EMT Review

Basically everything you need to know without outwardly giving you all the answers

Legalities

• Scope of Practice • Standard of Care • Duty to Act • Abandonment • Assault • Battery • 5150

• Negligence

Legalities

• Duty to Act • Breach of Duty to Act • Proximate Cause • Compensatable Injury

• Consent

Legalities

• Expressed • Implied • Minor/mentally incompetent

Patient Assessment

• Initial Assessment – BSI/Safety – Number of patients – MOI/NOI – Additional resources – Cspine

Patient Assessment

• General Impression • AVPU • Chief Complaint • ABC

Respiratory

• Pulmonary Embolism • Acute Pulmonary Edema • COPD • Asthma • Hyperventilation • Pneumonia

Emphysema

• Characterized by the destruction of the alveolar walls and the distention of the alveolar sacs. • Patients trap air and are unable to exhale.

Emphysema

• Thin, barrel chest appearance • Cough, little sputum • Prolonged exhalation • Diminished lung sounds with wheezes • Pursed lip breathing • Pink complexion (pink puffers) • Home oxygen

Chronic Bronchitis

• Affects primarily the bronchus and the bronchioles. • Characterized by a productive cough that persists for at least 3 consecutive months 2 years in a row.

Chronic Bronchitis

• Typically overweight (blue bloaters) • Chronic cyanotic complexion • Dyspnea, but not as bad as emphysema • Coarse rhonchi • Wheezes and crackles in lungs

Asthma

• A reactive airway disease that affects the bronchial tree and bronchioles • An increased sensitivity of the lower airways to irritants and allergens

Asthma • Bronchospasm • Edema of the inner lining of the airways • Increased secretion of mucus that causes plugging of the smaller airways.

Pulmonary Embolism

• An obstruction of blood flow in the pulmonary arteries. • Impedes the delivery of oxygenated blood back into the cardiovascular system. • Can be caused by blood clots, fat particles, foreign body, or amniotic fluid.

Pulmonary Embolism

• Causes include: – Sedentary lifestyle – Recent surgery – Long bone fractures – Smokers – Birth control pills

Pulmonary Embolism

• Signs/Symptoms include: – Sudden onset pinpoint chest pain – Shortness of breath – Poor skin signs – Possible diminished lung sounds

Acute Pulmonary Edema

• Excessive amounts of fluid collect in the spaces between the alveoli and the capillaries. • Cardiogenic: increased pressure in the pulmonary veins push fluid out of the capillaries. • Non cardiogenic: destruction of capillary beds causes fluid to leak out. (ARDS)

Acute Pulmonary Edema

• Signs/Symptoms include: – Dyspnea and orthopnea – Frothy sputum – Crackles in lungs – Cyanosis, or pale wet skins – JVD – Swollen lower extremeties – Hypertension

Acute Pulmonary Edema

• Oxygen via NRB or BVM • Sit upright • Dangle feet • Rapid transport

Hyperventilation Syndrome

• Most often caused by anxiety or emotional distress.

• Can also be caused by: – Methanphetamine OD – Hyperglycemia – ASA OD

Hyperventilation Syndrome

• Signs/Symptoms include: – Dizzy – Shortness of breath – Numbness/tingling to hands, feet, perioral – Spasms of fingers and toes

Assessment of Newborn

• Appearance • Pulse • Grimace • Activity • Respiration

Appearance

• Trunk and extremities pink = 2 points • Trunk pink with blue extremities = 1 point • Trunk and extremities blue = 0 points

Pulse

• Heart rate over 100 = 2 points • Heart rate under 100 = 1 point • Heart rate absent = 0 points

Grimace

• AKA Reflex irritability • Facial grimace plus cry = 2 points • Only facial grimace = 1 point • No reflex activity = 0 points

Activity

• Active movement = 2 points • Some flexion w/o active movement = 1 point • Limp = 0 points

Respiration

• Good respiration + strong cry = 2 points • Slow or irregular breathing = 1 point • Apnea = 0 points

APGAR Scores

• 0-3 points = aggressive resuscitation (BVM, CPR, etc.) • 4-6 points = Provide stimulation and O2 • 7-10 points = Provide routine care

Spontaneous Abortion

• AKA Miscarraige • Can occur for many reasons • Viability usually considered after 20 weeks • Check for severe lower abdominal pain, severe vaginal bleeding, passing of tissue or blood clots

Pre-Eclampsia

• Last trimester emergency, usually first pregnancy, with a history of hypertension or diabetes • Characterized by high blood pressure and swelling of the extremities • Seizures from pre-eclampsia is called Eclampsia

Placenta Previa

• The placenta attaches itself to the uterus over the cervix • Fetus pushes on placenta, causing severe bleeding, but little or no pain

Abruptio Placentae

• When the placenta tears away from the uterine wall prematurely • Causes fetal distress due to poor gas and nutrient exchange • Severe abdominal pain, although little or no external bleeding may occur.

Ruptured Uterus

• As the uterus expands and thins out, especially around the cervix, can cause spontaneous or traumatic rupture. • Usually more than 2 previous pregnancies, or history of C-section.

• Mothers mortality rate is 5-20%, Fetal mortality rate is 50%.

• Severe pain, minor vaginal bleeding.

Ectopic Pregnancy

• When the ovum is implanted outside the uterus. • 90% fallopian tube • 6% in peritoneum • 1% in cervix

Acute Coronary Syndromes: Angina Pectoris • Literally “pain in chest” • From a decrease of oxygen to the cardiac tissues (cardiac tissue ischemia) • Normally from an increased workload on the heart • Will feel a crushing or squeezing type pain radiating to the jaw, arm, or back • Normally relieved with rest, O2, NTG

Acute Coronary Syndrome: Myocardial Infarction • A portion of the heart muscle dies from the lack of an adequate supply of oxygenated blood.

• Usually from coronary artery disease.

• Heart muscle dies, leading to a build up of lactic acid, which causes the “pain.” • Can cause irregular heart rhythms and sudden death.

Assessment of ACS

• (O)nset: Sudden or Gradual?

• (P)rovocation: What caused the pain?

• (Q)uality: What does it feel like?

• (R)egion: Where does it hurt?

• (R)adiation: Does the pain travel?

• (R)eoccurance: Have you had before?

• (S)everity: Rate on 1-10 scale • (T)ime: How long have you had pain?

Pertinent Negatives of ACS

• Nausea • Vomiting • Diaphoresis • Dizziness • Weakness • Syncope • Palpitations • Shortness of Breath

Acute Coronary Syndromes: Treatment • Rest. Do not make your patient move more than they have to.

• O2 15l/m NRB • Nitroglycerin SL • ASA

Nitroglycerin (NTG)

• Class: Nitrate • Action: Dilates Coronary Arteries allowing blood to oxygenate ischemic tissues.

• Dose: 1 on SO, to a max of 3 on BHO • Side Effects: Headache, hypotension, tachycardia • Contraindications: Use of sexual enhancing drugs in last 48 hours

Aspirin (ASA)

• Class: Platelet Aggregation Inhibitor • Action: Reduces the ability of the platelets to bind to eachother.

• AKA “CHF”

Heart Failure

• Inability for one or both Ventricles to pump blood effectively • Several Causes

Heart Failure

• Main Causes: – AMI – Hypertension – Valve disorders – Pulmonary Embolism – Drug use

Right Heart Failure

• Right ventricle accepts de-oxygenated blood and ejects it to the lungs for oxygenation.

• Fluid (blood) backs up in the venous system causing JVD, Liver enlargement, peripheral edema.

• Normally not an emergent condition.

Left Heart Failure

• Left ventricle accepts oxygenated blood from the lungs, and ejects it out to the bodies arteries.

• Left ventricle cannot eject all its blood, which causes a build up of pressure.

• The pressure causes Pulmonary Edema • Left Ventricular failure is an emergent condition

Signs of Heart Failure

• Severe Shortness of breath with crackles • Tachycardia and Tachypnea • Orthopnea and PND • Fatigue with little movement • Pale, cool, sweaty skins • Cyanosis • Severe hypertension • JVD

Treatment for Heart Failure

• Sit patient upright and dangle legs • O2 15l/m by NRB or BVM • Positive Pressure Ventilation

Diabetes mellitus types

– Type I—Insulin dependent diabetes mellitus – Type II—Non-insulin dependent diabetes mellitus

Hypoglycemia • Emergencies related to diabetes mellitus • More common with Type I diabetics • Most dangerous complication of diabetes mellitus • Most common cause of coma in the diabetic patient

Causes/Signs & Symptoms Insulin Shock • Too much insulin • Too little food • Too much exercise or stress • May be precipitated by increased ETOH without CHO intake

Hyperglycemia

• Emergencies related to diabetes mellitus – Usually presents as either DKA or HHNS • Both syndromes have elevated BGL in the body – DKA usually > 350 mg/dl – HHNS usually > 600 mg/dl • Altered physiology leads to dehydration and acidosis

Causes/Signs & Symptoms

• Too little insulin • Too much food • Illness • Infection

Transient Ischemic Attack (TIA)

• A TIA looks just like a CVA symptomatically • TIA disappears within 24 hours of onset, without any permanent neurological changes • Usually, symptoms subside within 15–30 minutes

Cerebral Vascular Accident (CVA) • General signs and symptoms of a stroke or TIA • Progressive worsening of symptoms as stroke evolves

Types of seizures

• Primary seizures – Seizure disorder • Secondary seizures – Insult to body • Fever • Infection • Hypoxia • Hypoglycemia • Hyperglycemia • Drug intoxication • Drug withdrawal • Eclampsia in pregnancy • Degenerative brain diseases • Imbalances in the electrolytes in the body • Cardiac arrest – Generally full body seizures

• Grand Mal Generalized tonic-clonic • What we most commonly think of • Most self limiting • Occurs in phases • Aura • Tonic phase • Hypertonic phase • Clonic phase • Postictal phase • Status – Greater than 5 minutes – Recurrent with no lucid interval

Partial Seizures

• Simple partial seizure – Focal motor or Jacksonian seizure – Patient is usually awake – Results in an area of the body (face, arm, leg, or body) demonstrating the seizure-like motions – May progress to grand mal seizure • Complex partial seizure – Psychomotor or temporal lobe seizure – Due to the region of the brain involved with the seizure, the patient’s orientation may be altered – Usually lasts 1-2 minutes, characterized by repetitive type motions – Post-seizure confusion usually longer than seizure itself

Absence or petit mal seizure

• Most common in children • Characterized by a blank stare • Rarely necessitates emergency care

Febrile seizure

• Common to kids 6 months to 6 years • Usually self limiting • Due to rapid rise or fall of temperature • Gentle cooling

Routes of Exposure

• Ingestion • Inhalation • Injection • Absorption

CNS Stimulants S/S

• Excitability • Agitation • Tachycardias • Tachypnea • Dilated Pupils • Hypertension • Lack of sleep

CNS Depressants S/S

• Euphoria • Drowsiness • Hypoventilation • Bradycardias • Hypotension • Dilated, sluggish pupils

Narcotics S/S

• Hypotension • Bradycardia • Inadequate respirations • Cool, clammy skins • Pinpoint Pupils

Withdrawal S/S

• Anxiety • Confusion • Tremors • Sweating • Elevated V/S • Hallucinations • Abdominal Pain

Delerium Tremens

• Occurs 1-14 days after the patients last drink • An episode may last 1-3 days • S/S p. 589

Causes of Shock

• Fluid loss (not just blood loss) • Pump Failure • Vasodilation • Hypoxia

Hypovolemic Shock

• Results from a decrease of the volume of blood available for perfusion to the body’s organs.

– External or Internal Bleeding (hemorrhagic shock) – Plasma loss from burns – Dehydration from vomiting or diarrhea

Obstructive Shock

• Mechanical obstruction or compression that prevents blood from reaching the heart.

– Pulmonary embolism – Tension pneumothorax – Cardiac tamponade

Distributive Shock

• Abnormal distribution of blood in the vessels or throughout the body. • Causes and insufficient amount of blood to reach the heart. • Massive dilation of vessels or leakage of fluid from the capillaries. – Neurogenic – Anaphylactic – Septic

Neurogenic Shock

• Also known as Vasogenic Shock • Usually the result of a spinal cord or severe head injury.

• Causes the nervous system to lose control of the vascular system.

• Blood pools in the periphery.

Anaphylactic Shock

• Results from the body’s abnormal reaction to a foreign protein. • Normally from bee stings, foods, certain medications. • The body releases chemicals causing the blood vessels to dilate and leak. • Bronchioles constrict. • Without immediate care, the patient will die.

Septic Shock

• Results from toxins produced by a severe infection (usually bacterial).

• Toxins cause a reaction that dilates the blood vessels and allows blood to pool in the extremities and fluid to leak from the vessels.

Cardiogenic Shock

• Results from inadequate pumping of the heart.

– CAD – AMI – Heart rhythm abnormalities – Heart valve disease – CHF

Stages of Shock

• Compensatory • Decompensated (progressive) • Irreversible

Treatment of Shock

• Recognition is the most important key. • Lay patient flat.

• Elevate legs 10-12 inches (shock position) • Keep patient warm.

• O2 15l/m NRB • Treat patient gently.

Pneumothorax

• Defined as an accumulation of air in the pleural cavity, causing collapse of a portion of the lung.

• Causes?

• Results in a decrease in gas available within the alveoli.

• Signs and symptoms include: chest pain worse with inspiration, tachypnea, decreased or absent breath sounds.

Open Pneumothorax

• AKA “Sucking Chest Wound” • Caused by an open wound to the chest.

• Treatment includes immediate occlusion to the opening with a 3 sided occlusive dressing.

Tension Pneumothorax

• An immediately life-threatening condition.

• Results from a pneumothorax that continues to trap air in the thoracic cavity with no release of the air.

• Air accumulates in the thoracic cavity on the injured side.

• The lung completely collapses and compresses and shifts the mediastinum to the uninjured side.

Tension Pneumothorax

• Uninjured lung, heart, and large veins are compressed, resulting in reduced CO, ineffective ventilations, and severe hypoxia.

• Signs include: cyanosis, unequal movement of the chest, distended neck veins, deviation of the trachea to the uninjured side.

• Can this be caused by an open chest wound?

Pericardial Tamponade

• Trauma causes bleeding in the pericardium. • The pericardium cannot expand, so the blood causes pressure on the heart, resulting in reduced CO, blood backup into the venous system.

• This is a life threatening condition.

• Signs similar to a tension pneumothorax, but with normal breath sounds.

Pericardial Tamponade

• Signs include: JVD, shock, tachycardia, hypotension, narrowing pulse pressures, weak pulses.

• Symptoms progressively worse as the pericardium continues to fill with blood. • Normally causes from a penetrating injury.

Heat Cramps

Caused by electrolyte imbalances by over exerting muscles Normally in the large flexor muscle groups: abdominal, gluteus, hamstrings

Heat Exhaustion

The body has maximized its heat dissipating mechanisms and is beginning to shut down Pale and very sweaty Mild aloc, dizzy Normal body temperature

Heat Stroke

The Body’s heat dissipating systems shut down Body becomes over heated, and keeps heating Damages brain cells, causes seizures Hot, red skin. May or may not sweat (50%) Up to 80% mortality rate if not treated

Major Signs/Symptoms

Elevated Core Temperature Muscle Cramps Weakness/Exhaustion Dizziness Tachycardia Tachypnea Nausea/Vomiting Seizures Headache ALOC

Care and Treatment

Normal to Cool skin

Move to cool place Oxygen Remove clothing Apply cold compresses Shock position Fluids

Care and Treatment

Hot/dry skin Remove from heat Remove clothing Oxygen Cold packs to groin, neck, armpits, behind knees Spray tepid water on patient Fan patient Keep skin wet