NREMT Part III Flashcards
Signs
findings you can objectivly:
- See
- hear
- feel
- smell
- Exmpl: vomiting, deformity, wheezing
Symptoms
Subjective feelings the patient must tell you about
empl: Nausea, pain, dyspnea
OTC
Over The Counter Medications
when to reassess stable patient
Every 15 mins
When to reassess unstable patient
Every 5 mins
Six standard vital signs
- RR
- Pulse
- BP
- Pupils
- Skin temp
- Pulse ox
Tachypnea
and tachypnic rate for adult
Rapid breathing
Over 20 breaths a min
Bradypnea
And bradypnic rate for adult
Slow breathing
Under 12 breaths a min
Normal Respiratory Rhythm
Regular rhythm and adequate chest rise and fall
Shallow Respiratory Rhythm
Minimal chest rise and fall
Labored Respiratory Rhythm
Increased work of breathing
Irregular Respiratory Rhythm
Abnormal breathing pattern
Best place to hear lung sounds
pts back
Wheezing
High-pitched whistleing sound
- usually on expiration
Crackles/Rales
Wet, crackling sound
- usually on inspiration and expiration
Rhonchi
Low-pitched congested sounds
- usually due to mucus
- usually on expiration
Three fields to auscultate lungs
- Upper lungs (apices): below clavicals @ midclavicular line
- Middle lung field: middle chest @ midclavicular posterior
- Lower lungs (base): lower portion of thorax @ miclavicular or midaxillary
At what Systolic BP is it unlikely you can palpate a pulse
60 mmHg
3 componants to documenting a pulse
- Rate
- Rhythm
- Quality
Quality of pulse descriptors
- strong
- weak
Rhythm of pulse descriptors
- regular
- irregular
What is BP measured in?
Millimeteres of mercury (mmHg)
what is pulse pressure
Difference between systolic and diastolic
‘normal’ pulse pressure
Difference that is >25% but <50% of systolic
Wide pulse pressure
and indicates what
- Greater than 50% of systolic
- indicates increased ICP
Narrow pulse pressure
and indicates what
- <25%
- Indicates possible obstructive shock
Hypertension stages (BP Values)
Stage 1: 130/80 - 139/89
Stage 2: systolic > 140 OR diastolic >90
Hypertension crisis: Systolic >180 OR diastolic >120
Hypotension in child (1 - 10 Y.O)
Systolic below
70 + 2(age)
Exmpl: 5 y.o. with systolic BP of 80
orthostatic hypotension considerations
- have pt stand for 1 min then repeat BP
- do not assess if pt is already dizzy, weak, hypotensive while supine
orthostatic hypotension findings
- Drop is SBP >20
- Drop is DBP >10
- sharp rise in pt pulse rate
Mydriasis
Dialated pupils
Miosis
Constricted pupils
‘Normal’ pupil size
midsize:
2 - 5 mm in light
Anisocoria
pupils are different in size or shape
Body temp (Adult average & range)
Average: 98.6 F (37C)
Range: 97 F (36.1C) - 99 F (37.2C)
What age group has a lower body temp
Elderly
Where to palpate for relative skin temp
upper back or neck
(Not forehead)
What age group is cap refill a reliable sign of poor perfusion
Under 6 years
SaO2 and SpO2 difference
SaO2: O2 saturation of arterial blood
SpO2: O2 saturation detected by pulse oximeter
Pulse Oximetry limitations
- not only tool for respiratory efficiency
- cannot measure amount of hemoglobin (only saturation of hemoglobin that is present)
- Inaccurate readings due too :hypovolemia, hypothermia, anemia, nail polish, carbon monoxide, tabacco use
NIBP
Non-invasive Blood Pressure monitoring
What scope is capnography/capnometry in?
AEMT or Paramedic
Capnography
End-tidal CO2 (ETCO2)
- measurement of carbon dioxide in pts exhaled breath
Some systems allow EMT to assist set up ( LIKE COLORADO :) )
Capnography vs. Capnometry
Capnography: Co2 waveform and numerical value
Capnometry: numerical value only
5 components of Patient Assessment for EMT
- Scene Saftey
- Primary assessment
- Patient History
- Secondary Assessment
- Reassessment
Scene Size up componants
- Scene saftey
- BSI/PPE
- MOI or NOI
- # of patients
- additional resources
- consider spinal precautions
When should you carry a portable, compact, flashlight
all times
Primary Assessment
- begins when you reach the pt
- Identify and manage life threats
Primary Assessment componants
- General impression
- LOC
- ABC or CAB (AVPU)
- Rapid scan as needed
- transport priority
ABC vs. CAB
- Airway, Breathing, Circulation
- Circulation, Airway, Breathing
When do you use CAB instead of ABC
- unconscious pts
- obvious life threatening bleeding
How long do you check for a pulse in an unresponsive pt?
5 - 10 seconds
What type of PPV do pts with inadequate breathing always get
BVM
Rapid scan
head-to-toe assessment used to identify remaining life threatening conditions not already managed
Rapid scan componants
- should not take longer than 90 seconds
- utilize inspection, palpation, auscultation as needed
- includes assessment of posterior
- do NOT be distracted/focus on non-life threatening conditions
high transport priority pts (unstable pt)
- decreased LOC
- signs of shock
- serious medical condition
- severe pain
stable pt
- no obvious life-threatening condition
Secondary assessment
- should not delay transport for high priority pt
- identify remaining s/s, conditions, injuries
- all potentially life-threatening conditions should have already been found or managed
- can be a detailed head-to-toe assessment or focused exam
detailed head-to-toe indicated for
- unresponsive
- multisytem trauma
Focused secondary survey
- focuses only on areas/systems considered relevant to pt complaint
Focused secondary survey indication
- alert pt
- isolated complaint
Secondary assessment componants
- detailed or focused secondary survey
- baseline vitals
Reassessment
used to continuously monitor pt condition for deterioration or improvement
Reassessment componants
- begin by reassessing primary assessment for changes
- reassess pt CC
- Reassess interventions you performed
- continues until pt care is transferred or you discover something that requires attention
pt history componants
SAMPLE
what is the terminal (final) structure in the lower airway
Alveoli
What is spontaneous breathing driven by
Negative pressure
What is the active part of ventilation
Inhalation
What is the passive part of ventilation
Exhalation
Two primary methods brain uses to control O2 delivery
- Rate of ventilation
- Tidal volume
Hypoxic drive
- monitors O2 levels in plasma
Hypoxia
Inadequate delivery of O2 to the tissues of the body
S/S of mild (early) hypoxia
- resltess, anxiety, irritable
- Dyspnea
- Tachycardia, tachypnea
- SpO2 90% - 94%
S/S of severe (late) hypoxia
- Altered or decreased LOC
- Severe dyspnea
- Cyanosis
- Bradycardia (especially peds)
- SpO2 below 90%
Oxygenation
Delivery of O2 to the blood
- ventilation must be adequate for oxygenation to occur
NC, NRB, CPAP require what from pt
spontaneous ventilation
Respirations
Exchange of O2 and carbon dioxide
Assessment of breathing includes
- look
- listen
- feel
Adequate breathing componants
Adequate RR and tidal volume
Inadequate breathing componants
- Abnormal RR
- shallow chest rise
- accessory muscle
- abnormal/diminished/absent lung sounds
- paradoxical motion
- dyspnea
- Cyanosis
- Low Spo2
- Agonal breaths
- Apnea
Order of assessment and management of airway
- open airway
- suction
- secure
Aspiration
Entry of matter into the lungs
- can cause aspiration pneumonia
- 1 in 5 pt with aspiration pneumonia will die
Suction units require
- disposable canister
- generate vacuum of 300 mmHg when tubing clamped
Yankauer
Rigid suction catheter
- known as “tonsil tip”
- for oral airway
French catheter
Flexible
- several sizes
- for nose, stoma, inside advanced airway
Suctioning increases risk of
- hypoxia
- delays time
Suction times
adult: 15 seconds
Children: 10 seconds
Infants: 5 seconds
How to measure french catheter
from corner of mouth to earlobe
how to measure OPA
Corner of mouth to earlobe
OPA contraindications
- Gag reflex
- Responsive to pain
NPA contraindications
- pt awake and protecting own airway
- severe head injury
- severe facial trauma
- do not force when you meet resistance
How to measure NPA
Tip of nose to earlobe
NPA insertion considerations
- water-soluble lubricant ONLY
- insert with bevel toward septum
- rotate as necessary
- remove if pt begins to gag
What supraglottic airway is not currently part of NREMT
(yes its part of CO EMT scope)
i-gel
Indications for supplimental O2
- cardiac or respiratory arrest
- BVM
- dyspnea, cyanosis
- signs of shock
- Spo2 less than 95%
- altered or decreased LOC
AHA guidelines for administering O2 with suspected acute coronary syndrome or stroke
NOT recieve O2 UNLESS:
- SpO2 of 94 or less
- complain of dyspnea
- signs of shock
- signs of heart failure
Oxygen cylinders look like?
- seamless
- aluminum
- green
- various sizes
Amount of O2 in a tank is measured by
pounds per square inch (psi)
Full O2 tank is ____ psi
2,000 psi
When do you replace or refill O2 tank
200 psi
(Known as the safe residual pressure)
Regulators
Flow meters
- reduce pressure coming from tank
- measured in liters per minute (L/min or lpm)
NRB
- typicall set to 10 lpm (as needed to keep reservoir filled)
- pt recieves 90% O2
NRB cautions
- reservoir full before applying mask
- never under less than 10 lpm
- if reservoir deflates during inhale = increase flow rate
- Remove mask if O2 source is lost
NC
Nasal Cannula
- referred to as ‘low-flow’ O2
- flow rate 1 to 6 lpm
- pt recieves 24% - 45% depending on lpm
Venturi mask
- deliver specific concentrations of low flow O2
- Not commonly used in EMS
HFNO
High Flow Nasal Oxygen
- emergency therapy that delivers CPAP-like support
- 40 - 70 lpm
- not well tolerated
Hazards of O2 administration
- combustable
- highly pressurized tanks
- long term exposure to high concentration can cause retinal damage in infants
PPV
Positive pressure ventilations
also called: assisted ventilation or artificial ventilation
PPV devices
- Pocket mask
- BVM
PPV indications
- inadequate spontaneous breathing
- RR <10 or >30
- Apnea
- Agonal
- respiratory distress/failure
PPV complications
- hyperventilation
- gastric distention
- aspiration
- intrathoracid pressure = decrease coronary perfusion
Pocket mask O2 % deliver
16%
(think: amount of O2 in rescuers exhale)
Sizes and volumes of BVM devices
Infant: 150 - 280 mL
Child: 500 - 700 mL
Adult: 1,000 - 1,600 mL
Best way to assess adequate ventilation for PPV
- Gently chest rise and fall
Rates for ventilation for apneic pts with a pulse
- Adults - 1 breath every 6 sec
- Infants/children - 1 breath every 2-3 sec
- Newborns - 40-60 per min
rates for ventilation in cardiac arrest
Fancy tip
- Adults - 1-2 rescuer 30 compressions 2 breaths
- Children - 1 rescuer 30 compressions 2 breaths
- Children - 2 rescuer 15 compressions 2 breaths
- Newborns - 3 compressions 1 breath
Fancy tip: No need to pause compressions for ventilation once an advanced airway has been placed
CPAP
Contraindications
- Hypotension
- Can’t protect their own airway
- vomitting
- Not breathing spontaneously
- Can’t follow commands
- Upper GI bleeds
BiPAP
Define
- Bilevel Positive airway pressure
- 1 level of pressure for the patients inhalation and 1 level of pressure for the exhilation
FROPVD
- Automatic and manual settings
- Press button to initiate ventilation until chest rises
- In a spontaneously breathing patient relief valve open automatically
Pediatric considerations
Airway and ventilation
- Bradycardia is hypoxia until proven otherwise
- Hypoxia develops rapidly
- Less oxygen reserves
- Higher metabolic rates
- Sniffing position for PPV
Signs for respiratory fialure in pediatric pts
- Bradycardia
- Poor muscle tone
- Decreased LOC
- Headbobbing
- Grunting on exhilation
- Seesaw breathing
Tracheostomy
Surgical opening at the beginning of the trachea for artificial access to the airway
Trach tube/stoma considerations
- Stoma = infant or ped mask for BVM
- Trach tube = remove mask connect bvm directly to trach tube
- Have suction ready for both - Use a french catheter
FBAO
Whats it mean?
Foreign body airway obstruction
Good job! so smart
FBAO indications
- Inability to cough, speak, or breath
- Clutching throat
- Inability to ventilate pt despite repositioning airway
Managing FBAO
- Conscious = Abdominal thrusts unitl obstruction is releived or patient loses consciousness
- Conscious infant = 5 back slaps, 5 chest thrusts until obstruction is releived or pt loses consciousness
- Unconscious patient = Chest compressions, ventilations, inspect airway, remove if visible