trauma patients: Its

efficacy and implications for military medical care.” Military Medicine. 169:609-612, 2004.


Page 154


9. Gilmer B, Kilkenny J, Tomaszewski C, et al: “Hyperbaric oxygen does not improve

neurologic sequelae after carbon monoxide poisoning.” Academic Emergency Medicine. 9:1-

8, 2002.

Chapter 12: The Basic ECG

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Outline

Electrical Conduction System of the Heart

The Electrocardiogram

The ECG Complex

An In-depth Look at the ECG and Its Generation

ECG Rhythm Interpretation

Electrical Conduction System of the Heart

A network of specialized tissue in the heart.

Conducts electrical current throughout the heart.

The flow of electrical current causes contractions that produce pumping of

blood.

Chapter 12:

The Basic ECG


Page 156


The heart’s electrical system is made up of three main parts:

The sinoatrial (SA) node, located in the right atrium of the heart.

The atrioventricular (AV) node, located on the interatrial septum close to the tricuspid

valve.

The His-Purkinje system, located along the walls of the heart’s ventricles.

A heartbeat is a complex series of events that take place in the heart. A heartbeat is a single

cycle in which the heart’s chambers relax and contract to pump blood. This cycle includes

the opening and closing of the inlet and outlet valves of the right and left ventricles of the

heart.

Each heartbeat has two basic parts: diastole and atrial and ventricular systole. During

diastole, the atria and ventricles of the heart relax and begin to fill with blood.

At the end of diastole, the heart’s atria contract (atrial systole) and pump blood into the

ventricles. The atria then begin to relax. The heart’s ventricles then contract (ventricular

systole) pumping blood out of the heart.

Each beat of the heart is set in motion by an electrical signal from within the heart muscle. In

a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA

node is sometimes called the heart’s natural pacemaker. The pulse, or heart rate, is the

number of signals the SA node produces per minute. The signal is generated as the two vena

cavae fill the heart’s right atrium with blood from other parts of the body. The signal spreads

across the cells of the heart’s right and left atria. This signal causes the atria to contract. This

action pushes blood through the open valves from the atria into both ventricles.

The signal arrives at the AV node near the ventricles. It slows for an instant to allow the

heart’s right and left ventricles to fill with blood. The signal is released and moves along a

pathway called the bundle of His, which is located in the walls of the heart’s ventricles.

From the bundle of His, the signal fibers divide into left and right bundle branches through

the Purkinje fibers that connect directly to the cells in the walls of the heart’s left and right

ventricles. The signal spreads across the cells of the ventricle walls, and both ventricles

contract. However, this doesn’t happen at exactly the same moment. The left ventricle

contracts an instant before the right ventricle. This pushes blood through the pulmonary

valve (for the right ventricle) to the lungs, and through the aortic valve (for the left ventricle)

to the rest of the body.


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As the signal passes, the walls of the ventricles relax and await the next signal. This process

continues over and over as the atria refill with blood and other electrical signals come from

the SA node.

The Electrocardiogram

Records potential (voltage) differences between a ‘neutral’ ground and recording

electrodes.

3 lead ECG used for monitoring purposes.

12 lead ECG used for diagnostic purposes.

Lead II shows life-threatening rhythms.

Most ECG recordings are obtained with paper speeds of 25mm/sec and signal

calibration of 1.0mV/1cm.

The P-QRS-T complex of the normal ECG represents electrical activity over one cardiac

cycle.

The dominant pacemaker of the heart is the sinus node in the right atrium. It normally

fires between 60 and 100 times a minute. Should the sinus node fail, the AV node is a

potential pacemaker but it only fires at 40-60 beats per minute.

The ECG Complex

• One complex represents one beat in the heart.

• Complex consists of P, QRS, and T waves.


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Parts of the ECG Complex

P Wave - Atrial depolarization - 0.04-0.12 seconds - 1-2 small squares

PR Interval - SA Node-AV Node conduction time - 0.12-0.20 seconds - 3-5

small squares

QRS Complex - Ventricular depolarization - 0.04-0.10 seconds - 1-2 small

squares

ST Segment - Plateau phase ventricular depolarization - isoelectric (baseline)

T Wave - Ventricular repolarization - 0.5mV/5mm

QT Interval - Total duration of ventricular depolarization - 0.33-0.42 seconds -

8-10 small squares

An In-depth Look at the ECG and Its Generation


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ECG Rhythm Interpretation

Normal Sinus Rhythm

• Consistent P waves

• Consistent P-R interval

• 60–100 beats/min

Sinus Bradycardia



• Less than 60 beats/min

Sinus Tachycardia



• More than 100 beats/min


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Remember - A sinus rhythm is a rhythm that has

a P Wave present.

Ventricular Tachycardia

• Three or more ventricular complexes in a row

• More than 100 beats/min

Ventricular Fibrillation

• Rapid, completely disorganized rhythm

• Deadly arrhythmia that requires immediate treatment


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Asystole

• Complete absence of electrical cardiac activity

• Patient is clinically dead.

• Decision to terminate resuscitation efforts depends on local protocol.

Chapter 13: The Automated External Defibrillator

Page 164


Outline

The Chain of Survival

The Purpose of Defibrillation

The Importance of Early Defibrillation

Types of Defibrillators

Shockable Rhythms

Non-Shockable Rhythms

Advantages of the AED

Medical Direction

Energy Levels for AEDs

Monophasic vs. Biphasic

Indications for AED Use

Contraindications for AED Use

Preparing to Operate an AED

Using an AED - 3 Simple Steps

AED Treatment Algorithm

Using an AED – Detailed Steps

After AED shocks

Transport

Cardiac Arrest During Transport

Chapter 13:

The Automated External

Defibrillator


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The Chain of Survival

The Chain of Survival was developed by the American Heart Association in 1990 in

recognition of the fact that the vast majority of sudden cardiac arrests (SCA) occur outside of

hospitals, and that failure to defibrillate early results in a high rate of failure to resuscitate

patients. In response to the development of the chain of survival, public awareness of the

importance of its components has increased, particularly in western countries, where AEDs

are often located readily in public places. To provide the best opportunity for survival, each

of these four links must be put into motion within the first few minutes of SCA onset:

Early Access to Emergency Care must be provided by calling 911 (US) or a

universal access number.

Early CPR should be started and maintained until emergency medical services

(EMS) arrive.

Early Defibrillation is the only one that can re-start the heart function of a

person with ventricular fibrillation (VF). If an automated external defibrillator

(AED) is available, a trained operator should administer defibrillation as quickly

as possible until EMS personnel arrive.

Early Advanced Care, the final link, can then be administered as needed by

EMS personnel.

Time After the Onset of Attack Survival Chances

With every minute Chances are reduced by 7-10%

Within 4-6 minutes Brain damage and permanent death

start to occur

After 10 minutes Few attempts at resuscitation succeed


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Type of Care for SCA Victims

after Collapse

Chance of Survival

No care after collapse 0%

No CPR and delayed defibrillation (after 10

minutes)

0-2%

CPR from a non-medical person (such as a

bystander or family member) begun within

2 minutes, but delayed defibrillation

2-8%

CPR and defibrillation within 8 minutes 20%

CPR and defibrillation within 4 minutes;

paramedic help within 8 minutes

43%

In certain environments, where the Chain is strong and when defibrillation occurs within the

first few minutes of cardiac arrest, survival rates can approach 80% to 100%.

ILCOR AED Symbol


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The Purpose of Defibrillation

Defibrillation does not „jump start‟ the heart. The purpose of the shock is to produce

temporary aystole. The shock attempts to completely depolarize the myocardium and

provide an opportunity for the natural pacemaker centers of the heart to resume normal

activity.

The Importance of Early Defibrillation

Defibrillation is the single most important factor in determining the survival from cardiac

arrest.

Rationale for Early Defibrillation

The most common initial rhythm in witnessed sudden cardiac arrest is ventricular

fibrillation.

The most effective treatment for ventricular fibrillation is electrical defibrillation.

The probability of successful defibrillation diminishes rapidly over time.

VF tends to convert to asystole within a few minutes.

Types of Defibrillators

Manual defibrillators

Automated internal defibrillators

Automated external defibrillators

fully automated

semi-automated

Shockable Rhythms

Ventricular fibrillation (VF)


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Ventricular Tachycardia (V-Tach) - (if the patient is pulseless and unconscious)

Non-Shockable Rhythms

Asystole

Pulseless Electrical Activity (PEA) - (any heart rhythm observed on the ECG that

should be producing a pulse, but is not)

Advantages of the AED

ALS providers do not need to be on scene.

Remote, adhesive defibrillator pads are used.

Efficient transmission of electricity


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Medical Direction

Should approve protocols.

Should review AED usage.

Should review speed of defibrillation.

Should provide review of skills every 3 to 6 months.

Energy Levels of the AED

Electrical current is measured in joules (J)

Manual defibrillators - 5 or 10 to 360J

Fully or semi-automated defibrillators - preset values of 200 and 360J

programmed.

Monophasic vs. Biphasic

The earliest defibrillators were monophasic, which means that they passed an electrical

current in just one direction to try to reset the heart. Biphasic defibrillators use an

electrical current that flows in two directions to shock the heart. The advantage of using

biphasic defibrillators is that less electrical current is needed to successfully shock the

heart, which makes these devices more effective to restore the heart‟s regular rhythm

more quickly.

Indications for AED Use

The patient is unresponsive, and;

The patient demonstrates no effective breathing, and;

The patient has no signs of circulation.


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Contraindications for AED Use

The patient is under 1 year old;

The patient suffered cardiac arrest as a result of trauma (except electrocution);

The patient has a detectable pulse or respirations;

The patient demonstrates response to external stimulus.

Preparing to Operate an AED

Make sure the electricity injures no one.

Do not defibrillate a patient lying in pooled water.

Dry a soaking wet patient‟s chest first.

Do not defibrillate a patient who is touching metal.

Remove nitroglycerin patches.

Shave a hairy patient‟s chest if needed.

AED pads for adults (left) and children (right)


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Using an AED – 3 Simple Steps


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AED Treatment Algorithm


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Using an AED - Detailed Steps

Step 1

Assess responsiveness.

Stop CPR if in progress.

Check breathing and pulse.

If patient is unresponsive and not breathing adequately, give two slow

ventilations.

Step 2

If there is a delay in obtaining an AED, have your partner start or resume CPR.

If an AED is close at hand, prepare the AED pads.

Turn on the machine.

Step 3

Remove clothing from the patient‟s chest area. Apply pads to the chest.

Stop CPR.

State aloud, “Clear the patient.”

Step 4

Push the analyze button, if there is one.

Wait for the computer.

If shock is not needed, start CPR.

If shock is advised, make sure that no one is touching the patient.

Push the shock button

Step 5

After the shock is delivered, immediately resume CPR. Perform 5 cycles of CPR.

Reanalyze the rhythm.

If the machine advises a shock, deliver a shock then perform 5 cycles of CPR.


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Step 6

Check for pulse.

If the patient has a pulse, check breathing.

If the patient is breathing adequately, provide oxygen via non-rebreathing mask if

needed and transport.

Step 7

If the patient is not breathing adequately, use necessary airway adjuncts and proper

positioning to open airway.

Provide artificial ventilations with high concentration oxygen.

Transport.

Step 8

If the patient has no pulse, perform 1 minute of CPR.

Gather additional information on the arrest event.

After 1 minute of CPR, make sure no one is touching the patient.

Push the analyze button again (as applicable).

Transport and check with medical control.

Continue to support the patient as needed.

After AED Shocks

Check pulse.

No pulse, no shock advised

No pulse, shock advised

If a patient is breathing independently:

Administer oxygen if needed.

Check pulse.

If a patient has a pulse, but breathing is inadequate, assist ventilations.

Transport

When patient regains pulse; or

After delivering six to nine shocks; or


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After receiving three consecutive “no shock advised” messages.

Keep AED attached.

Check pulse frequently.

Stop ambulance to use an AED.

Cardiac Arrest During Transport

Check unconscious patient‟s pulse every 30 seconds.

If pulse is not present:

Stop the vehicle.

Perform CPR until AED is available.

Analyze rhythm.

Deliver shock(s).

Continue resuscitation according to local protocol

If patient becomes unconscious during transport:

Check pulse.

Stop the vehicle.

Perform CPR until AED is available.

Analyze rhythm.

Deliver up to three shocks.

Continue resuscitation according to local protocol.

Appendix 1

Page a


Basic life support

Changes in basic life support (BLS) since the 2005 guidelines include:

Dispatchers should be trained to interrogate callers with strict protocols to elicit

information. This information should focus on the recognition of unresponsiveness

and the quality of breathing. In combination with unresponsiveness, absence of

breathing or any abnormality of breathing should start a dispatch protocol for

suspected cardiac arrest. The importance of gasping as sign of cardiac arrest is

emphasised.

All rescuers, trained or not, should provide chest compressions to victims of cardiac

arrest. A strong emphasis on delivering high quality chest compressions remains

essential. The aim should be to push to a depth of at least 5 cm at a rate of at least

100 compressions min-1, to allow full chest recoil, and to minimise interruptions in

chest compressions. Trained rescuers should also provide ventilations with a

compression–ventilation (CV) ratio of 30:2. Telephone-guided chest compression-only

CPR is encouraged for untrained rescuers.

The use of prompt/feedback devices during CPR will enable immediate feedback to

rescuers and is encouraged. The data stored in rescue equipment can be used to

monitor and improve the quality of CPR performance and provide feedback to

professional rescuers during debriefing sessions.

Appendix 1:

Updated 2010 European

Resuscitation Council

Guidelines

Appendix 1

Page b


Electrical therapies

The most important changes in the 2010 ERC Guidelines for electrical therapies include:

The importance of early, uninterrupted chest compressions is emphasized

throughout these guidelines.

Much greater emphasis on minimizing the duration of the pre-shock and post-

shock pauses; the continuation of compressions during charging of the defibrillator

is recommended.

Immediate resumption of chest compressions following defibrillation is also

emphasised; in combination with continuation of compressions during defibrillator

charging, the delivery of defibrillation should be achievable with an interruption in

chest compressions of no more than 5 seconds.

Safety of the rescuer remains paramount, but there is recognition in these

guidelines that the risk of harm to a rescuer from a defibrillator is very small,

particularly if the rescuer is wearing gloves. The focus is now on a rapid safety

check to minimise the preshock pause.

When treating out-of-hospital cardiac arrest, emergency medical services (EMS)

personnel should provide good-quality CPR while a defibrillator is retrieved,

applied and charged, but routine delivery of a pre-specified period of CPR (e.g.,

two or three minutes) before rhythm analysis and a shock is delivered is no longer

recommended. For some EMS that have already fully implemented a pre-specified

period of chest compressions before defibrillation, given the lack of convincing

data either supporting or refuting this strategy, it is reasonable for them to

continue this practice.

The use of up to three-stacked shocks may be considered if VF/VT occurs during

cardiac catheterization or in the early post-operative period following cardiac

surgery. This three shock strategy may also be considered for an initial, witnessed

VF/VT cardiac arrest when the patient is already connected to a manual

defibrillator.

Further development of AED programmes is encouraged – there is a need for

further deployment of AEDs in both public and residential areas.

Appendix 1

Page c


Appendix 1

Page d


Appendix 1

Page e


Appendix 1

Page f


lsti emt-b manual

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