Secondquartermidtermstudy Flashcards
1
Q
Describe how the medical direction of an Ems system works and the EMTs role in the process
A
Each EMS system has a physician medical director who authorizes the EMTs in the service to provide medical care in the ield. Although in some systems the individual EMTs may not regularly encounter their medical director, in virtually all systems the appropriate care for each injury, condition, or illness encountered in the field is determined by the medical director and is described in a set of written standing orders and protocols. Standing orders are part of protocols, and they designate what the EMT is required to do for a specific complaint or condition. Providers are not required to consult medical direction before implementing standing orders.
The medical director is the ongoing working liaison between the medical community, hospitals, and the EMTs in the service. If treatment problems arise or different procedures should be considered, they are referred to the medical director for his or her decision and action. To ensure the proper training standards are met, the medical director determines and approves the continuing education and training that are required of each EMT in the service
Medical control is provided either off-line (indirect) or online (direct), as authorized by the medical director. Online medica control consists of direction given over the phone or radio directly from the medical director or a designated physician such as a base station physician at a receiving hospital. The medical direction can be transferred by the physician’s designee; it does not have to be transferred by the physician himself or herself. Off-line medical control consists of standing orders, training, and supervision authorized by the medical director. Each EMT must know and follow the protocols developed by his or her medical director.
The service’s protocols will identify an EMS physician or other designee, usually at a local hospital, who can be reached by radio or telephone for medical control during a call. This is a type of direct online medical control. On some calls, once the ambulance crew has initiated any immediate urgent care and gives their radio report, the online medical control physician may either confirm or modify the proposed treatment plan or may prescribe any additional special orders that the EMTs are to follow for that patient. The point at which the EMTs should give their radio report or obtain online medical direction will vary.
2
Q
A man with chest pain tells the EMTs that he hurt his chest 2 weeks ago. The EMTs conclude that the patient likely has a fractured rib or other chest wall injury. At the hospital, the man is diagnosed with acute myocardial infarction. Which of the following decision traps does this scenario depict?
A
Anchoring
3
Q
A 35-year-old obese woman is complaining of localized pain in the right upper quadrant with referred pain to the right shoulder. The MOST likely cause of her pain is:
A
acute cholecystitis.
4
Q
Pathophysiology is the study of the functional changes that occur when the body reacts to a particular:
A
Disease
5
Q
A patient has a large accumulation of blood in the sac surrounding the heart. Which of the following types of shock would this condition cause?
A
Obstructive
6
Q
A 60-year-old male presents with acute respiratory distress. He is conscious and alert, has pink and dry skin, and has respirations of 22 breaths/min with adequate depth. Which of the following treatments is MOST appropriate for this patient?
A
Oxygen via nonrebreathing mask and a focused secondary assessment
7
Q
A 38-year-old male with a history of schizophrenia is reported by neighbors to be screaming and throwing things in his house. You are familiar with the patient and have cared for him in the past for unrelated problems. Law enforcement officers escort you into the residence when you arrive. The patient tells you that he sees vampires and is attempting to ward them off by screaming and throwing things at them. He has several large lacerations to his forearms that are actively bleeding. The MOST appropriate way to manage this situation is to:
A
restrain the patient with appropriate force in order to treat his injuries.
8
Q
Abdominal thrusts in a conscious child or adult with a severe upper airway obstruction are performed:
A
until he or she loses consciousness.
9
Q
Clinical signs of labored breathing include all of the following, EXCEPT:
A
shallow chest movement.
10
Q
Your initial attempt to ventilate an unresponsive, apneic 30-year-old man is met with resistance and you do not see the chest rise. Your second ventilation attempt is also unsuccessful. You should:
A
perform 30 chest compressions.
11
Q
The diastolic blood pressure represents the:
A
minimum amount of pressure that is always present in the arteries.
12
Q
You and your partner are attempting to resuscitate a middle-aged female in cardiac arrest. Because of the remote geographic location, you are unable to contact medical control. What should you do?
A
Follow locally established protocols or standing orders.
13
Q
A decrease in blood pressure may indicate:
A
loss of vascular tone.
14
Q
The ____deals with the well-being of the EMT, career progression, and EMT compensation
A
human resources department
15
Q
Several attempts to adequately open a trauma patient’s airway with the jaw-thrust maneuver have been unsuccessful. You should:
A
carefully perform the head tilt-chin lift maneuver.
16
Q
A patient with atherosclerotic heart disease experiences chest pain during exertion because:
A
the lumen of the coronary artery is narrowed and cannot accommodate increased blood flow.
17
Q
Which of the following statements regarding glucose is correct?
A
The brain requires glucose as much as it requires oxygen.
18
Q
A 23-year-old male experienced severe head trauma after his motorcycle collided with an oncoming truck. He is unconscious, has agonal gasps, and has copious bloody secretions in his mouth. How should you manage his airway?
A
Alternate oropharyngeal suctioning and ventilation with a bag-mask device.
19
Q
When pulling a patient, you should extend your arms no more than ._ _ in front
of your torso
A
15” to 20*
20
Q
The proper depth of chest compressions on a 9-month-old infant is:
A
one third the diameter of the chest, or about 1½ inches.
21
Q
In late adults, the amount of air left in the lungs after expiration of the maximum amount of air:
A
increases, which hampers diffusion of gases because of the stagnant air that remains in the alveoli.
22
Q
Assessment of a patient with hypoglycemia will MOST likely reveal:
A
combativeness.
23
Q
In contrast to inhalation, exhalation:
A
is a passive process caused by increased intrathoracic pressure.
24
Q
A 40-year-old male crashed his motorcycle into a tree. He is semiconscious, has snoring respirations, and has a laceration to the forearm with minimal bleeding. You should:
A
open his airway with the jaw-thrust maneuver.
25
When assessing an 80-year-old patient in shock, it is important to remember that:
age-related changes in the cardiovascular system might make the patient less able to compensate for decreased perfusion.
26
The respiratory distress that accompanies emphysema is caused by:
chronic stretching of the alveolar walls.
27
A 3/-year-old male has an apparent foreign body airway obstruction. He is conscious and alert and is coughing forcefully. His skin is pink, warm, and moist.
The MOST appropriate treatment for this patient includes:
encouraging him to cough and transporting.
28
The impedance threshold device (ITD) may improve circulation during active compression decompression CPR by:
limiting the amount of air that enters the lungs during the recoil phase between chest compressions, which results in negative intrathoracio pressure and improved cardiac filling.
29
In the presence of oxygen, the cells convert glucose into energy through a process called:
aerobic metabolism.
30
When obtaining patient care orders from a physician via a two-way radio, it is important to remember that:
the physician's instructions are based on the information you provide.
31
A by product of involuntary muscle contraction and relaxation is:
Heat
32
What should be given in an oral report?
The verbal report should consist of the patient's priority conditions, prior care, current state, and immediate needs. The numerous other patient details should be transferred via a paper or electronic report. Avoid clouding the handover with information that is not immediately critical. (age, gender, chief complaint was what u wrote on study guide so idk)
33
When obtaining patient care orders from a physician, why is it important to give them all of the information?
Because of the large number of EMS calls to medical control, your radio report must be precise and well organized and must only contain important information. In addition, because you need specific directions on patient care, the information that you provide to medical control must be accurate. Remember, the physician on the other end bases his or her instructions on the information you provide. Orders that are unclear or seem inappropriate or incorrect should be respectfully questioned. Do not blindly follow an order that does not make sense to you. As discussed earlier, you should use proper medical terminology when giving your report. Never use codes when communicating with medical control unless you are directed by local protocol to do so. Most medical control systems handle many EMS agencies and will most likely not know your unit's special codes or signals.
To ensure complete understanding, once you receive an order from medical control, such as an order for a medication or
the denial of a request for a particular treatment, you must repeat the order back, word for word, and then receive confirmation. This helps to eliminate confusion and the possibility of poor patient care. Orders that are unclear or seem inappropriate or incorrect should be questioned. Do not blindly follow an order that does not make sense to you. The physician may have misunderstood or may have missed part of your report. In that case, the physician may not be able to respond appropriately to the patient's needs. The role of medical control will be discussed further in Chapter 12, Principles of Pharmacology
34
What should be given in an oral report? (different section, this might be the answer idk)
The patient report should follow a standard format established by your EMS system. The report commonly includes the following 10 elements:
1. Your unit identification and level of services. Example: "Columbus Fire 2-BLS."
2. Any special "alert" indicated by the patient's status or care. For example, a patient suffering from a severe traumatic injury will be a "trauma alert," or a heart attack may call for a "cardiac alert."
3. The receiving hospital and your estimated time of arrival. Example: "Columbus Community Hospital, ETA 10 minutes," or
"patient transport code" according to local protocols
4. The patient's age and sex. Example: "An 86-year-old woman." The patient's name should not be given over the radio because it may be overheard. This would be a violation of the patient's privacy.
5. The patient's chief complaint or your chief concern regarding the patient's problem and its severity. Example: "Patient reports severe pelvic and less severe back pain.
6. A brief history of the patient's current problem. Example: "Patient fell into bathtub at 0300 this morning and wasn't able to get out." Other important history information that may pertain to the current problem should also be included, such as
"The patient has diabetes and takes insulin.
7. A brief report of physical findings. This report should include level of consciousness, the patient's general appearance, pertinent abnormalities noted, and vital signs. Example: "The patient is alert and oriented, has adequate circulation based on examination of mucous membranes inside the inner lower eyelid and capillary refill, and is cold to the touch. We noted crepitus in the pelvic girdle. Her blood pressure is 112/84, pulse is 72, and respirations 14."
8. A brief summary of the care given and any patient response. Example: "We have applied a cervical collar. She still has pulse, motor, and sensory function distally in all four extremities."
9. A brief description of the patient's response to the treatment provided.
10. Determine whether the receiving facility has any additional questions or orders.
35
How does the handover report differ from the radio report
Patient care transfer occurs during your handover report, not your radio report. Once a hospital staff member is ready to take responsibility for the patient, you should provide that person with a formal oral report of the patient's condition.
The following components may be included in your handover report, depending on the process at the receiving hospital:
• Situation. The patient's name and the chief complaint or chief concern
• Background. A brief description of the nature of the problem and pertinent history
• Assessment. Key assessment findings and any changes in the patient's condition
• Treatment. Treatment provided to the patient prior to arrival
36
What are standing orders and when do you follow them
The simplest backup plan relies on written standing orders. Standing orders are written documents that have been signed by the EMS system's medical director. These orders outline specific directions, permissions, and sometimes prohibitions regarding patient care. By their very nature, standing orders do not require direct communication with medical control. When properly followed, standing orders or formal protocols have the same authority and legal status as orders given over the radio. They exist to one extent or another in every EMS system and can be applied to all levels of EMS providers. Other backup plans can involve using a cell phone and calling the ED directly. The problem with this approach is that the conversation may not be recorded. Medical command conversations are often recorded for the purpose of quality Improvement.
37
When does the legal transfer of care occur at the hospital
Verbal report
38
The front surface of the body
Anterior (ventral)
39
The back surface of the body
Posterior (dorsal)
40
Closest to the head
Superior
41
Closest to the feet
Inferior
42
Closest to the point of attachment
(closer to the trunk)
Proximal
43
Farthest from the point of attachment (farther from the trunk or nearer to the free end of the extremity
Distal
44
Closest to the midline
Medial
45
Farthest from the midline
Lateral
46
Farthest from the surface of the skin (farther inside the body and away from the skin)
Deep
47
Closest to the surface of the skin
(closer to or on the skin)
Superficial
48
A body part that appears on both sides of the midline is
Bilateral. For example, the eyes, ears, hands, and feet are bilateral structures, meaning there is one on each side of the midline. This is also true for structures inside the body, such as the lungs and kidneys. Something that appears on only one side of the body is said to occur unilaterally. For example, unilateral chest expansion means that only one lung is expanding with inhalation (such as with a pneumothorax). Pain that occurs on only one side of the body could be called unilateral pain.
49
What is caused by involuntary muscle contraction and relaxation?
Heat
50
Shock resulting from lack of blood volume
Circulating blood volume is inadequate to deliver sufficient oxygen and nutrients to the body
Trauma (blood loss results in inability to transport oxygen and nutrients)
• Severe vomiting/diarrhea (substantial loss of water can lead to decreased circulating blood volume; there is less blood to transport oxygen and nutrients)
Hypovolemic shock
51
Shock associated with impaired heart function
Compromised heart function prevents wastes and nutrients from moving around the body effectively
Weakened heart muscles as a result of myocardial infarction (heart attack) or other conditions
• Very fast or very slow heart rate (can prevent blood from moving effectively, blood pressure drops, and perfusion is diminished)
Cardiogenic
52
Shock resulting from blocked blood flow back to or through the heart
Severe lung collapse (tension pneumothorax) (pushes on the vena cava, preventing it from returning blood to the heart)
• Accumulation of fluid in the sac surrounding the heart (prevents heart from filling)
• Large blood clot in pulmonary artery (pulmonary embolus) (can prevent right ventricle from pumping blood out of the heart into the lungs)
Obstructive
53
Shock resulting from severe allergic reaction
Severe allergic reaction (blood vessels dilate, blood pressure drops, and perfusion decreases)
Anaphylactic
54
Shock resulting from severe infection.
Blood vessels dilate and decreased blood pressure results; leads to dysfunction in multiple organ systems and death
Severe infection (blood vessels dilate, blood pressure drops, and perfusion decreases
Septic
55
Shock resulting from injury to the nervous system.
For example, spinal cord injury may result in dilation of vessels (vasodilation) below the level of the injury
High spinal cord injury (blood vessels dilate, blood pressure drops, and perfusion decreases)
Neurogenic
56
Effects of shock on the body
The effects of inadequate perfusion on the body are similar to those of respiratory compromise. The level of oxygen supplied to the tissues falls. This causes the cells to engage in anaerobic metabolism, which results in increased lactic acid production. A severe metabolic acidosis ensues, leading to increased levels of carbonic acid within the blood. Patients who can compensate increase their breathing rate and depth, thereby increasing their minute volume
Baroreceptors detect the decreased blood pressure and initiate the release of epinephrine and norepinephrine. The heart rate will increase, the heart will beat more forcefully, and the blood vessels will constrict. The body's goal is to maintain blood pressure to the areas of the body that are unable to survive without oxygen: the brain and the heart.
Another compensatory mechanism, particularly with hypovolemic shock, is the movement of fluid outside of the cells and outside of the blood vessels (interstitial fluid) into the capillaries. This helps refill the blood vessels and restore some fluid volume so the heart has enough liquid to pump. However, in other forms of shock such as septic and anaphylactic shock
the capillaries leak and volume from the blood vessels (intravascular volume) moves into the interstitial space. This loss of vascular fluid means there is less blood returning to the heart to pump.
Ultimately the effect of all types of shock is decreased availability of fuel for the cells and impairment of cellular metabolism. Once a certain level of tissue hypoperfusion is reached, cell damage proceeds in a similar manner regardless of the underlying cause of the shock
57
Metabolism that takes place in the absence of oxygen; the main by-product is lactic acid
Anaerobic metabolism
58
Cells use oxygen to turn available nutrients into chemical energy through the biochemical process of metabolism.
Adenosine triphosphate (ATP) is used in energy metabolism and storage. Cells prefer to use oxygen for this process, referred to as_____ (meaning "with air"), as doing so provides the cells with 15 times more ATP than is possible without oxygen. The waste products of aerobic metabolism are carbon dioxide and water.
aerobic metabolism
59
In the absence of oxygen, most cells turn to a faster yet less efficient means of producing ATP called___(without air). The most well-known by-product of____ is lactic acid, which is the material that causes muscle burning during anaerobic activities like weight lifting. Most cells can tolerate_____ for only about 1 to 3 minutes, and some specialized cells (such as the heart and brain) are unable to survive without a constant supply of oxygen. Brain cells, for example, begin to die after only 4 to 6 minutes without oxygen.
As lactic acid and other wastes accumulate around the cells, the area becomes toxic. Cells subjected to this toxic waste may die. Given enough time and a large enough number of affected cells, whole organs may fail, and the individual may go into cardiac arrest.
The main force enabling all of this movement of material oxygen, waste, nutrients—is diffusion. Recall that when you
breathe, oxygen moves from an area of higher concentration to one of lower concentration.
anaerobic metabolism
60
Normal respiratory rate for adult
12 to 20
61
Normal respiratory rate for children
12 to 40
62
Normal respiratory rate for infants
30 to 60
63
The study of how normal physiologic processes are affe ted by disease
Pathophysiology
64
Metabolism that takes place in the absence of oxygen; the main by-product is lactic acid
Anaerobic metabolism
65
Metabolism that can proceed only in the presence of oxygen
Aerobic metabolism
66
When cells function with oxygen, they use aerobic metabolism.
They generate large amounts of ATP (cellular energy) and produce wastes of carbon dioxide and water.
• When cells function without oxygen, they use___
They generate small amounts of ATP. (cellular energy) and produce lactic acid as waste.
anaerobic metabolism
67
Why are infants belly breathers?
The rib cage of an infant is less rigid and the ribs sit horizontally. This explains the distinctive diaphragmatic breathing
(belly breathing) typically seen in infants.
68
In more modern times, that number has increased to approximately___ years, with a maximum life expectancy of approximately___ years. As a result, more and more people will live to become an older adult (age 61 years and older) (FIGURE 7-12). How long an individual lives is determined by many factors, including his or her birth year and country of residence. These two factors correlate with advances in public health, enhanced awareness of healthy eating habits, improved attitudes toward exercise, and access to ever-advancing medical care. Currently, older adults are staying active longer than their ancestors. Thanks to medical advances, they are often able to overcome numerous medical conditions, but may need multiple medications to do So
78. Max 120
69
Cardiac function declines with age, due in large part to____, a condition characterized by the buildup of cholesterol and calcium along the inner walls of blood vessels, resulting in the formation of plaque. As plaque accumulates, the flow of blood through the affected vessels becomes restricted or blocked entirely. More than 60% of people older than 65 years have atherosclerotic disease.
Additional cardiovascular effects of aging include a decrease in heart rate, a decline in cardiac output (the amount of blood pumped by the heart per minute), and diminished ability of the heart to increase cardiac output to meet the body's demands. These changes translate into a heart that is less able to cope with exercise or disease. In the event of a life-threatening illness, the body typically preserves blood pressure by increasing the heart rate. However, because cardiac muscle tends to weaken with age, the increased rate may cause damage to the heart. Combined with atherosclerosis of sufficient severity, the damage could prove fatal.
Because the vascular system of the older adult becomes stiff, blood vessels are unable to dilate and contract as effectively. As a result, the diastolic blood pressure increases and the heart must work harder to overcome vascular resistance to move blood throughout the body. Over time, the increase in workload can be detrimental to the heart. Human blood cells originate within bone marrow. But with advancing age, bone marrow is replaced by fatty tissue.
Consequently, the loss of marrow equals a reduction in the body's ability to manufacture new blood cells. Alone, this change is not cause for alarm. However, in the presence of traumatic injury in which a relatively large volume of blood is lost quickly, the impeded ability to replace lost cells can have devastating effects.
atherosclerosis
70
In older adults, the airway increases in size. However, the surface area of the____ decreases, as do the elasticity of the lungs and the strength of the intercostal muscles and diaphragm. Together, these factors make breathing more laborious for older adults. By the time the older adult is 75 years old, his or her vital capacity (the volume of air moved during the deepest inspiration and expiration) has declined to about 50% of that of a young adult.
The chest becomes more rigid, yet more fragile. Instead of bending and flexing under stress, the calcified rib case is more susceptible to fracture. Normally, these changes in the respiratory system are gradual, often going unnoticed until the onset of a severe, life-threatening condition, in which case the lack of respiratory reserve becomes more pronounced.
As the patient ages, the structures protecting the upper airway decrease in function. Cough and gag reflexes diminish along with the ability to clear secretions. The cilia that line the airway dwindle, and sensation within the airway declines, making it more difficult for the older adult to maintain upper airway patency. Thus, older adults are at greater risk of aspiration and airway obstruction.
When a younger patient inhales, the airway maintains its shape, allowing air to enter. As the smooth muscles of the lower
airway weaken with age, strong inhalation can cause the walls of the airway to collapse inward, producing inspiratory wheezing, lower flow rates, and air trapping in the alveoli (incomplete expiration). Because of these reductions in function, and because the white blood cells of the airway are less aggressive toward invading organisms, the older patient is more susceptible to lung infections.
alveoli
71
Endocrine function also declines with age. Glucose metabolism slows, while insulin production decreases. Sexually, men often continue to produce sperm long into their 80s (although the rigidity of the penis typically diminishes over time). The size of a woman's uterus and vagina decreases. Hormone production in both sexes gradually declines, and although sexual desire may lessen, it does not ordinarily cease entirely.
Older patients
72
Age-related changes in gastric and intestinal functions may inhibit nutritional intake and utilization. Tooth loss can make chewing more difficult; taste buds become less sensitive to salty and sweet foods; and food in general may be perceived as bland and flavorless, as the senses of smell and taste response begin to fade. A decrease in saliva secretion impairs the body's ability to break down complex carbohydrates. Similarly, gastric acid secretion diminishes. Peristalsis (the process by which intestinal contractions move food along the digestive tract) slows with age, sometimes resulting in constipation and/or suppressed feelings of hunger. And because blood flow to the intestines can drop by as much as 50%, the extraction of vitamins and minerals from digested food can also wane. Gallstones become increasingly common, and changes in the elasticity of the anal sphincter can lead to fecal incontinence.
Older patients
73
Between the ages of 20 to 90 years, the kidneys will decrease in size by 20%, and their filtration capabilities will decline by as much as 50%. This is due in part to a decrease in blood supply to the nephrons of the kidneys.____ filter blood within the kidney. In addition, the number of nephrons declines between the ages of 30 and 80 years. As a result of the changes, the renal system's ability to remove waste from the body declines, as does its ability to conserve fluids when needed.
Nephrons
74
By the time a person is 80 years of age, the brain has decreased in weight by as much as 10% to 20%. Motor and sensory neural networks are slower and less responsive. However, the brain's metabolic rate and oxygen consumption remain unchanged. And although it is generally true that the infant brain has a larger number of neurons than its adult counterpart, the adult brain is much more flexible. This is because the number of interconnections between neurons increases with age.
These connections produce redundancies within the brain that permit the loss of neurons without a loss of knowledge or skill. However, although cognitive function remains intact throughout most of older adulthood, mental function often declines in the 5 years immediately preceding death.
One consequence of the reduced number of neurons is the alteration of sleep patterns. Instead of sleeping through the
night, the older adult may take a nap during the day and be awake late at night. It is not uncommon for older adults to develop a biphasic (two-phased) sleep cycle (eg, sleeping from 0100 to 0600 hours and then taking a nap from 1200 to 1500 hours)
Throughout life, the cranial vault is almost entirely occupied by the brain, the meningeal layers, and the cerebrospinal fluid between these layers. As such, there is virtually no empty space. However, in older adults, the age-related shrinkage of the brain creates a void between the brain and the outermost layer of the meninges. The resulting space gives the brain room to move inside the cranium (FIGURE 7-14). As such, any mechanism that causes a rapid or forceful shifting of the brain has the potential to result in the tearing of bridging veins. Subsequent bleeding into the open space may go unnoticed for some time.
Older patients
75
The functioning of the peripheral nervous system slows with age. Sensations become diminished and may be misinterpreted. Nerve endings deteriorate, and the ability of the skin to sense the surroundings becomes hindered. Hot, cold, sharp, and wet objects all can create dangerous situations because the body cannot sense them quickly enough. Combined with prolonged reaction time and slower reflexes, these sensory alterations may contribute to the higher incidence of falls and trauma in older adults.
Older patients
76
Pupillary reaction and ocular movements become more restricted with age. The pupils are generally smaller in older patients, and the opacity of the eye's lens diminishes visual acuity and causes the pupils to be sluggish in their reaction to light. Visual distortions are also common in older people. Thickening of the lens makes it more difficult for the eye to focus, especially at close range. Peripheral fields of vision narrow, and increased sensitivity to glare constricts the visual field.
In late adulthood, hearing loss is about four times more common than vision loss. Changes in several hearing-related structures may lead to a loss of high-frequency hearing or even deafness. Even so, although it is often assumed that all older adults have difficulty hearing and seeing, many older adults have remarkably good vision and hearing. Some may need eyeglasses or hearing aids, but this does not mean they are almost deaf or nearly blind.
Older patients
77
Statistics indicate that 95% of older adults live at home. They may have the assistance of family, friends, or home health care, but they are shown to be relatively healthy, active, and independent. The increasing number of older adults in the United States as a result of the baby boom of the 1940s through the 1960s has produced a need for additional assisted living facilities. These facilities allow older adults to live in campus-based communities with people in their own age group, while enjoying the independence and privacy of their own apartment and the security of nursing care, maintenance, and food preparation, if desired (FIGURE 7-15). Unfortunately, these facilities can be expensive.
Psychosocial changes of older patients
78
Psychosocial changes of older patients
An additional and important consequence of congregate living facilities is the proximity of the residents to one another.
Although having people close to each other is advantageous from a social interaction standpoint, it limits the natural social distancing that occurs when people live completely independently. Residents of these communities interact with one another and with caregivers on a close, regular basis, which has the disadvantage of enhancing the spread of contagious diseases such as influenza virus and coronavirus. Furthermore, residents of these facilities are necessarily more susceptible to the consequences of these diseases. This helps explain the disproportionate effect that epidemics and pandemics associated with these diseases have on older adults living in continuing care, assisted living, and nursing home communities
Few things in life cause more worry and stress than money problems. Older adults, in particular, may worry about the rising cost of health care. At times, some may have to choose between paying for groceries or paying for medications. More than 50% of all single women in the United States who are 60 years of age or older are living at or below the poverty level.
The financial struggle is compounded by the fact that currently, compared to past generations, families of older adults are less likely to assume responsibility for their aging family members.
One challenge facing older adults is the growing realization of their mortality. Everyone dies; but for younger people, the concept of death is little more than an intellectual exercise with a distant connection to reality. By contrast, the death of a spouse, close friend, or other loved one with whom the older adult may have shared one-half of a century or more his or her life, can be a strong reminder that death is not only inevitable, but close by.
For some, the loss of loved ones leaves the older adult without a source of social support, and this places them at greater
risk of isolation and depression. Fortunately, many older adults are happy and actively participating in life. With good financial resources and a good support system of family and friends, adults in their 80s can enjoy life and continue to feel
79
Explain the general considerations required of EMTs to safely move patients without causing the patient further harm and while protecting themselves from injury
Communication, proper body mechanics and maintaining physical fitness
80
In lifting, if the shoulder girdle is aligned over the pelvis and the hands are held close to the legs, the force that is exerted against the spine occurs in an essentially straight line down the vertebrae in the spinal column. Therefore, with the back properly maintained in an____, little strain occurs against the muscles and ligaments that keep the spinal column in alignment, and significant weight can be lifted and carried without injury to the back (FIGURE 8-4). However, you may injure your back if you lift while leaning forward, or even if you lift while the back is straight, while you are bent significantly forward at the hips.
upright position
81
The____ is both the mechanical weight. bearing base of the spinal column and the fused central posterior section of the pelvic girdle.
sacrum
82
When lifting, spread your legs approximately shoulder width apart, and place your feet so that your center of gravity is properly balanced between them. Your weight should be balanced on the balls of your feet, not your toes.
Then, with the back held upright, bring your upper body down by bending the legs. Once you have properly grasped the patient or stretcher and made any necessary adjustments in the location of your feet, lift the patient by straightening your legs until you are in a standing position and then curling your arms up to waist height. If you still have not reached the desired height, reposition your legs so they are closer together and repeat the process. Because the leg muscles are regularly exercised by walking, climbing stairs, or running, they are well developed and strong.
Therefore, as well as being the safest method, lifting by extending the properly placed flexed legs is also the most powerful way to lift. This method is appropriately called a____.
power lift
83
When you use a body drag to move a patient, your back should always be locked in a____ created by tightening your abdominal muscles, not curved laterally or bent laterally.
slight curve
84
When there is a potential for danger to you or the patient, use an ____ to drag or pull a patient to a safe place before assessment and care are provided. The risk of serious harm or death due to fire, explosives, or hazardous materials, your inability to protect the patient from other hazards, or your inability to gain access to others in a vehicle who need lifesaving care all are situations in which you should use an_____. In such conditions, protecting the cervical spine is secondary to rapidly getting your patient to safety.
The only other time you should use an_____ is if you cannot properly assess the patient or provide critical
emergency care because of the patient's location or position.
If you are alone and danger at the scene makes it necessary for you to use an_____, regardless of a patient's injuries, you should use a drag to pull the patient along the long axis of the body. Remember that it is impossible to remove a patient quickly from a vehicle while providing as much protection to the spine as would a spinal immobilization device such as a Kendrick extrication device (KED). However, if you follow certain guidelines during the move, you can usually remove a patient from a life-threatening situation without causing further injury to the patient.
emergency move
85
You can move a patient on his or her back along the floor or ground by using one of the following methods : pull on the patients clothing in the neck and shoulder area, • If the shirt has buttons, the top two should be undone to prevent the patient from choking.
• Place the patient onto a blanket, coat, or other item that can be pulled (FIGURE 8-14B).
• Rotate the patient's arms so that they are extended straight on the ground beyond his or her head, grasp the wrists, and, with the arms elevated above the ground, drag the patient (FIGURE 8-14C).
• Place your arms under the patient's shoulders and through the armpits, and, while grasping your opposite wrist, drag the patient backward
Emergency clothes drag
Blanket drag
Arm drag
Arm-to-arm drag
86
If you are alone and must remove an unresponsive patient from a vehicle, first move the patient's____ so they are clear of the pedals and are against the seat. Then rotate the patient so that his or her back is positioned toward the open vehicle door. Next, place your arms through the armpits and support the patient's head against your body (FIGURE 8-15A). While supporting the patient's weight, drag the patient from the seat. If the legs and feet clear the vehicle easily, you can rapidly drag the patient to a safe location by continuing this method (FIGURE 8-15B). If the legs and feet do not clear the vehicle easily, you can slowly lower the patient until he or she is lying on his or her back next to the vehicle, clear the legs from the vehicle, and, as previously described, use a long-axis body drag to move the patient a safe distance from the vehicle.
legs
87
An _____may be necessary to move a patient with an altered level of consciousness, inadequate ventilation, or shock (hypoperfusion). An extreme weather condition may also make an urgent move necessary. In some cases, patients must be urgently moved from the location or position in which they are found. When a patient who is sitting in a vehicle must be urgently moved, use the rapid extrication technique.
urgent move
88
A technique to move a patient from a sitting position inside a vehicle to supine on a backboard in less than 1 minute when conditions do not allow for standard immobilization
Rapid extrication technique
89
The backboard, short backboard, and vest-type devices are known as spinal immobilization devices. Normally, you would use an extrication-type vest or short backboard device to immobilize a seated patient with a suspected spinal injury before removing the patient from the vehicle. (See Chapter 39, Vehicle Extrication and Special Rescue.) However, proper placement of either of these devices on the patient usually requires between 6 and 8 minutes, and in some cases even longer. By using the ___\instead, the patient can be moved from sitting in the vehicle to supine, on a backboard if required, in 1 minute or less. However, the rapid nature of this type of extrication can potentially increase the risk of damage if the patient has a spinal injury. Because of this possible patient injury, all available options need to be considered prior to performing a rapid extrication. TABLE 8-3 describes the situations in which you should use the rapid extrication technique.
rapid extrication technique
90
Situations in Which to Use the Rapid Extrication Technique
• The vehicle or scene is unsafe.
• Explosives or other hazardous materials are on the scene.
• There is a fire or a danger of fire.
• The patient cannot be properly assessed before being removed from the vehicle.
• The patient has a life-threatening condition
• The patient blocks your access to another seriously injured patient.
91
In such cases, the delay that occurs in applying immobilization devices is a contraindication. However, the manual support and stabilization that you provide when using the rapid extrication technique produce a greater risk of spine movement. Because of this increased risk, do not use the ____if no urgency exists. If the patient is able to stand and pivot to the stretcher, it is safer to have them do so.
The rapid extrication technique requires a team of three providers who are knowledgeable and practiced in the procedure. Take the following steps when using the rapid extrication technilue (SKILL DRILL 8-7). Whether a backboard is used for this skill will depend on your local protocols. Here, use of a backboard is included.
rapid extrication technique
92
Performing the rapid extrication technique
The first provider provides in-line manual support of the head and cervical spine
The second provider gives commands, applies a cervical collar, and performs the primary assessment
The second provider supports the torso. The third provider free the patients legs from the pedals and moves the legs together, without moving the pelvis or spine.
The second provider and the third provider rotate the patient as a unit in several short, coordinated moves. The first provider (relieved by the fourth provider as needed) supports the patient's head and neck during rotation (and later steps).
The first (or fourth) provider places the backboard on the seat against the patient's buttocks. (Use of a backboard may depend on local protocols.)
The third provider moves to an effective position for sliding the patient. The second and the third providers slide the patient along the backboard in coordinated 8- to 12-inch (20- to 30-cm) moves until the patient's hips rest on the backboard.
The third provider exits the vehicle and moves to the backboard opposite the second provider. They continue to slide the patient until the patient is fully on the backboard.
The first (or fourth) provider continues to stabilize the head and neck while the second provider and the third provider carry the patient away from the vehicle and onto the prepared stretcher.
93
Because of the weight and large girth of bariatric patients, they may not fit comfortably or safely on the standard wheeled stretcher. As a result, a specialized type of wheeled stretcher has been developed, called a bariatric stretcher (FIGURE 8-20).
This type of stretcher is similar in design to the common wheeled stretcher; however, it has several differences. Bariatric stretchers typically have a wider patient surface area to allow for increased comfort, and in addition ensure the patient's dignity is maintained during transport. Bariatric stretchers also have a wider wheelbase, allowing for increased stability when rolling the patient over uneven terrain. Bariatric stretchers are sometimes equipped with optional features such as a tow package, which allows an ambulance-mounted winch to assist in loading the patient into the ambulance, decreasing the potential for EMT back injuries. Another optional feature is telescoping side lift handles, which provide increased leverage when lifting with multiple providers. However, the most important feature of the bariatric stretcher is the increased weightlifting capacity. Typical wheeled ambulance stretchers, depending on manufacturer ratings, allow for a maximum weight of 650 lb (295 kg). Bariatric stretchers are usually able to support maximum weight as high as 1600 (725 kg) pounds when rolled in the lowest position.
Bariatric stretchers
94
A____ is a stretcher with a strong, rectangular, tubular metal frame and rigid fabric stretched across it (FIGURE 8-22). Portable stretchers do not have a second multipositioning frame or adjustable undercarriage. Some models have two wheels that fold down about 4 inches (10 cm) underneath the foot end of the frame and legs of a similar length that fold down from the head end at each side. The wheels make it easier to move the loaded stretcher. The legs should not be used as handles.
portable stretcher
95
A____ forms a rigid stretcher that conforms around the patient's sides and does not extend beyond them. When these stretchers are extended, they are particularly useful when you must remove a patient from or through a confined space.
Certain flexible stretchers can also be used if the patient must be belayed or rappelled by ropes.
flexible stretcher (Reeves I think)
96
You can use a____ to immobilize the torso, head, and neck of a seated patient with a suspected spinal injury until you can immobilize the patient on a backboard. Short backboards are 3 to 4 feet long (approximately 1 m). However, the wooden short backboard has generally been replaced with a vest-type device, such as the KED, that is specifically designed to immobilize the patient until he or she is moved from a sitting position to a supine position on a backboard
short backboard
97
Another alternative to the backboard is the____. With this device, the patient is placed on the mattress and the air is removed from the device, allowing it to mold around the patient. It fits snugly to the curvatures and contours of the body and limits pressure-point tenderness. Padding may be used for tender areas but is not required for most patients. The____ is seen as equivalent to padding to secure the patient's neck and spine and is more comfortable for the patient than the long spine board. See Chapter 29, Head and Spine Injuries, for more information about the__
vacuum mattress.
98
The____ fits snugly to the curvatures and contours of the body and limits pressure-point tenderness.
vacuum mattress
99
When you need to transport a neonatal patient from one hospital to another, the common wheeled ambulance stretcher will not suffice. To safely transport a neonatal patient, the patient must be placed inside of an isolette, sometimes referred to as an incubator. The isolette keeps the neonatal patient warm with moistened air in a clean environment and helps to protect the infant from noise, drafts, infection, and excess handling. These specialized transport devices come in one of two forms: an isolette that is placed directly on top of the wheeled stretcher and secured with seat belts or a free-standing isolette that is secured into the back of the ambulance, taking the place of the standard stretcher
Neonatal isolettes
100
Gradually, emergency health care providers recognized that by working as a unified team from first patient contact to patient discharge, it was possible to improve individual and team performance, patient and provider safety, and, ultimately, patient outcomes. This concept is known as the____
continuum of care
101
Explain the different ways of effectively communicating with the team members
For team members to collaborate successfully, you must communicate effectively with one another. Four important elements of team communication include:
• A clear message. Speak calmly, confidently, and concisely so that the information delivered or the action requested is clear to your listeners. Be clear who you are speaking to by using names or ranks when giving direction, as opposed to just asking "someone" to do a task.
• Closed-loop communication. When a team member speaks, you should repeat the message back to him or her. This technique helps confirm that you heard and understand the message, and will act on it.
• Courtesy. All team members expect and deserve to be spoken to politely. "Please" and "thank you" do not take that much time.
• Constructive intervention. Sometimes it is necessary for you to respectfully question or correct team members (or the team leader) if you believe a mistake has been or is about to be made. This technique is not only allowed and encouraged—it is essential for effective team performance.
102
Traps that frequently lead to decisions-maling errors in Ems are
Bias, anchoring, and overconfidence
103
Everyone has biases. Biases are fixed beliefs about something. Once established, they are hard to rethink. It can be harmful when an EMT remains locked into the bias and considers only one possible idea, ignoring or not seeking other data.
For example, suppose a patient has fallen and has an altered level of consciousness. This patient is known to be an alcoholic and has an odor resembling alcohol on his breath. The EMT assumes he is drunk and while gathering the patient's history asks only questions that follow that path. As a result, the EMT fails to ask detailed questions about the nature of the fall or the patient's other signs and symptoms and misses the fact that the patient has sustained a head injury.
Bias
104
Another type of error,_____, occurs when the EMT settles on one possible cause of the patient's problems early (sometimes before the call) and fails to consider other options. For example, EMTs arrive to find a 24-year-old woman with a history of asthma who is short of breath. They quickly administer a breathing treatment and begin transport without completing their assessment. Due to their incomplete assessment, they fail to realize that, although the patient does have asthma, today she is having a life-threatening allergic reaction (anaphylaxis), and her condition worsens en route to the hospital.
Anchoring
105
______is another decision trap that some EMTs fall into. It occurs when the EMT overestimates his or her ability.
In this case, ability may apply to skills such as emergency driving, assessment, splinting, or decision making.
________may cause the EMT to ignore others when they disagree with a decision, resulting in actions that harm either the patient, the crew, or the public.
Overconfidence
106
The____ has a single, all-important goal: to identify and begin treatment of immediate or imminent life threats. To do this, you must physically examine the patient and assess level of consciousness (LOC) and airway, breathing, and circulation (ABCs); however, this is not an in-depth physical exam or assessment of vital signs. These will be addressed later in the secondary assessment.
primary assessment
107
Anytime you meet someone new, you form an initial general impression about that person. Forming the ____of a patient is a similar process, but the focus is on rapid identification of potentially life-threatening problems. The general impression is formed to determine the priority of care and is the first part of your primary assessment. This includes noting things such as the person's age, sex, race, level of distress, and overall appearance which may lead you to anticipate different problems.
general impression
108
Early in your assessment, you will need to evaluate the patient's____. This will help you rapidly determine if the patient has a life-threatening injury and to what extent the patient will be able to provide reliable information about his or her own condition as well as follow your directions. The patient's___ can tell you a great deal about his or her neurologic and physiologic status. The brain requires a constant supply of oxygen and glucose to function properly. In the primary assessment, you need to ascertain only the gross__.
The AVPU scale is used to assess a patient's____ depending on how well he or she responds to external stimuli, including verbal stimuli (sound) and painful stimuli (such as pinching the trapezius muscle on top of the patient's shoulder). The AVPU scale tests a patient's responsiveness
LOC
109
Indications for spinal immobilization
Either blunt or penetrating trauma with any of the following : Pain or tenderness on palpation of the neck or spine
• Patient report of pain in neck or back
• Paralysis or neurologic complaint (numbness, tingling, partial paralysis of the legs or arms)
Blunt trauma with any of the following : Altered mental status
• Intoxication (alcohol or drugs)
• Difficulty or inability to communicate
110
An airway obstruction can result in partial or complete blockage of air movement into and out of the lungs and therefore inadequate____ of the entire body. As you move through the steps of the primary assessment, stay al for signs of airway obstruction. To prevent death or permanent disability to your patient, ensure that the airway remains open (patent) and adequate.
perfusion
111
Describe the assessment of a patient's breathing status, including the key information EMTs must obtain during this process and the care required for patients who have both adequate and inadequate breathing
Rate, rhythm, quality, depth (lung sounds)
Inadequate - oxygen and positive pressure ventilation
Adequate- patient who is breathing adequately but remains hypoxic, administer oxygen (oxygen saturation is supposed to be greater than 94%)
112
Discuss the importance of protecting a trauma patient's spine and identifying fractured extremities during patient packaging for transport.
- patient can become paralyzed, internal bleeding from fractures
(collar, backboard, jaw-thrust, splint, limit mobility)
113
The process of gathering a patient's past medical history, history of present illness, and signs and symptoms is important, but sometimes just as important are the signs and symptoms that the patient does not have. These important negative findings are referred to as____. Often, a patient's complaint would be expected to be associated with other related findings. Examples include chest pain with shortness of breath, palpitations, and sweating or a severe allergic reaction with itching, hives, and trouble breathing. The absence of these findings is relevant, and should be reported and documented _____are often helpful in identifying a patient's problem and choosing an appropriate treatment.
Pertinent negatives
114
Examples of___ would be a patient in respiratory distress who denies chest pain, or a patient with severe chest pain who denies shortness of breath.
pertinent negatives
115
Negative findings that warrant no care or intervention
Pertinent negatives
116
Treating a patient for shock before the blood pressure __ increases your patients chance to survive
Drops
117
__IS the pressure of circulating blood against the walls of the arteries. A decrease in the ___may indicate one o the following:
• Loss of blood or its fluid components
• Loss of vascular tone and sufficient arterial constriction to maintain the necessary pressure even without any actua fluid or blood loss
• A cardiac pumping problem
Blood pressure
118
Loss of blood or its fluid components
• Loss of vascular tone and sufficient arterial constriction to maintain the necessary pressure even without any actua fluid or blood loss
• A cardiac pumping problem
When any of these conditions occurs and results in a drop in circulation, the body's compensatory mechanisms are activated, resulting in an increased heart rate and constriction of the arteries. Normal blood pressure is maintained and by decreasing the blood flow to the skin and extremities, available blood volume is temporarily redirected to the vital organs so that they remain adequately perfused. However, as shock progresses, eventually the body's defense mechanisms can no longer keep up, and the blood pressure will fall. Decreased blood pressure is a late sign of shock and indicates that the patient is in the critical stage of decompensated shock. Any patient with a markedly low blood pressure has inadequate pressure to maintain proper perfusion of all vital organs and needs to have his or her blood pressure and perfusion restored to a normal level.
Blood pressure
119
____is the increased pressure that is caused along the artery with each contraction (systole) of the ventricles and the pulse wave that it produces.
Systolic pressure
120
____is the residual pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole), when the left ventricle is at rest.
Diastolic pressure
121
____represents the maximum pressure to which the arteries are subjected,
Systolic pressure
122
___represents the minimum amount of pressure that is always present in the arteries
diastolic pressure
123
When the ____becomes elevated, the body's defenses act to reduce it. Some people have chronically high_____ from progressive narrowing of the arteries that occurs with age, and during an acute episode, their ____may increase to even higher levels. Head injury or any number of other conditions may also cause____ to rise to very high levels. Abnormally high____ may result in a rupture or other critical damage in the arterial system.
blood pressure
124
How would you obtain a pulse in an infant or a child?
Palpte the brachial pulse, located at the medial area(inside) of the upper arm, in children younger than 1 year. Carotid for children
125
What does an increase in capillary refill time indicate
When evaluated in an uninjured limb, capillary refill time (CRT) may provide an indication of the pediatric patient's level of perfusion.
126
Normal cap refill time
2 seconds or less
127
As described earlier, air enters the body through the oral and nasal cavities and travels into the lungs. This occurs because a_____ is created in the chest when the thoracic cavity enlarges due to contraction of the diaphragm and intercostal muscles. Eventually the air reaches the alveolar sacs, where oxygen diffuses across the alveolar membrane and binds to hemoglobin in the bloodstream. At the same time, carbon dioxide diffuses from the bloodstream into the alveoli.
The carbon dioxide is exhaled from the lungs, and the oxygen is transported back to the heart, where it is distributed to the rest of the body.
negative pressure
128
The heart pumps blood to the tissues of the body through a series of arteries and veins. Arteries carry blood away from the heart and eventually branch into___. In the____, the exchange of nutrients and waste products takes place.
Oxygen and nutrients leave the____ and enter the cells. At the same time, waste products, such as carbon dioxide, diffuse from the cells back into the blood of the capillarie_____.
capillaries
129
From here, the deoxygenated blood travels back to the heart. The deoxygenated blood enters the right side of the heart through the right____. The right ventricle pumps the blood to the lungs for oxygenation and removal of carbon dioxide. The oxygenated blood then travels back to the heart and into the left atrium. The left ventricle then pumps the oxygenated blood to the rest of the body.
atrium
130
The physical act of moving air into and out of the lungs
Ventilation
131
The process of loading oxygen molecules onto hemoglobin molecules in the bloodstream
Oxygenation
132
The actual exchange of oxygen and carbon dioxide in the alveoli as well as the tissues of the body
Respiration
133
The active, muscular part of breathing is called___. When a person inhales, the diaphragm and intercostal muscles contract, allowing air to enter the body and travel to the lungs. When it contracts, the diaphragm moves down slightly, enlarging the thoracic cage from top to bottom. When the intercostal muscles contract, they lift the ribs up and out. The combined actions of these structures enlarge the thorax in all directions. Take a deep breath to see how your chest expands.
The lungs have no muscle tissue; therefore, they cannot move on their own. They need the help of other structures to be
able to expand and contract during inhalation and exhalation. Therefore, the ability of the lungs to function properly is dependent on the movement of the chest and supporting structures. These structures include the thorax, the thoracic cage (chest), the diaphragm, the intercostal muscles, and the accessory muscles of breathing. Accessory muscles are secondary muscles of respiration.
inhalation
134
____is the term used to describe the amount of gas in air or dissolved in fluid, such as blood.____ is measured in millimeters of mercury (mm Hg). The_____ of oxygen in air (Paoz) within the alveoli is 104 mm Hg.
Carbon dioxide (COz) enters the alveoli from the blood and causes a____ of 40 mm Hg.
Deoxygenated arterial blood from the right side of the heart has lower levels of oxygen (Paoz) than carbon dioxide (Paco2). The body attempts to equalize the two, which results in oxygen diffusion across the membrane into the blood and carbon dioxide diffusion in the opposite direction. The carbon dioxide is then eliminated from the lungs as waste during exhalation. This process occurs in reverse when the arterial blood reaches the tissues. Oxygen diffuses into the tissue fluid and then into the cells, and carbon dioxide diffuses out of the cells and then into the tissue fluid and blood
Partial pressure
135
The air pressure outside the body, called the___, is normally higher than the air pressure within the thorax. During inhalation, the thoracic cage expands and the air pressure within the thorax decreases, creating a slight vacuum. This pulls air in through the trachea, causing the lungs to fill—a process called negative pressure ventilation. When the air pressure outside equals the air pressure inside, air stops moving. Gases, such as oxygen, will move from an area of higher pressure to an area of lower pressure until the pressures are equal. At this point, the air stops moving, and inhalation stops. It may help you to understand this if you think of the thoracic cage as a bell jar in which balloons are suspended. In this example, the balloons are the lungs. The base of the jar is the diaphragm, which moves up and down slightly with each breath. The ribs, which are the sides of the jar, maintain the shape of the chest. The only opening into the jar is a small tube at the top, similar to the trachea. During inhalation, the bottom of the jar moves down slightly, causing a decrease in pressure in the jar and creating a slight vacuum. As a result, the balloons fill with air
atmospheric pressure
136
The entire process of inspiration is focused on delivering oxygen to the alveoli. However, not all of the air you breathe actually reaches the alveoli. TABLE 11-2 reviews terminology as it relates to the processes of inspiration and expiration.
(These processes are discussed further in Chapter 6, The Human Body). The average tidal volume, the amount of air in mililiters (mL) moved into or out of the lung during a single breath, for an average adult man is approximately 500 mL.
Breathing becomes deeper as the tidal volume responds to the increased metabolic demand for oxygen. However, as noted previously, not all inspired air reaches the alveoli for gas exchange.___ is described as the portion of inspired air that fails to reach the alveoli and deliver oxygen.
Dead space
137
The amount of air ( in mL) that is moved into or out of the lungs during one breath
Tidal volume
138
The air that remains in the lungs after maximal expiration
Residual volume
139
The volume of air that reaches the alveoli; calculated by subtracting the amount of dead space air from the tidal volume
Alveolar ventilation
140
The volume of air moved through the lungs in 1 minute; calculated by multiplying tidal volume and respiratory rate
Minute volume
141
The portion of the tidal volume that does not reach alveoli and thus does not participate in gas exchange
Dead space
142
Unlike inhalation,____ does not normally require muscular effort; therefore, it is a passive process. During exhalation, the diaphragm and the intercostal muscles relax. In response, the thorax decreases in size, and the ribs and muscles assume a normal resting position. When the size of the thoracic cage decreases, air in the lungs is compressed into a smaller space. The air pressure within the thorax then becomes higher than the outside pressure, and the air is pushed out through the trachea. Remember that air will reach the lungs only if it travels through the trachea. This is why clearing and maintaining an open airway is so important. Clearing the airway means removing obstructing material, tissue, or fluids from the nose, mouth, and throat. Maintaining the airway means keeping the airway patent so that air can enter and leave the lungs freely
exhalation
143
The body's need for oxygen is constantly changing. The respiratory system must be able to accommodate the changes in oxygen demand by altering the rate and depth of ventilation. The regulation of ventilation involves a complex series of receptors and feedback loops that sense gas concentrations in the body fluids and send messages to the respiratory center in the brain to adjust the rate and depth of ventilation accordingly. Failure to meet the body's needs for oxygen may result in___.____ is an extremely dangerous condition in which the tissues and cells of the body do not get enough oxygen.
____can be fatal if not promptly recognized and corrected.
Hypoxia
144
For most people, the drive to breathe is based on pH changes (related to carbon dioxide levels) in the blood and cerebrospinal fluid (CSF). When carbon dioxide levels in the blood increase, the pH of the CS decreases. When this occurs, a message is sent to the respiratory centers in the brain, which stimulates breathing. However, patients with a chronic obstructive pulmonary disease (COPD), such as emphysema or chronic bronchitis, have difficulty eliminating carbor dioxide through exhalation; thus, they always have higher levels of carbon dioxide. This condition potentially alters their respiratory drive. The theory is that the respiratory centers in the brain gradually adjust to accommodate high levels of carbon dioxide. In patients with COPD, the body uses a backup system to control breathing. This theory of secondary contro of breathing, called____, is based on levels of oxygen dissolved in plasma. This method is different from the primary control of breathing that uses carbon dioxide as the driving force.____ is typically found in end-stage COPD. Providing high concentrations of oxygen over time will increase the amount of oxygen dissolved in plasma. Some believe this could potentially negatively affect the body's drive to breathe. It is important to remember that high concentrations of oxygen should never be withheld from any patient who needs it. Patients with severe respiratory and/or circulatory compromise should receive high concentrations of oxygen regardless of their underlying medical conditions.
Hypoxic drive
145
Patients who are breathing inadequately will show varying signs and symptoms of__. The onset and degree of tissue damage caused by____ often depend on the quality of ventilations. Early signs of____ include restlessness, irritability, apprehension, fast heart rate (tachycardia), and anxiety. Late signs of____ include mental status changes, a weak (thready) pulse, and cyanosis. Conscious patients will complain of shortness of breath (dyspnea) and may not be able to talk in complete sentences. The best time to give a patient oxygen is before signs and symptoms of_____ appear.
hypoxia
146
All living cells perform a specific function and need energy to survive. Cells take energy from nutrients through a series of chemical processes. The name given to these processes is metabolism, or cellular respiration. During____, each cell combines nutrients (such as sugar) and oxygen and produces energy (in the form of adenosine triphosphate) and waste products, primarily water and carbon dioxide. Each cell in the body requires a continuous supply of oxygen and a regular means of disposing of waste (carbon dioxide). The body provides for these requirements through respiration.
Respiration is the process of exchanging oxygen and carbon dioxide. This exchange occurs by diffusion, a process in which a gas moves from an area of greater concentration to an area of lower concentration. In the body, gases diffuse rapidly across a distance of micrometers.
metabolism
147
____(pulmonary respiration) is the process of breathing fresh air into the respiratory system and exchanging oxygen and carbon dioxide between the alveoli and the blood in the pulmonary capillaries
External respiration
148
The exchange of oxygen and carbon dioxide between the systemic circulatory system and the cells of the body is called____. As blood travels through the body, it supplies oxygen and nutrients to tissues and cells. Oxygen passes from the blood in the capillaries to the cells in the body's tissues. At the same time, carbon dioxide and cell waste pass from the cells into the capillaries, where they are transported in the venous system back to the lungs
internal respiration
149
In the presence of oxygen, cells convert glucose into energy through a process known as___
aerobic metabolism.
150
Energy is produced through a series of biochemical reactions. Without adequate oxygen, the cells do not completely convert glucose into energy, and lactic acid and other toxins accumulate in the cell. This process,____, cannot meet the metabolic demands of the cell. If this process is not corrected, the cells will eventually die. Therefore, adequate perfusion (circulation of blood within an organ or tissue) and ventilation must be present for aerobic metabolism to occur. However, although these elements are necessary for aerobic metabolism, they do not guarantee that aerobic metabolism will occur.
anaerobic metabolism
151
Cells need a constant supply of oxygen to survive. Some cells may be severely or permanently damaged after _____without oxygen.
4 to 6 minutes
152
You must keep the airway clear so that you can ventilate the patient properly. If the airway is not clear, you will force the fluids and secretions into the lungs, resulting in___. If_____ occurs, mortality increases significantly.
Therefore, suctioning is your next priority. If you have any doubt about the situation, remember this rule: If you hear gurgling, the patient needs suctioning!
aspiration
153
A portable suctioning unit must provide enough vacuum pressure and flow to allow you to suction the mouth and
nose effectively. Hand-operated suctioning units with disposable chambers are reliable, effective, and relatively inexpensive. A fixed suctioning unit should generate a vacuum of more than ____when the tubing is clamped.
A portable or fixed suctioning unit should be fitted with the following:
• Wide-bore, thick-walled, nonkinking tubing
• Plastic, rigid pharyngeal suction tips, called tonsil tips (Yankauer tips or DuCanto catheter)
• Nonrigid plastic catheters, called French or whistle-tip catheters
• A nonbreakable, disposable collection bottle
• Water for rinsing the tips
300 mm Hg
154
A_____ is a hollow, cylindrical device that is used to remove fluids from the patient's airway. A tonsil-tip catheter is the best type of catheter for infants and children. The plastic tips have a large diameter and are rigid, so they do not collapse. Another type of suctioning device is designed for routine and emergency airway management
suction catheter
155
Tips with a curved contour allow for easy, rapid placement in the oropharynx. Nonrigid plastic catheters, sometimes called_____, are used to suction the nose and thin secretions in the back of the mouth and in situations in which you cannot use a rigid catheter, such as for a patient with a stoma (FIGURE 11-29). A stoma is an opening through the skin that goes into an organ or other structure.
French or whistle-tip catheters
156
______catheters are used in situations in which rigid catheters cannot be used, such as with a patient who has a stoma, patients whose teeth are clenched, or if suctioning the nose is necessary.
French, or whistle-tip,
157
Because mortality increases significantly if a patient aspirates, it is important to suction the airway until it is clear of
liquids or other debris. Ventilating a patient whose airway is full of blood, vomitus, or other secretions virtually guarantees___. Repeat suctioning as needed to keep the airway clear, ensuring that the patient remains adequately ventilated and oxygenated. Between suction attempts, rinse the catheter and tubing with water to prevent clogging of the tube with dried vomitus or other secretions.
Use extreme caution when suctioning a conscious or semiconscious patient. Put the tip of the suction catheter in
only as far as you can visualize. Be aware that suctioning may induce vomiting.
aspiration
158
Measure the father from the ___ of the mouth to the earlobe or angle of the jaw
Corner
159
Turn the patient's head to the side (unless you suspect cervical spine injury), open the mouth using the cross-finger technique or tongue-jaw lift, and insert the catheter to the predetermined depth without____.
suctioning
160
Apply suction in a ____as you withdraw the catheter.
circular motion
161
At times, a patient may have secretions or vomitus that cannot be suctioned quickly and easily, and some suction units cannot effectively remove solid objects such as teeth, foreign bodies, and food. In these cases, you should remove the catheter from the patient's mouth, log roll the patient to the side, and then clear the mouth carefully with your gloved finger. Only attempt to remove an object if it is visible during examination of the open mouth; blind sweeps of the back of the___ may push an object farther down in the airway, making the obstruction worse. A patient who requires assisted ventilations may also produce frothy secretions as quickly as you can suction them from the airway. In this situation, alternate suctioning with ventilations, ensuring that the airway remains as clear of secretions as possible. Continuous ventilation is not appropriate if vomitus or other particles are present in the airway.
Clean and decontaminate your suctioning equipment after each use according to the manufacturer's guidelines.
Place all disposable components (such as catheter, suction tubing) in a biohazard bag.
oropharynx
162
Describe how to perform mouth-to-mouth or mouth-to-mask ventilation
As you learned in your CPR course, mouth-to-mouth ventilations are now routinely done with a barrier device, such as a mask or face shield. Barrier devices provide some protection but not from diseases transmitted by airborne pathogens or aerosolized droplets such as SARS-CoV2 or tuberculosis (FIGURE 11-44). Mouth-to-mouth ventilations with or without a barrier device should be provided only in extreme situations. Performing mouth-to-mask ventilations with a pocket mask containing a one-way valve with an adequate filter is a safer method to prevent possible disease transmission. This method is used only when the EMT is off duty in a situation where no bag-mask device is available.
163
Are any actions of a medication other than the desired ones. __ can occur even when medications are administered correctly
Adverse effects
164
There are two types of adverse effects: unintended effects and untoward effects.
______are undesirable but pose little risk to the patient, such as a slight headache after taking nitroglycerin.
______can be harmful to the patient, such as hypotension after taking nitroglycerin.
Unintended effects
Untoward effects
165
Consider diphenhydramine (Benadryl). People take this medication for allergic reactions (indication). The medication is
supposed to block the effects of histamine (intended effect). Its____ include dry mouth and drowsiness (unintended effect) and it can increase the pressure of the fluid within the eye (untoward effect). Asthma is a relative contraindication for diphenhydramine because it can worsen lower airway constriction.
adverse effects
166
The____ (such as ibuprofen) is a simple, clear, nonproprietary name. The___ is not capitalized. Sometimes a medication is called by its_____ more often than by any of its trade names. For example, you may hear "nitroglycerin" used more often than the trade names Nitromist and Nitrostat. All medications that are licensed for use in the United States are listed by their ____ in the United States Pharmacopoeia and National Formulary (USP-NF).
generic name
167
Sublingual SL rate
Rapid
168
Per rectum PR rate
Rapid
169
By mouth PO rate
Slow
170
Intravenous IV rate
Immediate
171
Intraosseous IO rate
Immediate
172
Inhalation rate
Rapid
173
Intranasal IN rate
Rapid
174
Intramuscular IM rate
Moderate
175
Subcutaneous rate
Slow
176
Transcutaneous rate
Slow
177
_____. Per rectum literally means through the rectum. This route of delivery is most commonly used with children because of easier administration and more reliable absorption. (Children often regurgitate some or all of a medication.) For similar reasons, many medications that are used for nausea and vomiting come in a rectal suppository form. Some medications to control seizures are administered PR when it is impossible to administer them intravenously.
The PR route also is used to give some medications when the patient cannot swallow or is unconscious.
Per rectum (PR)
178
____. Many medications are taken by mouth, or per os (PO), and enter the bloodstream through the digestive system. This process often takes as long as 1 hour but may be surprisingly rapid, depending on the substance or form of preparation.
One of the advantages of using this route is that it is noninvasive. Patients are often much happier to take a pill than to have a needle stuck in them. It is also often less expensive to use enteral medications than to use parenteral forms. The main disadvantage of this administration route is the unpredictability of medication absorption. If the patient has vomiting or diarrhea, the amount of medication that is absorbed will be altered. Some medication preparations, referred to as orally disintegrating tablets, are put directly onto the tongue, where they dissolve. This is an alternative administration form for patients who may have difficulty swallowing. Some forms of medications are adversely affected by stomach acids, so dissolving them directly on the tongue avoids breakdown by gastric acids. An example of this type of medication is ondansetron (Zofran), which is used to treat nausea and vomiting
Oral
179
_____Intravenous means into the vein. Medications that need to enter the bloodstream immediately may be injected directly into a vein. This is the fastest way to deliver a chemical substance, but the IV route cannot be used for all chemicals. For example, aspirin, albuterol, and oxygen cannot be given by the IV route.
Intravenous (IV) injection.
180
____. Intraosseous means into the bone. Medications that are given by this route reach the bloodstream through the bone marrow. Giving a medication by the I0 route, into the marrow, requires drilling a needle into the outer layer of the bone. Because this is painful, the io route is used most often in patients who are unconscious as a result of cardiac arrest or extreme shock. Often, the io route is used for children who have fewer available (or difficult to access) IV sites. In general, any medication that can be given by the IV route can be given by the io route.
This route may be more desirable in critical patients in whom IV access will take longer.
Intraosseous (io) injection
181
____Subcutaneous means under the skin. A subcutaneous injection is given into the fatty tissu between the skin and the muscle. Because there is less blood here than in the muscles, medications that are given by this route are generally absorbed more slowly, and their effects last longer. A subcutaneous injection is a useful way to give medications that cannot be taken by mouth, as long as they do not irritate or damage the tissue. Daily insulin injections for patients with diabetes are given by the subcutaneous route. Some forms of epinephrine can be given by the subcutaneous route
Subcutaneous injection.
182
_____. Intramuscular means into the muscle. Usually, medications that are administered by IM injection are absorbed quickly because muscles have a lot of blood vessels. However, not all medications can be administered by the IM route. Possible problems with IM injections are damage to muscle tissue and uneven, unreliable absorption, especially in people with decreased tissue perfusion or who are in shock.
You will typically use the IM route of medication administration with an auto-injector. These devices deliver a predetermined amount of medication into the patient when pressed firmly into the thigh. Examples of this delivery method would be the EpiPen auto-injector, which is used for anaphylactic reactions (see Chapter 21, Allergy and Anaphylaxis), and the DuoDote auto-injector and Antidote Treatment-Nerve Agent Auto-Injector (ATNAA), which are used for nerve agent exposure. (See Chapter 41, Terrorism Response and Disaster Management.)
Intramuscular (IM) injection
183
____. Some medications are inhaled into the lungs so that they can be absorbed into the bloodstream more quickly.
Others are inhaled because they work in the lungs. Generally, inhalation helps minimize the effects of the medication in other body tissues. Such medications come in the form of aerosols, fine powders, and sprays
Inhalation
184
____Sublingual means under the tongue. Medications given by the SL route, such as nitroglycerin tablets, enter through the oral mucosa under the tongue and are absorbed into the bloodstream within minutes. This route is faster than the oral route, and it protects medications from chemicals in the digestive system, such as acids that can weaken or inactivate them.
Sublingual (SL).
185
____. Transcutaneous means through the skin. Some medications can be absorbed transcutaneously, such as the nicotine in patches used by people who are trying to quit smoking. On occasion, a medication that also comes in another form is administered transcutaneously to achieve a longer-lasting effect. An example is an adhesive patch containing nitroglycerin.
Transcutaneous (transdermal)
186
____. In the intranasal route of medication administration, a liquid medication is pushed through a specialized device called a mucosal atomizer device (MAD) (FIGURE 12-1). The liquid medication is aerosolized and is administered into a nostril. The mucous membranes lining the sinuses and passageways within the head and neck are very vascular; therefore, absorption is rather quick with this route.
Intranasal (IN)
187
A____ is a miniature spray canister used to direct such substances through the mouth and into the lungs (FIGURE 12-2) and is often used by a patient with a respiratory illness such as asthma or emphysema. An___ delivers the same amount of medication each time it is used. Because an inhaled medication usually is suspended in a propellant, the___ must be shaken vigorously before the medication is administered. Many patients who use___ medications also self-administer medications with a nebulizer.
metered-dose inhaler (MDI)
188
______is an antipyretic (reduces fever), analgesic (reduces pain), and anti-inflammatory (reduces inflammation) medication that inhibits platelet aggregation (clumping). This last property makes it one of the most used medications today. Research has shown that the aggregation of platelets in the coronary arteries under certain conditions is one of the direct causes of heart attack. Patients at risk for coronary artery disease are often prescribed one or two "baby" (children's) aspirins per day. During a potential heart attack, aspirin may be life-saving.
Contraindications for aspirin include documented hypersensitivity to aspirin (absolute), preexisting liver damage
(absolute), bleeding disorders (relative), and asthma (relative). Because of the association of aspirin with Reye syndrome (a rare but serious condition that causes swelling in the brain and liver), it should not be given to children.
Aspirin (acetylsalicylic acid or ASA)
189
If you have ever run for a prolonged period, you probably remember your muscles developed a painful, heavy, burning sensation. This is because the demand for oxygen by the muscles exceeded the supply. When a similar pain develops in heart muscle, it is called angina pectoris. The cause is the same-not enough oxygen. In this case the pain is due to a blockage or narrowing in the blood vessels that supply the heart. Occasionally, the cause is a spasm in these blood vessels. Unlike a runner with sore legs, the heart muscle cannot stop and rest until the pain goes away.
The purpose of_____ is to increase blood flow by relieving the spasms or causing the arteries to dilate. It does this by relaxing the muscular walls of the coronary arteries and veins.____ also relaxes veins throughout the body, so less blood is returned to the heart and the heart does not have to work as hard each time it contracts. In short, blood pressure is decreased. Because of this, it is important that you always take the patient's blood pressure before administering___. If the systolic blood pressure is less than 100 mm Hg, the nitroglycerin may have the harmful effect of lowering the blood flow to the heart's own blood vessels. Even a patient who has adequate blood pressure should sit or lie down with the head elevated before taking this medication. If the patient is standing, he or she may faint when blood flow to the brain is reduced as the nitroglycerin starts to work. If a significant decrease in the patient's blood pressure (15 to 20 mm Hg) occurs and the patient suddenly feels dizzy or sick, have the patient lie down.
nitroglycerin
190
During a heart attack (myocardial infarction [MI]), a narrowing or blockage in a coronary artery blocks the blood flow to a section of the heart muscle (myocardium). If the blockage is not cleared in time, the section of the heart muscle beyond the clot will die. If nitroglycerin no longer brings relief to a person in whom it has previously worked, the person may be experiencing an Ml instead of an angina attack. Therefore, it is important to know how much___ a patient has needed in the past to relieve chest pain and how much has been taken during the current emergency, including the use of nitroglycerin patches. Always report this information to medical control. Remember, you cannot administer this medication without clearance from medical control or standing orders.
There are important interactions to consider when administering___. Erectile dysfunction medications,
such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra), can have potentially fatal interactions with nitroglycerin. When taken together, nitroglycerin and these drugs can cause a dramatic drop in blood pressure. Always ask a patient who has been prescribed____ if he or she has used any medication for the treatment of erectile dysfunction within the previous 24 hours. If so, do not administer the nitroglycerin, and report this to medical control.
Keep in mind that drugs for erectile dysfunction may be used by both men and women; do not assume women have not taken erectile dysfunction drugs.
nitroglycerin
191
Nitroglycerin has the following effects:
• Relaxes the muscular walls of coronary arteries and veins
• Results in less blood returning to the heart
• Decreases blood pressure
• Relaxes arteries throughout the body
• Often causes a mild headache and/or burning under the tongue after administration
192
Some patients who take____ use a metered-dose spray, which deposits medication on or under the tongue.
Each spray is equivalent to one tablet. To ensure direct, proper dosing on the bottom of the tongue, hold the canister upright when administering, and do not use a spacer with the metered-dose canister when giving____ by this method. Do not shake the canister before spraying it.
Whether using the tablets or the metered-dose spray, you should wait 5 minutes for a response before repeating the dose. Closely monitor the patient's vital signs, particularly the blood pressure. Give repeated doses per medical control and/or local protocol. Remember, always wear gloves when handling____ tablets or spray, because this medication can be absorbed by your skin.
Next, you must reconfirm that the medication is still indicated for the patient. For example, suppose you have received and verified the order to give one sublingual nitroglycerin tablet to a patient with a cardiac condition. While you were getting the order, however, the patient begins to sweat more and becomes less responsive. Reassessment of the blood pressure reveals a pressure of 80/60 mm Hg. Using your knowledge of nitroglycerin, you recognize the contraindication and decide not to give the medication. Instead, you notify medical control of the changes in the patient's condition and seek new orders.
Knowing and understanding the local protocols under which you will be working are absolutely essential, as is a
thorough knowledge of the medications within your scope of practice. Refer to Table 12-4 for a review of all medications and the important information needed for their administration. See Chapter 17, Cardiovascular Emergencies, for more information on how to administer nitroglycerin.
nitroglycerin
193
The____ route of administration provides quick and easy access to the circulatory system without the need for placing a needle within a vein. Blood flow to the muscles is relatively stable, even during circumstances of severe illness or injury. This advantage makes the___ route an efficient means to deliver some medications. Al disadvantage for this route is the use of a needle and the subsequent pain it can cause. Patients may be reluctant for you to use the needle for fear of pain or injury. With proper technique, you can administer medications via the___ route and limit the amount of pain delivered to the patient.
intramuscular (IM)
194
____is the main hormone that controls the body's fight-or-flight response and is the primary medication that you will be administering intramuscularly.____ is a sympathomimetic. A sympathomimetic mimics the effect of the sympathetic nervous system. The body releases____ when there is sudden stress, such as during exercise or when the patient is suddenly scared. Because____ is secreted by the adrenal glands, it is also known as adrenaline.____ has different effects on different body tissues and is used as a medication in several forms.
Generally,____ will increase the heart rate and blood pressure and dilate passages in the lungs. It can ease breathing problems caused by the bronchial spasms common in asthma and allergic reactions. In a person who is close to anaphylactic shock as a result of an allergic reaction,_____ may also help to maintain the patient's blood pressure. However,____ is not indicated for patients who do not show signs of airway obstruction or wheezing due to an allergic reaction. In addition, this medication should not be given to patients with hypertension or hypothermia, or if you believe the patient may be experiencing an MI.
Epinephrine
195
Epinephrine has the following characteristics:
• Secreted naturally by the adrenal glands
• Dilates passages in the lungs
• Constricts blood vessels, causing increased blood pressure
• Increases heart rate and blood pressure
196
Many states and EMS agencies now authorize the use of____ by EMTs for the treatment of life-threatening anaphylaxis. In certain patients, insect venom or other allergens cause the body to over-release histamine, which, lowers blood pressure by relaxing the small blood vessels and allowing them to leak. The over-release of histamine may also cause wheezing from bronchial spasms and swelling of the airway tissues (edema), which make it difficult for the patient to breathe.____ acts as a specific antidote to reverse the effects of histamines, countering both of the harmful effects. It constricts the blood vessels, allowing blood pressure to rise and reducing the swelling. In the lungs, it has the opposite effect: It dilates the air passages, so the flow of air is less restricted.
_____may be dispensed from an auto-injector, which automatically delivers a preset amount of the medication (FIGURE 12-8). This is usually 0.3 mg of____. This is the method that you will most likely use.
epinephrine
197
Be sure to familiarize yourself with the procedures for using the auto-injector on your unit. Some manufacturers of
auto-injectors include verbal instructions for administration. The general procedure is as follows:
1. Grasp unit with the tip pointing downward.
2. Form a fist around the unit. Do not place your thumb over either end of the unit.
3. With the other hand, pull off the activation cap.
4. Hold the tip near the outer part of the patient's thigh.
5. Insert firmly into the outer thigh so that the unit is perpendicular (at a 90-degree angle) to the thigh. Do not allow the unit to bounce.
6. Hold firmly in the thigh for several seconds.
7. Immediately place the unit in an appropriate sharps container after administration.
Epinephrine causes a burning sensation where it is injected, and the patient's heart rate will increase after the injection, so be prepared for these adverse effects. Some services do not permit EMTs to carry epinephrine but do allow them to assist patients in administering their own epinephrine in life-threatening anaphylactic reactions.
Epinephrine
198
The US FDA has approved an auto-injector device that delivers an IM or subcutaneous injection of_____ to reverse the effects of an opioid overdose. This medication can be administered by family members or caregivers to help reverse dangerous adverse effects of opioid overdose, such as life-threatening respiratory depression. One version of auto-injectable____, called EVZIO, provides verbal instructions for administration similar to those provided by AEDs.
naloxone (Narcan)
199
There are several important considerations for EMTs related to auto-injectable naloxone:
• Consult medical direction to determine if EMTs are allowed to administer naloxone in your region. As always, follow your local protocol. Consider requesting assistance from ALS personnel if available for any suspected opioid overdose. Ensure that another rescuer is ventilating and oxygenating the patient if needed while you prepare the medication.
• Find out if naloxone has been administered by a bystander prior to your arrival.
• Be aware that the effects of naloxone may not last as long as those of opioids. Repeat doses of naloxone may be needed.
• Administration of naloxone to opioid-dependent patients can cause severe withdrawal symptoms, including seizures and cardiac arrest.
• You must consider your safety, as patients may become violent following naloxone administration. Make sure you are wearing proper PPE, including eye protection, mask, and gloves.
Most prefilled naloxone IM preparations are administered in increments of 2 mg, then gradually increase based on the patient response, or lack thereof, to achieve the desired effect of restoring respirations while avoiding withdrawal symptoms and associated complications.
Naloxone
200
Not all EMS departments will use naloxone auto-injectors, due to their expense. The most common technique for naloxone administration is via the intranasal route. Other common routes of administration include intravenous and intramuscular. All of the same considerations described for administering injectable naloxone apply when administering naloxone in any another form.
Follow these steps to administer a medication intranasally:
1. Obtain medical direction per local protocol.
2. Confirm correct medication and expiration date.
3. Attempt to determine if the patient is allergic to any medications.
4. Prepare the medication and attach the atomizer. Never use a needle.
5. Place the atomizer in one nostril, pointing up and slightly outward
6. Administer a half-dose (1mL maximum) into each nostril
7. Reassess the patient and document appropriately
Naloxone
201
_____are used to administer liquid medications that have been turned into a fine mist by a flow of air or oxygen (FIGURE 12-10). Respiratory illness can be spread through SVNs. When the medication is atomized, it is breathed into the lungs and delivered to the alveoli. Blood flow to the alveoli is very high and absorption rates are close to those found with IV medications. This route is fast and relatively easy to access. MDis are commonly used because of their convenience and portability. The major disadvantage of an MDI is that the patient needs to be cooperative and control his or her breathing. If the patient is unconscious, an MDI cannot be used, although you could use a nebulizer. Nebulizers are often used for more severe problems.
MDIs and small-volume nebulizers (SVNs)
202
Sometimes, a respiratory condition such as asthma is not severe enough to require the use of epinephrine. In such cases, patients may use one of the chemical "cousins" of epinephrine that are more narrowly focused on the lungs.
These medications are delivered using an____.
Proper use of an MDI requires some degree of coordination, something that may be difficult to achieve when a person is having trouble breathing. Patients must aim properly and spray just as they start to inhale. If administered improperly, most of the medication ends up on the roof of the patient's mouth. An adapter, called a spacer, fits over the inhaler like a sleeve and can be used to avoid misdirecting the spray (FIGURE 12-11). The patient sprays the prescribed dose into the chamber and then breathes in and out of the mouthpiece until the mist is completely inhaled.
Spacer devices are especially useful with young children who have difficulty using an MDI.
MDI or SVN
203
MDis contain both the medication and a propellant, a chemical used to help push the medication out of the inhaler.
It is possible for the medication to be depleted in the MDI, even though it continues to spray. It may be difficult to determine whether a patient's MDI is still providing needed medicine.
SVNs are much easier to use than MDIs; however, they take longer to deliver the medication and require an external air or oxygen source. An SVN can be more effective than an MDI in moderate to severe respiratory distress.
An SVN can also be used while a patient is on continuous positive airway pressure and during bag-mask ventilation. An SVN can easily be adapted to a nonrebreathing mask for patients unable to hold an SVN. This can be especially helpful with children.
Assisting a patient with an SVN involves placing the medication into the nebulizer and then running a flow of oxygen through the device, which will atomize the liquid and allow the patient to breathe in the medication (FIGURE 12-
12). You will typically use an oxygen tank to deliver an SVN treatment; however, many respiratory patients have a portable SVN machine at home that can also be used. Consult your local protocol to determine if use of an SVN is within the EMT scope of practice for your agency.
MDIs and SVNs
204
Follow these steps to administer a medication via SVN. See Chapter 16, Respiratory Emergencies, for more
information on steps for using MDis and SVNs.
1. Obtain medical direction per local protocol.
2. Confirm correct medication and expiration date.
3. Confirm that the patient is not allergic to the medication.
4. Add the appropriate medication and dose to the nebulizer reservoir and assemble according to the manufacturer's instructions.
5. Perform the medication cross-check.
6. Connect to the nebulizer machine (often in the patient's home) or oxygen tank at 6 to 8 L/min.
7. Place the nebulizer in the patient's mouth and instruct the patient to breathe until the medication is gone (usually about 5 minutes).
8. Reassess the patient and document appropriately.
SVN
205
Note: Some nebulizers come preconnected to an oxygen mask for easier administration for patients who are unable to hold the nebulizer.
You can activate the spray by pressing the canister into the adapter just as the patient starts to inhale. If relief is not achieved, wait 3 to 5 minutes and repeat this sequence according to the patient's prescription. Above all, it is important to ensure that the patient inhales all of the medication in a single-sprayed dose.
Mdi
206
_____, also known as reactive airway disease, can be a life-threatening condition. Therefore, some patients use rescue inhaler MDis to relieve bronchial spasms quickly. A few of the more common OTC MDis include Primatene Mist, Bronitin Mist, and Bronkaid Mist. Each of these MDis contains epinephrine and can cause significant adverse effects, such as tachycardia, hypertension, and restlessness. Therefore, as mentioned earlier, most patients with____ use certain chemical cousins of epinephrine that produce fewer adverse effects and act more specifically on the bronchi of the lungs. Common prescription MDis include albuterol (ProAir, Proventil, and Ventolin), ipratropium bromide (Atrovent), and levalbuterol (Xopenex). Often albuterol and ipratropium are combined in one inhaler (eg, Combivent, DuoNeb). Another type of MDI used by respiratory patients is the maintenance, or controller, inhaler. These MDis are slow acting and are meant to be used regularly to be effective. Maintenance inhalers are not useful for a patient experiencing acute respiratory distress and in need of immediate relief. Common maintenance inhalers include fluticasone propionate (Flovent Diskus), budesonide (Pulmicort), mometasone furoate (Asmanex Twisthaler), beclomethasone dipropionate (Qvar), and ciclesonide (Alvesco).
Asthma
207
___medications, such as aspirin and clopidogrel (Plavix), decrease the ability of blood platelets to aggregate (stick together).
Antiplatelet
208
___medications, such as warfarin (Coumadin), apixaban (Eliquis), and rivaroxaban (Xarelto), interfere with other blood clotting mechanisms in the body.
Anticoagulant
209
What are the signs, symptoms, and treatments of an opioid overdose?
Signs: respiratory depression, pinpoint pupils, Mental status
- Symptoms:
- Treatments: Narcan
210
Describe the two techniques EMTs may use to open an adult airway and the circumstances that would determine when to use each.
Trauma (jaw-thrust)
- medical (head-tilt-chin lift )
- Oral or nasal adjunct
211
What is a Impedance Threshold Device and when would you use it
Is a valve device placed between the ET tube and a bag-mask device; it may also be placed between the bag and mask if a ET tube is not in place.
- Designed to limit the air entering the lungs during recoil phase between chest compressions
212
Explain the factors involved in the decision to stop CPR after it has been started on a patient.
Pulse back or spontaneous breathing, medical command tells you to stop
213
As an EMT, you are generally not responsible for making the decision to stop CPR. After you begin CPR in the field, you must continue until one of the following events occurs (the STOP mnemonic):
• S The patient Starts breathing and has a pulse.
• T The patient's care is Transferred to another provider of equal or higher-level training.
• O You are Out of strength or too tired to continue CPR
• P A Physician who is present or providing online medical direction assumes responsibility for the patient and directs you to discontinue CPR.
214
Occasionally, a large foreign body will be aspirated and block the upper airway. An airway obstruction may be caused by various factors, including relaxation of the throat muscles in an unresponsive patient, vomited or regurgitated stomach contents, blood, damaged tissue after an injury, dentures, or foreign bodies such as food or small objects.
Large objects that are visible but cannot be removed from the airway with suction, such as loose dentures, large pieces
of food, or blood clots, should be swept forward and out with your gloved index finger. Suctioning can then be used as needed to keep the airway clear of thinner secretions such as blood, vomitus, and mucus.
Foreign body airway obstruction in adults
215
An airway obstruction by a foreign body in an adult usually occurs during a meal. In children, it usually occurs during mealtime or at play. If the foreign body is not removed quickly, then the lungs will use up their oxygen supply, and unconsciousness and death will follow. Management is based on the severity of the airway obstruction.
foreign body obstruction
216
Patients with a _____obstruction are able to exchange adequate amounts of air, but still have signs of respiratory distress. Breathing may be noisy; however, the patient usually has a strong, effective cough. Encourage the patient to continue coughing. Your main concern is to prevent a mild airway obstruction from becoming a severe (complete) airway obstruction. Abdominal thrusts are not indicated for patients with a mild airway obstruction.
For the patient with a mild airway obstruction, first encourage the patient to cough or to continue coughing if they are already doing so. Do not interfere with the patient's own attempts to expel the foreign body. Instead, give supplemental oxygen if needed and provide prompt transport to the ED. Closely monitor the patient and observe for signs of a severe airway obstruction (weak or absent cough, decreasing level of consciousness, cyanosis ).
mild (partial) airway
217
A sudden, _____is usually easy to recognize in someone who is eating or has just finished eating. The person is suddenly unable to speak or cough, grasps his or her throat, becomes cyanotic, and makes exaggerated efforts to breathe. Either air is not moving into and out of the airway, or the air movement is so slight that it is not detectable. At first, the patient will be responsive and able to clearly indicate the problem. Ask the patient, "Are you choking?" The patient will usually answer by nodding yes. Alternatively, he or she may use the universal sign to indicate airway blockage. If there is a minimal amount of air movement, then you may hear a high-pitched sound on inspiration called stridor. This occurs when the object is not fully blocking the airway, but the small amount of air entering the lungs is not enough to sustain life and the patient will eventually become unconscious if the obstruction is not relieved.
severe airway obstruction
218
When you discover an unresponsive patient, your first step is to determine whether he or she is breathing and has a__.
The unconsciousness may be caused by airway obstruction, cardiac arrest, or a number of other conditions. If the patient has a pulse, but is not breathing, then you must make sure that the airway is open and unobstructed.
You should suspect an airway obstruction if the standard maneuvers to open the airway and ventilate the lungs are
ineffective. If you feel resistance when attempting to ventilate, the patient probably has some type of obstruction.
pulse
219
The manual maneuver recommended for removing severe airway obstructions in responsive adults and children older than 1 year is the____. This technique creates an artificial cough by causing a sudden increase in intrathoracic pressure when thrusts are applied to the subdiaphragmatic region; it is a very effective method for removing a foreign body obstruction from the airway. If the patient with a severe airway obstruction is unresponsive, then perform chest compressions.
abdominal thrust maneuver (also called the Heimlich maneuver)
220
As mentioned previously, airway obstruction is a common problem in infants and children, usually caused by a foreign body (such as food or a toy) or by an infection, resulting in swelling and narrowing of the airway. Try to identify the cause of the obstruction as soon as possible. In patients who have signs and symptoms of an airway infection, do not waste time trying to dislodge a foreign body. Administer supplemental oxygen if needed and immediately transport the child to the ED.
A previously healthy child who is eating or playing with small toys or an infant who is crawling about the house and who suddenly has difficulty breathing has probably aspirated a foreign body. As in adults, foreign bodies may cause a mild or a severe airway obstruction.
With a mild airway obstruction, the child can cough forcefully, although he or she may wheeze between coughs. As long as the patient can breathe, cough, or talk, do not interfere with his or her attempts to expel the foreign body. As with an adult, encourage the child to continue coughing. Administer supplemental oxygen if needed (and tolerated) and provide transport to the ED.
Foreign Body Airway Obstruction in Infants and Children
221
Do not use abdominal thrusts on a responsive infant with an airway obstruction because of the risk of injury to the immature organs of the abdomen. Instead, perform back slaps and chest thrusts to try to clear a severe airway obstruction in a responsive infant,
Removing a Foreign Body Airway Obstruction in Infants
222
An ____is a valve device placed between the ET tube and a bag-mask device; it may also be placed between the bag and mask if an ET tube is not in place. The ITD is designed to limit the air entering the lungs during the recoil phase between chest compressions (FIGURE 14-18). This results in negative intrathoracic pressure that may draw more blood toward the heart, ultimately resulting in improved cardiac filling and circulation during each chest compression.
The ITD may be considered when used together with devices that provide active compression-decompression CPR. It is not currently recommended for use with conventional CPR. If ROSC occurs, then the ITD should be removed. You should understand research trends regarding the effectiveness of the ITD.
impedance threshold device (ITD)
223
Discuss the assessment of a patient with a medical emergency.
Assessment of a medical patient is similar to the assessment of a trauma patient but with a different focus. Whereas trauma assessments focus on the mechanism of injury or physical injuries, some of which can be detected on a physica examination, medical patient assessment focuses on the nature of illness (NOl), symptoms, and the patient's chief complaint.
When you are assessing a patient, establish an accurate medical history. Information received from dispatch can help you anticipate what you might find when you arrive on scene, but it is conceivable that what appears to be a traumatic emergency may in fact be a medical emergency, or vice versa. Use the dispatch information to guide your initial response, but do not get locked into a preconceived idea of the patient's condition strictly from what the dispatcher tells you. During assessment, be aware of several challenges. It is possible that a patient has sustained an injury that distracts you from an underlying medical condition. For example, a patient may have a medical condition that resulted in a motor vehicle crash, or the patient may have sustained a large laceration and you fail to recognize that the patient has had a hypoglycemic event that caused him to fall and sustain the injury. Tunnel vision occurs when you become focused on one aspect of the patient's condition and exclude all others, which may cause you to miss an important injury or illness.
Patients may sometimes be uncooperative or even hostile toward those who respond to care for them. Patients may be fearful, angry, and confused and may take out their frustrations on you. It is important that you maintain a professional, calm, and nonjudgmental demeanor at all times.
You are obligated as a medical professional to refrain from labeling patients and displaying personal biases. Never assume that you know what the problem is, even when you are treating patients who frequently call for EMS. This attitude could result in missing a serious condition. In conscious patients, ensure the airway is open and they are breathing adequately. Check the respiratory rate, depth, and quality. Consider applying oxygen at this time if there is any indication that breathing has been affected. For unconscious patients, make sure to open the airway using the proper technique for their condition, and take several seconds to evaluate their breathing. Apply oxygen to patients in shock, with difficulty breathing, and when low oxygen saturation measurements are obtained (Spo less than 94%). Consider having your partner administer oxygen as you continue your assessment. After completing the assessment and treatment, begin reassessment and continue it throughout transport, During the reassessment, repeat the primary assessment and reassess the chief complaint. Look for any changes in the level of consciousness; reassess the airway, breathing, and circulation; and reexamine the transport decision. Consider the need for ALS backup. Obtain another full set of vital signs every 5 minutes for unstable patients or every 15 minutes for stable patients. Reassessment also includes repeating your physical examination to identify and treat changes in the patient's
Finally, the reassessment includes reviewing all treatments that have been performed. Reassess oxygen delivery, any
bandages or splints applied, and any other treatment that has been performed
Document any changes that have developed as a result of the treatments, and, if needed, adjust any of the treatments accordingly. Reassessment is an important step in patient assessment; it allows you to modify care as needed and ensures you have the most current information on the patient's condition when you arrive at the hospital.
224
Explain the importance of transport time and destination selection for a medical patient
Critical patients include those with altered mental status, airway or breathing difficulties, or any sign of circulatory compromise. In addition, a patient who is very old or very young may be considered critical even if the patient appears to be relatively stable. Critical patients often need expeditious transport. The time on scene should be limited to 10 minutes or less for these patients. Differentiating a high-priority transport from a low-priority transport is a skill developed with experience, but it is a skill that
can be learned. A general rule for determining the priority of transport is to consider the results of the patient's primary assessment. Patients with an altered mental status, especially if it is still present at the completion of your assessment and treatment, should be considered a high-priority transport. Patients with circulatory compromise, including signs and symptoms of shock, should also be considered a high-priority transport. Most patients with circulatory problems cannot be stabilized in the prehospital setting and need to undergo treatment at a hospital quickly but safely. Patients with difficulty breathing often require high-priority transport. However, if the patient has responded well to your initial treatment, such as oxygen and albuterol administration, lights and siren may not be necessary. As a rule, if you choose to use lights and siren, you should be able to specifically describe in your report why such emergency transport was medically necessary and why the improved arrival time justified the increased risk to which you exposed the patient and public-at-large. It is generally appropriate to select the closest ED as your destination. However, there are times when the closest hospital is not necessarily the most appropriate choice. Patients with chest pain as a result of a heart attack may need a facility that is capable of performing cardiac catheterization, which may not necessarily be available at the closest hospital. If the patient is in cardiac arrest or experiences cardiac arrest during transport, immediately reroute to the closest hospital with emergency facilities. Stroke patients can also benefit from specialized hospital selection. Many hospitals have designated stroke teams and interventional neurology capabilities. Taking a possible stroke patient to a hospital without these resources may result in a delay in definitive treatment and may lead to a worse outcome for the patient.
Some medical patients may benefit from on-scene treatment provided by advanced EMS personnel such as paramedics.
It is important to recognize early when paramedics can provide added value on a scene so that, if they are readily available, they can be called to respond in a timely manner. High priority
- Low priority
- Life threat ( lights and sirens )
- Not a life threat ( no lights and sirens)
- Closed ED but some cases it's not necessary
- Within 30 minute distance
225
Identify types of physchiatric conditions
Depression
- PTSD
- Schizophrenia
- Alzhimers
- ********Substance abuse (not considered a psychiatric condition)SAY NO TO DRUG ABUSE IS THE ANSWER!!!!!!!!!!!!!!!!!!!
226
Describe the physical signs of a patient in respiratory distress
Agitation, anxiety, restlessness
Stridor, wheezing
Accessory muscle use; intercostal retractions, neck muscle use (sternomastoid)
Tachypnea
Mild tachycardia
Nasal flaring, seesaw breathing, head bobbing
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What is taken into account when forming a general impression?
Sick or not sick
As you approach a medical patient, you should develop a general impression of his or her condition. Perform a rapid examination of the patient to identify life threats. Visual clues include apparent unconsciousness, obvious severe bleeding, or extreme difficulty breathing.
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___is caused by inflammation and swelling of the pharynx, larynx, and trachea (FIGURE 16-4). This disease is often secondary to an acute viral infection of the upper respiratory tract and is typically seen in children between ages 6 months and 3 vears. It is easily passed between children. Peak seasonal outbreaks of this disease occur in the late fall and during the winter. The disease starts with a cold, cough, and a low-grade fever that develops over a few days. The hallmark signs of___ are stridor and a seal-bark cough, which signal a narrowing of the air passage of the trachea that may progress to significant obstruction.
___is rarely seen in adults because their breathing passages are larger and can accommodate the inflammation and mucus production without producing symptoms. The airways of adults are wider, and the supporting tissue is firmer than in children.
___often responds well to the administration of humidified oxygen. Note that bronchodilators are not indicated
for___ and can worsen a patient's symptoms.
Croup
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____is a life-threatening inflammatory disease of the epiglottis, the small flap of tissue at the back of the throat that protects the larynx and trachea during swallowing. Bacterial infection is the most common cause (FIGURE 16-5). In the past, epiglottitis was most often seen in infants and children. In some cases, it occurs in adults. The development of a childhood vaccine against Haemophilus influenzae has dramatically decreased the incidence of this disease. In preschool and school-age children especially, the epiglottis can swell to two to three times its normal size. This puts the airway at risk of complete obstruction. The condition usually develops in otherwise healthy children, and symptoms are sudden in onset. Children with this infection look ill, report a very sore throat, and have a high fever.
They will often be found in the tripod position and drooling. Stridor is a late sign in the development of airway obstruction.
Treat children with suspected____ gently and try not to do anything that will cause them to cry. Keep them in a position of comfort, and give them high-flow oxygen. Do not put anything in their mouths, as this could trigger a complete airway obstruction.
Deterioration can occur quickly in adults with acute___. You should be concerned if your adult patient presents with stridor or any other sign of airway obstruction without an obvious mechanical cause. Focus your patient management on maintaining a patent (adequate) airway, and provide prompt transport to the emergency department (ED).
Epiglottitis
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_____is a common cause of illness in young children. It causes an infection in the lungs and breathing passages, and can lead to other serious illnesses such as bronchiolitis and pneumonia, as well as serious heart and lung problems in premature infants and in children who have depressed immune systems.
RSV is highly contagious and can be spread through droplets when the patient coughs or sneezes. The virus can also survive on surfaces, including hands and clothing. Therefore, the infection tends to spread rapidly through schools and child care centers.
When you assess a child with suspected__, look for signs of dehydration. Infants with__ often refuse liquids.
Treat airway and breathing problems as appropriate. Humidified oxygen is helpful if available.
Respiratory syncytial virus (RSV)
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_____is a respiratory illness that often occurs due to RSV infection and results in severe inflammation of the bronchioles. Bronchioles, the tiny airways that lead from the larger airways (bronchi) to the alveoli in the lungs, become inflamed, swell, and fill with mucus. This condition occurs most frequently in newborns and toddlers, especially boys, whose airways can easily become blocked. Infections are common during the winter and spring. Young children who require hospitalization for bronchiolitis are at increased risk for developing childhood asthma.
The treatment for a child suffering from bronchiolitis is mainly supportive. Although many of these patients do well, there is still a risk for significant respiratory compromise. You should provide appropriate oxygen therapy and allow the patient to remain in a position of comfort. Suction thick mucus from the nostrils if present. Reassess frequently for signs of worsening respiratory distress. Be prepared to provide airway management and positive-pressure ventilation should the patient develop respiratory failure.
Bronchiolitis
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According to the World Health Organization,____ is a significant cause of morbidity worldwide.___ is a general term that refers to an infection of the lungs. The infection collects in the surrounding normal lung tissues, impairing the lung's ability to exchange oxygen and carbon dioxide
_____is often a secondary infection, meaning it begins after an upper respiratory tract infection such as a cold or sore throat. It can be caused by a virus or bacterium, or by a chemical injury after an accidental ingestion or a direct lung injury from a submersion incident. Interventions such as intubation and tracheostomy can increase the risk of developing____.____ commonly affects people who are chronically and terminally ill. Factors that predispose patients to pneumonia include the following:
• Institutional residence (nursing home or long-term care facilities)
• Recent hospitalization
• Chronic disease processes (such as renal failure requiring dialysis)
• Immune system compromise (patient receiving chemotherapy or diseases such as HIV)
• History of COPD
Symptoms of____ vary, depending on the age of the person and the cause of the illness. Children often present with unusually rapid or labored breathing or breathing characterized by grunting or wheezing sounds. In severe cases where oxygen exchange at the alveoli is markedly impaired, the lips and fingernails may be blue or gray. If the pneumonia is in the lower part of the lungs near the abdomen, there may be fever, abdominal pain, and vomiting rather than dyspnea.
Bacterial____ results in severe symptoms more quickly, including high fevers, which put the child at risk for
febrile seizures. A viral___ presents more gradually and is less severe
Other signs and symptoms include dry skin, decreased skin turgor, exertional dyspnea, a productive cough, chest discomfort or pain that varies with inspiration and expiration, headache, nausea and vomiting, musculoskeletal pain, weight loss, and confusion. The patient may be febrile, tachycardic, or even hypotensive. Assessment of the lungs may reveal diminished breath sounds, along with the presence of wheezing, crackles, or rhonchi. You will need to evaluate the patient's history for possible risk factors. If possible, assess temperature to determine the presence of fever. Pulse oximetry readings, if available, may be low.
Regardless of the cause, treatment includes airway support and providing supplemental oxygen. Use oxygen with appropriate adjuncts, and provide supportive measures if needed. Evaluate patient treatment through reassessment, and prepare for possible deterioration in the patients condition
pneumonia
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______is an airborne bacterial infection that primarily affects children younger than 6 years. It is highly contagious and is passed through droplet infection.
A patient with___ will be feverish and exhibit a "whoop" sound on inspiration after a coughing attack.
Symptoms are generally similar to colds, but coughing spells can last for more than 1 minute, during which the child may turn red or purple. This may frighten the parents or caregivers into calling 9-1-1.
Some infants and younger children with pertussis should be treated in a hospital because they are at greater risk for complications such as pneumonia, which occurs mostly in children younger than 1 year. In infants younger than 6 months, pertussis can be life threatening.
Children with___ may vomit or not want to eat or drink. Watch for signs of dehydration. You may have to
suction thick secretions to clear the airway. Give oxygen by the most appropriate means.
Pertussis can also occur in adults either because they were not vaccinated as children, or more commonly because the vaccine did not confer lifelong immunity. When it does occur, it can cause a severe upper respiratory infection, which can lead to pneumonia in geriatric patients or people with compromised immune systems. The infection can cause coughing spells that last for weeks and can be so severe that patients find it hard to breathe, eat, or sleep. In the worst cases of infection, particularly in geriatric patients, coughing can lead to cracked ribs. For patients who are already weak from other chronic conditions, pertussis can lead to hospitalization. According to the CDC, the disease has become a serious issue and physicians are becoming more aggressive about immunizing adults with the____ vaccine.
Pertussis (whooping cough)
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____is an animal respiratory disease that has mutated to infect humans. In 2009, the H1N1 strain of ____became pandemic (an outbreak that occurred on a global scale). Like seasonal flu, it may make chronic medical conditions worse. All strains of___ are transmitted by direct contact with nasal secretions and aerosolized droplets from coughing and sneezing by infected people.____ viruses cause fever, cough, sore throat, muscle aches, headache, and fatigue and may lead to pneumonia or dehydration.
Influenza type A
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___is a respiratory disease caused by the virus SARS-CoV-2. The virus is a coronavirus, similar to the one that causes the common cold. It is believed to have initially been native to bats and transferred to humans by contact in an open-livestock meat market in Wuhan, China, in 2019. Because the virus is extremely contagious, it spread rapidly across the entire world, creating a severe pandemic that resulted in hundreds of thousands of deaths worldwide. The virus preferentially affects the elderly, patients living in close quarters with one another, and those with weakened immune systems, but it has also sickened and even killed many people who were otherwise young and healthy.
______is transmitted by aerosol droplets, through airborne particles generated by sneezing or coughing, and by direct contact. The virus can survive on surfaces for several days. Symptoms include high fever, cough, chest pain during inspiration, vomiting and diarrhea, and anosmia (inability to smell). Respiratory deterioration in these patients can be dramatic and rapid.
COVID-19
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_____is a bacterial infection caused by Mycobacterium tuberculosis.___ spreads by cough and is dangerous because many strains are resistant to antibiotics.___ most commonly affects the lungs but can also be found in almost any organ of the body, particularly the kidneys, spine, and lining of the brain and spinal cord (meninges). In some cases,___ can remain dormant (inactive) for years without causing symptoms or being infectious to other people.
However, when the person is in a state of weakened immunity,___ can become active again. The patient may not even be aware he or she has the disease.
Patients with active___ involving the lungs will report fever, coughing, fatigue, night sweats, and weight loss. If the lung infection becomes severe, the patient will experience shortness of breath, coughing, productive sputum, bloody sputum, and chest pain.
___has a higher prevalence among people who live in close contact, such as prison inmates, nursing home residents, and people in homeless shelters.__ is also found in people who abuse intravenous drugs or alcohol and people whose immune systems are compromised by an infection such as HIV. Anyone who comes into close contact with people who have active___ or is in contact with people from countries that have a high prevalence of___ is at risk for contracting the disease. As an EMT, you are also at risk.
If you suspect your patient may have active__, you need to wear (at a minimum) your gloves, eye protection, and an N-95 respirator. These respirators are fit-tested to the individual to ensure no contaminated air can pass through.
Also place a surgical mask or oxygen mask on the patient.
Tuberculosis (TB)
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Sometimes, the heart muscle is so injured after a heart attack or other illness that it cannot circulate blood properly. In these cases, the left side of the heart cannot remove blood from the lung as fast as the right side delivers it. As a result, fluid builds up within the alveoli and in the lung tissue between the alveoli and the pulmonary capillaries. This accumulation of fluid is referred to as___, and it is usually a result of congestive heart failure. By physically separating the alveoli from the pulmonary capillary vessels, the edema interferes with the exchange of carbon dioxide and oxygen (FIGURE 16-6). High blood pressure and low cardiac output often trigger this flash (sudden) pulmonary edema. These patients are among the most sick, frightened, and worrisome patients you will encounter.
They are literally drowning in their own fluid. The patient usually experiences dyspnea with rapid, shallow respirations.
In the most severe cases, you will see frothy pink sputum at the nose and mouth. Patient risk factors for congestive heart failure include hypertension and a history of coronary artery disease
and/or atrial fibrillation, a condition in which the atria no longer contract, but instead quiver.
Congestive heart failure (which can lead to pulmonary edema) is often cited as one of the most common causes of hospital admission in the United States. It is not uncommon for a patient to have repeated bouts. In most cases, patients have a long-standing history of chronic congestive heart failure that can be kept under control with medication. However, an acute onset may occur if the patient stops taking the medication, eats food that is too salty, or has a stressful illness, a new heart attack, or an abnormal heart rhythm.
However, not all patients with pulmonary edema have heart disease. Poisonings from inhaling large amounts of smoke or toxic chemical fumes can produce pulmonary edema, as can traumatic injuries of the chest and exposure to high altitudes. In these cases, fluid collects in the alveoli and lung tissue in response to damage to the tissues of the lung or the bronchi.
Signs and symptoms of congestive heart failure include difficulty breathing with exertion because the heart cannot keep up with the body's need for oxygen. Patients may also report a sudden attack of respiratory distress that wakes them at night when they are in a reclining position. This is caused by fluid accumulation in the lungs. Patients also report coughing, feeling suffocated, cold sweats, and tachycardia.
In your primary assessment, you might find the patient has cool, diaphoretic, cyanotic skin and you will hear adventitious breath sounds such as crackles or wheezing. The patient's pulse will be tachycardic. The patient may have hypertension early, followed by deterioration to hypotension as a late finding.
pulmonary edema
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______, according to the World Health Organization, is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. According to the US Department of Health and Human Services,___ has been diagnosed in approximately 16 million people, and millions more people have___ and do not know it. According to the CDC, it is the fourth leading cause of death in the United States.____ is an umbrella term used to describe several lung diseases, including emphysema and chronic bronchitis, an ongoing irritation of the trachea and bronchi.
_____may be a result of direct lung and airway damage from repeated infections or inhalation of toxic gases and particles, but most often it results from cigarette smoking. Although it is well known that cigarettes are a direct cause of lung cancer, their role in the development of___ is far more significant and less publicized.
Tobacco smoke is a bronchial irritant and can create chronic bronchitis. With bronchitis, excess mucus is constantly produced, obstructing small airways and alveoli. Protective cells and lung mechanisms that remove foreign particles are destroyed, further weakening the airways. Chronic oxygenation problems can also lead to right-side heart failure and fluid retention, such as edema in the legs.
Pneumonia develops easily when the air passages are persistently obstructed. Ultimately, repeated episodes of irritation and pneumonia cause scarring in the lungs and some dilation of the obstructed alveoli, leading to___.
The most common form of___ is emphysema. Emphysema is a loss of the elastic material in the lungs that occurs when the alveolar air spaces are chronically stretched due to inflamed airways and obstruction of airflow out of the lungs. Smoking can also directly destroy the elasticity of the lung tissue. Normally, the lungs act like spongy balloons that are inflated; once they are inflated, they will naturally recoil because of their elastic nature, expelling gas rapidly.
However, when they are constantly obstructed or when the elasticity is diminished, air is no longer expelled rapidly, and the walls of the alveoli eventually fall apart, leaving large holes in the lung that resemble large air pockets or cavities. Most patients with____ have elements of both chronic bronchitis and emphysema. Some patients will have more elements of one condition than the other; few patients will have only emphysema or bronchitis. Therefore, most patients with___ will chronically produce sputum, have a chronic cough, and have difficulty expelling air from their lungs, with long expiration phases and wheezing. Patients may present with adventitious breath sounds such as crackles, rhonchi, and wheezes, or may have severely diminished breath sounds due to poor air movement.
Chronic obstructive pulmonary disease (COPD)
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Be aware that the signs and symptoms of COPD and congestive heart failure significantly overlap. Many patients suffer from both diseases, and it is often difficult to determine which disease is causing the patient's shortness of breath; often these patients are treated for both diseases after arrival to the hospital. Lung sounds (discussed later in the chapter) are one way to help you tell the difference. Patients with pulmonary edema caused most often by congestive heart failure will often have___(crackles), and patients with COPD will often have dry lung sounds (wheezes). However, do not assume all patients with COPD have wheezes and all congestive heart failure patients have crackles.
wet lung sounds
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A disease of the lungs in which there is extreme dilation and eventual destruction of the pulmonary alveoli with poor exchange of oxygen and carbon dioxide; it is one form of chronic obstructive pulmonary disease
Emphysema
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___\is a loss of the elastic material in the lungs that occurs when the alveolar air spaces are chronically stretched due to inflamed airways and obstruction of airflow out of the lungs. Smoking can also directly destroy the elasticity of the lung tissue.
Emphysema
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Suppose you are called to assist an 80-year-old man who has experienced shortness of breath for 45 minutes.
Physical examination reveals that his pulse and respirations are elevated, and you observe pedal edema (swollen legs and feet) and jugular vein distention. His lung sound check reveals wheezing. He has a history of hypertension, congestive heart failure, and myocardial infarction; however, he has no history of smoking, asthma, or COPD. What is your initial general impression?
This patient's elevated blood pressure, pedal edema, jugular vein distention, and history of congestive heart failure should lead you in the direction of congestive heart failure. Unlike a typical patient with COPD, he has no history of smoking and takes diuretics and medication for hypertension. In this case, the alveoli are so full of fluid that bubbles (the condition that gives the sound of crackles) cannot form. The bronchi also become constricted, which produces wheezing. The wheezing this patient is experiencing is called cardiac asthma, which is not a form of asthma, but rather a type of coughing or wheezing that occurs with left-side heart failure.
Patients with COPD wheeze because of bronchial constriction and present with shortness of breath. Their breathing
gets progressively worse, and they have the most trouble breathing on exertion. Patients with COPD have chronic coughing and thick sputum. They are usually long-term smokers with a thin, barrel chest appearance. Their medications would include home oxygen, bronchodilators, and corticosteroids.
Patients with COPD often have a slower onset of symptoms because their disease is worsened by infection and other stressors. Patients with congestive heart failure experience a fluid overload in the lung, which may develop quickly from a failing pump.
As you try to discern between COPD and congestive heart failure, keep an open mind so that you do not miss
important differences. The best advice is to treat the patient, not the lung sounds.
Comparison
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__: Acute spasm of bronchioles with excessive mucus production, and swelling of mucus lining of respiratory passages; wheezing on exhale, bronchospasms; MDI, nebulizer, oxygen
Asthma
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___: Severe allergic reaction; flushed skin, hives, generalized edema, decreased bp, laryngeal edema, wheezing or stridor; Epinephrine, oxygen, transport
Anaphylaxis
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___: Severe inflammation of bronchioles that often occurs due to RSV; SOB, wheezing, coughing, fever, dehydration, tachypnea, tachycardia; Oxygen, position of comfort, suction
Bronchiolitis
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__: Damaged ventricles and heart failing as a pump; abdominal distention, dependent edema, tachycardia, increased respiratory rate, anxiety, cant lie flat, ashen or cyanosis, crackles, wheezing, pink frothy sputum, fast onset; cpap, oxygen,
CHF
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__: Air leaks between lung and chest wall making lung collapse; sudden chest pain w/ dyspnea, decreased breath sounds, subcutaneous emphysema
Pneumothorax
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___: Blood Clot formed in vein that breaks off into venous system and into pulmonary artery where it gets lodged blocking blood flow; dyspnea, tachycardia, tachypnea, hypoxia, cyanosis, acute chest pain, coughing up blood (hemoptysis)
Pulmonary embolism
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___: Air sacs of lungs are damaged and enlarged; barrel chest, pursed lip breathing, dyspnea on exertion, cyanosis, wheezing, decreased breath sounds
Emphysema
251
___is a partial or complete accumulation of air in the pleural space. Pneumothorax is most often caused by trauma, but it can also be caused by some medical conditions. In these cases, the condition is called a spontaneous pneumothorax.
Normally, the vacuum pressure in the pleural space keeps the lung inflated. When the surface of the lung is disrupted, however, air escapes into the pleural cavity and results in a loss of negative vacuum pressure. The natural elasticity of the lung tissue causes the lung to collapse. The accumulation of air in the pleural space may be mild or severe
Pneumothorax
252
____may occur in patients with certain chronic lung infections or in young people born with weak areas of the lung. Patients with emphysema and asthma are at high risk for spontaneous pneumothorax when a weakened portion of lung ruptures, often during severe coughing. Tall, thin young men are also more susceptible than the rest of the population to development of spontaneous pneumothorax, particularly while performing strenuous activities, such as heavy lifting.
A patient with a spontaneous pneumothorax has dyspnea and might report pleuritic chest pain, a sharp, stabbing pain on one side that is worse during inspiration and expiration or with certain movement of the chest wall. By listening to the chest with a stethoscope, you can sometimes detect that breath sounds are absent or decreased on the affected side. However, altered breath sounds are very difficult to detect in a patient with severe emphysema.
Spontaneous pneumothorax may be the cause of sudden dyspnea in a patient with underlying emphysema. A spontaneous pneumothorax has the potential to evolve into a life-threatening pneumothorax. Continually reassess for anxiety, increased dyspnea, hypotension, absent or severely decreased breath sounds on one side, the presence of jugular vein distention, and cyanosis.
Spontaneous pneumothorax
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A____ is a collection of fluid outside the lung on one or both sides of the chest. It compresses the lung on lungs and causes dyspnea (FIGURE 16-11). This fluid may collect in large volumes in response to any form of irritation such as infection, congestive heart failure, or cancer. Although it can build up gradually, over days or even weeks, patients often report that their dyspnea came on suddenly.____ may also contribute to shortness of breath in a patient with lung cancer. When you listen with a stethoscope to the chest of a patient with dyspnea resulting from__, you will hear decreased breath sounds over the region of the chest where fluid has moved the lung away from the chest wall.
These patients frequently feel better if they are sitting upright. Nothing will completely relieve their symptoms, however, except removal of the fluid, which must be done by a physician in the hospital.
pleural effusion
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Än____ is anything in the circulatory system that moves from its point of origin to a distant site and lodges there, obstructing subsequent blood flow in that area. Beyond the point of obstruction, circulation can be significantly decreased or completely blocked, which can result in a life-threatening condition. Emboli can be fragments of blood clots in an artery or vein that break off and travel through the bloodstream, or foreign bodies that enter the circulation, such as a bubble of air.
embolus
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A ____is a blood clot formed in a vein, usually in the legs or pelvis, that breaks off and circulates through the venous system. The embolus can also come from the right atrium in a patient with atrial fibrillation. The clot moves through the right side of the heart and into the pulmonary artery, where it becomes lodged, significantly decreasing or blocking blood flow (FIGURE 16-13). Even though the lung itself can continue the process of inhalation and exhalation, no exchange of oxygen or carbon dioxide takes place in the areas of blocked blood flow because there is no effective circulation. In this circumstance, oxygen levels in the bloodstream may drop enough to cause cyanosis.
The severity of cyanosis and dyspnea is directly related to the size of the embolism and the amount of tissue affected.
pulmonary embolism
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___may occur as a result of damage to the lining of vessels, a tendency for blood to clot unusually fast, or, most often, slow blood flow in a lower extremity. Slow blood flow in the legs is usually caused by long-term bed rest, which can lead to the collapse of veins. Pregnancy, active cancer, and bed rest are other risk factors. Recent surgery in the legs or pelvis of any type increases the risk of pulmonary embolus. Although uncommon, pulmonary emboli may also occur in active, healthy people in the absence of any other known risk factors.
Although they are fairly common, pulmonary emboli are difficult to diagnose. According to the US Department of Health and Human Services, 100,000 cases of pulmonary embolism occur each year in the United States. Symptoms and signs of pulmonary emboli include the following:
• Dyspnea (often sudden onset)
• Tachycardia
• Tachypnea
• Varying degrees of hypoxia
• Cyanosis
• Acute chest pain
• Hemoptysis (coughing up blood)
With a large enough embolus, complete, sudden obstruction of the output of blood flow from the right side of the
heart can result in sudden death.
Pulmonary emboli
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_____is defined as rapid breathing to the point that the level of arterial carbon dioxide falls below normal.
This may be an indicator of a life threatening illness. For example, a patient with diabetes who has a high blood glucose level, a patient who has taken an overdose of aspirin, or a patient with a severe infection is likely to hyperventilate. In these cases, rapid, deep breathing is the body's attempt to stay alive. The body is trying to compensate for acidosis, the buildup of excess acid in the blood or body tissues that results from the primary illness.
Because carbon dioxide, mixed with water in the bloodstream, can add to the blood's acidity, lowering the level of carbon dioxide helps to compensate for the other acids.
Similarly, in an otherwise healthy person, blood acidity can be diminished by excessive breathing because it blows off too much carbon dioxide. The result is a relative lack of acids. The resulting condition, alkalosis, is the buildup of excess base (lack of acids) in the body fluids.
Alkalosis is the cause of many of the symptoms associated with hyperventilation syndrome, including anxiety, dizziness, numbness, tingling of the hands and feet, and painful spasms of the hands and/or feet (carpopedal spasms).
Patients often feel as if they cannot catch their breath despite the rapid breathing. Although hyperventilation can be a response to illness and a buildup of acids, hyperventilation syndrome is not caused by these conditions. Instead, this syndrome occurs in the absence of other physical problems. It commonly occurs when a person is experiencing psychological stress and affects some 10% of the population at one time or another. The respirations of an individual who is experiencing hyperventilation syndrome may be as high as 40 shallow breaths/min or as low as 20 deep breaths/min.
The decision whether hyperventilation is being caused by a life-threatening illness or a panic attack should not be made outside the hospital. Initially, you can verbally instruct the patient to slow his or her breathing; however, if that does not work, give supplemental oxygen and provide transport to the hospital where physicians will determine the cause of the hyperventilation.
Hyperventilation
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Describe the assessment of a patient who is in respiratory distress and the relationship of assessment findings to patient management and transport decisions
Perform a rapid examination to identify immediate life threats, which includes problems with the ABCs: airway, breathing, and circulation (discussed next). If any major problem is identified, treat it immediately. If you find life-threatening issues, provide rapid transport.
Note your general impression of the patient. What is the patient's age and position? A patient in significant respiratory distress will want to sit up. Assess the airway; air must flow in and out of the chest easily for the airway to be considered patent. If there is any question about airway patency, immediately open the airway using the head tilt-chin lift maneuver in nontrauma patients and the jaw-thrust maneuver in patients with suspected spinal trauma.
If the airway is patent, next evaluate whether the patient's breathing is adequate. What are the rate, rhythm, and quality of the respirations? After assessing breath sounds, assess circulation-the pulse rate, quality, and rhythm. If the pulse rate is too fast or too slow, the patient may not be getting enough oxygen. Determine the quality of the pulse. Is it strong, bounding, or weak? Also determine whether the rhythm is regular or irregular. Irregular beats could indicate a cardiac problem.
Assessing a patient's circulation includes an evaluation for the presence of shock and bleeding. Respiratory distress in a patient could be caused by an insufficient number of red blood cells to transport the oxygen. Assess capillary refill in infants and children. Normal capillary refill is less than 2 seconds; abnormal capillary refill is greater than 2 seconds.
Capillary refill is not considered a reliable assessment tool in the adult patient. Note that a patient with a severe chest injury, such as flail chest, or obstruction of the airway may be unable to breathe in an adequate amount of oxygen. This affects the ventilation process of respiration because not enough oxygen can be inspired to meet the metabolic demand.
An insufficient concentration of oxygen in the blood can produce a life-threatening situation as rapidly as vascular causes of shock, even if the volume of blood, the volume of the vessels, and the action of the heart are all normal.
Without oxygen, the organs in the body cannot survive, and their cells promptly start to deteriorate.
Assess the patient's perfusion by evaluating skin color, temperature, and condition. A loss of perfusion may be caused by chronic anemia, a wound, internal bleeding, or simply shock overwhelming the body's ability to compensate for the illness.
You now know enough to be able to identify any life threats in your patient. They would include any of the following
signs or symptoms:
• Problems with the ABCs
• Poor initial general impression
• Unresponsiveness
• Potential hypoperfusion or shock
• Chest pain associated with a low blood pressure
• Severe pain anywhere
• Excessive bleeding
Obtaining breath sounds, or lung sounds, is an important step when you assess a patient who is experiencing respiratory distress. Listen over the bare chest. Trying to listen over clothing or chest hair may give you inaccurate information. The diaphragm of the stethoscope must be in firm contact with the skin. If your patient is lying down, bring him or her to a sitting position, which is a better position for assessing breath sounds.
You need to determine whether your patient's breath sounds are normal (vesicular breath sounds, bronchial breath sounds) or decreased, absent, or abnormal (adventitious breath sounds). With your stethoscope, check breath sounds c the right and left sides of the chest, and compare each side (FIGURE 16-15). When listening on the patient's back, pläce the stethoscope head between and below the scapulae, not over them, or you will have an inaccurate assessment.
Snoring sounds are indicative of a partial upper airway obstruction, usually in the oropharynx. Wheezing indicates constriction and/or inflammation in the bronchus. Wheezing is generally heard on exhalation as a high-pitched, almost musical or whistling sound. This sound is commonly heard in patients with asthma and sometimes in patients with COPD.
Crackles (formerly called rales) are the sounds of air trying to pass through fluid in the alveoli. It is a crackling or bubbling sound typically heard on inspiration. High-pitched sounds are called fine crackles, and low-pitched sounds are called coarse crackles. These sounds are often a result of congestive heart failure or pulmonary edema.
Rhonchi are low-pitched rattling sounds caused by secretions or mucus in the larger airway. Rhonchi are sometimes referred to as junky lung sounds and can be heard with infections such as pneumonia and bronchitis or in cases of aspiration. When you perform a secondary assessment on the respiratory system, look for overall symmetry of the chest, adequate rise and fall of the chest, and evidence of retractions or accessory muscle use. Are the patient's respirations labored or unlabored? Assess breath sounds, and perform additional physical assessment if warranted.
A secondary assessment of the cardiovascular system, especially when there is associated chest pain, should include checking and comparing distal pulses, reassessing the skin condition, and being alert for bradycardia and tachycardia.
Feel for the skin temperature, and look for color changes in the extremities and in the core of the body. Cyanosis is an ominous sign that requires immediate, aggressive intervention. Once the assessment and treatment have been completed, you need to reassess the patient and closely watch patients with shortness of breath. Repeat the primary assessment and maintain an open airway. Monitor the patient's breathing and reassess circulation.
Determine if there have been changes in the patient's condition. Confirm the adequacy of interventions and patient status. Is the current treatment improving the patient's condition? Has an already identified problem improved? Has an already identified problem gotten worse? What is the nature of any newly identified problems?
If the changes you find are improvements, simply continue the treatments; however, if your patient's condition deteriorates, prepare to modify treatments. Be prepared to assist ventilations with a bag-mask device. Monitor the skin color and temperature. Reassess and record vital signs at least every 5 minutes for a patient in unstable condition and/or after the patient uses an inhaler. If the patient's condition is stable and no life threat exists, vital signs should be obtained at least every 15 minutes. Interventions for respiratory problems may include the following:
• Providing oxygen via a nonrebreathing mask at 15 L/min
• Providing positive-pressure ventilations using a bag-mask device
• Using airway management techniques such as an oropharyngeal (oral) airway, a nasopharyngeal (nasal) airway, suctioning, or airway positioning
• Providing noninvasive ventilatory support with continuous positive airway pressure (CAP)
• Positioning the patient in a high Fowler position or a position of choice to facilitate breathing
• Assisting with respiratory medications found in a patient-prescribed metered-dose inhaler or a small-volume nebulizer
259
Describe the primary emergency medical care of a person who is in respiratory distress
Management of respiratory distress involves continuing awareness of scene safety and the use of standard precautions. Management of ABCs and positioning are primary treatments, along with oxygen and suction.
You will usually administer oxygen to patients in respiratory distress. If a patient reports breathing difficulty, administer supplemental oxygen immediately. Adült patients breathing more than 20 breaths/min or fewer than 12 breaths/min should receive high-flow oxygen (defined as 15 L/min). Depending on the level of distress, some patients may benefit from CPAP (discussed later in the chapter). In addition, patients may require ventilatory support with a bag-mask device, particularly if their mental status is declining, if they are in moderate to severe respiratory distress, or if their depth of respiration is inadequate.
Take great care in monitoring the patient's respirations as you provide oxygen. Reevaluate the respirations and the patient's response to oxygen repeatedly, at least every 5 minutes, until you reach the ED. In a person with a chronically high carbon dioxide level (eg, certain patients with COPD), this is critical, because the supplemental oxygen may cause a rapid rise in the arterial oxygen level, which may depress the patient's hypoxic drive.
In patients who have long-standing COPD and probable carbon dioxide retention, administration of low-flow oxygen (2 L/min) is a good place to start, with adjustments to 3 L/min, then 4 L/min, and so on, until symptoms have improved (eg, the patient's breathing becomes easier, or the patient becomes more responsive). Pulse oximetry will help you understand the degree of oxygen deprivation and adjust oxygen therapy accordingly. When in doubt, err on the side of more oxygen, and monitor the patient closely.
Remember, do not withhold oxygen for fear of depressing or stopping breathing in a patient with COPD who needs oxygen. A decreased respiratory rate after administration of oxygen does not necessarily mean that the patient no longer needs the oxygen; the patient may need it even more. If respirations slow and the patient becomes unconscious, assist breathing with a bag-mask device.
Always provide emotional support to the patient who is anxious. Always speak with assurance and assume a
concerned, professional approach to reassure the patient, who is probably very frightened.
260
What are the causes of acute pulmonary edema compared to chronic edema?
Acute: Heart muscle so injured after heart attack or other illness that it can't properly circulate blood; left side of heart can't remove blood from lung as fast as right side delivers it
- Chronic edema- a broad term that the swelling has lasted longer than 3 months
261
Dyspnea caused by acute pulmonary edema may be associated with cardiac disease or direct lung damage. In either case, administer 100% oxygen, and, if necessary, carefully suction any secretions from the airway. The best position for a conscious patient who has acute pulmonary edema is the position in which it is easiest to breathe. Usually, this is sitting up.
An unconscious patient with acute pulmonary edema may require full ventilatory support, including placement of an airway. adjunct, positive-pressure ventilation with a bag-mask device, oxygen, and suctioning.
Continuous positive airway pressure (CPAP) is a noninvasive means of providing ventilatory support for patients experiencing respiratory distress associated with obstructive pulmonary disease (such as emphysema) and acute pulmonary edema. CPAP increases pressure in the lungs, opens collapsed alveoli, pushes more oxygen across the alveolar membrane, and forces interstitial fluid back into the pulmonary circulation. See Chapter 11, Airway Management, for a complete discussion and Skill Drill 11-10 for instructions on using CPAP. CPAP systems use oxygen to deliver the positive ventilatory pressure to the patient. Many patients show dramatic improvement with the use of CPAP. CAP can be used for patients who have moderate to severe respiratory distress from an underlying disease, such as pulmonary edema or obstructive pulmonary disease (including emphysema), are alert and able to follow commands, have tachypnea, or have a pulse oximetry reading of less than 90%. One potential contraindication to the use of CAP is low blood pressure. Because of the increased pressure inside the chest, blood flow returning to the heart is diminished, further decreasing blood pressure.
CPAP is also not used in patients in respiratory arrest or who have signs and symptoms of a pneumothorax or chest trauma, a tracheostomy, a decreased level of consciousness, inability to follow commands, or active gastrointestinal bleeding If you are authorized to apply CPAP for acute pulmonary edema according to your local protocols, do so. Call for ALS support or provide prompt transport to the nearest appropriate ED. Continue to reassess patients using CPAP for signs of deterioration and/or respiratory failure.
Acute pulmonary edema
262
Discuss the basic anatomy and physiology of the cardiovascular system.
The heart is a relatively simple organ with a simple job. It pumps blood to supply oxygen enriched red blood cells to the tissues of the body. The heart is divided down the middle into two sides (left and right) by a wall called the septum. Each side of the heart has an atrium, or upper chamber, to receive incoming blood, and a ventricle, or lower chamber, to pump outgoing blood (FIGURE 17-1). Blood leaves each of the four chambers of the heart through a one-way valve. These valves keep the blood moving through the circulatory system in the proper direction. The aorta, the body's main artery, receives the blood ejected from the left ventricle and delivers it to all the other arteries so they can carry blood to the tissues of the body.
The right side of the heart receives oxygen-poor (deoxygenated) blood from the veins of the body (FIGURE 17-2A). Blood from the superior and inferior venae cavae enters the right atrium, which then fills the right ventricle. After contraction of the right ventricle, blood flows into the pulmonary artery and travels through the pulmonary circulation in the lungs, where it is reoxygenated. As the blood reaches the lungs, it receives fresh oxygen from the alveoli and carbon dioxide waste is removed from the blood and moved into the alveoli. The blood then returns to the heart through the pulmonary veins. The left side of the heart receives oxygen-rich (oxygenated) blood from the lungs through the pulmonary veins (FIGURE 17-2B).
Blood enters the left atrium and then passes into the left ventricle. The left ventricle is more muscular than the right ventricle because it must pump blood into the aorta to supply all the other arteries of the body.
The heart contains more than muscle tissue. The heart's electrical conduction system controls heart rate and enables the atria and ventricles to work together (FIGURE 17-3). Normal electrical impulses begin in the sinus node, which is in the upper part of the right atrium and is also known as the sinoatrial (SA) node. The impulses travel across both atria, stimulating them to contract. Between the atria and the ventricles, the impulses cross a bridge of special electrical tissue called the atrioventricular (AV) node. Here, the signal is slowed for about one- to two-tenths of a second to allow blood time to pass from the atria to the ventricles. The impulses then exit the AV node and spread throughout both ventricles via the bundle of His, the right and left bundle branches, and the Purkinje fibers, ultimately causing the muscle cells of the ventricles to contract.
Cardiac muscle cells have a special characteristic called automaticity that is not found in any other type of muscle cells.
Automaticity allows a cardiac muscle cell to contract spontaneously without a stimulus from a nerve source. Normal impulses in the heart start at the SA node. As long as impulses come from the SA node, the other myocardial cells will contract when the impulse reaches them. However, if no impulse arrives, the other myocardial cells are capable of creating their own impulses and stimulating a contraction of the heart, although at a generally slower rate.
The stimulus that originates in the SA node is controlled by impulses from the brain, which arrive by way of the autonomic nervous system. The autonomic nervous system is the part of the brain that controls the functions of the body that do not require conscious thought, such as the heartbeat, respirations, dilation and constriction of blood vessels, and digestion of food. The autonomic nervous system has two parts, the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system is also known as the fight-or-flight system and makes adjustments to the body to compensate for increased physical activity. The sympathetic nervous system speeds up the heart rate, increases respiratory rate and depth, dilates blood vessels in the muscles, and constricts blood vessels in the digestive system. The parasympathetic nervous system directly opposes the sympathetic nervous system. The parasympathetic nervous system slows the heart and respiratory rates, constricts blood vessels in the muscles, and dilates blood vessels in the digestive system. Normally, these two systems balance each other, but in times of stress, the sympathetic nervous system gains primary control, whereas in times of relaxation, the parasympathetic system takes control.
To perform the function of pumping blood, the myocardium, or heart muscle, must have a continuous supply of oxygen and nutrients. During periods of physical exertion or stress, the myocardium requires more oxygen. The heart must increase cardiac output to meet the increased metabolic requirements of the body. Cardiac output is increased by increasing the heart rate or stroke volume. In the normal heart, this increased oxygen demand of the myocardium itself is accomplished by increasing the amount of blood flowing (and therefore the amount of oxygen being delivered) to the myocardium by dilation. or widening, of the coronary arteries. The coronary arteries are the blood vessels that supply blood to the heart muscle (FIGURE 17-4). They begin at the first part of the aorta, just above the aortic valve. The right coronary artery supplies blood to the right atrium and right ventricle and, in most people, the bottom part, or inferior wall, of the left ventricle. The left coronary artery supplies blood to the left atrium and left ventricle and divides into two major branches, just a short distance from the aorta.
263
Two major arteries branching from the upper aorta supply blood to the head and arms (FIGURE 17-5). The right and left____ supply the head and brain with blood. The right and left subclavian arteries (under the clavicles) supply blood to the upper extremities. As the subclavian artery enters each arm, it becomes the brachial artery, the major vessel that supplies blood to each arm. Just below the elbow, the brachial artery divides into two major branches: the radial and ulnar arteries, supplying blood to the lower arms and hands.
carotid arteries
264
At the level of the umbilicus, the descending aorta divides into two main branches called the right and left____, which supply blood to the groin, pelvis, and legs. As the ____enter the legs through the groin, they become the right and left femoral arteries. At the level of the knee, the femoral artery divides into the anterior (front) and posterior (back) tibial arteries and the peroneal artery, supplying blood to the lower legs and feet.
After blood travels through the arteries, it enters smaller and smaller vessels called arterioles and eventually enters the capillaries. Capillaries are tiny blood vessels about one cell thick that connect arterioles to venules. Capillaries, which are found in all parts of the body, allow the exchange of nutrients and waste at the cellular level. As the blood passes through the capillaries, it gives up oxygen to the tissues and picks up carbon dioxide and other waste products to be removed from the body.
Venules are the smallest branches of veins. After traveling through the capillaries, oxygen-poor blood enters the system of veins, starting with the venules, on its way back to the heart. The veins become larger and larger and eventually form the two large venae cavae: the superior vena cava and the inferior vena cava. The superior (upper) vena cava carries blood from the head and arms back to the right atrium. The inferior (lower) vena cava carries blood from the abdomen, pelvis, and legs back to the right atrium. The superior and inferior venae cavae join at the right atrium of the heart, where blood is then returned into the pulmonary circulation for oxygenation.
Blood consists of fluid and several types of cells (FIGURE 17-6). Red blood cells are the most numerous and give the blood its color-bright red when oxygenated and darker red when low on oxygen. Red blood cells carry oxygen to the body's tissues and remove carbon dioxide. Larger white blood cells help to fight infection. Platelets, which help the blood to clot, are much smaller than either red or white blood cells. Plasma is the fluid in which the cells float. It is' mixture of water, salts, nutrients, and proteins.
iliac arteries
265
_____is the force of circulating blood against the walls of the arteries. Systolic blood pressure is the maximum pressure generated in the arms and legs during the contraction of the left ventricle, during the time period known as systole!
As the left ventricle relaxes in the stage known as diastole, the arterial pressure falls. When the left ventricle relaxes, the aortic valve closes and blood flow between the left ventricle and the aorta stops. The diastolic blood pressure is the pressure exerted against the walls of the arteries while the left ventricle is at rest. Remember that the top number in a blood pressure reading is the systolic pressure, and the bottom number is the diastolic, or resting, pressure. The cardiac cycle consists of one systolic and one diastolic time period. The mean arterial pressure (MAP) measures the average blood pressure and is displayed when a noninvasive blood pressure is measured. The MAP is a good measure of perfusion.
As the blood passes through an artery during systole, a pulse is generated. This pulse can be felt by placing a finger on the skin over the artery at a point where the artery lies near the skin surface and gently compressing. Pulses felt in the extremities, such as the radial and the posterior tibial, are called peripheral pulses, whereas pulses near the trunk of the body, such as the femoral and carotid pulses, are known as central pulses.
The rate of cardiac contractions can be increased or decreased by the autonomic nervous system. The heart also has the
capability to increase or decrease the volume of blood it pumps with each contraction based on the autonomic nervous system response. To obtain an accurate measure of the efficiency of the heart, the volume of blood pumped and the heart rate are measured. This is determined by calculating the cardiac output. The cardiac output is calculated by multiplying the heart rate by the volume of blood ejected with each contraction, or the stroke volume. This is the volume of blood that passes through the heart in 1 minute and is the best measure of the output of the heart. In the field, we have no way of directly measuring the volume of blood being pumped; therefore, we must rely on the heart rate and the strength of the pulse to estimate the cardiac output.
Blood pressure
266
The constant flow of oxygenated blood to the tissues is known as__. Good perfusion requires three primary components. The first is a well-functioning heart, or pump. The heart must operate at an appropriate rate because a rate that is too slow or too fast will reduce the volume of blood circulated and, thus, reduce the cardiac output. When the heart beats too rapidly, there is not enough time between contractions for the heart to refill completely, and when the heart beats too slowly, the volume of blood circulated per minute decreases due to the slow pulse rate. The second component of good perfusion is an adequate volume of fluid, or blood. If there is blood loss through hemorrhage, the reduced volume will limit the amount of tissue that can be perfused. Third, the blood must be carried in a proper-size container. This means that the blood vessels must be appropriately constricted to match the volume of blood available so that circulation can occur without problems. If the blood vessels dilate, thereby increasing the size of the container, and the volume of fluid remains the same, there will not be enough blood to fill the blood vessels and perfusion will be reduced. If there is a problem with the functioning of the heart, the functioning of the blood vessels, or the volume of blood, perfusion will fall, which will lead to cellular death and, eventually, death of the patient.
perfusion
267
Most often, the low blood flow to heart tissue is caused by coronary artery____.____ is a disorder in which calcium and a fatty material called cholesterol build up and form a plaque inside the walls of blood vessels, obstructing flow and interfering with their ability to dilate or contract (FIGURE 17-8). Eventually,____ can even cause complete Daclusion, or blockage, of a coronary artery.____ usually involves other arteries of the body as well. The problem begins when the first trace of cholesterol is deposited on the inside of an artery. This may happen as early as the teenage years. As a person ages, more of this fatty material is deposited; the lumen, or the inside diameter of the artery, narrows. As the cholesterol deposits grow, calcium deposits can form as well. The inner wall of the artery, which is normally smooth and elastic, becomes rough and brittle with these atherosclerotic plaques. Damage to the coronary arteries may become so extensive that they cannot accommodate increased blood flow during times of maximum stress.
For reasons that are still not completely understood, a brittle plaque will sometimes develop a crack, exposing the inside of the atherosclerotic wall. Acting like a torn blood vessel, the ragged edge of the crack activates the blood-clotting system, just as when an injury has caused bleeding. In this situation, however, the resulting blood clot will partially or completely block the lumen of the artery. If it does not occlude the artery at that location, the blood clot may break loose and begin floating in the blood, becoming what is known as a thromboembolism. A thromboembolism is a blood clot that is floating through blood vessels until it reaches an area too narrow for it to pass, causing it to stop and block the blood flow at that point. Tissues downstream from the blood clot will experience a lack of oxygen (hypoxia). If blood flow is restored in a short time, the hypoxic tissues will recover. However, if too much time goes by before blood flow returns, the hypoxic tissues will die. If a blockage occurs in a coronary artery, the condition results in an acute myocardial infarction (AMI), a heart attack (FIGURE 17-9). Infarction means the death of tissue. The same sequence may also cause the death of cells in other organs, such as the brain. The death of heart muscle decreases the heart's ability to pump and can also cause it to stop pumping completely (cardiac arrest).
Atherosclerosis
268
The pain of an___ signals the actual death of cells in the area of the heart muscle where blood flow is obstructed. Once dead, the cells cannot be revived. Instead, they will eventually turn to scar tissue and become a burden to the beating heart.
Therefore, fast action is critical in treating a heart attack. The sooner the arterial blockage can be cleared, the fewer the cells that may die. About 30 minutes after blood flow is cut off, some heart muscle cells begin to die. After about 2 hours, as many as one-half of the cells in the area can be dead; in most cases, after 4 to 6 hours, more than 90% will be dead. In many cases, however, opening the coronary artery with clot-busting (thrombolytic) medications or angioplasty (mechanical clearing of the artery) can prevent permanent damage to the heart muscle if done within the first few hours after the onset of symptoms. Therefore, immediate prehospital treatment and transport to the emergency department (ED) are essential.
An___ is more likely to occur in the larger, thick-walled left ventricle, which needs more blood and oxygen than the right
ventricle.
AMI
269
A patient with an AMl may show any of the following signs and symptoms:
• Sudden onset of weakness, nausea, and sweating without an obvious cause
• Chest pain, discomfort, or pressure that is often crushing or squeezing and that does not change with each breath
• Pain, discomfort, or pressure in the lower jaw, arms, back, abdomen, or neck
• Irregular heartbeat and syncope (fainting)
• Shortness of breath, or dyspnea
• Nausea/vomiting
• Pink, frothy sputum (indicating possible pulmonary edema)
• Sudden death
The Pain of AMI
The pain of an AMl differs from the pain of angina in three ways:
• It may or may not be caused by exertion but can occur at any time, sometimes when a person is sitting quietly or even sleeping.
• It does not resolve in a few minutes; rather, it can last between 30 minutes and several hours.
• It may or may not be relieved by rest or nitroglycerin.
Not all patients who are having an AMI experience pain or recognize it when it occurs. Approximately one-third of patients never seek medical attention. This can be attributed, in part, to the fact that people are afraid of dying and do not want to face the possibility that their symptoms may be serious (cardiac denial). Middle-aged men, in particular, are likely to minimize their symptoms. However, some patients, particularly older people, women, and people with diabetes, may not experience any pain during an AMI but may have other common complaints associated with ischemia discussed earlier. Others may feel only mild discomfort and call it indigestion. It is not uncommon for the only complaint, especially in older patients and women, to be fatigue. AMl without the classic chest pain is often referred to as a silent myocardial infarction. Heart disease is the number one killer of women in the United States, and EMTs should consider AMl even when the classic symptom of chest pain is not present. This is also true for older people and people with diabetes.
Ami
270
Failure of the heart occurs when the ventricular myocardium is so profoundly damaged that it can no longer keep up with the return flow of blood from the atria. ____can occur at any time after a myocardial infarction, in the
setting of heart valve damage, or as a consequence of long-standing high blood pressure. Any condition that weakens the pumping strength of the heart may cause CHF, and this often happens after a heart attack.
Just as the pumping function of the left ventricle can be damaged by coronary artery disease, it can also be damaged by diseased heart valves or chronic hypertension. In any of these cases, when the muscle can no longer contract effectively, the heart tries other ways to maintain an adequate cardiac output. Two specific changes in heart function occur: The heart rate increases, and the left ventricle enlarges to increase the amount of blood pumped each minute.
When these adaptations can no longer make up for the decreased heart function, CHF eventually develops. With left-sided heart failure, the lungs become congested with fluid because the left side of the heart fails to pump the blood effectively. Blood tends to back up in the pulmonary veins, increasing the pressure in the capillaries of the lungs. When the pressure in the capillaries exceeds a certain level, fluid (mostly water) passes through the walls of the capillary vessels and into the alveoli. This condition is called pulmonary edema. It may occur suddenly, as in an AMl, or slowly over months, as in chronic CHF. Sometimes, in patients with an acute onset of CHF, severe pulmonary edema will develop, in which the patient has pink, frothy sputum and severe dyspnea. With right-sided heart failure, blood backs up in the venae cavae, resulting in edema in the lower extremities or distention of the veins in the neck.
Congestive heart failure (CHF)
271
Give the indications, contraindications, and side effects for the use of aspirin and nitroglycerin
Aspirin: Platelet Aggregation Inhibitor
Indication: Atraumatic chest pain
Oral Tablet
Authorized by med control
19+
Contras: Allergy, Bleeding/active bleeding disorder, 325mg taken in 24 hours, Pregnant, Expired, AAA
Side effects:
- Anaphylaxis
- Angioedema
- Bleeding
- Nausea
-Vomiting
- Stomach irritation
(3 in stomach, AAB) * idk what that is
Nitroglycerin: Vasodilator; increase blood flow to heart while decreasing workflow of the heart Indication: Atraumatic chest pain
Prescription
Med control authorization
Contras: BP below 100 sys, ED drugs in the last 72 hours, Under 18, Fall/head injury in past 24 hours, 3 Doses taken 15 minute period
Side effects:
- Headache
- Flushing
- Lightheadedness
- Hypotension
- Bradycardia
- Cardiovascular collapse
- Methemoglobinemia
(3 in head 3 in heart) *idk what that is
272
Explain how a LVAD works and what you would find with a patient who had one
Left ventricular assist devices (LVADs) are used to enhance the pumping function of the left ventricle in patients with severe heart failure or in patients who need a temporary boost due to a myocardial infarction (FIGURE 17-14). There are several types of LVADs; the most common ones have an internal pump unit and an external battery pack. These pumps are almost all continuous, so most of these patients will not have any palpable pulses. If you encounter a patient with an LVAD, he or she (or his or her family members) may be able to tell you about the unit. Unless it malfunctions, you should not need to deal with it. If you are unsure of what to do, contact medical control for assistance. Also, LVADs provide a number to call for assistance. Transport all LVAD supplies and battery packs to the hospital with the patient.
Enhance the pumping function of the left ventricle in patients with severe heart failure
No palpable pulse / no BP**?
273
Describe the anatomy, physiology, pathophysiology, assessment and management of angina pectoris and the difference between this and an AMI.
Chest pain does not always mean that a person is having an AMI, When, for a brief time, heart tissues are not getting enough oxygen, the pain is called angina pectoris, or angina. Although angina can result from a spasm of an artery, it is most often a symptom of atherosclerotic coronary artery disease. Angina occurs when the heart's need for oxygen exceeds its supply, usually during periods of physical or emotional stress when the heart is working hard. A large meal or sudden fear may also trigger an attack. When the increased oxygen demand goes away (eg, the person stops exercising), the pain typically goes away.
Anginal pain is commonly described as crushing, squeezing, or "like somebody standing on my chest." It is usually felt in the midportion of the chest, under the sternum. However, it can radiate to the jaw, the arms (frequently the left arm), the midportion of the back, or the epigastrium (the upper-middle region of the abdomen). The pain usually lasts from 3 to 8 minutes, rarely longer than 15 minutes. It may be associated with shortness of breath, nausea, or sweating. It usually disappears promptly with rest, supplemental oxygen, or nitroglycerin (NTG), all of which decrease the need for or increase the supply of oxygen to the heart. Although angina pectoris is frightening, it does not mean that heart cells are dying, nor does it usually lead to death or permanent heart damage. It is, however, a warning that you and the patient should take seriously. With angina, the electrical system can be compromised because the oxygen supply to the heart is diminished, and the person is at risk for problems with cardiac rhythm.
Angina can be further differentiated into stable and unstable angina. Unstable angina is characterized by pain or discomfort in the chest of coronary origin that occurs in the absence of a significant increase in myocardial oxygen demand If untreated, it is associated with a very high risk of spontaneous AMI. Stable angina is characterized by pain in the chest of coronary origin that occurs in response to exercise or some activity that increases the demand on the heart muscle beyond the heart's capacity to increase its own blood flow. EMS often becomes involved when stable angina becomes unstable, such as when a patient whose pain is normally relieved by sitting down and taking one nitroglycerin tablet has taken three tablets with no relief. Keep in mind that it can be difficult, even for physicians in hospitals, to distingu3h between the pain of angina and the pain of an AMI. Patients experiencing chest pain or discomfort, therefore, should always be treated initially as if they are having an AMI.
The pain of an AMI signals the actual death of cells in the area of the heart muscle where blood flow is obstructed. Once dead, the cells cannot be revived. Instead, they will eventually turn to scar tissue and become a burden to the beating heart!
Therefore, fast action is critical in treating a heart attack. The sooner the arterial blockage can be cleared, the fewer the cells that may die. About 30 minutes after blood flow is cut off, some heart muscle cells begin to die. After about 2 hours, as many as one-half of the cells in the area can be dead; in most cases, after 4 to 6 hours, more than 90% will be dead. In many cases, however, opening the coronary artery with clot-busting (thrombolytic) medications or angioplasty (mechanical clearing of the artery) can prevent permanent damage to the heart muscle if done within the first few hours after the onset of symptoms. Therefore, immediate prehospital treatment and transport to the emergency department (ED) are essential.
An AMl is more likely to occur in the larger, thick-walled left ventricle, which needs more blood and oxygen than the right
ventricle.
Angina pectoris- pain in the chest, the heart muscle is not happy, with rest it will go away, heart tissues are not getting enough oxygen, usually when the heart is working hard and is in need for oxygen
AMI- heart attack, blockage occurs in a coronary artery
274
Recognize that not all patients in cardiac arrest require an electric shock and know what to do if you get "no shock advised".
Not all patients in cardiac arrest require an electrical shock. Although the cardiac rhythm of all patients in cardiac arrest should be analyzed with an AED, some do not have shockable rhythms (eg, pulseless electrical activity and asystole).
Asystole (flatline) indicates that no electrical activity remains and therefore defibrillation will not help. Pulseless electrical activity refers to a state of cardiac arrest that exists despite an organized electrical complex; defibrillation could possibly make this situation worse. In both cases, CPR should be initiated as soon as possible, beginning with chest compressions.
275
Explain the reason not to touch the patient while the AED is analyzing and delivering shocks
Misreading movement. Can get shocked. will analyze your heart rate instead of the patient
276
Explain the care, treatment and transport of patients who are experiencing headaches or stroke.
Headaches- no lights and sirens strokes - lights and sirens
277
Discuss the causes, similarities, and differences of an ischemic stroke, hemorrhagic stroke, and transient ischemic attack.
Ischemic: blood flow to specific part of brain is stopped by blood clot in blood vessel
- Hemorrhagic: Blood vessel ruptures and forms a blood clot that compresses brain tissue
TIA: blood flow to brain obstructed due to atherosclerosis or small blood clot; goes away on its own within 24 hours
- All= some type of blood clot and blockage to the brain
278
According to the American Stroke Association,_____ is the most common type of stroke, accounting for 87% of all strokes. When blood flow to a specific part of the brain is stopped by a blockage (blood clot) inside a blood vessel, the result is an ischemic stroke. Patients who experience an ischemic stroke may have dramatic symptoms, including loss of movement on the side of the body opposite the side where the occlusion has occurred.
This blockage may be due to thrombosis, where a clot forms at the site of blockage, or an embolus, where the blood clot forms in a remote area (such as a diseased heart) and then travels to the site of the blockage. Patients with atrial fibrillation (a heart rhythm where the atria shake rather than squeeze) are prone to ischemic strokes caused by an embolus and often take blood thinners to reduce the risk of these events.
As with coronary artery disease, atherosclerosis in the blood vessels is often the cause of ischemic stroke.
Atherosclerosis is a disorder in which calcium and cholesterol build up, forming plaque inside the walls of the blood vessels.
This plaque may obstruct blood flow and interfere with the vessels' ability to dilate. Eventually, atherosclerosis may cause complete occlusion of an artery (FIGURE 18-3). In other cases, an atherosclerotic plaque in the carotid artery in the neck ruptures. A blood clot forms over the crack in the plaque. Sometimes, it grows large enough to completely block all blood flow through that artery. The parts of the brain supplied by the artery are deprived of oxygen and stop functioning. Even if the blockage in the carotid artery is not complete, smaller pieces of the blood clot may embolize (break off and be carried by the normal flow of blood) deep into the brain, where they may become lodged in a smaller branch of a blood vessel. This cerebral embolism then blocks blood flow (FIGURE 18-4). Depending on the location of the lodged blood clot, the patient's symptoms can vary widely, from nothing at all to complete paralysis or loss of function to the areas or functions of the body controlled by that portion of the brain.
ischemic stroke
279
_______occurs as a result of bleeding inside the brain. According to the American Stroke Association hemorrhagic strokes account for 13% of all strokes. In hemorrhagic stroke, a blood vessel ruptures and the accumulated blood then forms a blood clot, which compresses the brain tissue next to it. The compression prevents oxygenated blood from getting into the area, and the brain cells begin to die. Cerebral hemorrhages are often massive and rapidly fatal.
Hemorrhagic stroke commonly occurs in people experiencing stress or exertion. The people at highest risk for hemorrhagic stroke are those with extremely high blood pressure or long-term untreated elevated blood pressure. Many years of high blood pressure weaken the blood vessels in the brain. If a vessel ruptures, the bleeding in the brain will increase the pressure inside the cranium. Proper treatment of high blood pressure can help prevent this long-term damage to the blood vessels, decreasing the risk of this devastating complication.
Some people are born with a weakness in the walls of an artery. An aneurysm, a swelling or enlargement of the wall of an artery resulting from a defect or weakening of the arterial wall, may then develop. FIGURE 18-5 is an angiogram showing a cerebral aneurysm. The most notable symptom of a ruptured aneurysm is often a sudden-onset, severe headache, typically described by the patient as the worst headache he or she has ever had. The headache is caused by the irritation of blood on the brain tissue after the artery swells and ruptures. A hemorrhagic stroke in an otherwise healthy young person is often caused by a weakness in a blood vessel called a berry aneurysm. This type of aneurysm resembles a tiny balloon (or berry) that juts out from the artery. When the aneurysm is overstretched and ruptures, blood spurts into an area between two of the coverings of the brain called the subarachnoid space. These types of strokes are called subarachnoid hemorrhages. If the patient gets to the hospital quickly, surgical repair of the aneurysm may be possible. However, like other brain bleeding and cerebral hemorrhage, this condition is often fatal.
Hemorrhagic stroke
280
In a patient with coronary artery disease, blood flow to the heart muscle may be obstructed, causing chest pain (angina), which is considered a warning sign of a potential myocardial infarction. Similarly, when blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the patient may exhibit signs of a stroke. When these strokelike symptoms resolve on their own in less than 24 hours, the event is called a__. Some people call these min strokes. As with angina, no actual death of tissue (infarction) occurs with a TIA. However, because symptoms of a TIA can last up to 24 hours, you may not be able to differentiate between a stroke and a TIA.
Although most patients with TIAs do well, every TIA is an emergency. It may be a warning sign that a more significant stroke may occur in the future. Approximately one-third of patients who have a TIA will experience a stroke soon after the TIA. For this reason, all patients with a TIA should be evaluated by a physician to determine whether preventive action should be taken.
transient ischemic attack (TIA)
281
; difficulty expressing thoughts or inability to use the right words (expressive___) or difficulty understanding spoken words (receptive_____)
Aphasia
282
Slurred speech
Dysarthria
283
Lack of muscle coordination (____) or loss of balance
Ataxia
284
If the left cerebral hemisphere has been affected by a stroke, the patient may exhibit a speech disorder called___, the inability to produce or understand speech. Speech problems can vary widely. Some patients will have trouble understanding speech but will be able to speak clearly. You can detect this problem by asking the patient a question such as "What day is today?" The patient may respond with an inappropriate answer such as "Green." The speech is clear, but it does not make sense. Other patients will be able to understand the question but cannot produce the right sounds to provide an answer.
Strokes that affect the left side of the brain can also cause paralysis of the right side of the body.
aphasia
285
What are the appropriate time frames for various stroke interventions
3 hours (drugs) 6 hours (mechanical )
286
When is it important to strongly advise the seizure patient to go to the hospital
Status epilepticus, if its their first seizure
287
Describe the assessment of a patient with a gastrointestinal and urologic emergency.
Gastrointestinal- touch four quadrants for pain
When you are assessing the patient's circulation, remember to assess for major bleeding. Ask the patient about amount and frequency of blood in the vomit (hematemesis); black, tarry stools (melena); or bright red, bloody stools. The patient's pulse rate and quality, as well as skin condition, may indicate shock. Because skin paleness can be difficult to detect in patients with dark skin, check for pale mucous membranes inside the inner lower eyelid or slow capillary refill. On general observation, the patient may appear ashen or gray. Check the pulses in both feet because a difference in pulse strength may indicate AAA. The abdomen should be inspected for wounds or bruising. Bruising around the umbilicus or on the flanks may indicate internal abdominal bleeding. Shock may be caused by hypovolemia or may be the result of a severe infection (septic). If evidence of shock (inadequate perfusion) is present, interventions should include high-flow oxygen, placing the patient supine, and keeping the patient warm. Ensure that you provide prompt treatment for life threats and do not delay transport.
288
Describe the procedures to follow in managing the patient with shock associated with abdominal emergencies
Spleen- internal bleeding abdomen ( perfusion, bruising,
- Oxygen, blanket, supine
289
The pancreas forms digestive juices and is also the source of insulin and glucagon. Inflammation of the pancreas is called___.___ can be caused by an obstructing gallstone, alcohol abuse, and other diseases. Severe pain may present in the upper left and right quadrants and may often radiate to the back. In addition, the patient may report that the pain is worse after eating. Other signs and symptoms accompanying the pain are nausea and vomiting, abdomina distention, and tenderness. Complications such as sepsis or hemorrhage can occur, in which case assessment may also reveal fever or tachycardia.
pancreatitis
290
The appendix is a small recess in the large intestine. Inflammation or infection in the appendix is called_____, and it is a frequent cause of acute abdomen. This inflammation can eventually cause the tissues to die and/or rupture, causing an abscess, peritonitis, or shock. Initially, the pain caused by appendicitis is generalized, dull, and diffuse and may center in the umbilical area. The pain later localizes to the right lower quadrant of the abdomen. Appendicitis can also cause referred pain. The patient may also report nausea and vomiting, anorexia (lack of appetite for food), fever, and chills. A classic symptom of appendicitis is rebound tenderness. Rebound tenderness is a result of peritoneal irritation. This can be assessed by pressing down gently and firmly on the abdomen and then quickly releasing the pressure. The patient will feel pain when the pressure is released. Women with appendicitis who are also pregnant may not exhibit this symptom. Because the pain often increases when the patient's legs are straightened, the patient is often more comfortable in the fetal position.
appendicitis
291
Inflammation of the gallbladder. Causes referred pain in the right shoulder as well as in the abdomen
Acute cholecystitis
292
Explain the prehospital care for a patient who has missed kidney dialysis
If a patient misses a dialysis treatment, weakness and pulmonary edema can be the first in a series of conditions that can become progressively more serious if normal balance is not returned to the patient's body. The adverse effects of dialysis include hypotension, dyshythmias, chest pain, muscle cramps, nausea and vomiting, altered mental status, electrolyte imbalances, hemorrhage from the access site, and infection at the access site. If your call involves a patient on dialysis, start with the XABCs: control life-threatening hemorrhage (exsanguination), and assess and manage the airway, breathing, and circulation. Provide high-flow oxygen if indicated. Position the patient sitting up in cases of pulmonary edema or supine if the patient is in shock, and transport promptly. Remember, when assessing vital signs in a patient with a dialysis shunt or fistula, do not place a blood pressure cuff over the site. Doing so may damage the shunt or fistula or cause a blood clot to form. If possible, avoid using the arm with the shunt or fistula for vital signs; instead, use the patient's other arm.
293
Signs and symptoms of acute cholecystitis, appendicitis, and pancreatitis.
Cholecystitis- Inflammation of the gallbladder; severe constant pain in the right upper quadrant or mid abdominal region may refer to upper back right shoulder area or flank, jaundice, pain may increase for hours or come and go. Typically 30 minutes after a fatty meal, usually at night.
Appendicitis- pain lower right abdomen, pain went away (ruptured), hurts without touching and with touching
Pancreatitis- insulin, metabolism, blood sugar, endocrine system, inflammation (extreme pain, back pain, upper right abdomen) ( did they eat, radiating pain? Any recent trauma? )
294
Describe the differences and similarities between hyperglycemic and hypoglycemic diabetic emergencies, including their onset, signs and symptoms, and management considerations.
Hyper - onset is gradual, hours to days. Warm and dry. Intense thirst, hunger is present and increasing. Vomiting and abdominal pain is common. With DKA rapid deep kussmaul respirations. With DKA fruit Odor sweet breath. Treatment is gradual, within 6 to 12 hours following medical treatment.
Hypo - onset is rapid within minutes. Pale, cool, and moist. Absent thirst, absent hunger. Breathing is normal; may be become shallow or ineffective if hypoglycemia is severe and mental status is depressed. Immediate improvement after administration of glucose
295
Normal blood glucose level is between 80 and 120 mg/d. The body's metabolism is sensitive to the levels of particular substances, such as glucose, in the blood. The kidneys filter the blood and thus manage all substances present in the blood At normal levels, glucose remains in the blood as it is filtered
When a patient's blood glucose level is above normal, the kidney's filtration system becomes overwhelmed and glucose spills into the urine. The increased amount of glucose in the urine causes more water to be pulled out of the bloodstream into the urine. This results in more frequent urination, or____.
polyuria
296
Increased urine production and urination also cause dehydration and increased thirst, which can lead to severe electrolyte abnormalities. An increase in fluid consumption, called___, occurs in an attempt to quench this thirst.
polydipsia
297
In the early phase of diabetes, patients may report severe hunger and increased food intake, a condition known as___. Over time, particularly if diabetes remains undiagnosed or untreated, appetite will decrease and patients often lose weight.
polyphagia
298
____is an autoimmune disorder in which the individual's immune system produces antibodies against the pancreatic beta cells. Essentially, this disease is about the missing pancreatic hormone insulin. Insulin is the "key" to the
"door" of the cell. Without insulin, glucose cannot enter the cell, and the cell cannot produce energy.
The onset of this disorder usually happens from early childhood through the fourth decade of life. The patient's immune system progressively destroys the ability of the pancreas to produce insulin. Without the insulin from the pancreatic beta cells, the patient must obtain insulin from an external source. Patients with type 1 diabetes cannot survive without insulin.
Patients who inject insulin often need to check their blood glucose levels up to six times per day or more using a lancet and a small capillary blood sample read by using a glucometer
Type 1 diabetes
299
Many people with____ have an implanted insulin pump. Some of these devices continuously measure the body's glucose levels and provide an (adjustable) infusion of insulin and correction doses of insulin based on carbohydrate intake at mealtimes (FIGURE 20-5). The presence of an insulin pump that automatically measures blood glucose limits the number of times patients have to check their fingerstick glucose level. Some insulin pumps do not measure blood glucose automatically, but rather deliver a continuous baseline dose of insulin that may be supplemented by an additional bolus dose depending on the blood glucose measurement the patient takes at mealtimes. Unfortunately, insulin pumps can malfunction and hyperglycemic or hypoglycemic diabetic emergencies can develop. Always inquire about the presence of an insulin pump-particularly in patients with type 1 diabetes —and ask the patient if it is working properly.
type 1 diabetes
300
_____is the most common metabolic disease of childhood. A patient with new-onset type 1 diabetes will have
symptoms related to eating and drinking:
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Fatigue
Type 1 diabetes
301
____is caused by resistance to the effects of insulin at the cellular level. Recall that we described insulin as the key to the door of the cell. Insulin resistance means the lock is unable to accept the key. As a review, in type 1 diabetes, no insulin is produced, so there are no keys. In type 2 diabetes there are typically fewer insulin receptors
Obesity predisposes patients to type 2 diabetes; there is an association between obesity and increased resistance to the effects of insulin. As the number of obese people continues to rise, so does the number of patients with type 2 diabetes.
When diabetes begins, the individual's pancreas produces more insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors. Over time this response becomes inefficient. The blood glucose levels continue to rise and do not respond when the pancreas secretes insulin, a process called insulin resistance. In some cases, insulin resistance can be improved by exercise and dietary modification.
In many instances diet and exercise alone cannot control insulin resistance, and oral medications must be started to better control blood glucose levels. Oral medications used to treat type 2 diabetes vary widely. Some of them increase the secretion of insulin and create a high risk of hypoglycemic reaction, whereas others do not (TABLE 20-2). Injectable medications and various insulin preparations are also used for type 2 diabetes when oral medications alone will not regulate blood glucose.
type 2 diabetes
302
Insulin is a hormone that is destroyed when taken by mouth, so it must be injected. Many of the oral medications listed in Table 20-2 either encourage the pancreas to produce more insulin or the cells to stimulate receptors for insulin. Other medications decrease the effects of glucagon, decrease the release of glucose stored in the liver (glycogen), and prevent increased blood glucose levels during sleep or sedentary periods. None of the available medications is the perfect solution for every patient, however.
Diabetes mellitus type 2 is often diagnosed at a yearly medical examination. In some cases, the patient's physician discovers____ when treating the patient for a complaint related to high blood glucose levels. Examples of such complaints include recurrent infection, change in vision, or numbness in the feet.
diabetes mellitus type 2
303
In type 1 diabetes, hyperglycemia leads to ketoacidosis and dehydration from excessive urination. In type 2 diabetes, hyperglycemia leads to a state of dehydration due to the discharge of fluids from all body systems and eventually out through the kidneys, leading to a much more ominous situation of fluid imbalance known as___
hyperosmolar hyperglycemic nonketotic syndrome (HHNS).
304
When a patient with DKA has an altered mental status, ask the patient's family and friends about the patient's history and
presentation. Obtain a glucose level with a fingerstick using a lancet and a glucometer. (This procedure is covered in Chapter 10, Patient Assessment.) The patient with DKA will generally have a fingerstick glucose level higher than 400 mg/dL..
This presentation of the patient with type 1 diabetes in DKA does not only occur when there is an absolute lack of insulin.
DKA may also present in cases of a relative lack of insulin, which may occur when there is an acute illness, or an untreated infection or other stressor on the body that leaves the patient with____ in a weakened condition.
type 1 diabetes
305
When blood glucose levels are not controlled in___, HHNS can develop. HHNS can present similarly to the DKA seen in patients with type 1 diabetes. The onset of this disorder is commonly associated with a profounc infection or illness.
Key signs and symptoms of HHNS include the following:
• Hyperglycemia
• Altered mental status, drowsiness, lethargy
• Severe dehydration, thirst, dark urine
• Visual or sensory deficits
• Partial paralysis or muscle weakness
• Seizures
diabetes mellitus type 2
306
Explain what insulin and glucose do for the body
- Insulin: Need the insulin for the glucose to get into the body
- Fuel for the brain
- glucose : sugar
The brain needs glucose and oxygen to survive
Insulin is necessary for glucose to enter the cells for
metabolism. Without the proper balance of hormones (ie, without enough insulin), the cells do not get fed.
Glucose is one of the basic sugars; it is the primary fuel, in conjunction with oxygen, for cellular metabolism
307
What are the doses and adverse effect considerations for epinephrine administration
Tachycardia, swearing, pale skin, dizziness, headache, palpitations
Adults 0.3 im (4 and up)
Children 0.15 im (below age 4)
308
Explain the difference between a local and systemic response to allergens
Local is like itching, redness and tenderness.
Systemic is multiple body systems and life threatening
309
Describe the assessment and treatment of the patient with a suspected overdose.
Taking above the prescribed dose
- Opioid- pinpoint pupils, and respiratory depression (bradypnea, shallow breathing)
Perform scene safety, suction or wash away/brush any pills or poison away from their mouth, XABCs,collect information from bystanders or the scene around you, if an expected opiate/opioid OD manage airway and start on naloxone in order to reverse the effects of the overdose, look for evidence, track marks
310
Explain how activated charcoal works.
It binds to specific toxins (ex:pills ingested) and prevents their absorption in the body; the toxins are carried out through the stool. Patients may be constipated and have black stools and may vomit.
In certain cases, some EMS systems allow EMTs to give activated charcoal by mouth. Activated charcoal binds to specific toxins-for example, pills that have been ingested-and prevents their absorption by the body. The toxins are then carried out of the body in the stool.
Activated charcoal is not indicated, nor will it be effective, for patients who have ingested alkali poisons, cyanide, ethanol, iron, lithium, methanol, mineral acids, or organic solvents. If the patient has a decreased level of consciousness and cannot protect his or her airway, do not give activated charcoal.
If local protocol permits, your ambulance will likely carry plastic bottles of premixed suspension, each containing up to 50 g of activated charcoal (FIGURE 22-7). Some common trade names for the suspension form are InstaChar, Actidose, and LiquiChar. The usual dose for an adult or child is 1g of activated charcoal per kilogram of body weight (more if food is present). The usual adult dose is 30 to 100 g, and the usual pediatric dose is 15 to 30 g for children younger than age 13 years.
311
How do you know if you should brush off a chemical or flush it off?
Be aware that some chemicals react with water. Although small amounts can usually be flushed safely with large quantities of water, larger amounts of such chemicals can give off toxic fumes or explode when wet. Be sure to check the relevant warnings and placards, and avoid potential injury to your patient and yourself by calling for additional resources (hazmat team) when in doubt.
Remove all clothing that has been contaminated with poisons or irritating substances. If a dry powder has been spilled thoroughly brush off the chemical (avoid creating a dust cloud), flush the skin with clean water for 15 to 20 minutes, and then wash the skin with soap and water. If liquid material has been spilled on a patient, flood the affected part for 15 to 20 minutes. If the patient has a chemical agent in the eyes, irrigate them quickly and thoroughly. To avoid contaminating the other eye as you irrigate the affected eye, make sure the fluid runs from the bridge of the nose outward (FIGURE 22-4). Initiate this action on the scene and continue it during transport. Keep in mind that you may have to help the patient keep his or her eyes open.
312
Describe the assessment and treatment of a patient with a suspected poisoning or toxic exposure
Because of the risk of possible cross-contamination by poisons that can be inhaled, absorbed, ingested, and injected you must take appropriate standard precautions. As you approach the scene, think like a detective and look for clues that might indicate the substance involved. Ask yourself the following questions:
• Is there an unpleasant or odd odor in the room? If so, is the scene safe? (This could indicate an inhaled poison.)
• Are there medication bottles near the patient or at the scene? If so, is there medication missing that might indicate an overdose?
• Are there alcoholic beverage containers present?
• Are there syringes or other drug paraphernalia on the scene?
• Is there a suspicious odor and/or drug paraphernalia present that may indicate the presence of an illegal drug laboratory?
Drug laboratories can be volatile, so ensure scene safety
What is the substance involved? If you know the substance involved, you will be better able to access the appropriate resource, such as the poison center, to determine lethal doses, time before adverse effects begin, effects of the substance at toxic levels, and appropriate interventions.
• When did the patient ingest or become exposed to the substance? This will let you know if and when the adverse effects will begin. This will also let the emergency physician know what adverse effects can be reversed and which ones cannot because of the length of time the patient has been exposed to the substance.
• How much did the patient ingest or what was the level of exposure? With this information, the poison center will be able to inform you whether the patient has had a harmful or lethal dose.
• Over what period did the patient take or was the patient exposed to the substance? Did the exposure occur all at once or over minutes or hours?
• Has the patient or a bystander performed any intervention on the patient? Has the intervention helped? The patient's or bystander's intervention may cause complications. The emergency physician will need to know this information to be able to adjust interventions accordingly.
• How much does the patient weigh? If activated charcoal is indicated and permitted by local protocols, you will need to determine the dose based on the patient's weight. The antidote or neutralizing agent given by the emergency physician may be based on the patient's weight as well.
313
Who is the most important person when dealing with an unsafe scene
You
314
Know the main principles of care for the agitated, violent, or uncooperative patient.
Verbal de escalation, call the police, restraints
315
Remember that some sudden illnesses can cause behavioral health emergencies.
A patient displaying bizarre behavior may actually have an acute medical illness that is the cause, or a partial cause, of the behavior.
Behavioral changes may be the result or a symptom of a treatable medical condition such as diabetes or a stroke. They can also be the result of a head injury or drug or alcohol intoxication. Medical conditions presenting as behavioral disorders must be identified. A patient with hypoglycemia presenting with altered behavior can face a life-threatening situation if the medical condition is not treated.
Remember, a psychiatric diagnosis is never made until possible medical causes of altered behavior have been actively excluded as possibilities. This requires evaluation by a physician.
In geriatric patients, consider Alzheimer disease and other causes of dementia as possible causes of abnormal behavior. Determining the patient's baseline mental status will be essential in guiding your treatment and transport decisions and will also be extremely helpful to hospital personnel.
316
There is wide variation in prehospital patient restraint protocols throughout the country. Protocols should include
only the use of restraint devices that have been approved by the state health department or local EMS agency.
Restraint types can be soft, leather, or cloth. ___can include sheets, wide wristlets, and chest harnesses.
Hard restraints can include plastic ties, handcuffs, or leather restraints. EMS protocols should avoid the use of hard restraints if possible. If hard restraints are approved, they will most likely be limited to the use of leather wrist restraints. The type of restraints used should not occlude circulation in the extremity and should allow the EMT to quickly remove them if the patient vomits or respiratory distress develops.
Soft restraints
317
A ____technique is an option if allowed per local protocols. This technique is performed in the same way as four-point restraint, except instead of restraining all four extremities to the stationary frame of the stretcher, one arm is placed upward toward the head and the other is placed downward toward the waist
two-point restraint
318
Discuss the assessment and management of a patient who has been sexually assaulted or raped; include the additional steps EMTs must take on behalf of the patient.
Checking and treating any injuries and life threats
Checking the patient's psychological well being
- Preserving evidence of the crime
Extra steps: Calling the local rape crisis center for patients who refuse treatment, keep the patient's privacy from bystanders, offering comforting reassurance to the patient.
Remind the patient they are safe, be a good listener without judgment
319
Why are injuries to external genitalia so serious?
Because of the large number of nerves and blood vessels in this area
320
___IS caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply rapidly in the warm, moist areas of the reproductive tract, including the cervix, uterus, and fallopian tubes in women and in the urethra in women and men The bacterium can also grow in the mouth, throat, eyes, and anus. Symptoms, which are generally more severe in men than in women, appear approximately 2 to 10 days after exposure. Women may be infected with gonorrhea for months but not have any symptoms, or only mild ones, until the infection has spread to other parts of the reproductive system. When symptoms do appear in women, they generally present as painful urination, with associated burning or itching; a yellowish or bloody vaginal discharge, usually with a foul odor; and blood associated with vaginal sexual intercourse. More severe infections may present with cramping and abdominal pain, nausea and vomiting, and bleeding between menstrual periods; these symptoms indicate that the infection has progressed to PID. Rectal infections generally present with anal discharge and itching and occasional painful bowel movements with fecal blood spotting. Infection of the throat (for which oral sex is the introducing factor) usually results in mild symptoms consisting of painful or difficult swallowing, sore throat, swollen lymph glands, and fever. Headache and nasal congestion may also be present. If the infection is not treated, the bacterium may enter the bloodstream and spread to other parts of the body, including the brain.
Gonorrhea
321
What are the signs and symptoms of gonorrhea?
Appears 2-10 days after contact
- painful urination burning/itching
yellow/bloody discharge
foul odor
(More Severe)
Cramping
Stomach pain
Nausea/vomit
- Bleeding between periods
322
What is the normal heart rate range for adults and infant
60 - 100 adult
100 - 160 infant
