EMERGENCY MEDICAL TECHNICIAN FINAL REVIEW Barry Barkinsky EMS-I, Paramedic

Medical Emergencies Respiratory Common Problems Signs and Symptoms Adequate / Inadequate Treatment

Obstructive Lung Disease Types Emphysema Chronic Bronchitis Asthma Causes Genetic Disposition Smoking & Other Risk Factors

Emphysema Pathophysiology Exposure to Noxious Substances Exposure results in the destruction of the walls of the alveoli. Weakens the walls of the small bronchioles and results in increase residual volume. Increased Risk of Infection and Dysrhythmia

Emphysema Assessment History Lack of Cough Recent weight loss, dyspnea with exertion Cigarette and tobacco usage Lack of Cough

Emphysema Assessment Physical Exam Barrel chest. Prolonged expiration and rapid rest phase. Thin. Pink skin due to extra red cell production. Hypertrophy of accessory muscles. “Pink Puffers.”

RESPIRATORY

Chronic Bronchitis Pathophysiology Assessment History Results from an increase in mucus-secreting cells in the respiratory tree. Alveoli relatively unaffected. Decreased alveolar ventilation. Assessment History Frequent respiratory infections. Productive cough.

Chronic Bronchitis Physical Exam Often overweight. Rhonchi present on auscultation. Jugular vein distention. Ankle edema. Hepatic congestion. “Blue Bloater.”

RESPIRATORY

Bronchitis & Emphysema Management Maintain airway. Support breathing. Find position of comfort. Monitor oxygen saturation. Be prepared to ventilate. Administer medications. Bronchodilators.

Asthma Pathophysiology Chronic Inflammatory Disorder Results in widespread but variable air flow obstruction. The airway becomes hyperresponsive. Induced by a trigger, which can vary by individual. Trigger causes release of histamine, causing bronchoconstriction and bronchial edema.

Asthma Assessment Identify immediate threats. Obtain history. SAMPLE & OPQRST History History of asthma-related hospitalization? History of respiratory failure/ventilator use?

Asthma Physical Exam Presenting signs may include dyspnea, wheezing, cough. Wheezing is not present in all asthmatics. Speech may be limited to 1–2 consecutive words. Look for hyperinflation of the chest and accessory muscle use. Carefully auscultate breath sounds.

Asthma Management Treatment goals: Maintain the airway. Correct hypoxia. Reverse bronchospasm. Reduce inflammation. Maintain the airway. Support breathing. High-flow oxygen or assisted ventilations as indicated.

RESPIRATORY (Trauma)

Medical Emergencies Cardiac Compromise Cardiac Emergencies Signs and Symptoms Treatment

Managing Specific Cardiovascular Emergencies Angina Pectoris Myocardial Infarction Heart Failure Hypertensive Emergencies Cardiogenic Shock Cardiac Arrest Peripheral Vascular and Other Cardiovascular Emergencies

Angina Pectoris Causes of Chest Pain Cardiovascular, including acute coronary syndrome, or thoracic dissection of the aorta Respiratory, including pulmonary embolism, pneumothorax or pneumonia. Gastrointestinal, including pancreatitis, hiatal hernia, esophageal disease, gastroesophageal reflux, peptic ulcer disease. Musculoskeletal, chest wall trauma.

Angina Pectoris Field Assessment Signs of Shock Chest Discomfort Typically sudden onset, which may radiate or be localized to the chest. Patient often denies chest pain. Duration Episodes last 3–5 minutes. Pain relieved with rest and/or nitroglycerin.

Angina Pectoris Breathing History Past episodes of angina: Episodes of angina that are increasing in frequency, duration, or severity are significant.

Angina Pectoris Management Relieve anxiety: Administer oxygen. Place the patient in a position of physical and emotional comfort. Administer oxygen. Consider medication administration: Nitroglycerin tablets or spray

Angina Pectoris Special Considerations Patients with new-onset often require hospitalization. Symptoms not relieved by rest, nitroglycerin, and oxygen may indicate an overall worsening of the disease or the early stages of a myocardial infarction. Patients may refuse transport after pain is relieved, even though the underlying problem is not addressed.

Myocardial Infarction Pathophysiology Death and necrosis of heart muscle due to inadequate oxygen supply. Causes may include occlusion, spasm, acute volume overload, hypotension, acute respiratory failure, and trauma. Location and size dependent on the vessel involved.

Myocardial Infarction Effects of a Myocardial Infarction Dysrhythmias Heart Failure Goals of Treatment Pain Relief Reperfusion

Myocardial Infarction Field Assessment Breathing Signs of Shock Chief Complaint Typically related to chest pain. Evaluate using OPQRST: Discomfort > 30 minutes. Radiation to arms, neck, back, or epigastric region. Patients may minimize symptoms. Feelings of “impending doom.”

Myocardial Infarction Other Symptoms Nausea and vomiting Diaphoresis Myocardial Infarctions & the ECG Dysrhythmias: VF, VT, Asystole, PEA. Dysrhythmias are the leading cause of death in MI.

Myocardial Infarction Management Transport Rapid transport indicated when acute MI suspected Prehospital Administer oxygen. Consider medication administration: Aspirin Nitroglycerin

Nitroglycerine Indications Contraindications Side effects Dosage

Heart Failure Left Ventricular Failure Pathophysiology Results in increased back pressure into the pulmonary circulation.

Heart Failure Right Ventricular Failure Pathophysiology Results in increased back pressure into the systemic venous circulation. Pulmonary Embolism

Heart Failure Congestive Heart Failure Pathophysiology Reduction in the heart’s stroke volume causes fluid overload throughout the body’s other tissues.

Heart Failure Field Assessment Pulmonary Edema: Cough with copious amounts of clear or pink-tinged sputum. Labored breathing, especially with exertion. Abnormal breath sounds, including rales, rhonchi, and wheezes. Paroxysmal Nocturnal Dyspnea (PND) Medications: Diuretics. Medications to increase cardiac contractile force. Home oxygen.

Heart Failure Mental Status Breathing Skin Mental status changes indicate impending respiratory failure. Breathing Signs of labored breathing. Tripod positioning. “Number of pillows.” Skin Color changes. Peripheral and/or sacral edema.

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.

Hypertensive Emergencies Hypertensive Emergency Causes Typically occurs only in patients with a history of HTN. Primary cause is noncompliance with prescribed antihypertensive medications. Also occurs with toxemia of pregnancy. Risk Factors Age-related factors Race-related factors

Hypertensive Emergencies Field Assessment Initial Assessment Alterations in mental state Signs & Symptoms Headache accompanied by nausea and/or vomiting Blurred vision Shortness of breath Epistaxis Vertigo

Hypertensive Emergencies History Known history of hypertension Compliance with medications Exam BP > 160/90 Signs of left ventricular failure Strong, bounding pulse Abnormal skin color, temperature, and condition Presence of edema

Hypertensive Emergencies Management Maintain airway. Administer oxygen.

Cardiogenic Shock Pathophysiology General 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. Causes Tension pneumothorax and cardiac tamponade. Impaired ventricular emptying. Impaired myocardial contractility. Trauma.

Cardiogenic Shock Field Assessment Initial Assessment Chief Complaint Chief complaint is typically chest pain, shortness of breath, unconsciousness, or altered mental state. Onset may be acute or progressive. History History of recent MI or chest pain episode. Presence of shock in the absence of trauma.

Cardiogenic Shock Mental Status Airway and Breathing Circulation Restlessness progressing to confusion Airway and Breathing Dyspnea, labored breathing, and cough PND, tripod position, accessory muscle retraction, and adventitious lung sounds Circulation Hypotension Cool, clammy skin

Cardiogenic Shock Management Maintain airway. Administer oxygen Identify and treat underlying problem.

Cardiac Arrest Sudden Death Causes Electrolyte or acid–base imbalances Electrocution Drug intoxication Hypoxia Hypothermia Pulmonary embolism Stroke Drowning Trauma

Cardiac Arrest Field Assessment Initial Assessment ECG History Unresponsive, apneic, pulseless patient ECG Dysrhythmias History Prearrest events Bystander CPR “Down time”

Cardiac Arrest Management Resuscitation Return of Spontaneous Circulation Role of Basic Life Support General Guidelines Manage specific Dysrhythmias. AED CPR.

AED (Automatic External Defibrillator)

AED (Automatic External Defibrillator) Indications

AED (Automatic External Defibrillator) Contraindications

AED (Automatic External Defibrillator) Joules

AED (Automatic External Defibrillator) # of Shocks

AED (Automatic External Defibrillator) If NO SHOCK Advised

Peripheral Vascular and Other Cardiovascular Emergencies Aneurysm Pathophysiology Ballooning of an arterial wall, usually the aorta, that results from a weakness or defect in the wall Types Atherosclerotic Dissecting Traumatic

Peripheral Vascular and Other Cardiovascular Emergencies Abdominal Aortic Aneurysm Often the result of atherosclerosis Signs and symptoms Abdominal pain Back/flank pain Hypotension Urge to defecate

Peripheral Vascular and Other Cardiovascular Emergencies Dissecting Aortic Aneurysm Caused by degenerative changes in the smooth muscle and elastic tissue. Blood gets between and separates the wall of the aorta. Can extend throughout the aorta and into associated vessels.

Peripheral Vascular and Other Cardiovascular Emergencies Acute Pulmonary Embolism Pathophysiology Blockage of a pulmonary artery by a blood clot or other particle. The area served by the pulmonary artery fails. Signs and Symptoms Dependent upon size and location of the blockage. Onset of severe, unexplained dyspnea. History of recent lengthy immobilization.

Medical Emergencies Altered Mental Status (AMS) Causes Treatment

Medical Emergencies Diabetes Most common cause Signs and Symptoms Treatment

Medical Emergencies Seizures

Seizures Generalized Seizures Tonic-Clonic Aura Loss of Consciousness Tonic Phase Clonic Phase Postseizure Postictal

Seizures Partial Seizures Simple Partial Seizures Involve one body area. Can progress to generalized seizure. Complex Partial Seizures Characterized by auras. Typically 1–2 minutes in length. Loss of contact with surroundings.

Seizures Assessment Differentiating Between Syncope & Seizure Bystanders frequently confuse syncope and seizure.

Seizures Patient History History of Seizures History of Head Trauma Any Alcohol or Drug Abuse Recent History of Fever, Headache, or Stiff Neck History of Heart Disease, Diabetes, or Stroke Current Medications Phenytoin (Dilantin), phenobarbitol, valproic acid (Depakote), or carbamazepine (Tegretol) Physical Exam Signs of head trauma or injury to tongue, alcohol or drug abuse

Seizures Management Scene safety & BSI. Maintain the airway. Administer high-flow oxygen. Treat hypoglycemia if present. Do not restrain the patient. Protect the patient from the environment. Maintain body temperature.

Seizures Management Position the patient. Suction if required. Provide a quiet atmosphere. Transport.

Seizures Status Epilepticus Two or More Generalized Seizures Seizures occur without a return of consciousness. Management Management of airway and breathing is critical. Monitor the airway closely.

Medical Emergencies Stroke (CVA)

Stroke & Intracranial Hemorrhage Occlusive Strokes Embolic & Thrombotic Strokes Hemorrhagic Strokes

Stroke & Intracranial Hemorrhage Signs Facial Drooping Headache Aphasia/Dysphasia Hemiparesis Paresthesia Gait Disturbances Incontinence Symptoms Confusion Agitation Dizziness Vision Problems

Stroke & Intracranial Hemorrhage Transient Ischemic Attacks Indicative of carotid artery disease. Symptoms of neurological deficit: Symptoms resolve in less than 24 hours. No long-term effects. Evaluate through history taking: History of HTN, prior stroke, or TIA. Symptoms and their progression.

Stroke & Intracranial Hemorrhage Management Scene safety & BSI Maintain the airway. Support breathing. Obtain a detailed history. Position the patient. Protect paralyzed extremities.

Allergic Reaction (Anaphylaxis) Medical Emergencies Allergic Reaction (Anaphylaxis)

Allergies and Anaphylaxis Allergic Reaction An exaggerated response by the immune system to a foreign substance Anaphylaxis An unusual or exaggerated allergic reaction A life-threatening emergency

Anaphylaxis Causes

Assessment Findings in Anaphylaxis Focused History & Physical Exam Focused History SAMPLE & OPQRST History Rapid onset, usually 30–60 seconds following exposure. Speed of reaction is indicative of severity. Previous allergies and reactions. Physical Exam Presence of severe respiratory difficulty is key to differentiating anaphylaxis from allergic reaction.

Assessment Findings in Anaphylaxis Physical Exam Facial or laryngeal edema Abnormal breath sounds Hives and urticaria Hyperactive bowel sounds Vital sign deterioration as the reaction progresses

Management of Allergic Reactions Scene safety Protect the airway. Support breathing. Establish IV access. Administer medications: Epinephrine

Epi-Auto Injector Indications

Epi-Auto Injector Contraindications

Epi-Auto Injector Dosage

Epi-Auto Injector Actions

Epi-Auto Injector Side Effects

Epi-Auto Injector Administration

Medical Emergencies Poisons and Overdose Environmental How they enter the body Treatment Environmental Heat Cold Water Emergencies

Trauma Emergencies Bleeding

External Types, Treatment ( In order) Bleeding External Types, Treatment ( In order)

Hemorrhage Classification Capillary Slow, even flow Venous Steady, slow flow Dark red Arterial Spurting blood Pulsating flow Bright red color

Internal, S/S, Treatment Bleeding Internal, S/S, Treatment

Hemorrhage Control Internal Hemorrhage Hematoma Pocket of blood between muscle and fascia Humerus or Tibia/Fibula fracture: 500-750mL Femur fracture: 1,500mL UNEXPLAINED SHOCK is BEST attributed to abdominal trauma General Management Immobilization, Stabilization, Elevation

Hemorrhage Control Internal Hemorrhage Epistaxis: Nose Bleed Causes: Trauma, Hypertension Treatment: Lean forward, pinch nostrils Hemoptysis Esophageal Varices Chronic Hemorrhage Anemia

Trauma Emergencies Shock

SHOCK is… INADEQUATE TISSUE PERFUSION In a Nutshell….. SHOCK is… INADEQUATE TISSUE PERFUSION

Stages of Shock Compensated Shock Decompensated Shock Minimal Change Decompensated Shock System beginning to fail Irreversible Shock Ischemia and death imminent

Etiology of Shock Hypovolemic Shock Cardiogenic Shock Loss of blood volume Distributive Shock Prevent appropriate distribution of nutrients and removal of wastes Anaphylactic Septic Hypoglycemia Obstructive Shock Interference with the blood flowing through the cardiovascular system Tension Pneumothorax Cardiac Tamponade Pulmonary Emboli Cardiogenic Shock Pump failure Respiratory Shock Respiratory system not able to bring oxygen into the alveoli Airway obstruction Pneumothorax Neurogenic Shock Loss of nervous control from CNS to peripheral vasculature

Trauma Emergencies Soft Tissue

Introduction to Soft-Tissue Injury Skin is the largest, most important organ 16% of total body weight Function Protection Sensation Temperature Regulation AKA: Integumentary System

Introduction to Soft-Tissue Injury Epidemiology Open Wounds Over 10 million wounds present to ED Most require simple care and some suturing Up to 6.5% may become infected Closed Wounds More Common Contusions, Sprains, Strains

A&P of Soft Tissue Injuries Skin Layers Epidermis Outermost layer Helps prevent infection Dermis Upper Layer (Papillary Layer) Loose connective tissue, capillaries and nerves Lower Layer (Reticular Layer) Integrates dermis with SQ layer Blood vessels, nerve endings, glands Sebaceous & Sudoriferous Glands Subcutaneous Adipose tissue Heat retention

Pathophysiology of Soft-Tissue Injury Closed Wounds Contusions Ecchymosis Hematomas Crush Injuries Open Wounds Abrasions Lacerations Incisions Punctures Impaled Objects Avulsions Amputations

Trauma Emergencies Penetrating Injuries

Trauma Emergencies Evisceration

Trauma Emergencies Impaled Object

Trauma Emergencies Amputation

Management of Soft-Tissue Injury Objectives of Wound Dressing & Bandaging Hemorrhage Control Direct Pressure Elevation Pressure Points Consider Ice Constricting Band Tourniquet USE ALL COMPONENTS TOGETHER

Management of Soft-Tissue Injury Objectives of Wound Dressing & Bandaging Sterility Keep the wound as clean as possible If wound is grossly contaminated consider cleansing Immobilization Prevents movement and aggravation of wound Do not use an elastic bandage: TQ effect Monitor distal pulse, motor, and sensation (continued)

Management of Soft-Tissue Injury Pain & Edema Control Cold packs Moderate pressure over wound

Dressing & Bandage Materials Sterile & Non-sterile Dressings Sterile: Direct wound contact Non-sterile: Bulk dressing above sterile Occlusive/Non-occlusive Dressings Adherent/Non-adherent Dressings Adherent: stick to blood or fluid Absorbent/Non-absorbent Absorbent: soak up blood or fluids Wet/Dry Dressings Wet: Burns, postoperative wounds (Sterile NS) Dry: Most common

Trauma Emergencies Burns Classification Severity Superficial Partial-Thickness Full-Thickness Severity Depth Body Surface Area (BSA)

Burn Depth Superficial Burn: 1st Degree Burn Signs & Symptoms Reddened skin Pain at burn site Involves only epidermis

Burn Depth Partial-Thickness Burn: 2nd Degree Burn Signs & Symptoms Intense pain White to red skin Blisters Involves epidermis & dermis

Burn Depth Full-Thickness Burn: 3rd Degree Burn Signs & Symptoms Dry, leathery skin (white, dark brown, or charred) Loss of sensation (little pain) All dermal layers/tissue may be involved

Trauma Emergencies (Burns) Rule of Nines (Adult) Head and Neck: 9 % Each Upper Ext: 9 % Anterior Trunk: 18 % Posterior Trunk: 18 % Each Lower Ext: 18 % Genitalia: 1 %

Trauma Emergencies (Burns) Rule of Nines (Child) Head and Neck: 18 % Each Upper Ext: 9 % Anterior Trunk: 18 % Posterior Trunk: 18 % Each Lower Ext: 14 % Genitalia: 1 %

Trauma Emergencies Burns Rule of Palm Location Preexisting Medical Problems Age 5 – 55 Source Treatment

Rule of Palms A burn equivalent to the size of the patient’s hand is equal to 1% body surface area (BSA)

Pathophysiology of Burns Types of Burns Thermal Electrical Chemical Radiation

Thermal Burns Heat changes the molecular structure of tissue Denaturing (of proteins) Extent of burn damage depends on Temperature of agent Concentration of heat Duration of contact

Systemic Complications Hypothermia Disruption of skin and its ability to thermoregulate Hypovolemia Shift in proteins, fluids, and electrolytes to the burned tissue General electrolyte imbalance Eschar Hard, leathery product of a deep full thickness burn Dead and denatured skin

Systemic Complications Infection Greatest risk of burn is infection Organ Failure Special Factors Age & Health Physical Abuse Elderly, Infirm or Young

Assessment of Thermal Burns General Signs & Symptoms Pain Changes in skin condition at affected site Adventitious sounds Blisters Sloughing of skin Hoarseness Burnt hair Edema Paresthesia Hemorrhage Other soft tissue injury Musculoskeletal injury Dyspnea Chest pain

Assessment of Thermal Burns Burn Severity Minor Superficial <50% BSA Partial Thickness <15% BSA Full Thickness <2% BSA Moderate Superficial >50% BSA Partial Thickness >15% BSA Full Thickness >2% BSA Critical Partial Thickness >30% BSA Full Thickness >10% BSA Inhalation Injury Any partial or full thickness burn involving hands, feet, joints, face, or genitalia

Management of Thermal Burns Local & Minor Burns Local cooling Partial thickness: <15% of BSA Full thickness: <2% BSA Remove clothing Cool or Cold water immersion

Management of Thermal Burns Moderate to Severe Burns Dry sterile dressings Partial thickness: >15% BSA Full thickness: >5% BSA Maintain warmth Prevent hypothermia Consider aggressive fluid therapy Moderate to severe burns

Management of Thermal Burns Moderate to Severe Burns Caution for fluid overload Frequent auscultation of breath sounds Prevent infection

Management of Thermal Burns Inhalation Injury Provide high-flow O2 by NRB Consider intubation if swelling Consider hyperbaric oxygen therapy

Assessment & Management of Electrical, Chemical & Radiation Burns Electrical Injuries Safety Turn off power Energized lines act as whips Establish a safety zone Lightning Strikes High voltage, high current, high energy Lasts fraction of a second No danger of electrical shock to EMS

Assessment & Management of Electrical, Chemical & Radiation Burns Chemical Burns Scene size-up Hazardous materials team Establish hot, warm and cold zones Prevent personnel exposure from chemical Specific Chemicals Phenol Dry Lime Sodium Riot Control Agents

Assessment & Management of Electrical, Chemical & Radiation Burns Specific Chemicals Phenol Industrial cleaner Alcohol dissolves Phenol Irrigate with copious amounts of water Dry Lime Strong corrosive that reacts with water Brush off dry substance Irrigate with copious amounts of cool water Prevents reaction with patient tissues

Assessment & Management of Electrical, Chemical & Radiation Burns Riot Control Agents Agents CS, CN (Mace), Oleoresin, Capsicum (OC, pepper spray) Irritation of the eyes, mucous membranes, and respiratory tract. No permanent damage General Signs & Symptoms Coughing, gagging, and vomiting Eye pain, tearing, temporary blindness Management Irrigate eyes with normal saline

Assessment & Management of Electrical, Chemical & Radiation Burns Notify Hazardous Materials Team Establish Safety Zones Hot, Warm, & Cold Personnel positioned Upwind and Uphill Decontaminate ALL rescuers, equipment and patients

Musculoskeletal System

Pathophysiology of the Musculoskeletal System Joint Injury Sprain Subluxation Dislocation Bone Injury Open Fracture Closed Fracture Hairline Fracture Impacted Fracture

Musculoskeletal Ligament

Musculoskeletal Tendon

Pathophysiology of the Musculoskeletal System Pediatric Considerations Flexible nature Geriatric Considerations Osteoporosis Pathological Fractures Pathological diseases

Pathophysiology of the Musculoskeletal System General Considerations with musculoskeletal injuries Neurological compromise Decreased stability Muscle spasm Bone Repair Cycle Osteocytes produce osteoblasts Deposition of salts Increasing strength of matrix

Musculoskeletal Injury Management General Principles Protecting Open Wounds Positioning the limb Immobilizing the injury Checking Neurovascular Function

Trauma Emergencies Injuries Painful, swollen, deformed extremities Assessment Signs and Symptoms Splinting Upper Extremities Lower Extremities Hip / Pelvis

Musculoskeletal Injury Management Splinting Devices Rigid splints Formable Splints Soft Splints Traction Splints Other Splinting Aids Vacuum Splints Air Sprints Cravats or Velcro Splints Fracture Care Joint Care Muscular & Connective Tissue Care

Trauma Emergencies Injuries to Head Nervous System Brain Injuries Direct Indirect Patient Assessment Signs and Symptoms Neurological Assessment

Trauma Emergencies Injuries to Spine MOI Assessment Signs and Symptoms Treatment Immobilization Helmets Collars LSB Seated Patient

Musculoskeletal Injury Management Care for Specific Joint Injuries Hip Knee Ankle Foot Shoulder Elbow Wrist/Hand Finger Joint Injuries Alert for neurological Compromise

Triage

Command at Mass-Casualty Incidents

Incident Commander (IC) Coordinates all scene activities Also called Incident Manager (IM) or Officer in Charge (OIC)

The first on-scene unit must assume command and direct all rescue efforts at a mass-casualty incident (MCI)

Singular vs. Unified Command Singular command One person coordinates the incident. Most useful in smaller, single-jurisdictional incidents. Unified command Managers from different jurisdictions share command. Fire, EMS, law enforcement

Establishing Command First arriving unit establishes command. Assign command early in an incident. Establish a command post.

EMS Branch Functions Triage Treatment Transport

Triage Sorting of patients based upon the severity of their injuries Primary triage Secondary triage

Triage Tags Alerts care providers to patient priority Prevents re-triage of the same patient Serves as a tracking system

The METTAG

Treatment Red treatment unit Yellow treatment unit Green treatment unit

Triage Priority 1 (RED)

Triage Priority 2 (Yellow)

Triage Priority 3 (Green)

OB / GYN

OB / GYN Labor Bloody Show Crowning Predelivery Emergencies

Labor Stage One (Dilation) Stage Two (Expulsion) Stage Three (Placental Stage)

Management of a Patient in Labor Transport the patient in labor unless delivery is imminent. Maternal urge to push or the presence of crowning indicates imminent delivery. Delivery at the scene or in the ambulance will be necessary.

Field Delivery Set up delivery area. Give oxygen to mother and start Drape mother with toweling from OB kit. Monitor fetal heart rate. As head crowns, apply gentle pressure. Suction the mouth and then the nose. Clamp and cut the cord. Dry the infant and keep it warm. Deliver the placenta and save for transport with the mother.

OB / GYN ( Normal Delivery)

OB / GYN ( Normal Delivery)

OB / GYN ( Normal Delivery)

OB / GYN ( Normal Delivery)

OB / GYN ( Normal Delivery)

OB / GYN ( Normal Delivery)

Apgar Scoring

OB / GYN ( Normal Delivery) Care of Newborn

OB / GYN (Resuscitation) HR Less than 100

OB / GYN (Resuscitation) HR less than 80

OB / GYN (Resuscitation) HR less than 60

Neonatal Resuscitation If the infant’s respirations are below 30 per minute and tactile stimulation does not increase rate to normal range, assist ventilations using bag valve mask with high-flow oxygen. If the heart rate is below 80 and does not respond to ventilations, initiate chest compressions. Transport to a facility with neonatal intensive care capabilities.

Causes of Bleeding During Pregnancy Abortion Ectopic pregnancy Placenta previa Abruptio placentae

Abortion Termination of pregnancy before the 20th week of gestation. Different classifications. Signs and symptoms include cramping, abdominal pain, backache, and vaginal bleeding. Treat for shock. Provide emotional support.

Ectopic Pregnancy Assume that any female of childbearing age with lower abdominal pain is experiencing an ectopic pregnancy. Ectopic pregnancy is life-threatening. Transport the patient immediately.

Placenta Previa Usually presents with painless bleeding. Never attempt vaginal exam. Treat for shock. Transport immediately— treatment is delivery by c-section.

Abruptio Placentae Signs and symptoms vary. Classified as partial, severe, or complete. Life-threatening. Treat for shock, fluid resuscitation. Transport left lateral recumbent position.

Abnormal Delivery Situations

OB / GYN (Abnormal Deliveries) Breech

Breech Presentation The buttocks or both feet present first. If the infant starts to breath with its face pressed against the vaginal wall, form a “V” and push the vaginal wall away from infant’s face. Continue during transport.

OB / GYN (Abnormal Deliveries) Prolapsed Cord

Prolapsed Cord The umbilical cord precedes the fetal presenting part. Elevate the hips, administer oxygen, and keep warm. If the umbilical cord is seen in the vagina, insert two gloved fingers to raise the fetus off the cord. Do not push cord back. Wrap cord in sterile moist towel. Transport immediately; do not attempt delivery.

OB / GYN (Abnormal Deliveries) Limb Presentation

Limb Presentation With limb presentation, place the mother in knee–chest position, administer oxygen, and transport immediately. Do not attempt delivery.

Other Abnormal Presentations Whenever an abnormal presentation or position of the fetus makes normal delivery impossible, reassure the mother. Administer oxygen. Transport immediately. Do not attempt field delivery in these circumstances.

Other Delivery Complications

OB / GYN (Abnormal Deliveries) Multiple Births

Multiple Births Follow normal guidelines, but have additional personnel and equipment. In twin births, labor starts earlier and babies are smaller. Prevent hypothermia.

OB / GYN (Abnormal Deliveries) Meconium

Meconium Staining Fetus passes feces into the amniotic fluid. If meconium is thick, suction the hypopharynx and trachea using an endotracheal tube until all meconium has been cleared from the airway.

Maternal Complications of Labor and Delivery

Postpartum Hemorrhage Defined as a loss of more than 500 cc of blood following delivery. Treat for shock as necessary. Follow protocols if applying antishock trousers.

Uterine Rupture Tearing, or rupture, of the uterus. Patient complains of severe abdominal pain and will often be in shock. Abdomen is often tender and rigid. Fetal heart tones are absent. Treat for shock. Give high-flow oxygen. Transport patient rapidly.

Infants and Children Airway Maneuvers FBAO Adjuncts

Infants and Children Trauma Shock Common Causes Types Causes Assessment Treatment

Anatomical and physiological considerations in the infant and child.

a. In the supine position, an infant’s or child’s larger head tips forward, causing airway obstruction. b. Placing padding under the patient’s back and shoulders will bring the airway to a neutral or slightly extended position.

General Approach to Pediatric Assessment

Basic Considerations Much of the initial patient assessment can be done during visual examination of the scene. Involve the caregiver or parent as much as possible. Allow to stay with child during treatment and transport.

Scene Size-Up Conduct a quick scene size-up. Take BSI precautions. Look for clues to mechanism of injury or nature of illness. Allow child time to adjust to you before approaching. Speak softly, simply, at eye level.

Suctioning Decrease suction pressure to less than 100 mm/Hg in infants. Avoid excessive suctioning time—less than 15 seconds per attempt. Avoid stimulation of the vagus nerve. Check the pulse frequently.

Inserting an oropharyngeal airway in a child with the use of a tongue blade.

Ventilation Avoid excessive bag pressure and volume. Obtain chest rise and fall. Allow time for exhalation. Flow-restricted, oxygen-powered devices are contraindicated. Do not use BVMs with pop-off valves. Apply cricoid pressure. Avoid hyperextension of the neck.

Circulation Two problems lead to cardiopulmonary arrest in children: Shock Respiratory failure

Signs and symptoms of shock (hypoperfusion) in a child.

Respiratory Emergencies Infections Upper airway distress Croup Epiglottitis Lower airway distress Asthma Bronchiolitis

a. Croup and b. Epiglottitis

Positioning of the child with epiglottitis Positioning of the child with epiglottitis. Often there will be excessive drooling.

The child with epiglottitis should be administered humidified oxygen and transported in a comfortable position.

Poisoning and Toxic Exposure Accidental poisoning is a common childhood emergency. Leading cause of preventable death in children.

Medical Emergencies Seizures

Trauma Emergencies Falls Motor vehicle crashes Car vs. pedestrian injuries Drowning and near drowning Penetrating injuries Burns Physical abuse

Falls are the most common cause of injury in young children.

A deploying airbag can propel a child safety seat back into the vehicle’s seat, seriously injuring the child secured in it.

Medical Emergencies SIDS

Sudden Infant Death Syndrome (SIDS) SIDS is the sudden death of an infant during the first year of life from an illness of unknown etiology.

Child Abuse and Neglect

The stigmata of child abuse.

Infants and Children with Special Needs Common home-care devices Tracheostomy tubes Apnea monitors Home artificial ventilators Central intravenous lines Gastric feeding and gastrostomy tubes Shunts

Medical Emergencies Meningitis

Summary Questions ?