EMT Certifications - What We Need to Get Certified Part 2

• How to properly assess and Tx a patient with chest pain o Scene Size Up à BSI/PENMAN o General impression à begin CPR if necessary o Primary Assessment ▪ ABCDTs • Airway: open, clear, maintainable • Breathing: rate, depth, quality o O2 sat <95%: give O2 @15L/min o Not breathing or inadequate breathing: 100% O2 with BVM o Pulmonary edema: BVM or CPAP (continuous positive air pressure) • Circulation: pulse, quality, CRT, CMT, skin signs, obvious bleeding • Disability: A/O status (LOC), GCS • Transport: Critical or stable? o History Taking (SAMPLE, OPQRST) o Secondary Assessment ▪ Focused (IPA) assessment on cardiac and respiratory systems • DCAPBTLS • TIC • Lung sounds o Vitals (BELLSRP) o Reassessments during Transport ▪ Chief Complaint (C/C), LOC, ABCs, Vital signs, Interventions ▪ Every 5 minutes if critical, every 15 minutes if stable ▪ Perform CPR immediately if pt goes into cardiac arrest • S&S of o Congestive heart failure ▪ Signs and symptoms: respiratory distress, hyperventilation, tachycardia, HTN, cough, wheezing, feeling suffocated, crackles, anxiety, cold sweats, cyanosis, SOB when laying down, distended neck veins • Left CHF: pulmonary edema • Right CHF: dependent edema, swollen ankles o MI ▪ Signs and symptoms: chest pain that can radiate to left shoulder pain or back, dyspnea, incontinence, dizziness, fatigue, confusion, epigastric and abdominal pain, nausea, vomiting, clammy skin, sweating, issues with circulation, abnormal or decreased breaths o • Blood flow o ▪ Increases with time OD ▪ Signs and symptoms: decreased resp, resp depression, cardiac arrest, vomiting, possible seizures, sedated appearance, cyanosis, miosis à SVC and IVC à RA à Tricuspid Valve à RV à Pulmonary Valve à Pulmonary Arteries à Lungs à Pulmonary Veins à LA à Bicuspid à LV à Aortic Valve à Aorta à Body Body Valve • Electrical Conduction o Controls heart rate and coordinates atria and ventricles ▪ Automatically allows spontaneous contraction without a stimulus from a nerve source o SA Node (60-100 bpm) à Internodal Pathways à AV Node (40-60 bpm) à Bundle of His à Left and Right Bundle Branches à Purkinje Fibers (20-40 bpm) • V-fib o o Ventricular fibrillation: disorganized ineffective quivering of both the ventricles resulting in no blood flow and a state of cardiac arrest ! ▪ Diminishes 10% each minute until defib ▪ Must be defib within 2 minutes 40% survival rate at start • Indications and contraindications of o Aspirin ▪ Anti-inflammatory, antifever, anticoagulant/blood thinner (81-325 mg chewable) ▪ Indications: relief of mild pain, headache, chest pain of cardiac origin ▪ Contraindication: hypersensitivity, recent bleeding o Nitroglycerin ▪ Vasodilator to lower BP, increase blood flow ▪ Sublingual ▪ Contraindications: 53BASH • 5 – do not give nitro if patient took it within the last 5 minutes • 3 – do not give nitro if patient took more than 3 doses that day • B – do not give nitro if patient BP is already lower than 100mmHg • A – do not give nitro if patient has altered LOC • S – do not give nitro if patient took sexually enhancing drugs within last 24-72 hours • H – do not give nitro if patient head injury How to use an AED • Monophasic and biphasic v-fib o Monophasic: having a single phase, record of a nerve impulse that is negative or positive but not both ▪ Type of fib where shock is delivered to one vector of the heart o Biphasic: having two phases ▪ Shock is delivered to the heart via two vectors – use in implantable defibs and are the standard fibs (pacemaker, AEDs) • Perfusion triangle and shock o Heart ▪ Failure (caused by MI, trauma, obstruction) • Obstructive shock: mechanical obstruction that prevents the heart from pumping enough to fill o Signs and Symptoms ▪ Low BP ▪ Hypoxia ▪ Clammy skin ▪ Dyspnea ▪ Weak pulse ▪ Shallow breathing ▪ Hypothermia o Tx: High flow O2, supine/position of comfort, blanket, rapid transport o Cardiac tamponade: pericardial sac filled with fluid during a puncture ▪ Signs and Symptoms • Decreasing sys blood pressure • Distant/Muffled heart sounds • Distended neck veins o Tension pneumothorax: damage to lung tissue causing air to enter pleural space, causing lung to collapse à JVD o Pulmonary embolism: blood clot that occurs in the pulm circulation that blocks the flow of blood through pulm vessels ▪ Cardiogenic shock: the heart itself is not functioning properly; inadequate function of heart • Causes backup of blood into the lungs because the heart cannot pump the blood • Develops when the heart cannot maintain enough output to meet the demands of body • Signs and Symptoms o " o irregular/weak pulse o low BP o cyanosis o clammy skin o crackles o pulm edema •" • Tx: High flow O2, DO NOT GIVE NITROGLYCERIN because they are hypotensive, supine/position of comfort, blanket, rapid transport • Diseased myocardium; Myocardial infarction o Vessels ▪ Failure (caused by infection, drugs, spinal cord injury, anaphylaxis) ▪ Distributive shock: widespread throughout body vessels by vasodilation • Septic shock: due to infections, can have fever as a sign • Neurogenic shock: due to spinal cord and nervous system injury à rapid vasodilation • Anaphylactic shock: due to severe allergic reaction à bronchoconstriction • Psychogenic shock: due to nervous system failure that causes syncope, quick vasodil • Signs and Symptoms o o o o o o o o o Vasodilation Low BP Weak pulse Cool/clammy skin Cyanosis Septic shock: fever, tachycardia Neurogenic shock: bradycardia, absence of sweating below injury Anaphylactic shock: urticaria, bronchoconstriction Psychogenic shock: tachycardia, low to normal BP ▪" ▪ Tx: High flow O2, supine/position of comfort, blanket, rapid transport • Septic shock definitive Tx: hospitalization, antibiotics • Neurogenic shock: spinal immobilization, hospitalization • Anaphylactic shock: epinephrine o Blood ▪ Failure (caused by low fluid volume) • Hypovolemic shock: inadequate amount of fluid or volume in the circulatory system o Hemorrhagic shock: loss of blood due to injuries/trauma o Nonhemorrhagic shock: loss of blood from other sources, such as vomiting and diarrhea • Cell Death o o o o o ▪ Signs and Symptoms • Rapid, weak pulse • Low blood pressure • Cyanosis • Increased resp rate ▪ Tx: Control bleeding, high flow O2, supine/position of comfort, blanket, rapid transport 0 – 1 min: cardiac instability 0 – 4 min: brain damage not likely 4 – 6 min: brain damage possible 6 – 10 min: brain damage likely > 10 min: irreversible brain damage Medical " • Medications o Epi-pen (IM) ▪ Sympathomimetic: stimulates the nervous system ▪ Indications: causing bronchodilation, anaphylactic reactions ▪ Contraindications: chest pain, hyperthermia, HTN ▪ Adult: 0.3mg ▪ Child: 0.15mg • S&S o Stroke: treatment, focused assessment (FAST) ▪ Interruption of blood flow to an area within the brain that results in the loss of brain functions ▪ Ischemic stroke: most common; occurs when blood flow through the cerebral arteries is blocked ▪ Hemorrhagic stroke: most fatal; occurs when a blood vessel ruptures and the accumulated blood causes increased pressure in the brain • Aneurysm: swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall ▪ Signs and Symptoms • FAST Beck o Facial droop o Arm drift o Slurred speech (dysarthria) o Time is brain • Bleeding in the brain may be the cause of the bleeding or be caused by the bleeding ▪ Conditions that mimic stroke • Hypoglycemia: not enough blood glucose • Postictal state: period following seizure that lasts between 5 and 30 minutes characterized by labored respireations and some degree of altered LCO • Subdural or epidural bleeding: a collection of blood near the skull that presses on the brain ▪ Transient ischemic attack (TIA) : stroke-like symptoms that go away on their own in less than 24 hours (mini strokes) • It may be a warning sign that a more significant stroke may occur in the future o Gastroenteritis ▪ Stomach flu: intestinal infection that is spread by contact of contaminated food or liquids ▪ Signs and symptoms: diarrhea, cramps, nausea, vomiting, low grade fever o Hypo and hyperglycemia ▪ Hypoglycemia • Glucose levels that are lower than 80 • Immediate onset • Cool pale clammy, give them candy • Signs and symptoms: pale and clammy skin, no thirst, no hunger, altered LOC, shallow breaths, weakness on one side, diaphoresis, respirations are normal to rapid, pulse is weak to rapid, low BP • Tx: oral glucose at the size of the cheek ▪ Hyperglycemia • Glucose levels that are higher than 120 • Gradual onset • hot and dry, sugar is high • Signs and symptoms: altered LOC, drowsy, lethargic, dark urine, dehydration, visual deficits, muscle weakness, can lead to seizure, respirations may be deep and rapid, pulse is maybe rapid/weak/thready, skin may be warm and dry with normal BP o • Type 1: Autoimmune disease, body cannot produce enough insulin o Polyuria, polydipsia, polyphagia o DKA: >400 glucose levels ▪ fruity breath, kussmaul respirations (fast/deep), excessive urination • Type 2: Body develops resistance to insulin o HHNS: >400 glucose levels ▪ Not dehydrating from losing fluid, but losing due to fluid imbalance ▪ No fruity, no kussmaul Pulmonary embolism ▪ A blood clot that travels through the pulmonary circulation ▪ Signs and symptoms: sharp pinpoint pain, dyspnea, sudden onset, cyanosis, tachycardia, hypoxia, acute chest pain, hemoptysis o Seizures and the different types of seizures ▪ A neurologic episode caused by a surge of electrical activity in the brain ▪ Can result from metabolic causes • Abnormal levels of certain blood chemicals • Hypoglycemia • Poisons • Drug overdoses ▪ Generalized Seizure • Results from abnormal electrical discharges from large areas of the brain, usually involving both hemispheres, usually last 3-5 minutes • Signs and Symptoms: unconsciousness, generalized severe twitching of all muscles that lasts several minutes or longer • Absence or petit mal seizures: brief lapse of consciousness in which the patient seems to stare and not respond to anyone ▪ Partial (focal) seizure • Begins in one part of the brain and is classified as simple or complex • Simple partial seizure: no change in LOC, numbness, weakness, dizziness, visual changes, unusual smells and tastes, can have some twitching or brief paralysis • Complex partial seizure: altered LOC, does not interact normally with his or her environment, lip smacking, eye blinking, isolated jerking ▪ Aura: can be experienced before a seizure; visual changes, hallucinations ▪ Status epilepticus: seizures that last longer than 30 minutes or continue every few minutes without the person regaining consciousness ▪ Postictdal state: period after seizure, patient’s muscles become flaccid, floppy, and the breathing becomes labored (fast and deep), lethargy, confusion • Shock, different types, and Tx for each of them o The Stages of Shock ▪ Early Stages (Effective Compensation) • MAP decreased 10 mmHg from Baseline • Signs and Symptoms o Increased heart rate o Increased respiration o Restless o Anxious o Mild vasoconstriction • O2 can reach vital organs: heart, lungs, brain, kidneys ▪ Compensated " • MAP decreased 10-15mmHg from Baseline • Signs and Symptoms o Increased heart rate o Vasoconstriction o Decreased pulse pressure o Restless o Pale, cool, clammy skin • Hypoxia in non-vital organs ▪ Decompensated • MAP decreased 20mmHg from Baseline • Signs and Symptoms o Weak, rapid pulse o Sensory neural changes o Cool, clammy skin o Edema o Acute respiratory distress • Anoxia in the Vital organs, Tissue/Organ Hypoxia ▪ Irreversible • Signs and Symptoms o O2 below 70% o Severe hypotension o Anuria (kidneys shut down) • Multisystem organ failure o See shock from above J • Hypo and hyperthermia o Hypothermia: core temp falls below 95F, body loses ability to regulate and generate body heat ▪ Rapid weak pulse, low BP, altered LOC, cool clammy skin, increased respiratory rate ▪ Patients with injuries are more susceptible ▪ Take pulse for an entire minute ▪ Temperatures • 93-95°F o Shivering o Rapid breathing o • 89-92°F o o o • 80-88°F o o o • < 80°F o o o LOC: withdrawn Muscle stiffness Slow respirations /pulse LOC: confused, lethargic, sleepy Coma Weak pulse, dysrhythmia, very slow respirations LOC: unresponsive Apparent death Cardiac arrest LOC: unresponsive ▪ Tx: humidified O2, blanket over and under, active warming, passive warming o Hyperthermia: core temp above 101F ▪ Heat cramps: painful muscle spasms that occur after vigorous exercise, large amount of water lost ▪ Heat exhaustion: most common, heat exposure/stress/fatigue, dizziness, weakness, syncope, altered LOC, nausea, vomiting, headache ▪ Heat stroke: least common but most serious, overwhelmed by heat, tissues are destroyed, hot dry flushed skin, temp can >106, decreased LOC to unconscious • Treatment of a patient who has been poisoned o Activated charcoal: absorbing toxic substances in the digestive tract ▪ Indications: most oral poisoning and OD ▪ Contraindications: intact gag reflex ,decreased LOC, OD on petroleum substances o Naloxone: opiate OD Tx ▪ Indications: opiate poisoning ▪ Contraindications: hypersensitivity o Oxygen for inhaled poisons • Behavioral disorders (schizo, alzheimers, dementia) o Schizophrenia ▪ Functional disorder: physiological disorder that impairs bodily functions when the body seems to be structurally normal ▪ Signs and symptoms • Delusions • Hallucinations • Lack of interest in pleasures • Erratic speech o Delirium: condition of impairment in cognitive function that can present with disorientation, hallucinations and delusions o Organic Brain syndrome: temporary or permanent d dysfunction of the brain caused by a disturbance in the physical or psychological functioning of the brain tissue Trauma " • Different types of blast injuries o Mechanisms of Injury ▪ Primary blast injuries: due to the blast itself, doesn’t usually cause external visible injuries ▪ Secondary blast injuries: due to flying debris ▪ Tertiary blast injuries: due to being hurled by the force of the explosion against a stationary object ▪ Quaternary blast injuries: environmental, chemical, or toxic substance injuries (burns, respiratory injury, crush, suffocation, poisoning) o Most susceptible to damage from pressure changes: organs that contain air (ear, lung, GI tract, etc) as well as junctions between tissues of different densities, exposed areas such as head and neck o o The ear is most sensitive to blast injuries: the tympanic membrane detects minor changes in pressure Common injuries: pneumothorax, pulmonary edema, arterial air embolism (alveolar disruption with subsequent air embolization into the pulmonary vasculature), subarachnoid and subdural hematomas, bradycardia, hypotension o ▪ produces: disturbances in vision, changes in behavior, changes in LOC Signs and Symptoms of Internal Bleeding ▪ Delayed CRT ▪ Guarding, distention ▪ Pale/cool/clammy ▪ Bruising around umbilicus ▪ Weak pulse ▪ Tx: bleeding control, Tx for shock o Most common causes of death from blast injuries: neurologic injuries, head trauma • Arterial vs venous bleed o Arterial: bright red, high pressure, spurting, O2 rich o Venous: dark red, low pressure, slow flowing, O2 poor • S&S o Chest injuries ▪ Flail chest: 3 or more broken bones on 2 or more places on 1 side • Tx: bulky dressing taped on 4 sides ▪ Sucking chest wound: open penetrating wound that causes air to enter the pleural space, causing the lung to collapse, can hear a sucking sound during inhalation • Tx: flutter valve or occlusive dressing taped on 3 sides ▪ Commotio cordis: trauma to the chest at a specific heart rhythm that causes cardiac arrest ▪ MI: heart attack stuff ▪ Compartment syndrome: ▪ Aortic DisseCtion: o Cardiac and pulmonary contusion ▪ Cardiac contusion: bruising of the heart muscles: mimic a heart attack, chest pain/discomfort, irregular pulse, change in BP ▪ Pulmonary contusion: injury or bruising of the lung tissue: flail chest, bruising of the chest wall, hypoxia, hypercarbia o ICP ▪ Cushing’s Triad: Hypertension, brady cardia, wide pulse pressure, cheyne stokes respirations • Burns o Depth of the burn ▪ superficial/first degree • involve the epidermis only • skin turns red but does not blister or burn through the top layer ▪ partial thickness/second degree • involves epidermis and some portion of the dermis, but does not destroy the entire thickness of skin or affect subcutaneous layer • moist, mottled, and white to red skin with blisters ▪ full thickness/third degree • extends through all skin layers, may involve subcutaneous layer, muscle, bone, or organs • dry, leathery, white/dark brown/charred black skin • no feeling o Extent of the burn ▪ Rule of Palm: estimates the surface area that has been burned by comparing it to the size of the patient’s palm (1%) ▪ Rule of Nines: estimates the extent of a burn by dividing the body into sections, each representing 9% of the total body surface area • head, arms = 9% circumferentially • legs = 18% circumferentially • chest and abdomen = 36% circumferentially (9% chest, 9% abdomen, 18% back) • genitalia = 1% • Tx of eye injuries o Stabilize the eye with a donut shaped covering, never put pressure, cover the unaffected eye o Irrigate from the inside out, supine • Tx of abdominal injuries o Eviscerations Tx: moist sterile dressing layered with dry sterile dressing o Signs and Symptoms of Internal Bleeding ▪ Delayed CRT ▪ Guarding, distention ▪ Pale/cool/clammy ▪ Bruising around umbilicus ▪ Weak pulse ▪ Tx: bleeding control, Tx for shock • Different types of pneumothorax (simple, spontaneous, tension, hemo etc) o S&S ▪ Simple: accumulation of air in pleural space that does not affect the cardiovascular system • Fractured ribs, decreased breath sounds, lung collapse, subcutaneous emphysema, use of accessory muscles to breath ▪ Spontaneous: accumulation of air in the pleural space around the lungs due to a medical condition rather than blunt trauma • Respiratory distress, sudden stabbing chest pain, pleuritic chest pain, high respiration, hyperinflation ▪ Tension: air accumulating in the pleural space, pushing the heart to one side, causing heart inability to pump • JVD, tracheal deviation, complete collapse of lung, decreased CO, air increases pressure in the chest ▪ Hemo: blood in the pleural space • Chest pain, respiratory distress, signs of shock, decreased sounds on the affected side • Spinal immobilization o See skills • Treating patients with injuries to the extremities o See skills • Treating patients with multisystem trauma o Order of operations OB/peds " • How is an assessment of a peds different from an adults o Start at the feet for children under 6 o Peds can sustain shock for a longer time than adults and compensate for longer periods of time • S&S o Hypoperfusion in a ped ▪ Causes • Diarrhea and Vomiting • Dehydration • Trauma and blood loss • Infection • Abdominal injuries • Allergic reactions • Poisoning • Cardiac problems ▪ Signs • Rapid breathing • Pale, cool, clammy skin • Weak/absent peripheral pulse • Delayed capillary refill • Decreased urine output o Inspect diapers • Changes in mental status • Lack of tears ▪ They will compensate longer and then all of a sudden they will crash • They do this by constricting the vessels in the skin o Impending cardiac arrest in a ped ▪ They become hypoxic (just like an adult) but their heart rate SLOWS DOWN ▪ It will slow down until there is not pulse ▪ The survival rate is 70% • Pediatric assessment triangle (PAT) o Way to form general impression without touching him or her o Work of breathing ▪ Sounds ▪ Positioning ▪ Retractions ▪ Nasal flaring o Appearance ▪ Tone ▪ Gaze ▪ Cry ▪ Consolability o Circulation of the skin ▪ Pallor ▪ Mottling ▪ Cyanosis • S&S in OB o Pelvic Inflammatory Disease (PID) ▪ Infection of the upper organs of reproduction (uterus, ovaries, fallopian tube) ▪ Occurs almost exclusively in sexually active women ▪ Signs and Symptoms •! • Lower abdominal pain (during/after menstruation) • Abnormal/foul smelling vaginal discharge • Increased pain with intercourse • Fever • General malaise • Nausea • Vomiting • Shuffling gait due to pain ! ▪ Can result in increased risk for: Ectopic pregnancy: pregnancy that develops outside uterus, characterized by lower abdominal pain o Sexually Transmitted Diseases (STDs) ▪ Can lead to more serious conditions like PID ▪ Chlamydia • Most common STD in the United States. caused by bacteria • Signs and Symptoms o ! o Usually mild/absent symptoms o Lower abdominal pain o Low back pain o Nausea o o o Fever Pain during intercourse Bleeding between menstrual periods •! • Infection of the cervix can spread to the rectum and progress to PID ▪ Bacterial Vaginosis • Most common vaginal infection, affects women 15-44 y/o, caused by overgrowth of bacteria • Signs and Symptoms o ! o Itching o Burning o Pain o Fishy/foul smelling discharge •! • Can lead to premature birth, low birth weight, make patient more susceptible to other infections, and cause PID ▪ Gonorrhea • Caused by bacteria that grow and multiply rapidly in warm, moist areas of reproductive tract • Signs and Symptoms o ! o Cramping o Abdominal pain o o o o o o o Nausea Vomiting Bleeding between periods Painful urination Burning/itching Yellowish/bloody vaginal discharge Blood associated with sexual intercourse • Can progress to PID and enter bloodstream and brain o Supine Hypotensive Syndrome ▪ Hypotension as a result of fetus compressing the descending aorta and inferior vena cava • Tx: rapid transport on her Left side, towels underneath the right side for support o Diabetes ▪ Gestational Diabetes • Pregnancy induced diabetes • Resolves in most women after delivery • Tx is same as with any other patient with diabetes o Control blood glucose level with diet, exercise, or medications (insulin injections) o EMT care for hyperglycemia or hypoglycemia same as for any other patient ▪ Pale, cool, and clammy, give them candy ▪ Hot and dry, sugar is high o Hypertensive disorders ▪ Preeclampsia • Pregnancy induced hypertension • Develops after 20 week of gestation • Preeclampsia Signs and Symptoms o P – proteinuria o R – rising blood pressure o E – edema (swelling in hands and feet) o Severe or persistent headache o Visual abnormalities (seeing spots, blurred vision, sensitivity to light) o Anxiety ▪ Eclampsia: seizures that occur as a result of hypertension th o Bleeding ▪ Ectopic Pregnancy • When an embryo develops outside the uterus, most often in a fallopian tube • Leading cause of maternal death in the first trimester is internal hemorrhage into the abdomen following rupture of ectopic pregnancy • Signs and Symptoms o Internal bleeding o Missed menstrual cycle o Sudden, severe, unilateral pain in lower abdomen ▪ Abruptio placenta • The placenta separates prematurely from the wall of the uterus • Caused by hypertension or trauma • Suspect when MOI is blunt trauma to abdomen and patient’s S&S are suggestive of shock • Signs and Symptoms o Severe pain o Minimal vaginal bleeding • Tx for shock ▪ Placenta previa • The placenta develops over and covers the cervix • Signs and Symptoms o Minimal pain o Severe vaginal bleeding • Tx for shock • How to deliver a baby in the field o Stages of labor ▪ 1. The onset of contractions to the cervix being fully dilated • This is the longest stage – 16 hours • Breaking of the amniotic sac • Contractions become more regular – intensity of contractions will increase with time ▪ 2. Fetus enters the birth canal to the delivery of the fetus • Once the baby is in the canal, there is no turning back • Crowning – when the baby’s head begins to be pushed out of the vagina ▪ 3. The birth of the new born to the delivery of the placenta ▪ Position the mother in a sitting position with hips elevated 2-4 inches o Baby is born ▪ Suction the mouth and then the nose – use sterile gauze ▪ Cover the babies head and the whole body • Cut the umbilical cord 6 inches from the baby (first clamp) 2 inches from the clamp (second clamp) when stops pulsating • Rub the fundus to stop the vaginal bleeding ▪ Record an Apgar score at 1 minutes and 5 minutes after that • Appearance o Entire newborn is pink o Body is pink but extremities are blue o Entire newborn is blue • Pulse o More than 100 beats/min o Fewer than 100 beats/min o No pulse • Grimace o New born cries and tries to moves foot away from finger being snapped against the foot o New born gives a weak cry in response to stimulus o New born does not cry or react • Activity of muscle o New born resists attempts to straighten hips and knees o New born makes weak attempts to resist o • Respiration o o o New born is completely limp Rapid respirations Slow respirations Absent respirations