4 Emphysema Pathophysiology Exposure to Noxious Substances Exposure results in the destruction of the walls of the alveoli.Weakens the walls of the small bronchioles and results in increase residual volume.Increased Risk of Infection and Dysrhythmia
5 Emphysema Assessment History Lack of Cough Recent weight loss, dyspnea with exertionCigarette and tobacco usageLack of Cough
6 Emphysema Assessment Physical Exam Barrel chest. Prolonged expiration and rapid rest phase.Thin.Pink skin due to extra red cell production.Hypertrophy of accessory muscles.“Pink Puffers.”
8 Chronic Bronchitis Pathophysiology Assessment History Results from an increase in mucus-secreting cells in the respiratory tree.Alveoli relatively unaffected.Decreased alveolar ventilation.AssessmentHistoryFrequent respiratory infections.Productive cough.
9 Chronic Bronchitis Physical Exam Often overweight. Rhonchi present on auscultation.Jugular vein distention.Ankle edema.Hepatic congestion.“Blue Bloater.”
11 Bronchitis & Emphysema ManagementMaintain airway.Support breathing.Find position of comfort.Monitor oxygen saturation.Be prepared to ventilate.Administer medications.Bronchodilators.
12 Asthma Pathophysiology Chronic Inflammatory Disorder Results in widespread but variable air flow obstruction.The airway becomes hyperresponsive.Induced by a trigger, which can vary by individual.Trigger causes release of histamine, causing bronchoconstriction and bronchial edema.
13 Asthma Assessment Identify immediate threats. Obtain history. SAMPLE & OPQRST HistoryHistory of asthma-related hospitalization?History of respiratory failure/ventilator use?
14 AsthmaPhysical ExamPresenting signs may include dyspnea, wheezing, cough.Wheezing is not present in all asthmatics.Speech may be limited to 1–2 consecutive words.Look for hyperinflation of the chest and accessory muscle use.Carefully auscultate breath sounds.
15 Asthma Management Treatment goals: Maintain the airway. Correct hypoxia.Reverse bronchospasm.Reduce inflammation.Maintain the airway.Support breathing.High-flow oxygen or assisted ventilations as indicated.
17 Medical Emergencies Cardiac Compromise Cardiac Emergencies Signs and SymptomsTreatment
18 Managing Specific Cardiovascular Emergencies Angina PectorisMyocardial InfarctionHeart FailureHypertensive EmergenciesCardiogenic ShockCardiac ArrestPeripheral Vascular and Other Cardiovascular Emergencies
19 Angina Pectoris Causes of Chest Pain Cardiovascular, including acute coronary syndrome, or thoracic dissection of the aortaRespiratory, including pulmonary embolism, pneumothorax or pneumonia.Gastrointestinal, including pancreatitis, hiatal hernia, esophageal disease, gastroesophageal reflux, peptic ulcer disease.Musculoskeletal, chest wall trauma.
20 Angina Pectoris Field Assessment Signs of Shock Chest Discomfort Typically sudden onset, which may radiate or be localized to the chest.Patient often denies chest pain.DurationEpisodes last 3–5 minutes.Pain relieved with rest and/or nitroglycerin.
21 Angina Pectoris Breathing History Past episodes of angina: Episodes of angina that are increasing in frequency, duration, or severity are significant.
22 Angina Pectoris Management Relieve anxiety: Administer oxygen. Place the patient in a position of physical and emotional comfort.Administer oxygen.Consider medication administration:Nitroglycerin tablets or spray
23 Angina Pectoris Special Considerations Patients with new-onset often require hospitalization.Symptoms not relieved by rest, nitroglycerin, and oxygen may indicate an overall worsening of the disease or the early stages of a myocardial infarction.Patients may refuse transport after pain is relieved, even though the underlying problem is not addressed.
24 Myocardial Infarction PathophysiologyDeath and necrosis of heart muscle due to inadequate oxygen supply.Causes may include occlusion, spasm, acute volume overload, hypotension, acute respiratory failure, and trauma.Location and size dependent on the vessel involved.
25 Myocardial Infarction Effects of a Myocardial InfarctionDysrhythmiasHeart FailureGoals of TreatmentPain ReliefReperfusion
26 Myocardial Infarction Field AssessmentBreathingSigns of ShockChief ComplaintTypically related to chest pain.Evaluate using OPQRST:Discomfort > 30 minutes.Radiation to arms, neck, back, or epigastric region.Patients may minimize symptoms.Feelings of “impending doom.”
27 Myocardial Infarction Other SymptomsNausea and vomitingDiaphoresisMyocardial Infarctions & the ECGDysrhythmias:VF, VT, Asystole, PEA.Dysrhythmias are the leading cause of death in MI.
28 Myocardial Infarction ManagementTransportRapid transport indicated when acute MI suspectedPrehospitalAdminister oxygen.Consider medication administration:AspirinNitroglycerin
30 Heart Failure Left Ventricular Failure Pathophysiology Results in increased back pressure intothe pulmonary circulation.
31 Heart Failure Right Ventricular Failure Pathophysiology Results in increased back pressure into the systemic venous circulation.Pulmonary Embolism
32 Heart Failure Congestive Heart Failure Pathophysiology Reduction in the heart’s stroke volume causes fluid overload throughout the body’s other tissues.
33 Heart Failure Field Assessment Pulmonary Edema: Cough with copious amounts of clear or pink-tinged sputum.Labored breathing, especially with exertion.Abnormal breath sounds, including rales, rhonchi, and wheezes.Paroxysmal Nocturnal Dyspnea (PND)Medications:Diuretics.Medications to increase cardiac contractile force.Home oxygen.
34 Heart Failure Mental Status Breathing Skin Mental status changes indicate impending respiratory failure.BreathingSigns of labored breathing.Tripod positioning.“Number of pillows.”SkinColor changes.Peripheral and/or sacral edema.
35 Heart Failure Management General management: Maintain the airway. Avoid supine positioning.Avoid exertion such as standing or walking.Maintain the airway.Administer oxygen.Avoid patient refusals if at all possible.
36 Hypertensive Emergencies Hypertensive EmergencyCausesTypically occurs only in patients with a history of HTN.Primary cause is noncompliance with prescribed antihypertensive medications.Also occurs with toxemia of pregnancy.Risk FactorsAge-related factorsRace-related factors
37 Hypertensive Emergencies Field AssessmentInitial AssessmentAlterations in mental stateSigns & SymptomsHeadache accompanied by nausea and/or vomitingBlurred visionShortness of breathEpistaxisVertigo
38 Hypertensive Emergencies HistoryKnown history of hypertensionCompliance with medicationsExamBP > 160/90Signs of left ventricular failureStrong, bounding pulseAbnormal skin color, temperature, and conditionPresence of edema
40 Cardiogenic Shock Pathophysiology General Causes Inability of the heart to meet the body’s metabolic needs.Often remains after correction of other problems.Severe form of pump failure.High mortality rate.CausesTension pneumothorax and cardiac tamponade.Impaired ventricular emptying.Impaired myocardial contractility.Trauma.
41 Cardiogenic Shock Field Assessment Initial Assessment Chief Complaint Chief complaint is typically chest pain, shortness of breath, unconsciousness, or altered mental state.Onset may be acute or progressive.HistoryHistory of recent MI or chest pain episode.Presence of shock in the absence of trauma.
42 Cardiogenic Shock Mental Status Airway and Breathing Circulation Restlessness progressing to confusionAirway and BreathingDyspnea, labored breathing, and coughPND, tripod position, accessory muscle retraction, and adventitious lung soundsCirculationHypotensionCool, clammy skin
43 Cardiogenic Shock Management Maintain airway. Administer oxygen Identify and treat underlying problem.
44 Cardiac Arrest Sudden Death Causes Electrolyte or acid–base imbalances ElectrocutionDrug intoxicationHypoxiaHypothermiaPulmonary embolismStrokeDrowningTrauma
45 Cardiac Arrest Field Assessment Initial Assessment ECG History Unresponsive, apneic, pulseless patientECGDysrhythmiasHistoryPrearrest eventsBystander CPR“Down time”
46 Cardiac Arrest Management Resuscitation Return of Spontaneous CirculationRole of Basic Life SupportGeneral GuidelinesManage specific Dysrhythmias.AEDCPR.
51 AED (Automatic External Defibrillator) # of Shocks
52 AED (Automatic External Defibrillator) If NO SHOCK Advised
53 Peripheral Vascular and Other Cardiovascular Emergencies AneurysmPathophysiologyBallooning of an arterial wall, usually the aorta, that results from a weakness or defect in the wallTypesAtheroscleroticDissectingTraumatic
54 Peripheral Vascular and Other Cardiovascular Emergencies Abdominal Aortic AneurysmOften the result of atherosclerosisSigns and symptomsAbdominal painBack/flank painHypotensionUrge to defecate
55 Peripheral Vascular and Other Cardiovascular Emergencies Dissecting Aortic AneurysmCaused by degenerative changes in the smooth muscle and elastic tissue.Blood gets between and separates the wall of the aorta.Can extend throughout the aorta and into associated vessels.
56 Peripheral Vascular and Other Cardiovascular Emergencies Acute Pulmonary EmbolismPathophysiologyBlockage of a pulmonary artery by a blood clot or other particle.The area served by the pulmonary artery fails.Signs and SymptomsDependent upon size and location of the blockage.Onset of severe, unexplained dyspnea.History of recent lengthy immobilization.
57 Medical EmergenciesAltered Mental Status (AMS)CausesTreatment
58 Medical Emergencies Diabetes Most common cause Signs and Symptoms Treatment
60 Seizures Generalized Seizures Tonic-Clonic Aura Loss of Consciousness Tonic PhaseClonic PhasePostseizurePostictal
61 Seizures Partial Seizures Simple Partial Seizures Involve one body area.Can progress to generalized seizure.Complex Partial SeizuresCharacterized by auras.Typically 1–2 minutes in length.Loss of contact with surroundings.
62 Seizures Assessment Differentiating Between Syncope & Seizure Bystanders frequently confuse syncope and seizure.
63 Seizures Patient History History of Seizures History of Head Trauma Any Alcohol or Drug AbuseRecent History of Fever, Headache, or Stiff NeckHistory of Heart Disease, Diabetes, or StrokeCurrent MedicationsPhenytoin (Dilantin), phenobarbitol, valproic acid (Depakote), or carbamazepine (Tegretol)Physical ExamSigns of head trauma or injury to tongue, alcohol or drug abuse
64 Seizures Management Scene safety & BSI. Maintain the airway. Administer high-flow oxygen.Treat hypoglycemia if present.Do not restrain the patient.Protect the patient from the environment.Maintain body temperature.
65 Seizures Management Position the patient. Suction if required. Provide a quiet atmosphere.Transport.
66 Seizures Status Epilepticus Two or More Generalized Seizures Seizures occur without a return of consciousness.ManagementManagement of airway and breathing is critical.Monitor the airway closely.
70 Stroke & Intracranial Hemorrhage Transient Ischemic AttacksIndicative of carotid artery disease.Symptoms of neurological deficit:Symptoms resolve in less than 24 hours.No long-term effects.Evaluate through history taking:History of HTN, prior stroke, or TIA.Symptoms and their progression.
71 Stroke & Intracranial Hemorrhage ManagementScene safety & BSIMaintain the airway.Support breathing.Obtain a detailed history.Position the patient.Protect paralyzed extremities.
72 Allergic Reaction (Anaphylaxis) Medical EmergenciesAllergic Reaction (Anaphylaxis)
73 Allergies and Anaphylaxis Allergic ReactionAn exaggerated response by the immune system to a foreign substanceAnaphylaxisAn unusual or exaggerated allergic reactionA life-threatening emergency
75 Assessment Findings in Anaphylaxis Focused History & Physical ExamFocused HistorySAMPLE & OPQRST HistoryRapid onset, usually 30–60 seconds following exposure.Speed of reaction is indicative of severity.Previous allergies and reactions.Physical ExamPresence of severe respiratory difficulty is key to differentiating anaphylaxis from allergic reaction.
76 Assessment Findings in Anaphylaxis Physical ExamFacial or laryngeal edemaAbnormal breath soundsHives and urticariaHyperactive bowel soundsVital sign deterioration as the reaction progresses
77 Management of Allergic Reactions Scene safetyProtect the airway.Support breathing.Establish IV access.Administer medications:Epinephrine
91 Hemorrhage Control Internal Hemorrhage Hematoma Pocket of blood between muscle and fasciaHumerus or Tibia/Fibula fracture: mLFemur fracture: 1,500mLUNEXPLAINED SHOCK is BEST attributed to abdominal traumaGeneral ManagementImmobilization, Stabilization, Elevation
92 Hemorrhage Control Internal Hemorrhage Epistaxis: Nose Bleed Causes: Trauma, HypertensionTreatment: Lean forward, pinch nostrilsHemoptysisEsophageal VaricesChronic HemorrhageAnemia
97 Etiology of Shock Hypovolemic Shock Cardiogenic Shock Loss of blood volumeDistributive ShockPrevent appropriate distribution of nutrients and removal of wastesAnaphylacticSepticHypoglycemiaObstructive ShockInterference with the blood flowing through the cardiovascular systemTension PneumothoraxCardiac TamponadePulmonary EmboliCardiogenic ShockPump failureRespiratory ShockRespiratory system not able to bring oxygen into the alveoliAirway obstructionPneumothoraxNeurogenic ShockLoss of nervous control from CNS to peripheral vasculature
99 Introduction to Soft-Tissue Injury Skin is the largest, most important organ16% of total body weightFunctionProtectionSensationTemperature RegulationAKA: Integumentary System
100 Introduction to Soft-Tissue Injury EpidemiologyOpen WoundsOver 10 million wounds present to EDMost require simple care and some suturingUp to 6.5% may become infectedClosed WoundsMore CommonContusions, Sprains, Strains
112 Management of Soft-Tissue Injury Objectives of Wound Dressing & BandagingHemorrhage ControlDirect PressureElevationPressure PointsConsiderIceConstricting BandTourniquetUSE ALL COMPONENTS TOGETHER
113 Management of Soft-Tissue Injury Objectives of Wound Dressing & BandagingSterilityKeep the wound as clean as possibleIf wound is grossly contaminated consider cleansingImmobilizationPrevents movement and aggravation of woundDo not use an elastic bandage: TQ effectMonitor distal pulse, motor, and sensation(continued)
114 Management of Soft-Tissue Injury Pain & Edema ControlCold packsModerate pressure over wound
115 Dressing & Bandage Materials Sterile & Non-sterile DressingsSterile: Direct wound contactNon-sterile: Bulk dressing above sterileOcclusive/Non-occlusive DressingsAdherent/Non-adherent DressingsAdherent: stick to blood or fluidAbsorbent/Non-absorbentAbsorbent: soak up blood or fluidsWet/Dry DressingsWet: Burns, postoperative wounds (Sterile NS)Dry: Most common
123 Trauma Emergencies Burns Rule of Palm Location Preexisting Medical ProblemsAge5 – 55SourceTreatment
124 Rule of PalmsA burn equivalent to the size of the patient’s hand is equal to 1% body surface area (BSA)
125 Pathophysiology of Burns Types of BurnsThermalElectricalChemicalRadiation
126 Thermal Burns Heat changes the molecular structure of tissue Denaturing (of proteins)Extent of burn damage depends onTemperature of agentConcentration of heatDuration of contact
127 Systemic Complications HypothermiaDisruption of skin and its ability to thermoregulateHypovolemiaShift in proteins, fluids, and electrolytes to the burned tissueGeneral electrolyte imbalanceEscharHard, leathery product of a deep full thickness burnDead and denatured skin
128 Systemic Complications InfectionGreatest risk of burn is infectionOrgan FailureSpecial FactorsAge & HealthPhysical AbuseElderly, Infirm or Young
129 Assessment of Thermal Burns General Signs & Symptoms PainChanges in skin condition at affected siteAdventitious soundsBlistersSloughing of skinHoarsenessBurnt hairEdemaParesthesiaHemorrhageOther soft tissue injuryMusculoskeletal injuryDyspneaChest pain
130 Assessment of Thermal Burns Burn SeverityMinorSuperficial<50% BSAPartial Thickness<15% BSAFull Thickness<2% BSAModerateSuperficial>50% BSAPartial Thickness>15% BSAFull Thickness>2% BSACriticalPartial Thickness>30% BSAFull Thickness>10% BSAInhalation InjuryAny partial or full thickness burn involving hands, feet, joints,face, or genitalia
131 Management of Thermal Burns Local & Minor BurnsLocal coolingPartial thickness: <15% of BSAFull thickness: <2% BSARemove clothingCool or Cold water immersion
132 Management of Thermal Burns Moderate to Severe BurnsDry sterile dressingsPartial thickness: >15% BSAFull thickness: >5% BSAMaintain warmthPrevent hypothermiaConsider aggressive fluid therapyModerate to severe burns
133 Management of Thermal Burns Moderate to Severe BurnsCaution for fluid overloadFrequent auscultation of breath soundsPrevent infection
134 Management of Thermal Burns Inhalation InjuryProvide high-flow O2 by NRBConsider intubation if swellingConsider hyperbaric oxygen therapy
135 Assessment & Management of Electrical, Chemical & Radiation Burns Electrical InjuriesSafetyTurn off powerEnergized lines act as whipsEstablish a safety zoneLightning StrikesHigh voltage, high current, high energyLasts fraction of a secondNo danger of electrical shock to EMS
136 Assessment & Management of Electrical, Chemical & Radiation Burns Chemical BurnsScene size-upHazardous materials teamEstablish hot, warm and cold zonesPrevent personnel exposure from chemicalSpecific ChemicalsPhenolDry LimeSodiumRiot Control Agents
137 Assessment & Management of Electrical, Chemical & Radiation Burns Specific ChemicalsPhenolIndustrial cleanerAlcohol dissolves PhenolIrrigate with copious amounts of waterDry LimeStrong corrosive that reacts with waterBrush off dry substanceIrrigate with copious amounts of cool waterPrevents reaction with patient tissues
138 Assessment & Management of Electrical, Chemical & Radiation Burns Riot Control AgentsAgentsCS, CN (Mace), Oleoresin, Capsicum (OC, pepper spray)Irritation of the eyes, mucous membranes, and respiratory tract.No permanent damageGeneral Signs & SymptomsCoughing, gagging, and vomitingEye pain, tearing, temporary blindnessManagementIrrigate eyes with normal saline
139 Assessment & Management of Electrical, Chemical & Radiation Burns Notify Hazardous Materials TeamEstablish Safety ZonesHot, Warm, & ColdPersonnel positioned Upwind and UphillDecontaminate ALL rescuers, equipment and patients
145 Pathophysiology of the Musculoskeletal System Pediatric ConsiderationsFlexible natureGeriatric ConsiderationsOsteoporosisPathological FracturesPathological diseases
146 Pathophysiology of the Musculoskeletal System General Considerations with musculoskeletal injuriesNeurological compromiseDecreased stabilityMuscle spasmBone Repair CycleOsteocytes produce osteoblastsDeposition of saltsIncreasing strength of matrix
147 Musculoskeletal Injury Management General PrinciplesProtecting Open WoundsPositioning the limbImmobilizing the injuryChecking Neurovascular Function
155 Incident Commander (IC) Coordinates all scene activitiesAlso called Incident Manager (IM) orOfficer in Charge (OIC)
156 The first on-scene unit must assume command and direct all rescue efforts at a mass-casualty incident (MCI)
157 Singular vs. Unified Command Singular commandOne person coordinates the incident.Most useful in smaller, single-jurisdictional incidents.Unified commandManagers from different jurisdictions share command.Fire, EMS, law enforcement
158 Establishing Command First arriving unit establishes command. Assign command early in an incident.Establish a command post.
168 OB / GYNLaborBloody ShowCrowningPredelivery Emergencies
169 Labor Stage One (Dilation) Stage Two (Expulsion) Stage Three (Placental Stage)
170 Management of a Patient in Labor Transport the patient in labor unless delivery is imminent.Maternal urge to push or the presence of crowning indicates imminent delivery.Delivery at the scene or in the ambulance will be necessary.
171 Field Delivery Set up delivery area. Give oxygen to mother and startDrape mother with toweling from OB kit.Monitor fetal heart rate.As head crowns, apply gentle pressure.Suction the mouth and then the nose.Clamp and cut the cord.Dry the infant and keep it warm.Deliver the placenta and save for transport with the mother.
184 Neonatal Resuscitation If the infant’s respirations are below 30 per minute and tactile stimulation does not increase rate to normal range, assist ventilations using bag valve mask with high-flow oxygen.If the heart rate is below 80 and does not respond to ventilations, initiate chest compressions.Transport to a facility with neonatal intensive care capabilities.
185 Causes of Bleeding During Pregnancy AbortionEctopic pregnancyPlacenta previaAbruptio placentae
186 Abortion Termination of pregnancy before the 20th week of gestation. Different classifications.Signs and symptoms include cramping, abdominal pain, backache, and vaginal bleeding.Treat for shock.Provide emotional support.
187 Ectopic PregnancyAssume that any female of childbearing age with lower abdominal pain is experiencing an ectopic pregnancy.Ectopic pregnancy is life-threatening. Transport the patient immediately.
188 Placenta Previa Usually presents with painless bleeding. Never attempt vaginal exam.Treat for shock.Transport immediately— treatment is delivery by c-section.
189 Abruptio Placentae Signs and symptoms vary. Classified as partial, severe, or complete.Life-threatening.Treat for shock, fluid resuscitation.Transport left lateral recumbent position.
192 Breech Presentation The buttocks or both feet present first. If the infant starts to breath with its face pressed against the vaginal wall, form a “V” and push the vaginal wall away from infant’s face. Continue during transport.
194 Prolapsed Cord The umbilical cord precedes the fetal presenting part. Elevate the hips, administer oxygen, and keep warm.If the umbilical cord is seen in the vagina, insert two gloved fingers to raise the fetus off the cord. Do not push cord back.Wrap cord in sterile moist towel.Transport immediately; do not attempt delivery.
195 OB / GYN (Abnormal Deliveries) Limb Presentation
196 Limb Presentation With limb presentation, place the mother in knee–chest position, administer oxygen, and transport immediately. Do not attempt delivery.
197 Other Abnormal Presentations Whenever an abnormal presentation or position of the fetus makes normal delivery impossible, reassure the mother.Administer oxygen.Transport immediately.Do not attempt field delivery in these circumstances.
202 Meconium Staining Fetus passes feces into the amniotic fluid. If meconium is thick, suction the hypopharynx and trachea using an endotracheal tube until all meconium has been cleared from the airway.
204 Postpartum Hemorrhage Defined as a loss of more than500 cc of blood following delivery.Treat for shock as necessary.Follow protocols if applying antishock trousers.
205 Uterine Rupture Tearing, or rupture, of the uterus. Patient complains of severe abdominal pain and will often be in shock. Abdomen is often tender and rigid.Fetal heart tones are absent.Treat for shock.Give high-flow oxygen.Transport patient rapidly.
206 Infants and ChildrenAirwayManeuversFBAOAdjuncts
207 Infants and Children Trauma Shock Common Causes Types Causes AssessmentTreatment
208 Anatomical and physiological considerations in the infant and child.
209 a. In the supine position, an infant’s or child’s larger head tips forward, causing airway obstruction. b. Placing padding under the patient’s back and shoulders will bring the airway to a neutral or slightly extended position.
211 Basic ConsiderationsMuch of the initial patient assessment can be done during visual examination of the scene.Involve the caregiver or parent as much as possible.Allow to stay with child during treatment and transport.
212 Scene Size-Up Conduct a quick scene size-up. Take BSI precautions. Look for clues to mechanism of injury or nature of illness.Allow child time to adjust to you before approaching.Speak softly, simply, at eye level.
213 SuctioningDecrease suction pressure to less than 100 mm/Hg in infants.Avoid excessive suctioning time—less than 15 seconds per attempt.Avoid stimulation of the vagus nerve.Check the pulse frequently.
214 Inserting an oropharyngeal airway in a child with the use of a tongue blade.
215 Ventilation Avoid excessive bag pressure and volume. Obtain chest rise and fall.Allow time for exhalation.Flow-restricted, oxygen-powered devices are contraindicated.Do not use BVMs with pop-off valves.Apply cricoid pressure.Avoid hyperextension of the neck.
216 Circulation Two problems lead to cardiopulmonary arrest in children: ShockRespiratory failure
217 Signs and symptoms of shock (hypoperfusion) in a child.