EMS Manual Flashcards
A person becomes a patient the moment the EMS provider has determined __ __________ __ _________ to ensure that no illness or injury is overlooked and to ensure that the individual’s capacity to decline an assessment is not impaired by illness, injury, or intoxication.
an assessment is necessary
Patients demonstrate impaired decision-making capacity __ ____ ___ ______ __ __________ ____ _________ or our recommendations or if they have unreasonable excuses for refusal or transport.
if they are unable to understand their condition
The CURVES Mnemonic may aid the assessment of Decision-Making Capacity
- C ommunicate – Must be able to communicate.
- U nderstand – Must be able to understand the following elements and state them back:
- R eason – Must be able to explain the reasons behind their decision.
- V alues – Their reasons must be based on their values and not clouded by
psychosis or suicidal intent. - E mergent condition – Remember under emergent conditions, consent is implied.
- S urrogate – Remember surrogate decision-makers may make decisions on behalf of the patient such as: descending order spouse, adult child, parents,
adult sibling
If the EMS provider has reason to believe the patient’s decision-making capacity is impaired by psychiatric illness, the ___ __________ should be notified, and ___ ______ should be requested immediately to evaluate the patient.
EMS Supervisor, the police
If the patient is deemed a threat, the officers may take the patient into custody on their own authority for _ _____ (“8-hour rule”) during which providers and officers may coordinate transport to the hospital or other facility.
8 hours
Consent is not required in the presence of life-threatening (or potentially life-threatening) illness or injury, or if the patient is unconscious or unable to communicate due to _______, ______ __ ____________ and may reasonably be presumed to have a life-threatening condition.
illness, injury or intoxication
In Virginia Code §54.1-2969 persons between the ages of __ ___ __ _____ ___may be declared an emancipated minor by court order. Emancipated minors may make medical decisions on their own behalf.
14 and 18 years-old
Minors with intact decision-making capacity, who are __ _____ __ ___ __ _____ and whose parent or legal guardian are unable to be contacted, may refuse assessment, treatment and/or transportation.
14 years of age or older
Preexisting agreements between the schools and parents require students must leave
school any time one of the following medications is given at the clinic:
- Epinephrine autoinjector.
- Glucagon.
- Diastat (Diazepam).
- Solu-Cortef.
– Involves a patient who may need care yet has no primary
physician and/or has limited ability to navigate the health-care system.
Medical isolation
Involves barriers to care due to social circumstances – no phone,
no car, no childcare, etc.
Social isolation
Willful infliction of physical pain, injury, mental anguish, or unreasonable
confinement. Sexual abuse falls into this category as well
Abuse
Nonexistent or insufficient care and support necessary to maintain a
person’s physical and/or mental health to the extent that his/her well-being is
impaired or threatened. Persons who live alone/unaided and are unable to care for themselves can be considered to fall into this category, as can a lack of supervision of young children.
Neglect
The illegal use of an incapacitated adult/child or their resources for
another person’s profit or advantage.
Exploitation
As an EMS provider in Virginia, you are also legally required to
report your suspicions of abuse, neglect, and/or exploitation of members of the following
patient populations:
- Children (all patients under 18 years of age, including physically or mentally
disabled/incapacitated). - The elderly (all patients 60 years of age or greater, including those physically or
mentally disabled/incapacitated). - The physically or mentally disabled/incapacitated from 18-59 years of age.
The CRT focuses on individuals or patients that call 9-1-1 greater ____ _ _____ ______ __ ____ , identified as “Super Utilizers.”
than 6 times within 60 days
Legible copies of the VDDNR or other authorized DNR forms may be honored. There are five key parts of the form:
- The patient’s full legal name.
- A DNR determination.
- Signature of Physician (MD) or Nurse Practitioner (NP).
- Date of issue.
- The patient’s signature or, if applicable, that of the person authorized to consent on the patient’s behalf.
In the rare event providers are unable to contact POLMD, attempts should be made to contact __ ___ through the Department of Public Safety Communications (DPSC) and the ___ __________.
an OMD, EMS Supervisor
FRD providers may be called to assist a patient who is incidentally in possession of a weapon (firearm or edged, concealed or otherwise). Such weapons may present a hazard to providers and in all cases are not permitted in receiving facilities. Upon discovery of such a weapon in the possession of a patient with decision-making capacity, providers should utilize the following strategies:
Preferred: The patient willingly leaves the weapon on scene
Alternative: Request law enforcement to the scene if not already present and ask the patient to turn over the weapon to the officer for safekeeping until it can be retrieved
Contingency: EMS Supervisor keeps weapon and accompanies unit to hospital to determine best course of action at destination
5-5-10-2.
- At patient side to 12 Lead ECG less than 5 minutes.
- STEMI identification to Alert less than 5 minutes.
- STEMI identification to enroute to facility less than 10 minutes.
- Two ALS providers should be at the patient’s side during transport
If the patient is prescribed nitroglycerin and has been instructed to take it for the observed symptoms, assist patient with prescribed Nitroglycerin up to a total of…?
3 doses administered by EMS
- If the patient has a blood glucose level less than __, can protect his or her airway, able to swallow, and can follow commands, assist the patient with self-administration of:
o 1 Instant Glucose tube (15 grams).
▪ Reassess and monitor for signs of clinical improvement. Repeat blood
glucose assessment _ _______ after glucose administration. Instant
Glucose tube can be repeated once, if necessary.
70, 5 minutes
All patients greater than __ ____ pregnant who are having an obstetric (OB)-
related emergency should be transported to an OB-capable facility.
20 weeks
Transport the supine patient in the ____ _______ _________ position if delivery is not imminent.
left lateral recumbent
Symptoms associated with organophosphate poisoning are SLUDGE:
- Salivation.
- Lacrimation.
- Urination.
- Defecation.
- Gastric Hypermotility.
- Emesis.
MARCHE
Massive bleeding, Airway, Respiration, Circulation, Head injury,
Hypothermia, Every other injury
EMS BLOOD PROGRAM
The Incident Commander (IC) or designee anticipates
the patient will be entrapped greater than __ ________ from the time of activation
(Stuck).
30 minutes
The following definitions may be helpful in thinking about pediatric patients:
Newly born (Newborn) –
Neonate –
Infant –
Child –
Adolescent –
Adult –
Newly born (Newborn) – minutes to hours post-birth.
Neonate – First 28 days.
Infant – First year (12 months).
Child – 1 year through 8 years.
Adolescent – 9 years through 16 years.
Adult – age 17 or older
Assess the patient’s level of consciousness – AVPU
- Alert.
- Verbal.
- Painful.
- Unresponsive.
HYPOTHERMIC ARREST
* If patient is greater than ____, follow Cardiac Arrest – Universal Management protocol.
86°F
___________ is the most common complication of prehospital deliveries
Hypothermia
A patient with a core body temperature less than ____ is hypothermic.
Mild hypothermia is a core temperature between ____ _____ Severe hypothermia is a core body temperature less than____.
95°F, 90° - 95°F, 90°F
Shivering stops when the core body temperature falls below ?
90°F
For infants and small children if blood glucose is ____ ____ __, can protect his or her airway, able to swallow, and can follow commands, assist the patient with self-administration of 1 Instant Glucose tube (15 grams).
less than 60
If greater than 1 year of age and there is clinical suspicion for opioid overdose (decreased level of consciousness, decreased respirations, pinpoint pupils), administer Narcan Nasal Spray via the ______ ____, prepackaged, nasal atomization
delivery unit 2-4 mg if available.
single dose
______is a complex and dynamic systemic infection that can potentially become life-threatening. Septic shock is severe sepsis plus ____________
Sepsis,.hypotension.
(PACE) framework is the rationale for the differences in strategy and tactics compared with traditional EMS contexts.
Preferred, Alternative, Contingency, Emergency (PACE)
The burned body surface area of a child can be estimated by
- Using the Rule of Nines see below
- Using the size of the child’s palm (including fingers). It is approximately 1% of the total body surface area.
Mild hypothermia is a core temperature between…..? Severe hypothermia is a core bodytemperature less than ?
90° - 95°F, 90°F
Shivering stops when the core body temperature falls below?.
90°F
Treat Frostbite
- Bandage injured areas lightly to protect from pressure, trauma, or friction.
- Place bandages between fingers and toes for protection.
- Do not rub the skin or break blisters.
- Transport patient with frostbitten areas supported, elevated, and covered.
- Place electrodes – acquire 12 Lead ECG.
When outside temperatures are 86° to 104° F, the temperature inside a vehicle can
reach _____ within 15 minutes
140° F
A rule of thumb for the lower limit of normal pediatric systolic blood pressure is?
70 + (2 x Age in years).
Consult with the following parties to obtain a TDO (temporary detention order) if necessary….
*EMS Supervisor.
○ Law enforcement officer.
○ Merrifield Crisis Response Center (MCRC) or Mobile Crisis Unit (MCU).
○ POLMD.
__ _______ is frequently misdiagnosed as a simple headache or viral syndrome. A high
index of suspicion must be maintained, particularly during the winter months, when
faulty heating systems and enclosed spaces make __ _________ more common than it
is at other times.
CO toxicity, CO poisoning
A ______ is defined as an episode of impaired neurological function caused by an abnormal
electrical discharge of brain neurons.
seizure
Threat is real, directly present and poses greater risk than
benefit of most patient care interventions. Good tactics is good medicine. Tactical
superiority is paramount and patient care is limited.
Hot Zone (direct threat):
Threat is conceivable, but remote. Benefits of time critical, life- saving interventions are justified, followed by removal from the threat
environment as soon as achievable.
Warm Zone (indirect threat)
Threat is mitigated, or the patient has been removed
from the threat environment. Care is centered on injury specific and context specific
stabilization, packaging and preparation and completion of transport to definitive care
Cold Zone (evacuation care)
MARCHE
Massive, bleeding, Airway, Respiration, Circulation, Head injury,
Hypothermia, Every other injury
If the patient’s preference involves a long transport interval (greater than 60
minutes one way), contact the ____ ___ ___ ________ for approval.
UFO and EMS Supervisor
All patients greater than __ _____ _______ who are having an obstetric-related
emergency should be transported to an OB-capable facility.
20 weeks pregnant
All children under the age of _____ should be properly restrained during transport in a
child safety seat (CSS) which meets the standards adopted by the National Highway
Traffic Safety Administration (NHTSA)
eight
If the patient is over 18 years of age, administer Baby Aspirin_ ________ orally (81 mg
per tablet), chew and swallow.
2 tablets
When do employee medical evaluations and monitoring?
Pre and post assessments for hazardous materials personnel and Incident requiring rehab. Pg 14
When does a person become a patient?
When the ems provider determines an assessment is necessary to ensure no illness or injury is overlooked and the patient has no impairment to decline assessment. Pg 14
What are factors when determining if a person is a patient or not?
Mechanism of injury. Origin of call, first party vs third party. Potential for missed illness/injury and consequences. Social variables. If a patient asks for assessment. Pg 14.
Who May patient information be shared with?
Parties involved in patient care. Quality improvement representatives. Cost recovery representatives. Pg 15
What is a patient’s INTACT decision making capacity dependent upon?
There ability to understand their condition. Recommended treatment in benefits of the treatment. The risks of refusing treatment. Alternatives to our recommendations. Page 16
What may make informed consent in assessment decision making capacity difficult?
A language barrier. Pg 16
When does the patient have IMPAIRED decision making capacity?
If they are unable to understand their condition or recommendations or if they have unreasonable excuses for transport refusal. Page 16
What does the acronym CURVES stand for regarding decision making capacity?
Communicate. Understand. Reason. Values. Emergent condition. Surrogate. Page 16
If the EMS provider believes decision making capacity is impaired by psychiatric illness what must he do?
Notify the EMS supervisor and police should be requested. Page 17
What is the eight hour rule?
Officers may take the patient into custody on their own authority for eight hours if patient is deemed a threat. Page 17
If psychiatric patient does not meet the police paperless emergency custody order who may be contacted?
Mobile crisis to evaluate for psychiatric ECO. Page 17
What are the steps for an emergency custody order mental?
- Notify EMS supervisor. 2 Call mobile crisis in law enforcement. 3. Notify POLMD. 4. Obtain ECU through the magistrate. 5. Deliver ECO to seen by law-enforcement. 6. Transport the patient. If police transport the patient the disposition is a refusal. Pg 17
When does a durable power of attorney (DPOA) come into play?
when the patient is impaired and not lucid. Page 18
What other people are authorized to consent for patients who lack decision making capacity?
In order: Guardian. Spouse. Adult child. Parent. Adult brother sister. Other blood relatives. Page 18
What is used to Evaluate decision making capacity and impairment due to delirium?
The Richmond agitation sedation scale (RASS) from +4 to -5. 0 is normal. Delirium triage screen (DTS). Brief confusion assessment method (bCam). Page 18-20
What are the three levels of patient consent?
Informed consent. Implied consent (for life threatening illness or injury). Consent obtained from authorized decision makers not present on scene. Page 22
What falls under “loco parentis”?
Education institution were a minor is in rolled has received written authorization to consent for my person having the right to consent for the minor. Page 23
If a minor makes a claim to emancipated status that cannot be verified what must happen?
EMS supervisor she requested to assist in resolution. Page 23
When will do not transport orders or any similar documents be recognized or honored for minors?
Will not be recognized ever. Page 24
Who can a pregnant minor give medical consent for?
For herself and baby solely related to the delivery of the child. And for the baby only. Pg 24
When may non-emancipated children 14 years or older refuse assessment, treatment, or transport?
When a parent or legal guardian are unable to be contacted. Page 25
Who must suspected abuse, neglect, or exploitation be reported to?
Adult protective services. Child Protective Services. After hours: Virginia Department of social services. Page 28-30
What information should be provided for suspected abuse, neglect, exploitation to reporting agency?
Name, address, date of birth. Location if not home address. Victim caregiver identity. Circumstances and your actions. Disposition. FRD contact info. Page 30
What should still be done for patients with a VDDNR or DNR?
Humane comfort measures while avoiding aggressive resuscitation efforts. Page 34
What are the five key parts for a VDDNR or DNR?
Patients full legal name. DNR determination. Signature of MD or NP. Date of issue. Patient signature or person authorized to consent on patient’s behalf. Pg 34
What is a physician orders for scope of treatment (POST)?
A distinctive bright lime colored form that lets serious or terminally ill patients choose what treatment they receive. Considered a companion document to the DNR. Page 35
Who can revoke a DNR at any time by destroying or verbally withdrawn consent?
The patient. Person authorized to consent on behalf of the patient. Provider who issued the order. Pg 36
What measures should be avoided with a valid DNR status?
CPR. Intubation. Artificial ventilation. Defibrillation. Cardiac resuscitation medications. Page 36
If a patient’s personal physician is on scene and takes responsibility for patient care what must happen?
Physician must accompany the patient to the emergency room. Page 40
As a rule, During START patient contact time should be limited to what?
30 to 45 seconds or less. Page 42
What is the key difference between START and JUMP START?
If an adult is not breathing after opening the airway he’s considered deceased. Pediatric patients get their pulse checked after opening airway and still not breathing. If there is a pulse, five rescue breaths are administered. Page 42
What is the only treatment allowed to be administer to animals except Fairfax county working dogs?
Oxygen. Naloxone May be given to the handler of the working dog to administer. Pg 43.
What may be used on an aggressive animal ic necessary?
Structural gear and a CO2 extinguisher. Pg 43
What are the two regional hospitals have dedicated bariatric in patient care units?
INOVA fair oakes and reston. Pg 44
What are the four options for securing patient weapons?
Preferred: willingly leaves at the scene. Alternative: request PD and ask patient to turn over for safekeeping. Contingency: ems supervisor keeps weopon or less desirable, weopon is secured in the medication compartment. Emergency: contact EMS supervisor, PD, POLMD, and consider a refusal. Pg 45
How should inmates or subjects in custody be transported?
Secured, but not to the cot, with an officer in the back of the unit. Never restrained in a prone position. Pg 46
What is PMSC?
Neurological assessment. Pulse. Motor. Sensation. Capillary refill. Pg 54
What does SAMPLE stand for?
Signs and symptoms, allergies, medications, past medical history, last meal, events lead to current state. Pg 54
What does OPQRST stand for?
Onset of symptoms. Provoking factor. Quality of pain. Region/radiation of pain.
Severity. Time/treatment prior to arrival. Page 54
What does DCAPP-BTLS stand for?
Deformity.
Contusion.
Abrasion.
Puncture.
Penetration.
Burn.
Tenderness.
Laceration.
Swelling
What are the core principles of pit crew cpr management?
Good quality CPR and early defibrillation. Minimize interruptions. Switch providers every two minutes.
Airway and breathing is important but secondary to CPR.
Two-handed mask seal when possible and control ventilation. Avoid over ventilation. Page 71
Cardiac arrest should be worked until one of what three end points?
ROSC is obtained. After 30 minutes of full resuscitative efforts. To the point of three shocks for a shockable rhythm end or three drugs for non-shockable rhythms. Page 71
What does TOR stand for?
Termination of resuscitation. Pg 71
What are the first person ‘s, P1, tasks in pit crew CPR?
Initial assessment of responsiveness, breathing, pulse, and begin CPR.
What are the second person’s, P2, tasks in pit crew cpr?
Primary responsibility is AED or monitor operations. Secondary is alternating compressions with first provider. PG 71
What are the third person’s, P3, tasks in pit crew CPR?
Airway management and BVM use. Bring her way back, oxygen, and suction in positions that patient’s head. Page 71
What is the fourth person, ALS provider left/P four right/, responsible for?
Team lead. Following first shock or no shock advised, move to a position to allow three BLS providers to form triangle around patient’s head for quality CPR and assist with superglottic airway as well as provide two-handed mask seal. Vascular access and drugs at the appropriate time. Pg 71
What criteria mandate transport to the burn center barring no major trauma?
First degree burns over 50% of body. Second degree burns greater than 10%. Third degree greater than 2%. Electrical. Inhalation. Circumferential. Special area (feet, hands, general, face, joints). Chemical. Pg 184
What patients must be transported to the burn center regardless of type of burn?
Chronic illness patients. Possible functional or cosmetic impairment. Pregnancy. Less than five or greater than 55. Page 184
What does FACT*R stand for?
Field-available component therapy response. Pg 192
What are the two factors that are considered for activation of the FACT R protocol?
Patient status and entrapment status. Patient must be sick, stuck, and survivable. Page 192
What are the five patient considerations for activating FACT R?
- Patient must be adult. 2. Significant MOI. 3. Signs/symptoms of hemorrhagic shock. 4. Responsive to pain or better mental status. 5. IV or IO access.
What is the timeframe Consideration for patient entrapment to activate FACT R?
Greater than 30 minutes from time of activation. Pg 192
What high risk factors mandate spinal motion restriction for trauma patients
Less than five or more than 65 years old. Dangerous mechanism. numbness or tingling in extremities. Page 203
What dangerous mechanism of injury’s mandate spinal motion restriction?
Fall for more than 3 feet/five stairs. Axle load to head such as diving. Greater than 65 mph MVC, rollover, ejection. Recreational vehicles. Bicycle struck or collision. Page 203
What is the criteria for low risk factor trauma that would still require spinal motion restriction?
If patient is unable to actively rotate neck. Page 203
When should helicopter transport be considered?
Only if faster than ground transport of more than 30 minutes considering time of day and traffic restrictions. Pg 211
f drawn up medication does not fit in what size syringe, it should not be administered to a newborn/infant?
1cc. Pg 213
How old is a newborn?
Minutes to hours post birth. Page 213
How old is an infant?
First year. Page 213
How old is a neonate?
first 28 days of life. Pg 213
How old is a child?
1-8 years. Pg 21:
How old is an adolescent?
9-16 years.
How old is an adult?
17 or older
Pediatric orders always apply to patients less than how old?
14 years old, generally the age of puberty. Page 213
Where’s the best place for examination for a stable pediatric?
The parents lap. But not during transport. Page 213
What should be considered when the need to expose a patient arrives?
Make every effort to respect patients dignity inconsiderate ambient temperatures and conditions. Page 214
What does TICLS acronym stand for regarding pediatrics?
Tone. Interactivity. Console ability. Look/keys. Speech/cry. Page 250
What is the two-step process for determining patient destination for transport?
Formulate best recommendation based on: clinical need and ED capability, home hospital status, patient preference, proximity. Second present information to patient as a treatment recommendation. Pg 340
If a patient’s preference for transport destinations involves greater than 60 minutes one way or transport out of state who must be contacted?
UFO and EMS supervisor for approval. Page 340
What complex burn criteria mandate transportation to the burn center according to destination facility section?
Superficial burns greater than 50%. Electrical. Inhalation. Circumferential. Special area. Chemical. Any for thickness third-degree burn. Less than 10 or greater than 50 years old. Page 341
Where should cardiac arrest patients be transported?
To the closest ED or FSED. Page 341
If there is a return of spontaneous circulation in route to a facility where should the patient be transported to?
The closest PTCA (STEMI) center. Page 341
Patients with post operative complications within how many weeks should be transported to facility where surgery was done?
Within four weeks. Pg 342.
A patient within how many weeks of being discharged from a facility should be transported to the same facility?
Within 2 weeks. Pg 342
All patients greater than how many weeks pregnant having an ob emergency should be transported to an OB capable facility?
Greater than 20 weeks. Pg 342.
A patient screening positive for a stroke should be transported to a MT capable or comprehensive stroke center rather than a primary stroke center it less than how many minutes further than the primary stroke center?
20 minutes. Pg 342
What are the three regional pediatric icu’s?
Children’s national. Inova Fairfax. Georgetown university hospital. Pg 34-
Trauma patients who cannot be maintained or managed prehospital with complete airway obstruction, or in cardiac arrest may be transported to where?
Closest ER regardless if it’s a trauma center. May be required to transport to trauma center after initial stabilization. Pg 343
Glucometers are calibrated to are based on what blood samples?
Capillary samples. Venous samples will be higher. Pg 409
If a glucometer reads KETONES, the reading is how high?
300mg/dL or higher. Pg 409
What must be done prior to the delivery of any therapeutic intervention to a patient unless immediate treatment is necessary and no provider is present to perform it?
Cross-check. Als provider is preferred. Bls is acceptable.
She should endotrachial intubation (ETI) be used over supraglottic (SGA) airway?
If the patient has progressive airway swelling or airway requires definitive protection from blood or aspiration. Pg 450
What are the indications for a supraglottic airway?
Patient needs an advanced airway and has no gag reflex. Pg 450
What are general contraindications for a supra glottic airway?
Patient ingested caustic substance. Gag reflex. Pg 450
How many attempts and how many seconds should you not exceed for each supraglottic airway attempt?
2 attempts for 12 or older. 1 attempt for <12. 30 seconds per attempt. Pg 451
How do you apply a pressure bandage?
Place pressure bar/H over wound. Wrap elastic side to side. Secure. Pg 462
What is the same sling to used for?
Effective reduction in stabilization of open book pelvic fractures from th fauna such as pedestrian struck or MVC. Page 463
What does SSMR stand for?
Selective spinal motion restriction preferred method is a c collar. Page 464
When is a c-collar and long board used?
Preferred method for altered mental status. Pg 464.
Where should the tourniquet be placed?
2 to 3 inches above the injury. Avoid placing over joints. Placed above the injury as proximal to the torso as possible. Pg 468
If the decision is made to remove a tourniquet what should be done?
Apply pressure dressing. Then loosen the tourniquet but leave in place. Pg 468
What is a contraindication for rooms packing?
Wounds to chest and abdomen because they are non-compressible spaces. Page 469
When caring and adult patient upper down for a more steps how many personnel shall be used?
Minimum of three with one used as a spotter on the lower side. Pg 486
What is a contraindication for an NP airway?
Suspected basilar skull fracture. Pg 454
What is the maximum suction time?
No more than 15 seconds for adult or five seconds for infant child. Page 457
What is livor mortis?
Settling of blood in the dependent portion of the body. 20min-3hrs after death. Maximum lividity 6-12 hrs.
That is rigor mortis?
Stiffening of all muscles in the body. 3-4 hrs, maximum stiffness 12 hrs
Who should be treated first in a multiple patient lightening strike?
Unconscious and those in cardiac arrest. May be in recoverable asystole.
Defibrillation may not work on a heart below what temp?
86 degrees Fahrenheit
How long should you check for a pulse on hypothermic patients?
30-45 seconds
What is the hospital target temperature management for ROSC patients?
96.8
